Publications by authors named "Lee M Akst"

98 Publications

Laryngeal disorders in people living with HIV.

Am J Otolaryngol 2021 Sep 20;43(1):103234. Epub 2021 Sep 20.

Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, United States of America.

Objectives: Several studies have shown that HIV infected individuals are at higher risk compared to the general population of developing non-AIDS defining conditions such as some types of cancer, kidney disease, liver disease and others. In this case-control study, we compared the incidence of laryngeal disorders between a treatment-seeking HIV-positive population and uninfected controls. We aimed to investigate whether there are any laryngeal disorders that are overrepresented in HIV-positive individuals.

Methods: This was a case-control study based on retrospective chart review, comparing the incidence of laryngeal, airway, and swallowing disorders in sixty-nine HIV positive individuals and 4178 HIV negative controls treated between January 1, 2016 and December 31, 2017, at the Johns Hopkins Voice Center.

Results: A majority of HIV-infected patients (59.4%) had at least one diagnosis belonging to the Vocal cord pathology category compared to 48.2% of controls (OR 1.57, p = 0.065). Compared to the entire treatment-seeking population, HIV patients were more likely to present with laryngeal cancer (15.9% vs. 3.4% in controls, OR 5.43, p < 0.001) and chronic laryngitis (17.4% vs. 4.2%, OR 4.79, p < 0.001). Fungal and ulcerative laryngitis were also overrepresented in HIV-positive individuals (OR 9.45, p < 0.001 and 6.29, p < 0.001, respectively). None of the diagnoses categorized as functional voice disorders, swallowing, or airway problems showed a significant difference between groups. Laryngeal papillomatosis, which is an HPV-dependent disease, had similar prevalence in both groups.

Conclusions: Treatment-seeking HIV-positive patients presenting to a laryngology clinic suffer significantly more often from laryngeal squamous cell carcinoma as well as chronic, fungal, and ulcerative laryngitis compared to HIV-negative individuals.

Level Of Evidence: 4.
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http://dx.doi.org/10.1016/j.amjoto.2021.103234DOI Listing
September 2021

Readability of Online Materials Related to Vocal Cord Leukoplakia.

OTO Open 2021 Jul-Sep;5(3):2473974X211032644. Epub 2021 Aug 9.

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

Objectives: To assess readability and understandability of online materials for vocal cord leukoplakia.

Study Design: Review of online materials.

Setting: Academic medical center.

Methods: A Google search of "vocal cord leukoplakia" was performed, and the first 50 websites were considered for analysis. Readability was measured by the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), and Simple Measure of Gobbledygook (SMOG). Understandability and actionability were assessed by 2 independent reviewers with the PEMAT-P (Patient Education Materials Assessment Tool for Printable Materials). Unpaired tests compared scores between sites aimed at physicians and those at patients, and a Cohen's kappa was calculated to measure interrater reliability.

Results: Twenty-two websites (17 patient oriented, 5 physician oriented) met inclusion criteria. For the entire cohort, FRES, FKGL, and SMOG scores (mean ± SD) were 36.90 ± 20.65, 12.96 ± 3.28, and 15.65 ± 3.57, respectively, indicating that materials were difficult to read at a >12th-grade level. PEMAT-P understandability and actionability scores were 73.65% ± 7.05% and 13.63% ± 22.47%. Statistically, patient-oriented sites were more easily read than physician-oriented sites ( < .02 for each of the FRES, FKGL, and SMOG comparisons); there were no differences in understandability or actionability scores between these categories of sites.

Conclusion: Online materials for vocal cord leukoplakia are written at a level more advanced than what is recommended for patient education materials. Awareness of the current ways that these online materials are failing our patients may lead to improved education materials in the future.
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http://dx.doi.org/10.1177/2473974X211032644DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8358515PMC
August 2021

Response of Laryngopharyngeal Symptoms to Transoral Incisionless Fundoplication in Patients with Refractory Proven Gastroesophageal Reflux.

Ann Otol Rhinol Laryngol 2021 Aug 11:34894211037414. Epub 2021 Aug 11.

