Recurrent Laryngeal Nerve Monitoring: Nuts and Bolts

Intraoperative neuromonitoring (IONM) of the laryngeal nerves has become an important tool for neck endocrine surgery. In this article, the authors review the current evidence behind its use in neck endocrine procedures. The subtypes of IONM, including intermittent IONM, continuous vagal IONM (vagal-CIONM), and laryngeal adductor reflex CIONM, will be discussed. Finally, the authors review recent advances in IONM, and how standardization of outcomes reporting will help minimise conjecture regarding the usefulness of IONM.

Radiofrequency Ablation for Benign Thyroid Nodules

CONTEXT

Thermal ablative techniques of the thyroid have recently gained clinical traction as a therapeutic alternative that provides symptomatic relief and confers potential advantages over surgery. A truly multidisciplinary technique, thyroid ablation is currently performed by endocrinologists, interventional radiologists, otolaryngologists, and endocrine surgeons. Radiofrequency ablation (RFA), specifically, has seen widespread adoption, particularly in the treatment of benign thyroid nodules. This review summarizes current evidence on the application of RFA in benign thyroid nodules, and provides a start to finish overview of procedural preparation, performance, and outcomes.

EVIDENCE ACQUISITION

A narrative review of literature focusing on RFA in the treatment of benign nodular disease was performed. Emphasis was placed on consensus statements, best practice guidelines, multi-institutional studies, and systematic reviews to summarize key concepts in candidacy, techniques, expectations, and outcomes.

FINDINGS

RFA is increasingly recognized as a first-line treatment strategy in the management of symptomatic nonfunctional benign thyroid nodules. It can also be considered in functional thyroid nodules with small volumes or in patients ineligible for surgery. A targeted and efficacious technique, RFA results in gradual volume reduction that preserves the function of the surrounding thyroid parenchyma. Proper procedural technique, proficiency in ultrasound, and experience in ultrasound-guided procedures are instrumental to maintaining low complication rates and achieving successful ablation outcomes.

CONCLUSIONS

In pursuit of a personalized approach, physicians across disciplines are increasingly incorporating RFA into their treatment algorithms, most commonly for benign nodules. As with any intervention, thoughtful selection and implementation ensure a safe procedure with optimal patient benefit.

General Principles for the Safe Performance, Training, and Adoption of Ablation Techniques for Benign Thyroid Nodules: An American Thyroid Association Statement

Background: The primary goal of this interdisciplinary consensus statement is to provide a framework for the safe adoption and implementation of ablation technologies for benign thyroid nodules. Summary: This consensus statement is organized around three key themes: (1) safety of ablation techniques and their implementation, (2) optimal skillset criteria for proceduralists performing ablative procedures, and (3) defining expectations of success for this treatment option given its unique risks and benefits. Ablation safety considerations in pre-procedural, peri-procedural, and post-procedural settings are discussed, including clinical factors related to patient selection and counseling, anesthetic and technical considerations to optimize patient safety, peri-procedural risk mitigation strategies, post-procedural complication management, and safe follow-up practices. Prior training, knowledge, and steps that should be considered by any physician who desires to incorporate thyroid nodule ablation into their practice are defined and discussed. Examples of successful clinical practice implementation models of this emerging technology are provided. Conclusions: Thyroid ablative procedures provide valid alternative treatment strategies to conventional surgical management for a subset of patients with symptomatic benign thyroid nodules. Careful patient and nodule selection are critical to the success of these procedures as is extensive pre-procedural patient counseling. Although these emerging technologies hold great promise, they are not without risk and require the development of a unique skillset and environment for optimal, safe performance and consistent outcomes.

Continuous intraoperative neuromonitoring of the recurrent laryngeal nerve by eliciting the laryngeal adductor reflex (LAR-CIONM)

The laryngeal adductor reflex (LAR) is a life-sustaining airway protective mechanism that serves to shield the lower airways from inhaled foreign bodies. Over the past half century, the LAR has been extensively investigated and its dysfunction has been linked to far-ranging pathologies, from dysphagia to sudden infant death syndrome. Over the past 6 years, specific electromyographic waves in the LAR response have been used to devise a methodology for monitoring the vagus and recurrently laryngeal nerves during surgical procedures. This methodology involves continuous intraoperative neuromonitoring of the laryngeal adductor reflex and isthus termed 'LAR-CIONM'. In this review paper, the physiology of the LAR will be summarized as it relates to LAR-CIONM and the technique of LAR-CIONM will be described. Applications of this technique and published outcomes of LAR-CIONM will be highlighted.

Radiofrequency ablation (RFA) compared to observation for benign thyroid nodules: emerging considerations for judicious use

PURPOSE OF REVIEW

Radiofrequency ablation (RFA) for thyroid nodules confers tangible advantages over surgery, which include promising outcomes in the context of a minimally invasive procedure and the functional benefits of organ preservation. However, the ubiquity of benign nodules worldwide may spur the risk of misuse in cases where there is negligible gain over conventional surveillance. This review summarizes new developments in RFA and examines its judicious utilization in benign nodules.

