Michael J. Pitman

Office-based 532-Nanometer pulsed potassium-titanyl-phosphate laser for marsupialization of laryngeal and vallecular mucoceles.

Many laryngopharyngeal disorders are effectively managed in the office. Herein, an in‐office method utilizing the 532‐nm potassium‐titanyl‐phosphate (KTP) laser for the treatment of benign laryngeal and vallecular mucoceles is described.

Vibratory function and healing outcomes after small intestinal submucosa biomaterial implantation for chronic vocal fold scar

Vocal fold scar is a major cause of dysphonia, and optimal treatments do not currently exist. Small intestinal submucosa (SIS) is a biomaterial developed for the treatment of a variety of pathologies. The purpose of this study was to investigate the effects of SIS implantation on tissue remodeling in scarred vocal folds using routine staining, immunohistochemistry, and high‐speed videoendoscopy (HSV).

Serial in-office laser treatment of vocal fold leukoplakia: Disease control and voice outcomes

Although vocal fold (VF) leukoplakia is commonly treated with in‐office laser, there is no data on its long‐term effectiveness. This study hypothesizes that VF leukoplakia treated by serial in‐office laser results in long‐term disease control with maintenance of voice and minimal morbidity.

Temporalis Fascia Transplantation for Sulcus Vocalis and Vocal Fold Scar: Long-Term Outcomes:

Objective: Sulcus vocalis and vocal fold scar involve derangement of the superficial lamina propria of the vocal fold, which results in significant dysphonia. Many options exist for treatment, most of which have unsatisfactory and unpredictable outcomes. Autologous transplantation of temporalis fascia into the vocal fold (ATFV) has the potential to be a better treatment option, but long-term outcomes have not been well studied. Methods: Retrospective chart review and patient survey. Twenty-one patients diagnosed with vocal fold scar or sulcus vocalis and treated with ATFV with at least 1-year follow-up were included. Voice Handicap Index 10 (VHI-10) questionnaires were collected preoperatively and 6 months postoperatively. Patients were reached at the time of the study to complete another VHI-10 and a Likert scale survey. Results: The mean decrease in VHI-10 scores between preoperation and 6 months postoperation was 8.35 (P < .001). From preoperation to the time of the study (average 44 months; range, 12-72 months), the VHI decreased 13.53 (P < .001). Eighty-eight percent of patients reported they would recommend this surgery to others with the same diagnosis. Only 1 minor self-limited complication occurred. Conclusion: Autologous transplantation of temporalis fascia into the vocal fold for the treatment of vocal fold scar and sulcus vocalis is a safe surgery with good long-term outcomes and high patient satisfaction.

Contralateral Vocal Fold Reactive Lesions Nomenclature, Treatment Choice, and Outcome

Objective Contralateral reactive lesions (RLs) represent a distinct entity among benign bilateral vocal fold (VF) lesions. Lack of uniform nomenclature and a myriad of surgical options have hampered attempts to develop treatment guidelines. The objective of this study is to better define RLs and their prognosis, through the development of a standard nomenclature, with an aim to guide treatment and delineate the role of phonosurgery. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Analysis was performed on patients with Current Procedural Terminology code 31545. Operative reports with a primary lesion and contralateral RL were included. Outcomes included the Voice Handicap Index–10 (VHI-10) and GRBAS (grade, roughness, breathiness, asthenia, and strain) scale, lesion persistence/recurrence, mucosal wave, and edge character based on blinded videostroboscopy review. Results A nomenclature was developed based on intraoperative RLs (n = 30), defined by lesion consistency (fibrous or polypoid) and relationship to normal VF edge (gradual or steep). Reactive lesion treatment included no intervention, excision, potassium titanyl phosphate laser, steroid injection, or a combination thereof. Observations included the following: inconsistent treatment modalities were employed, excision of RLs did not yield better outcomes, fibrous RLs were more likely to persist and polypoid lesions more likely to recur, gradual lesions were more likely to remain disease free, and most treatments showed improved mucosal wave, VHI-10, and GRBAS. Conclusions Reactive lesions have not been well classified, and treatments are based on subjective intraoperative decision making with unpredictable outcomes. The nomenclature proposed will allow for a better definition of the RL and provide a framework for future research to identify optimal treatment.

Prospective multi-institutional transnasal esophagoscopy: Predictors of a change in management.

To evaluate clinical indications and endoscopic findings for patients undergoing transnasal esophagoscopy (TNE).

