Publications by authors named "Catherine F Sinclair"

41 Publications

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

Head Neck 2021 08 3;43(8):2281-2294. Epub 2021 Jun 3.

Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.

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.
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http://dx.doi.org/10.1002/hed.26774DOI Listing
August 2021

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

Neuroradiol J 2021 Apr 8:19714009211008790. Epub 2021 Apr 8.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, USA.

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.
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http://dx.doi.org/10.1177/19714009211008790DOI Listing
April 2021

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

Am J Surg 2021 Aug 24;222(2):354-360. Epub 2020 Dec 24.

Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA.

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.
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http://dx.doi.org/10.1016/j.amjsurg.2020.12.033DOI Listing
August 2021

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

Front Endocrinol (Lausanne) 2020 18;11:565. Epub 2020 Aug 18.

Department of Otolaryngology- Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States.

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): 1.23 (95% Confidence Interval (CI): 0.88- 1.70)], mechanical ventilation [OR: 1.17 (95% CI: 0.81-1.69)] nor death [OR: 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.
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http://dx.doi.org/10.3389/fendo.2020.00565DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461836PMC
October 2020

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

Head Neck 2020 12 21;42(12):3779-3794. Epub 2020 Sep 21.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA.

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.
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http://dx.doi.org/10.1002/hed.26472DOI Listing
December 2020

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

Laryngoscope 2021 01 4;131(1):230-236. Epub 2020 May 4.

Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA.

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.
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http://dx.doi.org/10.1002/lary.28710DOI Listing
January 2021

Laryngeal adductor reflex hyperexcitability may predict permanent vocal fold paralysis.

Laryngoscope 2020 11 19;130(11):E625-E627. Epub 2019 Dec 19.

Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York, U.S.A.

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.
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http://dx.doi.org/10.1002/lary.28477DOI Listing
November 2020

Unforeseen clinical outcome for laryngeal adductor reflex loss during intraaxial brainstem surgery.

Clin Neurophysiol 2019 10 19;130(10):2001-2002. Epub 2019 Jul 19.

Mount Sinai West Hospital Head and Neck Surgery Department - Intraoperative Neurophysiology Department, New York, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.clinph.2019.07.010DOI Listing
October 2019

Intraoperative mapping and monitoring of sensory vagal fibers during vagal schwannoma resection.

Laryngoscope 2019 12 18;129(12):E434-E436. Epub 2019 Jun 18.

the Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York, U.S.A.

Vagal schwannomas are rare, benign tumors. Intermittent intraoperative neuromonitoring via selective stimulation of splayed motor fibers running on the schwannoma surface to elicit a compound muscle action potential has been previously reported as a method of preserving vagal motor fibers. In this case report, vagal sensory fibers are mapped and continuously monitored intraoperatively during high vagus schwannoma resection using the laryngeal adductor reflex (LAR). Mapping of nerve fibers on the schwannoma surface enabled identification of sensory fibers. Continuous LAR monitoring during schwannoma subcapsular microsurgical dissection enabled sensory (and motor) vagal fibers to be monitored in real time with excellent postoperative functional outcomes. Laryngoscope, 129:E434-E436, 2019.
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http://dx.doi.org/10.1002/lary.28147DOI Listing
December 2019

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

JAMA Otolaryngol Head Neck Surg 2019 May;145(5):453-458

Department of Otolaryngology, Emory University School of Medicine, Atlanta, Georgia.

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.
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http://dx.doi.org/10.1001/jamaoto.2019.0104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537789PMC
May 2019

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

Otolaryngol Head Neck Surg 2019 07 12;161(1):118-122. Epub 2019 Mar 12.

2 Department of Otolaryngology-Head and Neck Surgery, Mount Sinai West Hospital, New York, New York, USA.

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 ( = .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 intraoperative nerve monitoring, frequent tissue relaxation, and saline irrigation as means to minimize nerve stress intraoperatively.
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http://dx.doi.org/10.1177/0194599819835781DOI Listing
July 2019

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.

Laryngoscope 2018 10 6;128 Suppl 3:S18-S27. Epub 2018 Oct 6.

Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.

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.
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http://dx.doi.org/10.1002/lary.27360DOI Listing
October 2018

International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal.

Laryngoscope 2018 10 5;128 Suppl 3:S1-S17. Epub 2018 Oct 5.

Mount Sinai Hospital, Department of Otolaryngology, Toronto, Ontario, Canada.

