Joshua S. Schindler

Human papillomavirus in early laryngeal carcinoma

To examine the role of HPV status in the etiology, prognosis, and treatment of head and neck squamous cell carcinoma in early larynx malignancies.

Clinical Manifestations and Treatment of Idiopathic and Wegener Granulomatosis-Associated Subglottic Stenosis

OBJECTIVE To compare and contrast the manifestations and surgical management of subglottic stenosis in patients with airway obstruction attributed to granulomatosis with polyangiitis (GPA), previously known as Wegener granulomatosis, and those with idiopathic subglottic stenosis (iSGS). DESIGN Retrospective medical chart review. Review of subglottic stenosis cases seen in the otolaryngology department of an academic medical center from 2005 through 2010. Data were obtained on disease presentation, operative management. and findings. SETTING Tertiary referral center. PARTICIPANTS A total of 24 patients with iSGS and 15 patients with GPA-associated subglottic stenosis (GPA-SGS). RESULTS All individuals with iSGS were female, and 40% of patients with GPA-SGS were male (P < .01). Patients with iSGS tended to have a higher Myer-Cotton stenosis grade at the time of dilation than those with GPA-SGS (P = .02). Individuals with GPA-SGS were more likely to undergo tracheotomy as a result of disease-related complications than individuals with iSGS (P < .01). No patients with an open airway reconstruction in the iSGS group required follow-up mechanical dilation. In contrast, all patients with open airway reconstructions in the GPA-SGS group underwent more than 1 subsequent airway dilation (P < .01). CONCLUSIONS While surgical utilization is the mainstay of treatment in iSGS and GPA-SGS, iSGS occurs almost exclusively in females and presents with a greater degree of stenosis at the time of endoscopic dilation. In contrast, GPA-SGS is associated with greater rates of tracheotomy. Open airway reconstruction may be used in the treatment of iSGS and GPA-SGS but is much more effective in iSGS.

Prospective Study of Venous Thromboembolism in Patients With Head and Neck Cancer After Surgery

IMPORTANCE Venous thromboembolism (VTE) is associated with significant morbidity and mortality in surgery patients, but little data exist on the incidence of VTE in head and neck cancer surgical patients. OBJECTIVE To determine the incidence of VTE in postoperative patients with head and neck cancer. DESIGN, SETTING, AND PARTICIPANTS A prospective study of 100 consecutive patients hospitalized at a tertiary care academic surgical center who underwent surgery to treat head and neck cancer. Routine chemoprophylaxis was not used. On postoperative day (POD) 2 or 3, participants received clinical examination and duplex ultrasonographic evaluation (US). Participants with negative findings on clinical examination and US were followed up clinically; participants with evidence of deep venous thrombosis (DVT) or pulmonary embolism (PE) were given therapeutic anticoagulation. Participants with superficial VTE underwent repeated US on POD 4, 5, or 6. Participants were monitored for 30 days after surgery. MAIN OUTCOME AND MEASURE Total number of new cases of VTE (superficial and deep) identified within 30 days of surgery and confirmed on diagnostic imaging. RESULTS Of the 111 participants enrolled, 11 withdrew before completing the study; thus, 100 participants were included. The overall incidence of VTE was 13%. Eight participants were identified with clinically significant VTE: 7 DVT and 1 PE. An additional 5 participants had asymptomatic lower extremity superficial VTE detected on US alone. Fourteen percent of patients received some form of postoperative anticoagulation therapy; the rate of bleeding complications in these patients (30.1%) was higher than that in patients without anticoagulation therapy (5.6%) (P = .01). CONCLUSIONS AND RELEVANCE Hospitalized patients with head and neck cancer not routinely receiving anticoagulation therapy after surgery have an increased risk of VTE. Bleeding complications are elevated in patients receiving postoperative anticoagulation.

Disease homogeneity and treatment heterogeneity in idiopathic subglottic stenosis

Idiopathic subglottic stenosis (iSGS) is a rare and potentially life‐threatening disease marked by recurrent and progressive airway obstruction frequently requiring repeated surgery to stabilize the airway. Unknown etiology and low disease prevalence have limited the ability to characterize the natural history of iSGS and resulted in variability in surgical management. It is uncertain how this variation relates to clinical outcomes.