Division of Gastroenterology, Department of Medicine and Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objective: Patients with laryngopharyngeal reflux (LPR) symptoms may not respond to proton pump inhibitors (PPI) if they have an alternative laryngeal diagnosis or high-volume reflux. Transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) are effective in decreasing symptoms of gastroesophageal reflux disease (GERD) but are not well studied in patients with LPR symptoms. This prospective multicenter study assessed the patient-reported and clinical outcomes after TIF/cTIF in patients with LPR symptoms and proven GERD.

Methods: Patients with refractory LPR symptoms (reflux symptom index [RSI] > 13) and with erosive esophagitis, Barrett's esophagus, and/or pathologic acid reflux by distal esophageal pH testing were evaluated before and after a minimum of 6 months after TIF/cTIF. The primary outcome was normalization of RSI. Secondary outcomes were >50% improvement in GERD-Health-Related Quality of Life (GERD-HRQL), normalization of esophageal acid exposure time, discontinuation of PPI, and patient satisfaction.

Results: Forty-nine patients had TIF (n = 26) or cTIF (n = 23) with at least 6 months follow-up. Mean pre- and post TIF/cTIF RSI were 23.6 and 5.9 (mean difference: 17.7,  < .001). Post TIF/cTIF, 90% of patients had improved GERD-HQRL score, 85% normalized RSI, 75% normalized esophageal acid exposure time, and 80% discontinued PPI. No serious procedure-related adverse events occurred. Patient satisfaction was 4% prior to TIF/cTIF and 73% after TIF/cTIF ( < .001).

Conclusion: In patients with objective evidence of GERD, TIF, or cTIF are safe and effective in controlling LPR symptoms as measured by normalization of RSI and improvement in patient satisfaction after TIF/cTIF.

Level Of Evidence: Level 4.
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http://dx.doi.org/10.1177/00034894211037414DOI Listing
August 2021

Twenty-One for 2021: The Most Influential Papers in Laryngology Since 2000.

Laryngoscope 2021 Jul 28. Epub 2021 Jul 28.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A.

Objectives/hypothesis: To identify the most influential publications in laryngology since 2000.

Study Design: Modified Delphi process.

Methods: Samples of laryngologists drawn from editors of leading journals, organization officers, and thought leaders were invited to participate in a modified Delphi identification of influential laryngology papers. Influential was defined as follows: yielding meaningful practice changes, catalyzing further work as a foundation for an important topic, altering traditional views, or demonstrating durability over time. Quality and validity were not among the selection criteria. Each participant nominated 5 to 10 papers in Round 1. These nominations, augmented with papers from bibliometric analysis, were narrowed further in Round 2 as participants identified their top 20. The 40 papers with the most Round 2 votes were discussed by video conference and then subjected to Round 3 voting, with each participant again selecting their top 20 most influential papers. Final results were collated by the number of Round 3 votes.

Results: Sixteen of 18 invited laryngologists participated overall (all 16 in Rounds 1 and 3; 14 in Round 2). Twenty-one papers were identified as most influential. One paper appeared on all 16 Round 3 lists; three papers with eight (50%) votes each were lasted to make the list. Eleven of these 21 focused on voice; three each related to cancer, airway, and swallowing; and one encompassed all of these clinical areas.

Conclusions: This list of 21 influential laryngology papers serves to focus further research, provides perspective on recent advances within the field, and is an educational resource for trainees and practicing physicians.

Level Of Evidence: N/A Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29781DOI Listing
July 2021

Normative Ambulatory Reflux Monitoring Metrics for Laryngopharyngeal Reflux: A Systematic Review of 720 Healthy Individuals.

Otolaryngol Head Neck Surg 2021 Jul 27:1945998211029831. Epub 2021 Jul 27.

Department of Otorhinolaryngology-Head & Neck Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

Objectives: To review the normative data for acid, weakly acid, and nonacid proximal esophageal (PRE) and hypopharyngeal reflux (HRE) events in diagnosing laryngopharyngeal reflux (LPR) using ambulatory reflux monitoring.

Data Sources: PubMed, Cochrane Library, and Scopus.

Review Methods: A literature search was conducted about the normative data for PRE and HRE on multichannel intraluminal impedance-pH monitoring (MII-pH), hypopharyngeal-esophageal MII-pH (HEMII-pH), or oropharyngeal pH monitoring using PICOTS (population, intervention, comparison, outcome, timing, and setting) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statements. Outcomes reviewed included device characteristics, impedance/pH sensor placements, study duration, number/average and percentiles of PRE or HRE occurrence, and the event characteristics (pH, composition, and position).

