David E. Rosow

Considerations for Initial Dosing of Botulinum Toxin in Treatment of Adductor Spasmodic Dysphonia

Objectives To assess the effect on voice improvement and duration of breathiness based on initial dose of onabotulinum toxin A (BTX-A) in the management of adductor spasmodic dysphonia (SD) and to compare voice outcomes for initial bilaterally injected doses of 1.25 units (group A) vs 2.5 units (group B) of BTX-A. Study Design Case series with chart review of patients with adductor SD treated at a tertiary care facility from 1990 to 2011. Setting Academic subspecialty laryngology practice. Methods Demographic data (age and sex), voice rating, duration of voice improvement, and breathiness were evaluated and compared between groups A and B using the Student t test and χ2 analysis. Results Of 478 patients identified, 305 (223 in group A, 82 in group B) patients met inclusion criteria. The average age was 56.2 years in group A and 57.4 years in group B (P = .5). The female to male ratio was 2.91 for group A vs 3.56 for group B (P = .61). Good voice outcomes (grade 3 or 4) were reported by 91% of group A patients vs 94% of group B (P = .75). The average duration of voice improvement was 99.7 days for group A and 108.3 days for group B (P = .54). The average duration of breathiness was 10.88 days for group A vs 15.42 days for group B (P = .02). Conclusion Patients injected with 1.25 units bilaterally had a statistically significant shorter duration of breathiness without a statistically significant difference in clinical effectiveness or voice outcome. It is therefore recommended that a relatively low initial BTX-A dose be used with subsequent titration to achieve improved voice outcomes.

Factors Influencing Botulinum Toxin Dose Instability in Spasmodic Dysphonia Patients

OBJECTIVE Many patients with spasmodic dysphonia (SD) see consistent effects from botulinum toxin (BTX) injections of the same dose, whereas others require dosage changes over time. We sought to determine whether demographics (age and gender) or environmental factors (smoking) affect the long-term stability of BTX dosing in these patients. STUDY DESIGN Retrospective review. METHODS Charts of all patients undergoing BTX injection for adductor SD were reviewed. Dosage change, defined as whether there was any difference in total dosage used between two beneficial injections, was used as a measure of dosing stability. Beneficial injections were indicated by a voice rating score of at least three of four and any non-zero duration of improved voice. Logistic regression analysis was performed to determine whether age, gender, smoking status, or duration of treatment correlated with odds of having a dosage change. RESULTS A total of 211 patients were ultimately included. Age, gender, and smoking status were all found to have no correlative effect on dosing stability. The only factor that was predictive of dose stability was the number of previous beneficial injections, as every additional injection led to decreased odds of a change in dosage for the next injection (odds ratio=0.964; 95% confidence interval=0.947-0.981). CONCLUSIONS Dosage of BTX injections for long-term treatment of SD has a significant propensity to remain stable over time. Factors such as age, gender, and smoking status do not appear to influence the dosage stability. These findings should allow for better patient counseling regarding expectations for their long-term treatment.

The economic impact of vocal attrition in public school teachers in Miami-Dade County

Teachers are a known at‐risk population for voice disorders. The prevalence and risk factors for voice disorders have been well studied in this population, but little is known about the associated economic cost. The purpose of this study is to assess the economic impact of voice dysfunction in teachers and understand the difference between the cost of absenteeism and presenteeism as a direct result of voice dysfunction.

Type I Thyroplasty in Previously Irradiated Patients: Assessing Safety and Efficacy

Objectives (1) Review and report our experience performing medialization thyroplasty (MT) in previously irradiated patients and (2) compare complications and voice outcomes in 2 cohorts (irradiated vs nonradiated) to evaluate safety and efficacy. Study Design Case series with chart review. Setting Academic medical center. Subjects All patients (44 total) who underwent MT from 2011 to 2015. Methods Demographic data, complications, and acoustic and subjective voice outcome parameters were collected. The complication rates and voice outcome results were compared between 2 cohorts: patients with a history of radiation to the neck versus those with no radiation history. Results There were 7 previously irradiated patients and 37 nonradiated patients, with median follow-up of 314 and 538 days, respectively. One complication was noted in each group, and this complication rate was not significantly different (P = .26). Both cohorts demonstrated significant postoperative improvement in subjective voice assessment (P = .04, P < .0001) as well as maximum phonation time (P = .02, .001) when compared with preoperative data. Conclusions Our study suggests that MT can be safely and effectively performed in irradiated patients. We found no statistically significant difference in the safety of performing MT in irradiated versus nonradiated patients, and there was significant improvement in subjective voice parameters and maximum phonation time in both groups. A larger prospective study is required to statistically determine whether the significant improvements in objective parameters seen in the nonradiated group are present in irradiated patients as well.

Lipoma and liposarcoma of the larynx: case reports and literature review

OBJECTIVE Two cases of laryngeal lipomatous tumors are presented. Their diagnoses and management are discussed and contrasted. METHODS Case report and literature review. RESULTS Patient 1 is a 58 year old male presenting with five years of progressive shortness of breath, dysphagia, and globus sensation. Clinical exam and imaging study showed a 3.5 cm hypodense laryngeal mass, and he underwent transoral robotic-assisted surgery for complete excision. Final pathology revealed a well-differentiated liposarcoma. Patient 2 is a 79 year old female presenting with one year of non-progressive hoarseness and globus sensation. Clinical examination and imaging study revealed a 1.8 cm hypodense laryngeal mass. Transoral endoscopic complete excision of the submucosal mass was performed. Final pathology revealed benign spindle-cell lipoma. CONCLUSION Liposarcoma and lipoma may present with similar symptomatology, clinical, and imaging findings. Pathology evaluation is of utmost importance for definitive diagnosis. Therefore, diagnosis and treatment of laryngeal lipomatous lesions are best accomplished with complete excision of the mass.