This publication offers modern, state-of-the-art International Neural Monitoring Study Group (INMSG) guidelines based on a detailed review of the recent monitoring literature. The guidelines outline evidence-based definitions of adverse electrophysiologic events, especially loss of signal, and their incorporation in surgical strategy. These recommendations are designed to reduce technique variations, enhance the quality of neural monitoring, and assist surgeons in the clinical decision-making process involved in surgical management of recurrent laryngeal nerve. The guidelines are published in conjunction with the INMSG Guidelines Part II, Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer-Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data. Laryngoscope, 128:S1-S17, 2018.
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http://dx.doi.org/10.1002/lary.27359DOI Listing
October 2018

Unearthing a consistent bilateral R1 component of the laryngeal adductor reflex in awake humans.

Laryngoscope 2018 11 8;128(11):2581-2587. Epub 2018 Sep 8.

Department of Otolaryngology Head and Neck Surgery, Mount Sinai West Hospital, New York, New York, U.S.A.

Objective: The laryngeal adductor reflex (LAR) is an essential tracheobronchial protective mechanism resulting in vocal fold adduction to laryngeal stimulation. It was thought to consist of an early ipsilateral R1 component and a later, bilateral but highly centrally modulated R2 component. We recently demonstrated that bilateral R1 responses are robustly present in humans under general anesthesia. We herein give evidence that the R1 response is also bilateral in awake humans and is likely the primary component responsible for initiating the LAR.

Methods: Seven volunteers were included (3 males, 4 females). The reflex was elicited by direct percutaneous monopolar needle stimulation of the internal superior laryngeal nerve. Electromyography traces from bilateral lateral cricoarytenoid muscles were recorded using hookwire electrodes. Reflex responses to variations in stimulus intensity and duration were evaluated.

Results: Bilateral R1 responses were recorded in all patients, even during deep inspiration when the vocal folds were maximally abducted. R1, but not R2, responses increased linearly in amplitude, with sequential increases in both stimulation intensity (1-8 mA) and duration (100-500 µsec) (Pearson correlation 0.94).

Conclusion: Contradicting over 40 years of research, we demonstrate that the R1 LAR component is consistently bilateral in awake humans. It increases linearly with stimulus intensity and is unaffected by conscious state suggesting minimal central control. These findings may provide a means to objectively stratify patients for risk of laryngeal aspiration, even in unconscious states, and its potentially cardinal role in disease states such as laryngospasm and sudden infant death needs to be reevaluated.

Level Of Evidence: 4. Laryngoscope, 2581-2587, 2018.
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http://dx.doi.org/10.1002/lary.27249DOI Listing
November 2018

Human laryngeal sensory receptor mapping illuminates the mechanisms of laryngeal adductor reflex control.

Laryngoscope 2018 11 8;128(11):E365-E370. Epub 2018 Sep 8.

Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York, U.S.A.

Objective: The laryngeal adductor reflex (LAR) is an airway protective response triggered by sensory laryngeal receptors. It is unknown whether different glottic and supraglottic subsites vary in their reflex elicitation abilities. The recent discovery that a bilateral LAR is present in humans under general anesthesia upon laryngeal mucosal stimulation has enabled us to map the sensory receptor density for LAR elicitation at different laryngeal subsites. Our findings expose the likely mechanisms of LAR control.

Methods: Prospective series of 10 patients undergoing laryngoscopy. Laryngeal subsites (epiglottic tip, membranous vocal fold, midventricular vocal fold, posterior supraglottis, epiglottic petiole) were stimulated via direct laryngoscopy with a bipolar probe. Vocal fold responses were recorded by endotracheal tube and hook wire electrodes, and visual observation.

Results: Posterior supraglottic stimulation elicited bilateral LARs in all patients at all intensities. Membranous vocal folds, epiglottic petiole, and subglottis elicited no LAR. Ventricular fold and epiglottic tip responses converted from ipsi- to bilateral at high intensities.

Conclusion: There are likely three checkpoints for control of the LAR in humans. These checkpoints protect against inappropriate LAR activation during volitional tasks without compromising airway protection: 1) topographical differences in receptor density with the highest density in subsites most likely to contact foreign substances; 2) absence of receptors in membranous vocal folds; and 3) central summation threshold for crossed interneuron activation at brainstem level where only strong intensity stimuli will elicit bilateral responses. Checkpoint dysfunction provides a novel framework to diagnose and treat disease processes, including aspiration, laryngospasm, and sudden infant death.

Level Of Evidence: 4. Laryngoscope, E365-E370, 2018.
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http://dx.doi.org/10.1002/lary.27248DOI Listing
November 2018

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

Head Neck 2018 11 18;40(11):2498-2506. Epub 2018 Aug 18.

Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York.

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.
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http://dx.doi.org/10.1002/hed.25377DOI Listing
November 2018

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

Head Neck 2018 04 20;40(4):663-675. Epub 2018 Feb 20.

Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.

"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).
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http://dx.doi.org/10.1002/hed.24928DOI Listing
April 2018

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

J Clin Mov Disord 2017 13;4:20. Epub 2017 Dec 13.