Results: Of 154 identified studies, 18 met criteria for analysis, including 720 healthy individuals. HEMII-pH, MII-pH, and oropharyngeal pH monitoring were used in 7, 6, and 5 studies, respectively. The definition and inclusion/exclusion criteria of healthy individuals varied substantially across studies, with 6 studies considering only digestive symptoms to exclude potential LPR patients. Substantial heterogeneity across studies was noted, including impedance/pH sensor placements/configurations and definitions of composition (liquid, gas, mixed) and type (acid, weakly acid, nonacid) of PRE/HRE. The 95th percentile thresholds were 10 to 73 events for PRE, 0 to 10 events for HRE on HEMII-pH, and 40 to 128 for events with pH <6.0 on oropharyngeal pH monitoring. Most HREs were nonacid and occurred upright. The mean HRE among healthy individuals was 1.

Conclusion: The low number of studies and the heterogeneity in inclusion criteria, definitions, and characterization of PRE and HRE limit the establishment of consensual normative criteria for LPR on ambulatory reflux monitoring. Future large multicenter studies are needed.
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http://dx.doi.org/10.1177/01945998211029831DOI Listing
July 2021

The Geographic Distribution of Videolaryngostroboscopy in the United States.

J Voice 2021 Jun 20. Epub 2021 Jun 20.

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

Purpose: To study the geographic utilization of videolaryngostroboscopy (VLS) with the hypothesis that office-based voice care is unevenly distributed across the United States.

Materials And Methods: This is a cross-sectional database analysis of Medicare beneficiaries. The Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Physician and Other Supplier Public Use File from 2012 to 2017 was analyzed to evaluate VLS utilization. VLS distribution was assessed by calculating the density of VLS in each of the 306 hospital referral regions (HRRs) nationally. Associations between VLS density and population demographics and health system factors were assessed using Pearson correlation and multivariate regression analyses.

Results: In total, 957,648 outpatient VLS were billed to Medicare part B between 2012 and 2017. The annual VLS density per HRR ranged from 0 to 38.2 per 1,000 enrollees. Pearson correlation revealed positive correlations between VLS density and number of Medicare enrollees (r = 0.2584, P < 0.001), income (r = 0.1913, P = 0.0008), education (r = 0.2089, P = 0.0002), and density of otolaryngologists (r = 0.1589, P = 0.0053) and medical specialists (r = 0.2326, P < 0.0001). A negative Pearson correlation was observed between VLS density and percent male (r = -0.1338, P = 0.0192) and Medicare mortality rate (r = -0.1628, P = 0.0043). On multivariate regression positive associations between VLS and number of Medicare enrollees (P = 0.002) and otolaryngologists (P = 0.049), and negative association with Medicare mortality rates (P = 0.032) remained significant.

Conclusions: The distribution of office-based voice care varies widely across the country, even when analysis by HRR should have homogenized access to specialty care. Greater availability of VLS is seen in HRRs with more Medicare enrollees, greater density of otolaryngologists, and lower mortality rates.
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http://dx.doi.org/10.1016/j.jvoice.2021.05.002DOI Listing
June 2021

Voice Quality and Laryngeal Findings in Patients With Suspected Lung Cancer.

Otolaryngol Head Neck Surg 2021 Apr 20:1945998211008382. Epub 2021 Apr 20.

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

Objective: To describe laryngeal findings and voice quality in patients with suspected lung cancer, relative to voice quality and possible laryngeal pathology.

Study Design: Prospective cohort study.

Setting: Tertiary care center.

Methods: Patients with known or suspected lung cancer were approached before planned thoracic surgery, and they completed acoustic analysis, the Voice-Related Quality of Life (V-RQOL) questionnaire, and stroboscopy. The prevalence of dysphonia, V-RQOL and Cepstral Spectral Index of Dysphonia (CSID) scores, and laryngeal findings were examined and compared between patients ultimately found to have lung cancer and those without cancer.

