Maggie A. Kuhn

Sudden Sensorineural Hearing Loss A Review of Diagnosis, Treatment, and Prognosis

Sudden sensorineural hearing loss (SSNHL) is commonly encountered in audiologic and otolaryngologic practice. SSNHL is most commonly defined as sensorineural hearing loss of 30dB or greater over at least three contiguous audiometric frequencies occurring within a 72-hr period. Although the differential for SSNHL is vast, for the majority of patients an etiologic factor is not identified. Treatment for SSNHL of known etiology is directed toward that agent, with poor hearing outcomes characteristic for discoverable etiologies that cause inner ear hair cell loss. Steroid therapy is the current mainstay of treatment of idiopathic SSNHL in the United States. The prognosis for hearing recovery for idiopathic SSNHL is dependent on a number of factors including the severity of hearing loss, age, presence of vertigo, and shape of the audiogram.

The Ability of the 10-Item Eating Assessment Tool (EAT-10) to Predict Aspiration Risk in Persons With Dysphagia

Background: Dysphagia is common and costly. The ability of patient symptoms to predict objective swallowing dysfunction is uncertain. Purpose: This study aimed to evaluate the ability of the Eating Assessment Tool (EAT-10) to screen for aspiration risk in patients with dysphagia. Methods: Data from individuals with dysphagia undergoing a videofluoroscopic swallow study between January 2012 and July 2013 were abstracted from a clinical database. Data included the EAT-10, Penetration Aspiration Scale (PAS), total pharyngeal transit (TPT) time, and underlying diagnoses. Bivariate linear correlation analysis, sensitivity, specificity, and predictive values were calculated. Results: The mean age of the entire cohort (N = 360) was 64.40 (± 14.75) years. Forty-six percent were female. The mean EAT-10 was 16.08 (± 10.25) for nonaspirators and 23.16 (± 10.88) for aspirators (P < .0001). There was a linear correlation between the total EAT-10 score and the PAS (r = 0.273, P < .001). Sensitivity and specificity of an EAT-10 > 15 in predicting aspiration were 71% and 53%, respectively. Conclusion: Subjective dysphagia symptoms as documented with the EAT-10 can predict aspiration risk. A linear correlation exists between the EAT-10 and aspiration events (PAS) and aspiration risk (TPT time). Persons with an EAT-10 > 15 are 2.2 times more likely to aspirate (95% confidence interval, 1.3907-3.6245). The sensitivity of an EAT-10 > 15 is 71%.

Management of Cricopharyngeus Muscle Dysfunction

The cricopharyngeus muscle (CPM) is a key component of the upper esophageal sphincter (UES). In dysphagia, cricopharyngeus muscle dysfunction (CPD) refers to the muscles failure to appropriately and completely relax or expand during deglutition. A variety of disease processes may cause CPD, and the resultant clinical manifestation is solid food or solid and liquid dysphagia. Several diagnostic tools are available for dysphagia clinicians to distinguish CPD from other causes of UES dysfunction. For CPD, accurate diagnosis is paramount for the recommendation of appropriate treatment. In appropriately selected patients, intervention at the CPM may yield significant improvement in dysphagia.

Multi-institutional experience with the in-office potassium Titanyl phosphate laser for laryngeal lesions

OBJECTIVE/HYPOTHESIS To determine the efficacy of the potassium titanyl phosphate (KTP) laser in lesion reduction, as well as preservation of mucosal wave and glottic closure in a cohort of patients with benign laryngeal pathology across multiple institutions. STUDY DESIGN Multi-institutional and retrospective. METHODS One hundred two patients who underwent in-office KTP procedures at multiple academic laryngology practices with at least a single follow-up visit were included. Image analysis was used to quantify vocal fold lesion size before and after treatment. A subset of images was analyzed by expert reviewers to determine the impact of this treatment on glottic closure and mucosal wave. RESULTS Statistically, when considering all lesions, KTP induced a significant reduction in lesion size. Post hoc analyses revealed some lesion specificity; all lesions decreased in size, with the exception of vocal fold scar. Mucosal wave and glottic closure were improved or unchanged in more than 90% of the patients examined. The inter- and intrarater reliabilities of the lesion quantification method were excellent. CONCLUSIONS With great care and insight, the KTP laser appears to be a valuable tool for the treatment of various benign laryngeal lesions. Furthermore, KTP laser therapy appears to preserve or improve mucosal wave and glottic closure. The lesion measurement protocol previously described by our group appears to be reliable.