RECENT FINDINGS

RFA appears to be safe and effective for addressing compressive or cosmetic issues caused by benign functional and nonfunctional thyroid nodules. Volume regression occurs over 12 months, with some cases requiring multiple staged RFA procedures to achieve adequate shrinkage or to address regrowth. Complication rates including recurrent laryngeal nerve injury are reportedly low and are mitigated by strategic technical maneuvers, training, and experience. Consensus guidelines across international societies have emerged to better define appropriate patient candidates. Although association of overuse in analogous disciplines has been well established, no evidence of misuse in thyroid RFA has been described thus far.

SUMMARY

Compelling multi-institutional data support RFA as first-line treatment for select benign thyroid nodules. Defining the nuances of patient selection and long-term surveillance are necessary to substantiate current observed results. Given the high incidence of thyroid nodules worldwide, it is important to emphasize that the majority of benign nodules will not require any intervention. Thorough consideration and careful implementation of recommended guidelines will hopefully lead to measurable benefit and avoid financial misuse.

Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring

BACKGROUND

Intraoperative neuromonitoring (IONM) techniques have evolved over the past decade into intermittent IONM (I-IONM) and continuous IONM (C-IONM) modes of application. Despite many prior publications on both types of IONM, there remains uncertainty about what outcomes should be measured for each form of IONM. The primary objective of this paper is to define categories of benefit for I-IONM/C-IONM and to clarify and standardize their reporting outcomes.

METHODS

Expert review consensus statement utilizing modified Delphi methodology.

RESULTS

I-IONM provides diagnosis, classification, and prevention of nerve injury through accurate and early nerve identification. C-IONM provides real-time information on nerve functional integrity and thus may prevent some types of nerve injury but cannot assist in nerve localization. Sudden mechanisms of nerve injury cannot be predicted or prevented by either technique.

CONCLUSIONS

I-IONM and C-IONM are complementary techniques. Future studies evaluating the utility of IONM should focus on outcomes that are appropriate to the type of IONM being utilized.

A comprehensive review of interventional ablation techniques for the management of thyroid nodules and metastatic lymph nodes

Thyroidectomy remains the gold standard treatment for benign, symptomatic, or enlarging thyroid nodules, malignant nodules, and metastatic lymph node disease. However, in the past 2 decades, image-guided interventional techniques have emerged as promising alternative treatments for these conditions. Percutaneous ethanol ablation is now an accepted first-line treatment for recurring cystic thyroid nodules. Thermal ablation techniques such as high-intensity focused ultrasound, laser ablation, radiofrequency ablation, and microwave ablation have shown efficacy in producing a nodular volume reduction of greater than 50% that is maintained for several years with resolution of local compressive symptoms. There is also increasing evidence that these techniques can effectively treat papillary thyroid microcarcinomas and recurrent metastatic lymph node disease. Because these interventional ablation techniques are performed safely in an outpatient setting, are well tolerated, and the risk for needing thyroid hormone supplementation is negligible, they are becoming a popular alternative treatment to surgical resection. In this comprehensive review, we discuss each of these percutaneous interventions: the devices and techniques, the advantages and disadvantages of each energy, and summarize the outcomes published in the literature.

The short-latency R1 response of the electrical laryngeal adductor reflex contributes to airway protection by initiating glottic closure

OBJECTIVE

The fundamental role of the short-latency (R1) laryngeal adductor reflex (LAR) response remains unclear with conflicting reports in the literature. This study's primary aim was to objectively determine whether the bilateral R1 response, which was elicited by electrical stimulation of the supraglottic mucosa, triggered bilateral glottis closure.

METHODS

Video recording of the LAR in a prospective case series of patients undergoing trans-oral rigid laryngoscopy. The LAR was elicited by electrical stimulation of supraglottic mucosa. The LAR R1 and long-latency (R2) responses in laryngeal adductor musculature were correlated with mechanical vocal fold (VF) adduction in a time-locked manner. A high-speed camera recording 1057 frames per second was used to determine where in the LAR contractile closure the electrical R1 component occurred.

RESULTS

Five patients were prospectively enrolled. The R1 response was present in all trials for all patients. The R2 response was recorded in four patients (80%). As assessed by the latency of the R1 response, electrical activation of the adductor muscles always preceded the mechanical onset of VF movement. VF adduction began near the middle of the R1 response in all trials for all patients. The R2 response of the LAR began after visible VF adduction for all patients.

CONCLUSIONS

This study provides the first objective evidence that the bilateral R1 response of the electrically elicited LAR is the electrical event that initiates reflex airway closure.

SIGNIFICANCE

These results suggest that under total intravenous anesthesia, the larynx preserves its capacity to elicit a LAR, thereby maintaining some protective functions that can prevent airway penetration.

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement

BACKGROUND

This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking.

METHODS

An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements.

CONCLUSIONS

This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

Bleomycin sclerotherapy following doxycycline lavage in the treatment of ranulas: A retrospective analysis and review of the literature

OBJECTIVE

A ranula is a mucus-filled salivary pseudocyst that forms in the floor of the mouth, commonly arising from the sublingual or submandibular salivary glands following obstruction or trauma. Complete excision of the injured gland and removal of the cyst content is the first-choice therapy, but has the potential for complications related to injury to nearby structures. As such, minimally invasive approaches such as percutaneous sclerotherapy have been investigated. We aim to contribute to the literature by assessing the efficacy and safety of our technique through our experience with 18 patients over the last decade.

METHODS

This retrospective study evaluated 18 patients with intraoral and plunging ranulas treated by percutaneous bleomycin ablation. The primary endpoint was the treatment result. Secondary endpoints included bleomycin dosage and complications.