Results: Sixty-one patients (45 cancer, 16 noncancer) were analyzed. Patients with cancer were older than those without (mean ± SD, 72.3 ± 9.94 vs 62.6 ± 9.30 years; = .001). Otherwise, the distribution of stroboscopy findings, acoustic measures, and self-reported voice handicap were similar between the cancer and noncancer cohorts. Prior to surgery, no patients had vocal cord paralysis or obvious neoplasm, though 4 (6.56%) had leukoplakia and 28 (45.9%) had vocal fold movement asymmetry on stroboscopy. Overall, 21 patients (35.0%) had average CSID scores >19, and 13 (21.7%) had CSID scores >24; however, only 4 self-described their voice as not working as it should, and only 2 had a V-RQOL score <85.

Conclusion: Patients with suspected lung cancer have moderate dysphonia on acoustic measures, though self-reported impact on quality of life is low. While leukoplakia was seen in 4 patients, obvious neoplasm and occult paralysis were not seen in this cohort. Together, these findings suggest that patients with suspected lung cancer should be assessed for subjective voice dysfunction, but routine laryngeal screening may otherwise be unnecessary.
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http://dx.doi.org/10.1177/01945998211008382DOI Listing
April 2021

Preoperative Briefings and Postoperative Debriefings to Increase Resident Operative Autonomy and Performance.

J Surg Educ 2021 Sep-Oct;78(5):1450-1460. Epub 2021 Mar 20.

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

Objective: To implement the use of standardized preoperative briefings and postoperative debriefings for surgical cases involving residents in an effort to improve resident autonomy and skill acquisition.

Design: Prospective longitudinal study.

Setting: Johns Hopkins Department of Otolaryngology-Head and Neck Surgery.

Participants: Resident and attending physicians.

Results: Joint Huddles for Improving Resident Education (JHFIRE) tool was created and successfully implemented by 19 residents and 17 faculty members. Over the course of three data collection periods spanning an academic year, overall scores improved though not statistically significantly in the metrics of Zwisch autonomy, Resident Performance, and Objective Structured Assessment of Technical Skills (OSATS) scores. Female residents were scored significantly higher by attendings than their male counterparts in the assessment of baseline Resident Performance.

Conclusions: (1) JHFIRE tool implemented a standardized preoperative briefing and postoperative debriefing to improve communication and resident skill acquisition; (2) The tool was accepted and utilized throughout an academic year; (3) Zwisch, Resident Performance, and OSATS scores improved though not significantly.
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http://dx.doi.org/10.1016/j.jsurg.2021.03.002DOI Listing
March 2021

Clinical Excellence in Otolaryngology-Head and Neck Surgery: Examples from the Published Literature.

Laryngoscope 2021 07 10;131(7):E2153-E2158. Epub 2021 Mar 10.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.

Objective/hypothesis: To apply the domains of clinical excellence, as published by the Miller-Coulson Academy of Clinical Excellence, to the field of otolaryngology-head and neck surgery (OHNS) as a framework for evaluating and improving clinical excellence.

Methods: A search of PubMed, Scopus, the Cochrane Library, and the National Institute for Health and Care Excellence (NICE) databases was performed and 229 publications were reviewed.

Results: Case reports and other articles were selected that exemplify each of the distinct domains of clinical excellence within our specialty.

Conclusions: The Miller-Coulson Academy's domains of clinical excellence are relevant to OHNS and can provide a framework for fostering clinical excellence in otolaryngologists. The many examples of excellent care by otolaryngologists found in the published literature can inspire otolaryngologists to provide outstanding care to all patients consistently and to advance our specialty.

Level Of Evidence: N/A Laryngoscope, 131:E2153-E2158, 2021.
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http://dx.doi.org/10.1002/lary.29511DOI Listing
July 2021

Impact of subspecialty training on management of laryngopharyngeal reflux: results of a worldwide survey.

Eur Arch Otorhinolaryngol 2021 Jun 27;278(6):1933-1943. Epub 2021 Feb 27.

Division of Laryngology and the Professional Voice Department of Otolaryngology, Communication Science Medical College of Wisconsin, Milwaukee, WI, USA.

Objective: To study the management of laryngopharyngeal reflux (LPR) among the subspecialties of practicing otolaryngology-head and neck surgeons and their trainees.

Methods: A survey was sent to over 8000 otolaryngologists (OTOHNS) over 65 countries, utilizing membership lists of participating otolaryngological societies. The outcomes were answers to questions regarding LPR knowledge and practice patterns, and included queries about its definition, prevalence, clinical presentation, diagnosis, and treatment.