Subjective and Objective Parameters of the Adult Female Voice after Cricotracheal Resection and Dilation

Objectives: We compared the voice outcomes after cricotracheal resection (CTR) and airway dilation in adult women. Methods: We performed long-term comprehensive voice assessments in 23 adult women treated for laryngotracheal stenosis, including acoustic and perceptual measurements of voice, videostroboscopy, the Voice Handicap Index, and an open-ended subjective questionnaire. Results: Voice measures were abnormal in both groups. Objective pitch and loudness measurements were significantly more impaired after CTR than after dilation. Perceptual ratings of voice were worse after CTR than after dilation, particularly with regard to breathiness, pitch, and loudness. The CTR group was more likely to report a voice disorder, reported significantly more voice symptoms, and had higher voice handicap scores. Videostroboscopy was frequently abnormal in both groups, with more evidence of vocal hyperfunction after CTR. Self-ratings of breathing and swallowing were generally high in both groups, but voice satisfaction was rated lower after CTR. Conclusions: Voice was more significantly negatively impacted by CTR than by dilation. Surprisingly, many individuals in both groups reported improvements — A finding that possibly highlights the impact of laryngotracheal stenosis on airflow and vocal function before surgery. The importance of patient selection and preoperative counseling is emphasized, along with the potential need for voice therapy.

Progression and management of Wegener's granulomatosis in the head and neck.

To describe the otolaryngologic presentation and natural history of granulomatosis with polyangiitis (GPA), previously known as Wegeners granulomatosis, and to compare otolaryngologic outcomes of patients with systemic GPA to those with a limited form of GPA confined to the head and neck.

Airway reconstruction in Wegener's granulomatosis-associated laryngotracheal stenosis†‡§

Open airway reconstruction is considered definitive treatment of laryngotracheal stenosis (LTS). Although most cases of LTS are not autoimmune, there are few data reported in patients with Wegeners granulomatosis. In this study, we aimed to assess outcomes of airway reconstruction in LTS patients with Wegeners compared to nonautoimmune patients.

The Integrity of Esophagogastric Junction Anatomy in Patients with Isolated Laryngopharyngeal Reflux Symptoms

BackgroundDistortion of esophagogastric junction anatomy in patients with gastroesophageal reflux disease produces permanent dilation of the gastric cardia proportional to disease severity, but it remains unclear whether this mechanism underlies reflux in patients with isolated laryngopharyngeal reflux symptoms.MethodIn a prospective study, 113 patients were stratified into three populations based on symptom complex: laryngopharyngeal reflux symptoms, typical reflux symptoms, and both laryngopharyngeal and typical symptoms. Subjects underwent small-caliber upper endoscopy in the upright position. Outcome measures included gastric cardia circumference, presence and size of hiatal hernia, and prevalence of esophagitis and Barrett’s esophagus within each group.ResultsThere were no differences in gastric cardia circumference between patient groups. The prevalence of Barrett’s esophagus was 20.4% overall and 15.6% in pure laryngopharyngeal reflux patients. Barrett’s esophagus patients had a greater cardia circumference compared to those without it. In the upright position, patients with isolated laryngopharyngeal reflux display the same degree of esophagogastric junction distortion as those with typical reflux symptoms, suggesting a similar pathophysiology.ConclusionThis indicates that, although these patients may sense reflux differently, they have similar risks as patients with typical symptoms. Further, the identification of Barrett’s esophagus in the absence of typical reflux symptoms suggests the potential for occult disease progression and late discovery of cancer.

Factors associated with supracricoid laryngectomy functional outcomes

Supracricoid partial laryngectomy (SCPL) is an option for laryngeal cancer resection that preserves laryngeal function; however, little information exists regarding factors that are associated with functional outcomes.

Complex adult laryngotracheal reconstruction with a prefabricated flap: A case series

Laryngotracheal stenosis (LTS) can cause persistent or recurrent airway obstruction. Although there is extensive literature on surgical techniques to treat LTS at onset, there are few techniques described for complex adult LTS after failed prior airway surgery. We describe a procedure used successfully in 3 patients who required structural augmentation for complex LTS.