RESULTS

The study evaluated 12 males and six females with a median age of 23.5 years (range 13-39 years). At a final follow-up of at least 2 months (6.5±5.5 months), four patients demonstrated complete response (22%) and 14 patients demonstrated residual presence, recurrence, or regrowth of the lesion (78%). There were no statistically significant associations between outcomes and history of prior treatment, number of treatments, and size or type of ranula. No complications were noted.

CONCLUSIONS

Our findings indicate that bleomycin, while safe for use in various head and neck malformations, is of limited utility in ranula therapy when the offending gland is not addressed primarily.

Continuous neuromonitoring during radiofrequency ablation of benign thyroid nodules provides objective evidence of laryngeal nerve safety

INTRODUCTION

The recurrent laryngeal nerves(RLN) run immediately posterior to the thyroid capsule and could be injured during thyroid radiofrequency ablation(RFA). This study assesses whether RLN functional integrity is altered during RFA using continuous intraoperative neuromonitoring(CIONM).

METHODS

Prospective case series of twenty nodules treated with RFA under general anesthesia utilizing the laryngeal adductor reflex(LAR) for CIONM.

RESULTS

Thirteen nodules abutted the posterior thyroid capsule and 'danger triangle' for RLN injury. The ablative field did not breach the posterior capsule; 40 W was the maximal power used adjacent to the capsule. No patient experienced significant LAR amplitude alterations. Pre and postoperative laryngoscopy and voice assessments were comparable. At 12 months' median follow-up, no patient displayed posterior nodule regrowth.

CONCLUSIONS

This prospective case series supports the premise that benign nodule RFA is safe with regards to RLN functional integrity provided the posterior capsule is not breached by the ablation zone and posterior power is ≤ 40 W.

Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment

BACKGROUND

Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group.

METHODS

A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach.

RESULTS

Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery.

CONCLUSION

After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.

Continuous Laryngeal Adductor Reflex Versus Intermittent Nerve Monitoring in Neck Endocrine Surgery

OBJECTIVE

Intraoperative neuromonitoring (IONM) techniques aim to identify and potentially prevent nerve injury during surgeries. Prior studies into the efficacy of recurrent laryngeal nerve (RLN) IONM convey mixed results, with some claiming equivalence between IONM and no monitoring at all. The goal of the current study was to compare continuous RLN monitoring using the laryngeal adductor reflex (LAR) to intermittent RLN monitoring (intermittent IONM) to determine whether continuous monitoring reduces the incidence of intraoperative RLN injury during neck endocrine surgeries.

METHODS

In this observational, historical case-control study, a historical cohort of patients monitored with intermittent-IONM (group 1, n = 130) were compared to prospectively collected data from consecutive nerves-at-risk monitored continuously with the LAR (LAR-CIONM, group 2, n = 205), at a single center by a single surgeon. The test benefit ratio and relative risk reduction (RRR) for LAR-CIONM over intermittent IONM were calculated.

RESULTS

For group 1, nine nerves at risk exhibited intraoperative LOS with transient postoperative vocal fold (VF) hypomobility (n = 2) or immobility (VFI, n = 7). For group 2, two nerves at risk (0.98%) had sudden intraoperative LAR LOS following bipolar cautery, resulting in postoperative transient VFI (P = .004). In each group, there was one case of permanent postoperative VFI. The test benefit rate ratio for LAR-CIONM demonstrated a dramatic effect at 5.23, with an RRR of 81.0%.

CONCLUSION

LAR-CIONM significantly decreased rates of postoperative transient VF paralysis and paresis over intermittent IONM alone (P = .004). Surgeons should be aware of the benefits and limitations of intermittent IONM versus CIONM. Intermittent IONM, although useful in nerve mapping and intraoperative decision making, has minimal benefit for the prevention of nerve injury, whereas CIONM can potentially reduce nerve injury rates and improve patient outcomes.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:230-236, 2021.

Assessment of Gender Differences in Perceptions of Work-Life Integration Among Head and Neck Surgeons

Importance

The factors that contribute to gender discrepancies among attending head and neck surgeons have yet to be fully characterized.

Objective

To evaluate the association of gender difference with the perceived quality of life of head and neck oncological surgeons.

Design, Setting, and Participants

Following approval from the American Head and Neck Society (AHNS) review board, a web-based survey study of 37 questions, mainly assessing daily lifestyle and quality of life, was sent to the entire membership.

Main Outcomes and Measures

The main outcome assessed was perceived quality of life among female and male surgeons.

Results

A total of 261 members (13.0%) responded, 71 women (27.2%) and 190 men (72.8%). In all, 66 female (92.5%) and 152 male (80%) surgeons worked at an academic institution. A greater percentage of women were at the associate professor level than men (20/64 [31%] vs 37/152 [24%]; difference, 6.9%; 95% CI, -5.6% to 20.5%) and a greater percentage of men were at the professor level than women (72/152 [47%] vs 18/64 [28%]; difference, 19%; 95% CI, 4.9% to 31.6%). This discrepancy was evident in administrative roles as well, with 4 female (6.2%) vs 23 male (17.6%) department chairs (difference, 11.3%; 95% CI, 0.9%-19.6%). Of the 71 women, 18 (25%) were not in a long-term relationship or were divorced, as opposed to 6 (3.2%) men (difference, 22%; 95% CI, 12.8%-33.5%). Women had a mean (median) 1.18 (1) children, whereas men had 2.29 (2) children. Mean age that participating women had their first child was 35.1 years, whereas the man age for men was 31.9 years. Overall, 117 men (61.9%) and 45 women (67.2%) found their family time limited compared with other otolaryngological subspecialties. Despite these results, 101 men (53.4%) vs 37 women (55.2%) stated that they had a good work-life balance. Six women vs 8 men indicated they would choose a different subspecialty if they could.