Results: Of the 824 respondents, 658 practiced in one specific otolaryngologic subspecialty. The symptoms and findings thought to be the most related to LPR varied significantly between subspecialists. Extra-laryngeal findings were considered less by laryngologists while more experienced OTOHNS did not often consider digestive complaints. Compared with colleagues, otologists, rhinologists and laryngologists were less aware of the involvement of LPR in otological, rhinological and laryngological disorders, respectively. Irrespective of subspecialty, OTOHNS consider symptoms and signs and a positive response to empirical therapeutic trial to establish a LPR diagnosis. Awareness regarding the usefulness of impedance pH-studies is low in all groups. The therapeutic approach significantly varies between groups, although all were in agreement for the treatment duration. The management of non-responder patients demonstrated significant differences among laryngologists who performed additional examinations. The majority of participants (37.1%) admitted to being less than knowledgeable about LPR management.

Conclusions: LPR knowledge and management vary significantly across otolaryngology subspecialties. International guidelines on LPR management appear necessary to improve knowledge and management of LPR across all subspecialties of otolaryngology.
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http://dx.doi.org/10.1007/s00405-021-06710-yDOI Listing
June 2021

Management of laryngopharyngeal reflux in Brazil: a national survey.

Braz J Otorhinolaryngol 2020 Dec 29. Epub 2020 Dec 29.

Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Otorrinolaringologia, São Paulo, SP, Brazil. Electronic address:

Introduction: Studies assessing the management of laryngopharyngeal reflux by otolaryngologists have reported an important heterogeneity regarding the definition, diagnosis, and treatment, which leads to discrepancies in the management of the patient. Information about the current knowledge and practices of Brazilian otolaryngologists in laryngopharyngeal reflux is lacking.

Objective: To investigate the trends in management of laryngopharyngeal reflux disease among Brazilian otolaryngologists.

Methods: A survey was sent by email to the members of the Brazilian Association of Otolaryngology-Head Neck Surgery. This survey has initially been conducted by the laryngopharyngeal reflux study group of young otolaryngologists of the International Federation of Otolaryngological Societies.

Results: According to the survey responders, the prevalence of laryngopharyngeal reflux was estimated to be 26.8% of patients consulting in otolaryngology and the most common symptoms were globus sensation, throat clearing, cough and stomach acid reflux. Nasal obstruction, Eustachian tube dysfunction, acute and chronic otitis media, vocal fold nodules and hemorrhage were considered not associated with laryngopharyngeal reflux by the majority of responders. About 2/3 of Brazilian otolaryngologists based the diagnosis of laryngopharyngeal reflux on the assessment of both symptoms and findings and a positive response to empiric therapeutic trials. Proton pump inhibitor utilized once or twice daily, was the most commonly used therapeutic scheme. Only 21.4% of Brazilian otolaryngologists have heard about nonacid and mixed laryngopharyngeal reflux and the awareness about the usefulness of multichannel intraluminal impedance pH monitoring (MII-pH) was minimal; 30.5% of responders did not consider themselves as well-informed about laryngopharyngeal reflux.

Conclusion: Although the laryngopharyngeal reflux-related symptoms, main diagnostic and treatment approaches referred by Brazilian otolaryngologists are consistent with the literature, the survey identified some limitations, such as the insufficient awareness of the role of laryngopharyngeal reflux in many otolaryngological conditions and of the possibility of non-acid or mixed reflux in refractory cases. Future studies are needed to establish international recommendations for the management of laryngopharyngeal reflux disease.
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http://dx.doi.org/10.1016/j.bjorl.2020.11.017DOI Listing
December 2020

The Role of Preoperative Briefing and Postoperative Debriefing in Surgical Education.

J Surg Educ 2021 Jul-Aug;78(4):1182-1188. Epub 2020 Nov 27.

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

Objective: To study the impact of a new preoperative briefing and postoperative debriefing tool on the perceived quality of surgical education and to assess attitudes of residents and attendings regarding this tool.

Design: Surrounding introduction and use of the tool (JHFIRE: Joint Huddles for Improving Resident Education), perceived quality of surgical education was assessed with pre- and postintervention System for Evaluation of Teaching Qualities (SETQ) surveys. Additionally, a postintervention Likert survey regarding the JHFIRE tool itself was completed by residents and faculty.