Tongue Necrosis: A Rare Complication of Oral Intubation

OBJECTIVES (1) Present a unique case of partial necrosis of the dorsal tongue caused by an endotracheal tube; (2) highlight the importance of verifying proper endotracheal tube positioning during cases requiring prolonged intubation. METHODS Case report and literature review. RESULTS A 50 year-old man underwent total thyroidectomy and bilateral lymphadenectomies for papillary thyroid carcinoma. A nerve monitoring endotracheal tube was used during the case. Postoperatively, the patient reported tongue pain and examination revealed partial necrosis of his dorsal tongue. On follow up, the patient had improved tongue pain and well-healing dorsal tongue. DISCUSSION We present the a case of tongue ischemia and partial necrosis due to oral endotracheal intubation, specifically with a nerve monitoring endotracheal tube, which has not previously been reported in the English literature. Tongue necrosis due to compression by an endotracheal tube during prolonged intubation is unusual, however surgeons, anesthesiologists and those involved in the care of intubated patients should consider the potential for this complication when orienting and securing endotracheal tubes. CONCLUSIONS This unique case of tongue necrosis underscores the importance of proper endotracheal tube positioning during prolonged intubation.

Large jugular bulb abnormalities involving the middle ear.

Objective Jugular bulb abnormalities (JBA), such as jugular bulb diverticula (JBD) or large jugular bulbs, rarely present in the middle ear. We review a large series of temporal bone histopathologic specimens to determine their prevalence and present a series of cases of JB abnormalities involving the middle ear (JBME) that shed light on the probable mechanism for their development. Patients 1,579 unique temporal bone specimens and individuals with radiographically-diagnosed JBME. Intervention Histopathologic and clinical review of temporal bone specimens and patient presentations, radiographic findings, treatments and outcomes. Main Outcome Measure Shared characteristics of JBME. Results There were 17 cases of JBME in 1,579 temporal bone (1.1%), of which, 15 involved the inferior mesotympanum below the level of the round window membrane (RWM), whereas 2 encroached upon the RWM or ossicles. In addition, 4 clinical cases of large JBME extending above RWM were encountered; these occurred in both sexes with ages spanning from young to old (7–66 yr). They presented with conductive hearing loss (n = 3), ear canal mass (n = 1), and intraoperative bleeding (n = 1). Radiologically, they had multiple diverticula of the JB on the side with JBME, with 1 patient demonstrating growth on serial imaging studies. All patients who underwent additional imaging had marked hypoplastic contralateral transverse sinus. Conclusion JBME abnormalities are rare, present across age groups, and may demonstrate serial growth over time. They are usually associated with multiple other diverticula within the same JB. Our clinical series suggests that JBME’s development and uniquely aggressive behavior results from contralateral transverse sinus outflow obstruction.

Neurophysiology and Clinical Implications of the Laryngeal Adductor Reflex

The laryngeal adductor reflex (LAR) is an involuntary protective response to stimuli in the larynx. The superior laryngeal nerve acts as the afferent limb and the recurrent laryngeal nerve as the efferent limb of this reflex, which is modulated by the central nervous system. Perhaps the most clinically significant application of the LAR is its use in laryngopharyngeal (LP) sensory discrimination testing. Importantly, aberrations in the LAR may predict dysphagia or portend clinical phenotypes of chronic cough, vocal cord dysfunction or pediatric apneas. LP sensation is a potential target for interventions addressing the aforementioned conditions though currently remains an area of active investigation.

A cell culture model of facial palsy resulting from reactivation of latent herpes simplex type 1.