Familial congenital bilateral vocal fold paralysis: A novel gene translocation

OBJECTIVES True vocal fold (TVF) paralysis is a common cause of neonatal stridor and airway obstruction, though bilateral TVF paralysis is seen less frequently. Rare cases of familial congenital TVF paralysis have been described with implied genetic origin, but few genetic abnormalities have been discovered to date. The purpose of this study is to describe a novel chromosomal translocation responsible for congenital bilateral TVF immobility. METHODS The charts of three patients were retrospectively reviewed: a 35 year-old woman and her two children. The mother had bilateral TVF paralysis at birth requiring tracheotomy. Her oldest child had a similar presentation at birth and also required tracheotomy, while the younger child had laryngomalacia without TVF paralysis. Standard karyotype analysis was done using samples from all three patients and the parents of the mother, to assess whether a chromosomal abnormality was responsible. RESULTS Karyotype analysis revealed the same balanced translocation between chromosomes 5 and 14, t(5;14) (p15.3, q11.2) in the mother and her two daughters. No other genetic abnormalities were identified. Neither maternal grandparent had the translocation, which appeared to be a spontaneous mutation in the mother with autosomal dominant inheritance and variable penetrance. CONCLUSIONS A novel chromosomal translocation was identified that appears to be responsible for familial congenital bilateral TVF paralysis. While there are other reports of genetic abnormalities responsible for this condition, we believe this is the first describing this particular translocation.

Trends in Utilization of Vocal Fold Injection Procedures

Office-based vocal fold injections have become increasingly popular over the past 15 years. Examination of trends in procedure coding for vocal fold injections in the United States from 2000 to 2012 was undertaken to see if they reflect this shift. The US Part B Medicare claims database was queried from 2000 through 2012 for multiple Current Procedural Terminology codes. Over the period studied, the number of nonoperative laryngoscopic injections (31513, 31570) and operative medialization laryngoplasties (31588) remained constant. Operative vocal fold injection (31571) demonstrated marked linear growth over the 12-year study period, from 744 procedures in 2000 to 4788 in 2012—an increase >640%. The dramatic increased incidence in the use of code 31571 reflects an increasing share of vocal fold injections being performed in the operating room and not in an office setting, running counter to the prevailing trend toward awake, office-based injection procedures.

Office Removal of a Subglottic Bread Clip

Objective. The presence of an upper airway foreign body is an emergent, potentially life-threatening situation that requires careful but rapid evaluation and management. Organic or nonorganic material may typically be found in the pyriform sinuses or tongue base or may be aspirated directly into the tracheobronchial tree. We present here an unusual case report of a patient who accidentally ingested a plastic bread clip that was lodged in his subglottis for 15 months and report successful removal in the office under local anesthesia. Methods. Mucosal anesthesia was achieved with inhaled 4% lidocaine spray. Flexible laryngoscopic removal of the foreign body was then successfully accomplished. Results. The patients symptoms resolved completely following removal, with no sequelae. Conclusions. Office removal of airway foreign bodies is feasible and can be safely done with adequate topical anesthesia, but great caution and emergency planning must be exercised.

Laryngeal Involvement of Multiple Myeloma

The objectives of this paper are to discuss a rare cause of laryngeal multiple myeloma, to review unique pathologic findings associated with plasma cell neoplasms, to discuss epidemiology, differential diagnosis, and treatment options for plasma cell neoplasms of the larynx. Laryngeal multiple myeloma, also noted in the literature as “metastatic” multiple myeloma, presenting as a de novo laryngeal mass is extremely rare with few reported cases. Laryngeal involvement of extramedullary tumors is reported to be between 6% and 18% with the epiglottis, glottis, false vocal folds, aryepiglottic folds, and subglottis involved in decreasing the order of frequency. We present the case of a 58-year-old male with a history of IgA smoldering myeloma who presented to a tertiary care laryngological practice with a two-month history of dysphonia, which was found to be laryngeal involvement of multiple myeloma. We review the classification of and differentiation between different plasma cell neoplasms, disease workups, pathologic findings, and treatment options.

Review of adult laryngotracheal stenosis: pathogenesis, management, and outcomes.

Purpose of reviewAdult laryngotracheal stenosis (LTS) is a potentially life-threatening disorder that can be difficult to diagnose and treat. Much is unknown regarding the etiology of airway stenosis, and while many patients do well with standard surgical management, the recurrence rate is significant. Few medical therapies exist, but there is a growing need. Recent findingsSeveral basic science studies have shown a role of inflammatory signaling pathways in the development of LTS. Infectious processes may also play a role in development of stenosis, while treatment with anti-inflammatory and immunosuppressive medications has shown some promise in preventing disease. Several risk factors, such as diabetes, BMI, length of stenosis, and need for T-tube, have been identified that portend worse surgical outcomes and may assist physicians in choosing appropriate treatment. SummaryWhile adult LTS is a complex, challenging clinical entity, there is promising research into the inflammatory origins of the disorder, which may open up groundbreaking new avenues of medical treatment.