Setting: Johns Hopkins University Department of Otolaryngology-Head and Neck Surgery, a tertiary care academic institution.

Participants: All residents and attendings who used the tool were invited to participate. 40 participants (13 residents, 27 attendings) completed the preintervention SETQ. 11 participants (3 residents, 7 attendings, 1 unspecified) completed the postintervention SETQ. For postintervention qualitative assessment of the tool itself, 12 participants (3 residents, 7 attendings, 2 unspecified) provided feedback.

Results: The tool was well-received with large subjective benefit in improving resident surgical education. A total of 88% thought that the time spent on the debriefings was "just right" and 91% planned to make the debriefings a regular part of operative performance assessments. Despite this overwhelmingly positive feedback, there was no overall difference in pre- and postintervention SETQ scores for climate of surgical education in the Department (4.25 ± 0.55 vs. 4.10 ± 0.88, p = 0.63).

Conclusions: Introduction of 4 item preoperative briefing and 4 item postoperative debriefing checklists was welcomed by both residents and faculty for its ability to shape surgical education in the operating room into a guided discovery model of hands-on education. Overall SETQ scores did not change, but most participants found value in the tool and plan to continue its use.
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http://dx.doi.org/10.1016/j.jsurg.2020.11.001DOI Listing
June 2021

Management of Laryngopharyngeal Reflux Around the World: An International Study.

Laryngoscope 2021 05 17;131(5):E1589-E1597. Epub 2020 Nov 17.

Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France.

Objective: To investigate worldwide practices of otolaryngologists in the management of laryngopharyngeal reflux (LPR).

Methods: An online survey was sent on the management of LPR to members of many otolaryngological societies. The following aspects were evaluated: LPR definition, prevalence, clinical presentation, diagnosis, and treatment.

Results: A total of 824 otolaryngologists participated, spread over 65 countries. The symptoms most usually attributed to LPR are cough after lying down/meal, throat clearing and globus sensation while LPR-related findings are arytenoid erythema and posterior commissure hypertrophy. Irrespective to geography, otolaryngologists indicate lack of familiarity with impedance pH monitoring, which they attribute to lack of knowledge in result interpretation. The most common therapeutic regimens significantly vary between world regions, with a higher use of H2 blocker in North America and a lower use of alginate in South America. The duration of treatment also significantly varies between different regions, with West Asia/Africa and East Asia/Oceania otolaryngologists prescribing medication for a shorter period than the others. Only 21.1% of respondents are aware about the existence of nonacid LPR. Overall, only 43.2% of otolaryngologists believe themselves sufficiently knowledgeable about LPR.

Conclusions: LPR knowledge and management significantly vary across the world. International guidelines on LPR definition, diagnosis, and treatment are needed to improve knowledge and management around the world.

Level Of Evidence: N.A. Laryngoscope, 131:E1589-E1597, 2021.
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http://dx.doi.org/10.1002/lary.29270DOI Listing
May 2021

Laryngeal Injury and Upper Airway Symptoms After Endotracheal Intubation During Surgery: A Systematic Review and Meta-analysis.

Anesth Analg 2021 04;132(4):1023-1032

Department of Emergency Medicine.