Columbia University College of Physicians and Surgeons, Neurology, Icahn School of Medicine at Mt. Sinai, Center for Voice and Swallowing Disorders, 425 West 59th Street, New York, NY 10019 USA.

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 ( < 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.
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http://dx.doi.org/10.1186/s40734-017-0066-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5727950PMC
December 2017

Contralateral R1 and R2 components of the laryngeal adductor reflex in humans under general anesthesia.

Laryngoscope 2017 12 4;127(12):E443-E448. Epub 2017 Aug 4.

Department of Otolaryngology Head and Neck Surgery, Mount Sinai West Hospital, New York, New York, U.S.A.

Objectives: To demonstrate that under total intravenous general anesthesia (TIVA), the contralateral R1 (cRI) and contralateral R2 (cR2) components of the laryngeal adductor reflex (LAR) can be reliably elicited; to determine effects of topical anesthesia and inhalational anesthesia on the LAR; and to discuss how this technique may be utilized to continuously monitor the vagus nerve reflex arc.

Study Design: Case series.

Methods: Vocal fold mucosa was electrically stimulated via endotracheal tube surface-based electrodes to elicit a LAR. Responses were recorded using the endotracheal tube electrode contralateral to the simulating electrode for each side.

Results: Twenty-one patients (31 nerves at risk), aged between 28 to 84 years, who underwent thyroid and cervical spine surgeries (4 males, 17 females) were included. cR1 responses were reliably elicited in all patients, and cR2 responses were obtained in 14 patients (66.6%). Mean cR1 latencies ± standard deviation were 22.5 ± 2.5 milliseconds (ms) (left) and 23.4 ± 3.3 ms (right). Mean cR1 amplitudes were 237.9 ± 153.9 microvolts (uV) (left) and 265.0 ± 226.5 uV (right). Mean R2 latencies were 59.8 ± 4.9 ms (left) and 61.8 ± 7.9 ms (right). Intraoperative reversible cR1 amplitude decreases correlated temporally with surgical maneuvers stretching or compressing the RLN or internal branch of the superior laryngeal nerve (iSLN). Inhalational anesthetic agents abolished cR2 and minimized cR1 at mean alveolar concentrations > 0.5. Topical lidocaine significantly reduced LAR amplitude.

Conclusion: LAR cR1 and cR2 responses are present in humans under TIVA and may afford some airway protection against aspiration under anesthesia. They are inhibited by inhalational anesthetics and topical lidocaine. Continuous intraoperative iSLN and RLN monitoring are possible using surface-based endotracheal tube electrodes alone to stimulate and record cR1 responses.

Level Of Evidence: 4. Laryngoscope, 127:E443-E448, 2017.
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http://dx.doi.org/10.1002/lary.26744DOI Listing
December 2017

The electrolarynx: voice restoration after total laryngectomy.

Med Devices (Auckl) 2017 21;10:133-140. Epub 2017 Jun 21.

Department of Otolaryngology, Mount Sinai Icahn School of Medicine, New York, NY, USA.

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.
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http://dx.doi.org/10.2147/MDER.S133225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5484568PMC
June 2017

A novel methodology for assessing laryngeal and vagus nerve integrity in patients under general anesthesia.

Clin Neurophysiol 2017 07 14;128(7):1399-1405. Epub 2017 Mar 14.

Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, NY, USA.

Objective: To describe a novel methodology for intraoperative neuro-monitoring of laryngeal and vagus nerves by utilizing the laryngeal adductor reflex (LAR).

Methods: Case series of 15 patients undergoing thyroid and cervical spine surgeries under total intravenous general anesthesia. Vocal fold mucosa was electrically stimulated to elicit a LAR using endotracheal tube based electrodes. Contralateral R1 (cR1) and R2 (cR2) responses were recorded using the endotracheal tube electrode contralateral to the simulating electrode.

Results: The LAR was reliably elicited in 100% of patients for the duration of each surgical procedure. Mean onset latency of cR1 response was 22.4±2.5ms (right) and 22.2±2.4ms (left). cR2 responses were noted in 10 patients (66.7%). No peri-operative complications or adverse outcomes were observed.

Conclusions: The LAR is a novel neuro-monitoring technique for the vagus nerve. Advantages over current monitoring techniques including simplicity, ability to continuously monitor neural function without placement of additional neural probes and ability to assess integrity of both sensory and motor pathways.

Significance: The LAR represents a novel method for intraoperatively monitoring laryngeal and vagus nerves. The LAR monitors the entire vagus nerve reflex arc and is thus applicable to all surgeries where vagal nerve integrity may be compromised.
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http://dx.doi.org/10.1016/j.clinph.2017.03.002DOI Listing
July 2017

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

Ann Thorac Surg 2017 Feb 27;103(2):381-389. Epub 2016 Oct 27.

Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York. Electronic address:

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.
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http://dx.doi.org/10.1016/j.athoracsur.2016.10.034DOI Listing
February 2017

An extended toboggan technique for resection of substernal thyroid goiters.

Ear Nose Throat J 2016 Apr-May;95(4-5):175-7

Department of Otolaryngology, Mount Sinai West Hospital, 425 W. 59th St., 10th Floor, New York, NY 10019, USA.

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.
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April 2017

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

Head Neck 2016 06 11;38(6):811-9. Epub 2016 Mar 11.

Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.

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.
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http://dx.doi.org/10.1002/hed.24409DOI Listing
June 2016

In response to Palatal myoclonus: Algorithm for management with botulinum toxin based on clinical disease characteristics.

Laryngoscope 2015 Oct 7;125(10):E355. Epub 2015 Jul 7.

New York Center for Voice and Swallowing Disorders, St. Luke's Roosevelt Medical Center, New York, New York, U.S.A.

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http://dx.doi.org/10.1002/lary.25303DOI Listing
October 2015

Voice Restoration After Total Laryngectomy.

Otolaryngol Clin North Am 2015 Aug 18;48(4):687-702. Epub 2015 Jun 18.

Department of Otolaryngology, Mount Sinai Icahn School of Medicine, 425 West 59th Street, 10th Floor, New York, NY 10019, USA. Electronic address:

The ability to speak and communicate vocally is a unique human characteristic that is often taken for granted but is fundamental to many activities of daily living. Loss of voice after total laryngectomy can lead to a serious decrease in quality of life and can precipitate significant frustration over the inability to communicate effectively. There are 3 main methods of voice restoration: esophageal speech, usage of the electrolarynx, and tracheal-esophageal puncture for tracheal-esophageal speech, which can be performed primarily or secondarily. Although all 3 methods have potential benefits, the gold standard is tracheal-esophageal speech.
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http://dx.doi.org/10.1016/j.otc.2015.04.013DOI Listing
August 2015

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

Laryngoscope 2015 Jun 3;125(6):1426-32. Epub 2015 Feb 3.

New York Center for Voice and Swallowing Disorders, Mount Sinai Icahn School of Medicine, New York, New York, U.S.A.

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.
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http://dx.doi.org/10.1002/lary.25165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4718549PMC
June 2015

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

Laryngoscope 2014 May 25;124(5):1164-9. Epub 2014 Mar 25.

New York Center for Voice and Swallowing Disorders, St. Luke's Roosevelt Medical Center, New York, New York, U.S.A.

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.
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http://dx.doi.org/10.1002/lary.23485DOI Listing
May 2014

Oromandibular dystonia: long-term management with botulinum toxin.

Laryngoscope 2013 Dec 5;123(12):3078-83. Epub 2013 Oct 5.

New York Center for Voice and Swallowing Disorders, St. Luke's Roosevelt Medical Center, New York, New York, U.S.A.

Objectives/hypothesis: To review the long-term management of patients with oromandibular dystonia (OMD) treated using botulinum toxin.

Study Design: Retrospective chart review at a clinical research center.

Methods: Between 1995 and 2011, 59 patients with a diagnosis of OMD were treated with botulinum toxin. Data were collected on patient demographics, disease characteristics, and long-term treatment outcomes. Differences in management between an earlier published series of the first 20 OMD patients treated with botulinum toxin at this center and subsequent patients were analyzed.

Results: Patients were more commonly female (72% vs. 28%) with an average age at first botulinum treatment of 56.6 years. The median number of treatments was five (range, 1-35 treatments). Average time between treatments was 3.8 months (± 5.2). Overall, 47.5%, had the jaw-closing form of OMD, which was associated with a preferential deviation to one side in 53.6%. These patients received initial injections to the masseter ± temporalis muscle; the external pterygoid was injected for associated lateral jaw deviation. Internal pterygoid injections were rarely used (3.4%). For the jaw-opening form, injections were initially administered to the external pterygoid, with the addition of anterior digastric for ongoing symptoms. When compared with patients in the older series, more patients since 1988 had treatments to the external pterygoid (P = .001) and anterior digastric (P = .006) in accordance with an increase in the diagnosis of jaw-opening OMD (P = .05).

Conclusions: Long-term management of OMD with botulinum toxin has minimal morbidity and is useful for all clinical forms. Injections can be titrated by dose and location to address the predominant muscle groups involved.
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http://dx.doi.org/10.1002/lary.23265DOI Listing
December 2013

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

J Health Care Poor Underserved 2013 Aug;24(3):1266-75

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.
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http://dx.doi.org/10.1353/hpu.2013.0126DOI Listing
August 2013
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