Conclusions and Relevance

Despite improvements in work hours and gender balance in residency programs, discrepancy in the number of female surgeons with senior academic rankings continues. However, female and male head and neck surgeons appear equally content with their subspecialty choice.

Outcomes of Patients With Hypothyroidism and COVID-19: A Retrospective Cohort Study

Coronavirus diseases (COVID-19) is associated with high rates of morbidity and mortality and worse outcomes have been reported for various morbidities. The impact of pre-existing hypothyroidism on COVID-19 outcomes remains unknown. The aim of the present study was to identify a possible association between hypothyroidism and outcomes related to COVID-19 including hospitalization, need for mechanical ventilation, and all-cause mortality. All patients with a laboratory confirmed COVID-19 diagnosis in March 2020 in a large New York City health system were reviewed. Of the 3703 COVID-19 positive patients included in present study, 251 patients (6.8%) had pre-existing hypothyroidism and received thyroid hormone therapy. Hypothyroidism was not associated with increased risk of hospitalization [Adjusted Odds Ratio (OR_adj): 1.23 (95% Confidence Interval (CI): 0.88- 1.70)], mechanical ventilation [OR_adj: 1.17 (95% CI: 0.81-1.69)] nor death [OR_adj: 1.07 (95% CI: 0.75-1.54)]. This study provides insight into the role of hypothyroidism on the outcomes of COVID-19 positive patients, indicating that no additional precautions or consultations are needed. However, future research into the potential complications of COVID-19 on the thyroid gland and function is warranted.

Laryngeal adductor reflex hyperexcitability may predict permanent vocal fold paralysis

Laryngeal adductor reflex-continuous intraoperative neuromonitoring (LAR-CIONM) is a novel method of continuous intraoperative neuromonitoring. In contrast to other vagal nerve monitoring techniques, which elicit a laryngeal compound muscle action potential, LAR-CIONM elicits a laryngeal reflex response (LAR). In 300 nerves at risk monitored with LAR-CIONM, two patients have had postoperative permanent vocal fold immobility (VFI). Both patients exhibited a significant LAR amplitude increase prior to complete loss of signal. No other patients have exhibited LAR hyperexcitability. If confirmed in a larger sample, this represents the first time that a vagal intraoperative neuromonitoring technique can distinguish transient from permanent VFI, which could improve patient outcomes. Laryngoscope, 2019 Laryngoscope, 130:E625-E627, 2020.

Continuous Vagal Neuromonitoring Using the Laryngeal Adductor Reflex: Can Preincision Dyssynchrony Predict Intraoperative Nerve Behavior?

Objective

The laryngeal adductor reflex (LAR) is an airway-protective response triggered by sensory laryngeal receptors and resulting in bilateral vocal fold adduction. The normal morphology of the early R1 response resembles that of the compound muscle action potential (CMAP). However, in a small subset of patients, the morphology is dyssynchronous with multiple peaks. This study investigates whether preoperative LAR dyssynchrony predicts intraoperative nerve behavior during thyroid surgeries.

Study Design

Retrospective case-control study.

Setting

US academic health center.

Subjects and Methods

Opening and closing LAR waveforms from 200 patients with normal preoperative laryngeal examinations monitored continuously during thyroid surgeries using the LAR were analyzed. Area under the curve (AUC) and number of “events” during surgery (defined as any transient decline in AUC >50% baseline) were determined for patients who demonstrated opening dyssynchronous LAR traces compared to demographically matched controls.

Results

Six patients had opening dyssynchronous LAR traces. These patients had significantly greater declines in R1 AUC than demographically matched patients with opening synchronized R1 traces ( P = .007). Upon thyroid removal, 1 patient converted from a dyssynchronous to synchronous trace.

Conclusions

Preincision dyssynchronous LAR waveforms may indicate subclinical, potentially reversible, neuropathy of the recurrent laryngeal nerve (RLN) and predict intraoperative RLN behavior. Preincision knowledge of R1 dyssynchrony can facilitate surgical planning as such patients may glean particular benefit from continuous intraoperative nerve monitoring, frequent tissue relaxation, and saline irrigation as means to minimize nerve stress intraoperatively.

International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer-incorporation of surgical, laryngeal, and neural electrophysiologic data

The purpose of this publication was to inform surgeons as to the modern state-of-the-art evidence-based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real-time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision-making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal. Level of Evidence: 5 Laryngoscope, 128:S18-S27, 2018.

Noninvasive, tube-based, continuous vagal nerve monitoring using the laryngeal adductor reflex: Feasibility study of 134 nerves at risk

BACKGROUND

Continuous vagal intraoperative neuromonitoring (IONM) currently requires placement of a vagal nerve electrode. Herein, we present data from 100 patients (134 nerves-at-risk) monitored continuously during neck endocrine surgeries using a noninvasive, new methodology that solely utilizes endotracheal tube electrodes to simultaneously stimulate laryngeal mucosa and record a laryngeal adductor reflex continuous IONM (LAR-C-IONM) response.