Spasmodic Dysphonia in Hereditary Spastic Paraplegia Type 7

Hereditary spastic paraplegia (HSP) is a heterogeneous group of inherited disorders characterized by lower limb predominant spasticity with or without weakness. HSP can be classified as uncomplicated or complicated based on the presence of other neurological or systemic features. HSP7 is an autosomal recessive disorder caused by a mutation in the SPG7 (paraplegin) gene on chromosome 16q. It accounts for 4–12% of autosomal recessive HSP. Onset is generally in adulthood; however, it can range from 11 to 72 years. HSP7 is usually complicated (69%), with cerebellar ataxia as the most frequent additional feature (57%). Other features include optic atrophy, ptosis, vertical supranuclear gaze palsy, hearing loss, bladder dysfunction, sensorimotor polyneuropathy, cognitive impairment, and dystonia. Dystonia is rarely seen in HSP7; to date only cervical dystonia has been reported. We describe a case of a 26-year-old man who presented with a progressive gait disorder and abnormal speech. At age 17, he began toe walking. Over time, his gait developed a limping, unsteady quality with leg stiffness and falls. At age 25, his voice became progressively hoarse and strangulated with dysphagia. He is of Pakistani origin and his parents are first cousins. His paternal uncle has intellectual disability; otherwise, there is no family history of neurological disorders. Examination revealed spastic tone in the legs and normal strength throughout. He had diffuse hyperreflexia in the extremities with bilateral Hoffmann’s reflexes, ankle clonus, and upgoing toes. He had pronounced foot plantar flexion when walking. His gait did not change when running or walking backwards. His voice had a strained quality with occasional breaks on voiced phonation. His voice quality normalized when laughing and the strain and breaks resolved with whispering (Video S1). A brain MRI was normal. A cervical spine MRI revealed mild cord flattening. Nerve conduction studies and electromyography were normal. A laryngo-videostroboscopy revealed normal laryngeal function with occasional spasm with connected speech, consistent with adductor spasmodic dysphonia. Trio whole exome sequencing (WES) was performed after written informed consent was obtained through an institutional review and board-approved research study. WES detected a homozygous, previously reported pathogenic nonsense variant p.L78X (c.233T>A) in the SPG7 gene. Clinical Sanger sequencing confirmed the presence of the homozygous variant in the patient. One report suggested that the L78X mutation might have a dominant effect; however, a second pathogenic variant could not be excluded in that patient. Our patient’s parents, both of whom were carriers of the L78X variant, had no subjective complaints, though neither was examined. He is being treated with botulinum toxin injections to the thyroarytenoid muscles for adductor spasmodic dysphonia and to the bilateral gastrocnemius for gait dysfunction, thought to be a combination of spasticity and dystonia. The injections and voice therapy improved his voice. We believe this is the first description of spasmodic dysphonia, a focal dystonia of the laryngeal muscles, in association with a SPG7 mutation. Since spasmodic dysphonia responds well to botulinum toxin injections, it is important to distinguish between it and other types of dysarthria (cerebellar and spastic), which combined are present in over one-third of HSP7 cases.

Investigation of the presence of HPV on KTP laser fibers following KTP laser treatment of papilloma: RRP and KTP Laser Fiber

Recurrent respiratory papillomatosis is often treated with in‐office laser procedures using a potassium titanyl phosphate (KTP) laser transmitted through a laser fiber. Although effective, this procedure has notable downsides, including the possibility of transmitting human papillomavirus (HPV) in the smoke plume and the high cost of these single‐use fibers. The objective of this study is to determine if HPV can be detected on a laser fiber after use, with or without sterilization.

Influence of Netrin-1 on Reinnervation of Laryngeal Muscles Following Recurrent Laryngeal Nerve Injury

Following recurrent laryngeal nerve (RLN) injury, recovery results in poor functional restitution of the paralyzed vocal fold. Netrin-1 has been found to be upregulated in the rat posterior cricoarytenoid muscle (PCA) during nerve regeneration. We evaluated the effect of ectopic Netrin-1 in the PCA during RLN reinnervation. The right RLN was transected and Netrin-1 was injected into the PCA (2.5, 5, 10, 15, 20μg/ml). At 7 days post injury fluorescent retrograde tracer was injected into the PCA and Thyroarytenoid (TA) muscles. At 9 days tissues were harvested. Immunostaining showed reinnervation patterns in the laryngeal muscles and labelled motoneurons in the nucleus ambiguus. Lower concentrations of Netrin-1 (2.5 and 5μg/ml) showed no significant changes in laryngeal muscles reinnervation. Higher concentrations of Netrin-1 significantly reduced motor end plate innervation. The most effective dose was 10μg/ml showing reduced number of innervated motor endplates in the PCA. The somatotopic organization of the nucleus ambiguus was altered in all concentrations of Netrin-1 injection. These findings indicate that injection of Netrin-1 into the PCA changes the reinnervation pattern of the RLN.

Postoperative Management of Superior Laryngeal Nerve Paralysis

Superior laryngeal nerve (SLN) injury can cause many symptoms, the most common complaints being the inability to access the upper vocal range, difficulty projecting the voice, and vocal fatigue. Treatment with voice therapy has some limited utility in these patients. Its greatest benefit may be in preventing or treating muscle tension dysphonia, developed in compensation of the SLN injury. Numerous static and one theoretical dynamic procedure have been proposed. These procedures can help augment the cricothyroid distance. These procedures may elevate the modal pitch of the voice with varying success, with only a few patients appreciating improvement in their pitch modulation. The most promising technique described is a muscle-nerve-muscle anastomosis with a neural conduit. This allows the nerve of the healthy cricothyroid muscle to innervate the paralyzed cricothyroid and ultimately leads to simultaneous bilateral muscle contraction. Although patients undergoing this procedure have shown some benefit, it has been reported only in patients who had additional procedures for voice restoration. This results in multiple confounding variables and the true utility of the procedure is unknown. Further research is needed to help identify an optimal treatment for SLN paralysis. Due to the dearth of successful treatment options, prevention of SLN injury should be emphasized.