Hypothesis Reactivation of herpes simplex virus type 1 (HSV-1) in geniculate ganglion neurons (GGNs) is an etiologic mechanism of Bell’s palsy (BP) and delayed facial palsy (DFP) after otologic surgery. Background Several clinical studies, including temporal bone studies, antibody, titers, and intraoperative studies, suggest that reactivation of HSV-1 from latently infected GGNs may lead to both BP and DFP. However, it is difficult to study these processes in humans or live animals. Methods Primary cultures of GGNs were latently infected with Patton strain HSV-1 expressing a green fluorescent protein–late lytic gene chimera. Four days later, these cultures were treated with trichostatin A (TSA), a known chemical reactivator of HSV-1 in other neurons. Cultures were monitored daily by fluorescent microscopy. Titers of media from lytic, latent, and latent/TSA treated GGN cultures were obtained using plaque assays on Vero cells. RNA was harvested from latently infected GGN cultures and examined for the presence of viral transcripts using reverse transcription–polymerase chain reaction. Results Latently infected GGN cultures displayed latency-associated transcripts only, whereas lytically infected and reactivated latent cultures produced other viral transcripts, as well. The GGN cultures displayed a reactivation rate of 65% after treatment with TSA. Media from latently infected cultures contained no detectable infectious HSV-1, whereas infectious virus was observed in both lytically and latently infected/TSA–treated culture media. Conclusion We have shown that cultured GGNs can be latently infected with HSV-1, and HSV-1 in these latently infected neurons can be reactivated using TSA, yielding infectious virus. These results have implications for the cause of both BP and DFP.

The effects of dexamethasone and acyclovir on a cell culture model of delayed facial palsy

Hypothesis Pretreatment with antiherpetic medications and steroids decreases likelihood of development of delayed facial paralysis (DFP) after otologic surgery. Background Heat-induced reactivation of herpes simplex virus type 1 (HSV1) in geniculate ganglion neurons (GGNs) is thought to cause of DFP after otologic surgery. Antiherpetic medications and dexamethasone are used to treat DFP. Pretreatment with these medications has been proposed to prevent development of DFP. Methods Rat GGN cultures were latently infected with HSV1 expressing a lytic protein-GFP chimera. Cultures were divided into pretreatment groups receiving acyclovir (ACV), acyclovir-plus-dexamethasone (ACV + DEX), dexamethasone alone (DEX), or untreated media (control). After pretreatment, all cultures were heated 43°C for 2 hours. Cultures were monitored daily for reactivation with fluorescent microscopy. Viral titers were determined from culture media. Results Heating cultures to 43°C for 2 hours leads to HSV1 reactivation and production of infectious virus particles (59 ± 6.8%); heating cultures to 41°C showed a more variable frequency of reactivation (60 ± 40%), compared with baseline rates of 14.4 ± 5%. Cultures pretreated with ACV showed lower reactivation rates (ACV = 3.7%, ACV + DEX = 1.04%) compared with 44% for DEX alone. Viral titers were lowest for cultures treated with ACV or ACV + DEX. Conclusion GGN cultures harboring latent HSV1 infection reactivate when exposed to increased temperatures that can occur during otologic surgery. Pretreatment with ACV before heat provides prophylaxis against heat-induced HSV reactivation, whereas DEX alone is associated with higher viral reactivation rates. This study provides evidence supporting the use of prophylactic antivirals for otologic surgeries associated with high rates of DFP.

Histological changes in vocal fold growth and aging.

Purpose of reviewSophisticated descriptions of the highly specialized vocal fold microarchitecture have been available for over three decades, but how this anatomy evolves with growth and aging remains an area of active investigation and, at times, a source of controversy. As our aging population expands and interest in pediatric voice disorders blossoms, it is timely to consider our contemporary understanding of evolving vocal fold histology and its implications for voice production. Recent findingsNovel applications of existing and emerging biotechnology, development of animal models and skillful use of human specimens have afforded greater insights into the histologic vocal fold changes seen throughout the lifespan in health and disease. SummaryBurgeoning knowledge has laid the foundation for more comprehensive models of vocal fold histology and has led to the development of innovative therapies for challenging voice disorders.