METHODS

The laryngeal adductor reflex (LAR) was elicited by electrical laryngeal mucosal stimulation on the side contralateral to the operative field using endotracheal tube electrodes. All patients completed preoperative and postoperative laryngeal and voice examinations.

RESULTS

One hundred patients (134 nerves-at-risk) were included. Significantly more nerves-at-risk with an LAR opening to closing amplitude decrement >60% or with absolute closing amplitude <100 μV had postoperative vocal fold paralysis (P < .001). The LAR-C-IONM was highly sensitive to recurrent laryngeal nerve (RLN) stretch or compression.

CONCLUSION

The LAR-C-IONM is a promising new way to perform continuous vagal monitoring that requires no equipment other than an electromyography (EMG) endotracheal tube and is undergoing further, large-scale evaluation.

Surgical management of the recurrent laryngeal nerve in thyroidectomy: American Head and Neck Society Consensus Statement

"I have noticed in operations of this kind, which I have seen performed by others upon the living, and in a number of excisions, which I have myself performed on the dead body, that most of the difficulty in the separation of the tumor has occurred in the region of these ligaments…. This difficulty, I believe, to be a very frequent source of that accident, which so commonly occurs in removal of goiter, I mean division of the recurrent laryngeal nerve." Sir James Berry (1887).

Adductor focal laryngeal Dystonia: correlation between clinicians' ratings and subjects' perception of Dysphonia

Background

Although considerable research has focused on the etiology and symptomology of adductor focal laryngeal dystonia (AD-FLD), little is known about the correlation between clinicians’ ratings and patients’ perception of this voice disturbance. This study has five objectives: first, to determine if there is a relationship between subjects’ symptom-severity and its impact on their quality of life; to compare clinicians’ ratings with subjects’ perception of the individual characteristics and severity of AD-FLD; to document the subjects’ perception of changes in dysphonia since diagnosis; to record the frequency of voice arrest during connected speech; and, finally, to calculate inter-clinician reliability based on results from the Unified Spasmodic Dysphonia Rating Scale (USDRS) (Stewart et al, J Voice 1195-10, 1997).

Methods

Sixty subjects with AD-FLD who were receiving ongoing injections of BoNT participated in this study. Subjects’ mean age was 60.78 years and their mean duration of symptoms was 16.1 years. Subjects completed the Disease Symptom Questionnaire (DSQ) (specifically designed for this study) and the Voice Handicap Index-10 (VHI-10) (Jacobson et al, Am J Speech Lang Pathol 6:66–70, 1997) to measure the symptoms of their dysphonia and the impact of the disease on their quality of life.

Two speech-language pathologists and two laryngologists used the Voice Arrest Measure (VAM) (specifically designed for this study) and the USDRS to independently rate voice recordings of 56/60 subjects.

Results

The mean VHI-10 score was 21.3 which is clinically significant. The results of the DSQ and the USDRS were highly correlated. The most severe symptoms identified by both subjects and clinicians were roughness, strain-strangled voice quality, and increased expiratory effort. Voice arrest, aphonia, and tremor were uncommon. Subjects rated their current voice quality at the time of reinjection (i.e., at the time of the study) as significantly better than at the time of their initial AD-FLD diagnosis (p < 0.0001). Inter-clinician reliability on the USDRS was significant at the 0.001 level.

Conclusions

The findings from the VHI-10 suggest that AD-FLD has a profound impact on quality of life. The results of the DSQ and the USDRS suggest that there is a strong correlation between subjects’ perception and clinicians’ assessment of the individual symptoms and the severity of the dysphonia. The findings from the VAM suggest that voice arrests are infrequent in subjects with AD-FLD who are receiving ongoing BoNT injections. The strong inter-clinician reliability on the USDRS suggests that it is an appropriate measure for identifying symptoms and severity of AD-FLD.

Electronic supplementary material

The online version of this article (10.1186/s40734-017-0066-y) contains supplementary material, which is available to authorized users.

The electrolarynx: voice restoration after total laryngectomy

The ability to speak and communicate with one’s voice is a unique human characteristic and is fundamental to many activities of daily living, such as talking on the phone and speaking to loved ones. When the larynx is removed during a total laryngectomy (TL), loss of voice can lead to a devastating decrease in a patient’s quality of life, and precipitate significant frustration over their inability to communicate with others effectively. Over the past 50 years there have been many advances in techniques of voice restoration after TL. Currently, there are three main methods of voice restoration: the electrolarynx, esophageal speech, and tracheoesophageal speech through a tracheoesophageal puncture (TEP) with voice prosthesis. Although TEP voice is the current gold standard for vocal rehabilitation, a significant minority of patients cannot use or obtain TEP speech for various reasons. As such, the electrolarynx is a viable and useful alternative for these patients. This article will focus on voice restoration using an electrolarynx with the following objectives: 1) To provide an understanding of the importance of voice restoration after total laryngectomy. 2) To discuss how the electrolarynx may be used to restore voice following total laryngectomy. 3) To outline some of the current electrolarynx devices available, including their mechanism of action and limitations. 4) To compare pros and cons of electrolaryngeal speech to TEP and esophageal speech.

Reconstruction of Anterior Tracheal Defects Using a Bioengineered Graft in a Porcine Model

BACKGROUND

Reconstruction of long-segment tracheal defects can be challenging and a suitable tracheal substitute remains lacking. We sought to create a bioengineered tracheal graft to repair such lesions using acellullar bovine dermis extracellular matrix (ECM) and male human mesenchymal stem cells (hMSCs) and implant it in a porcine model.

METHODS

hMSCs were seeded on the ECM and incubated for 1 week with chondrogenic factors. An anterior 4 cm × 3 cm defect was surgically created in the trachea of 4-week-old female Yorkshire pigs. The defect was reconstructed using the bioengineered graft (n = 7) or control (n = 3, ECM only). The study duration was 3 months.

RESULTS

Survival ranged from 7 days (n = 3) to 3 months (n = 7). Early death was due to graft malacia (n = 1, control), graft infection (n = 1, bioengineered), and pneumonia (n = 1, bioengineered). There was substantial animal growth at 3 months (>200% weight). Surveillance bronchoscopy showed patent airway, mild stenosis, and integration of the graft with the native trachea. On histology, luminal epithelialization and neovascularization with scant submucosa were observed in both the bioengineered graft and control groups. Chondrogenesis was seen only in the bioengineered graft. The neocartilage was less mature and organized compared to native cartilage. SRY immunostain was positive in the neocartilage but not control or native trachea.

CONCLUSIONS

We demonstrate the feasibility of the bioengineered graft for reconstruction of long anterior tracheal defects with favorable short-term outcomes. Furthermore, we show its ability to facilitate chondrogenesis, neovascularization, and epithelialization. Importantly, it supported rapid animal growth offering potential solutions for both pediatric and adult applications.

An extended toboggan technique for resection of substernal thyroid goiters

We describe our technique for the safe resection of substernal thyroid goiters. Early mobilization of the thyroid gland from tracheal attachments anteriorly and laterally facilitates extraction of the goiter from the mediastinum. Retrograde dissection through the ligament of Berry on the ipsilateral side can also facilitate identification of the recurrent laryngeal nerve and delivery of the substernal portion of the gland. We describe 2 representative cases in which we successfully used this technique.

Laryngeal examination in thyroid and parathyroid surgery: An American Head and Neck Society consensus statement: AHNS Consensus Statement

This American Head and Neck Society (AHNS) consensus statement discusses the techniques of laryngeal examination for patients undergoing thyroidectomy and parathyroidectomy. It is intended to help guide all clinicians who diagnose or manage adult patients with thyroid disease for whom surgery is indicated, contemplated, or has been performed. This consensus statement concludes that flexible transnasal laryngoscopy is the optimal laryngeal examination technique, with other techniques including laryngeal ultrasound and stroboscopy being useful in selected scenarios. © 2016 Wiley Periodicals, Inc. Head Neck 38: 811-819, 2016.

Negative dystonia of the palate: a novel entity and diagnostic consideration in hypernasal speech

OBJECTIVE

To present the first documented series of patients with negative dystonia (ND) of the palate, including clinical symptoms, functional MRI findings, and management options.

STUDY DESIGN

Case series ascertained from clinical research centers that evaluated patients with both hyperkinetic and hypokinetic movement disorders.

METHODS

Between July 1983 and March 2013, data was collected on patient demographics, disease characteristics, functional MRI findings, long-term management options, and outcomes. We sought patients whose clinical examination demonstrated absent palatal movement on speaking, despite normal palatal activity on other activities.

RESULTS

Five patients (2 males, 3 females) met clinical criteria. All patients presented with hypernasal speech without associated dysphagia. Clinical examination revealed absent palatal movement on speaking despite intact gag reflexes, normal palate elevation on swallowing, and normal cranial nerve examinations. Other cranial and/or limb dystonias were present in four patients (80.0%). Three patients (60.0%) had previously failed oral pharmacologic therapy. Two patients underwent functional magnetic resonance imaging (fMRI) studies, which demonstrated an overall decrease of cortical and subcortical activation during production of symptomatic syllables and asymptomatic coughing. Management included speech therapy (all patients) and palatal lift (2 patients) with limited improvement. Calcium hydroxyapatite injection (1 patient) into the soft palate and Passavants' ridge was beneficial.

CONCLUSIONS

This is the first report of ND of the palate. Characteristic findings were task-specific absent palatal movement with speech, despite normal movement on swallowing, coughing, and an intact gag reflex, as well as disorder-specific decreased brain activation on functional MRI. A diagnosis of ND of the palate should be considered for patients who present with hypernasal speech.

LEVEL OF EVIDENCE

4.

Perceptions of harm to health from cigarettes, blunts, and marijuana among young adult African American men

OBJECTIVES

To assess perceptions and knowledge of health effects of smoking tobacco, blunts, and marijuana among adult African American (AA) men aged 19-30 in five Black Belt counties of rural Alabama.

METHODS

Cross-sectional study using interviewer-administered oral surveys.

RESULTS

Four hundred and fifteen participants completed surveys. Cigarettes were the most common initial and current product used (40%) and there were more current than initial users of marijuana and blunts. Significantly more cigarette users (80%) felt that smoking cigarettes was harmful to health compared with marijuana (33%) and blunt (53%) users (p < .001). Many marijuana smokers (71%) and blunt smokers (48%) believed smoking their product was safer than cigarettes for reasons including more natural and less addictive.

CONCLUSIONS

When compared with cigarettes, knowledge of the health-related effects of smoking marijuana-containing products among young African American men is poor. Intervention strategies focusing on the adverse health effects of smoking marijuana are needed.

Palatal myoclonus: algorithm for management with botulinum toxin based on clinical disease characteristics

OBJECTIVES/HYPOTHESIS

To review the clinical characteristics and management of patients with palatal myoclonus and devise an algorithm for treatment with botulinum toxin based on presenting symptoms, clinical examination findings, and involved muscle groups.

STUDY DESIGN

Retrospective chart review at two clinical research centers.

METHODS

Between 1985 and 2011, 15 patients with a diagnosis of essential palatal myoclonus were assessed. Data were collected on patient demographics, disease characteristics, and treatment outcomes.

RESULTS

Patients were more commonly female (60.0% vs. 40.0%) with average age at onset of 35.6 years. In 40.0% of patients, the myoclonus began after a viral upper respiratory tract infection. Two-thirds of patients had been previously treated unsuccessfully with oral medications. Predominant presenting symptoms included clicking tinnitus (46.7%), nonaudible awareness of palatal movements ± rhinolalia (20.0%), or both (33.3%). Clinical examination revealed co-incident involvement of pharyngeal musculature in 53.3%. Palatal site for initial botulinum toxin injection depended on the predominant presenting symptom: for tinnitus, 2.5 U were injected transorally into the tensor veli palatini muscle at the level of the pterygoid hamulus/lateral soft palate; for palatal movements, the injection was placed medially on either side of the uvula. Dose and location of subsequent injections were tailored depending on response to the toxin and location of subsequent observed maximal muscular contractions.

CONCLUSIONS

Palatal myoclonus can present with tinnitus or patient-perceived palatal movements. Management with botulinum toxin can be tailored to address the muscles contributing to the predominant presenting symptoms.

Surgical management of airway dysfunction in Parkinson's disease compared with Parkinson-plus syndromes

OBJECTIVES

We sought to compare the laryngeal symptoms of Parkinson's disease (PD) with those of multiple system atrophy (MSA), a Parkinson-plus syndrome; to review the differences in surgical management of upper airway dysfunction between patients with PD and those with MSA; and to present a treatment algorithm for management of upper airway disorders in patients with PD and MSA.

METHODS

We analyzed the airway manifestations of each disease, including clinical and physiological test results and management outcomes, in a case series of 30 patients (24 with PD and 6 with MSA).

RESULTS

Vocal fold atrophy causing bowing with a midfold glottic gap was common in patients with PD. One third of patients with PD underwent vocal fold augmentation with noticeable improvement in vocal volume and phonation time. Tracheostomy was required for life-threatening sleep apnea in 50% of the patients with MSA. Systemic medications and speech therapy were integral components of the management regimen.

CONCLUSIONS

Surgical management of laryngeal disorders in patients with PD should focus on restoring bulk to atrophic vocal folds to minimize glottic gaps, thus improving vocalization efficiency even in the presence of impaired respiratory effort. Conversely, the autonomic dysfunction that characterizes MSA results in upper airway obstruction, and thus surgical management focuses primarily on maintaining an adequate airway, which frequently necessitates tracheostomy.

Assessment of donor site morbidity for free radial forearm osteocutaneous flaps

PURPOSE

Assessment of donor site morbidity and recipient site complications following free radial forearm osteocutaneous flap (FRFOCF) harvest and evaluation of patient perceived upper limb disability for free radial forearm osteocutaneous versus fasciocutaneous flaps (FRFF).

METHODS

First a case series was undertaken of 218 patients who underwent an FRFOCF at two tertiary referral centers between February 1998 and November 2010. Outcomes included forearm donor site morbidity and recipient site complications. Second, the disability of the arm, shoulder, and hand (DASH) questionnaire assessing patient perceived arm disability was administered by phone to 60 consecutive patients who underwent an FRFOCF or FRFF.

RESULTS

Mean patient age was 63 years with male predominance (62.8%). Median bone length harvested was 8 cm (range, 3-12 cm) with prophylactic plating of the radius following harvest. Donor site morbidity included fracture (1 patient, 0.5%) and sensory neuropathy (5 patients, 2.3%). Mean DASH scores were comparative between groups and to established normative values. Mandibular malunion rate was 3.2% and hardware extrusion at the recipient site occurred in 15.6%.

CONCLUSION

Reluctance to perform FRFOCF by surgeons usually centers on concerns regarding potential donor site morbidity and adequacy of available bone stock; however, we identified minimal objective or patient perceived donor site morbidity or recipient site complications following harvest of FRFOCFs. Mild wrist weakness and stiffness are common but do not impede ability to perform activities of daily living. Data from this and other reports suggest this flap is particularly useful for midfacial and short segment mandibular reconstruction.

Patterns of blunt use among rural young adult African-American men

BACKGROUND

Blunts are hollowed-out cigars or leaf tobacco filled with marijuana. Use of blunts has increased since the 1990s and, in 2005, 3.5% of all American youth were estimated to have used blunts in the past month. Blunt smokers may have greater odds of cannabis and tobacco dependency and are at risk of smoking-related diseases. Previous studies have suggested that blunt use is more common among blacks, older teens, and men. However, data pertaining to blunt use in non-adolescent African-American populations are scarce.

PURPOSE

To assess patterns of blunt use among young adult African-American men aged 19-30 years residing in five rural Black Belt counties in Alabama and to compare these data with those from tobacco cigarette smokers within the same study population.

METHODS

Verbal, face-to-face interviewer-administered survey of 415 participants collected and analyzed between December 2008 and February 2011.

RESULTS

159 respondents (38.3%) smoked cigarettes and 45 smoked blunts (10.8%). Of blunt smokers, 33 also smoked cigarettes (73.3%). Use of blunts was prevalent among unemployed, single men, and occupational blunt use was uncommon. Factors important in the initiation, maintenance, and cessation of product use were similar for blunt and cigarette smokers, especially product use and acceptance by friends. Legal concerns were an important factor facilitating blunt cessation.

CONCLUSIONS

Blunt use is relatively common among male African Americans aged 19-30 years and is frequently associated with concomitant cigarette use. Tobacco control efforts in this male African-American population should also address blunt usage.

Functional and Survival Outcomes in Patients Undergoing Total Glossectomy Compared with Total Laryngoglossectomy

Objective. To compare functional and survival outcomes for patients undergoing total glossectomy (TG) or total glossectomy plus laryngectomy (TGL) for advanced squamous cell carcinoma (SCC) of the tongue.

Study Design. Case series with chart review.

Setting. Academic tertiary referral center.

Subjects and Methods. There were 30 included patients (20 TG, 10 TGL). Outcomes included tumor recurrence, disease-free survival, and functional data (swallowing, gastrostomy tube dependence, speech, airway).

Results. Mean patient age was 56 years with a male predominance (90%). Compared with TG, TGL was more commonly performed for recurrent tumors (90% vs 55%, P = .06). Perineural invasion and extracapsular extension occurred more commonly in the TGL group (80% vs 50%, P = .12). At 12 months postoperatively, 61% of TG patients had disease recurrence compared with 40% of TGL patients ( P = .43), and 12-month disease-free survival was 40% (TG) and 50% (TGL). Functionally, more TG patients were totally gastrostomy tube dependent (70% vs 30%, P = .04), and 50% of TG patients were also tracheostomy dependent. Intelligible speech was achieved by 30% of TG and 10% of TGL patients ( P = .68).

Conclusion. Patients undergoing TGL had similar functional and survival outcomes to patients undergoing TG alone despite the presence of more locally advanced disease with greater adverse pathological features. Following TG alone, positive or close margins occurred most commonly at the inferior margin of resection (hyoid/valleculae), which could explain why TGL in patients with advanced tongue SCC may improve local disease control.

Tobacco use among rural African American young adult males

OBJECTIVE

Tobacco-related disease is a primary source of mortality for African American men. Recent studies suggest that alternative tobacco products may have supplanted cigarettes as the most common products used by young African Americans. Effective cessation strategies require community-specific prevalence data. This project measures the prevalence of 9 tobacco products among young African American men in rural Alabama.

STUDY DESIGN

Principles of community-based participatory research were used to design a verbally administered tobacco product survey to measure the prevalence and behavioral factors influencing use.

SETTING

Black Belt counties of rural Alabama.

SUBJECTS AND METHODS

African American men aged 19 to 30 years were recruited from the target counties. Participants were stratified by income and education level. Prevalence rates for 9 products were determined, and logistic regression analysis was performed.

RESULTS

A total of 415 participants completed surveys. Cigarettes were the most common product ever (54%) and currently (39.9%) used. Participants who attended school for more than 12 years or attended religious services were less likely to use cigarettes. Marijuana and blunts were used next most commonly. Only 35 respondents (8.9%) currently used mini-cigars. Other products, bidis/kreteks, smokeless tobacco, and pipes were used uncommonly in this sample.

CONCLUSIONS

Cigarettes remain the dominant tobacco product used by young African American men in rural Alabama. Cigarette prevalence far exceeds that measured statewide for African American men of the same age. Alternative products were not commonly used in this study population. Effective community-based intervention must target cigarette initiation and cessation in this vulnerable population.

Prior antibiotic therapy for acute sinusitis in children and the development of subperiosteal orbital abscess

OBJECTIVE

To determine the pattern of pre-hospitalization antibiotic use in children developing a subperiosteal orbital abscess (SPA) as a complication of acute sinusitis.

STUDY DESIGN AND SETTING

Ten-year retrospective chart review in a tertiary pediatric center of children under the age of 18 years requiring operative drainage of a SPA as a complication of acute sinusitis.

RESULTS

There were 39 children (M 25; F 14). Ten children (26%) received antibiotic therapy prior to admission, for a median duration of 1.6 days. On presentation, 72% had rhinorrhea and/or fever, for average durations of 3.9 and 2.5 days, respectively. Streptococcal species sensitive to penicillin were grown from 51% of SPA cultures.

CONCLUSION

Although few children in this series received antibiotics prior to their presentation with a SPA, prodromal sinusitis symptoms were of too short a duration to warrant institution of antibiotic therapy based on the American Academy of Pediatrics guidelines for acute sinusitis.

SIGNIFICANCE

SPA may not be a preventable complication of acute sinusitis in children.