Laryngeal injury from intubation can substantially impact airway, voice, and swallowing, thus necessitating multidisciplinary interventions. The goals of this systematic review were (1) to review the types of laryngeal injuries and their patient-reported symptoms and clinical signs resulting from endotracheal intubation in patients intubated for surgeries and (2) to better understand the overall the frequency at which these injuries occur. We conducted a search of 4 online bibliographic databases (ie, PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature [CINAHL], and The Cochrane Library) and ProQuest and Open Access Thesis Dissertations (OPTD) from database inception to September 2019 without restrictions for language. Studies that completed postextubation laryngeal examinations with visualization in adult patients who were endotracheally intubated for surgeries were included. We excluded (1) retrospective studies, (2) case studies, (3) preexisting laryngeal injury/disease, (4) patients with histories of or surgical interventions that risk injury to the recurrent laryngeal nerve, (5) conference abstracts, and (6) patient populations with nonfocal, neurological impairments that may impact voice and swallowing function, thus making it difficult to identify isolated postextubation laryngeal injury. Independent, double-data extraction, and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Collaboration's criteria. Twenty-one articles (1 cross-sectional, 3 cohort, 5 case series, 12 randomized controlled trials) representing 21 surgical studies containing 6140 patients met eligibility criteria. The mean patient age across studies reporting age was 49 (95% confidence interval [CI], 45-53) years with a mean intubation duration of 132 (95% CI, 106-159) minutes. Studies reported no injuries in 80% (95% CI, 69-88) of patients. All 21 studies presented on type of injury. Edema was the most frequently reported mild injury, with a prevalence of 9%-84%. Vocal fold hematomas were the most frequently reported moderate injury, with a prevalence of 4% (95% CI, 2-10). Severe injuries that include subluxation of the arytenoids and vocal fold paralysis are rare (<1%) outcomes. The most prevalent patient complaints postextubation were dysphagia (43%), pain (38%), coughing (32%), a sore throat (27%), and hoarseness (27%). Overall, laryngeal injury from short-duration surgical intubation is common and is most often mild. No uniform guidelines for laryngeal assessment postextubation from surgery are available and hoarseness is neither a good indicator of laryngeal injury or dysphagia. Protocolized screening for dysphonia and dysphagia postextubation may lead to improved identification of injury and, therefore, improved patient outcomes and reduced health care utilization.
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http://dx.doi.org/10.1213/ANE.0000000000005276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969363PMC
April 2021

Laryngeal Leukoplakia: State of the Art Review.

Otolaryngol Head Neck Surg 2021 06 10;164(6):1153-1159. Epub 2020 Nov 10.

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

Objective: This state-of-the-art article reviews the epidemiology, diagnosis, and management of vocal fold leukoplakia, with focus on recent advances. It focuses on the clinical challenges that otolaryngologists face balancing both oncological efficacy and functional outcomes in leukoplakia and presents the current philosophies and techniques to consider when managing such patients.

Data Sources: PubMed/MEDLINE.

Review Methods: We conducted a detailed review of publications related to vocal cord and laryngeal leukoplakia, dysplasia, hyperkeratosis, leukoplakia endoscopy, and leukoplakia management focusing specifically on oncologic outcomes, voice preservation, current and emerging diagnosis, and management techniques.

Conclusions: There has been a paradigm shift away from performing "vocal cord stripping" procedures that can cause irreversible hoarseness toward voice preservation surgery while achieving comparable oncologic control. Surgical technical and instrumental developments have been designed to maximally treat superficial disease while preserving underling vibratory mucosa. Recent improvements in histopathological grading systems and advances in biomarker classification may allow for improved oncologic risk stratification. Furthermore, improvements in endoscopic imaging capabilities and contact endoscopy are currently being studied for their potential diagnostic significance.

Implications For Practice: To optimally manage vocal fold leukoplakia, the otolaryngologist should become familiar with the oncologic implications of the disease and the importance of obtaining pathologic diagnosis to rule out malignancy. In addition, the surgeon should maintain surgical techniques and knowledge of available instruments and lasers that can assist in surgical management while prioritizing the preservation of vibratory tissue and voice quality. Finally, the surgeon and the patient should understand the clinical importance of routine endoscopic surveillance.
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http://dx.doi.org/10.1177/0194599820965910DOI Listing
June 2021

Vocal Fold Immobility: An Algorithm for Treating Glottal Insufficiency.

Adv Otorhinolaryngol 2020 9;85:59-67. Epub 2020 Nov 9.

Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA,

The objectives of this chapter are to discuss the factors involved in the decision-making algorithm of an appropriate intervention for glottal insufficiency. Management strategies not only depend on the etiology, history, symptoms, size of glottal gap on visualization, but also on patient goals and expectations. The goal of this chapter is to organize the management of glottal incompetence for patients and providers, supported by an evidence-based approach.
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http://dx.doi.org/10.1159/000496491DOI Listing
November 2020

Dysphonia and dysphagia as early manifestations of autoimmune inflammatory myopathy.

Am J Otolaryngol 2021 Jan - Feb;42(1):102747. Epub 2020 Oct 3.

Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, 601 N Caroline Street, Baltimore, MD, USA. Electronic address:

Purpose: While dysphagia is a recognized manifestation of autoimmune inflammatory myopathy, a relationship between myositis and dysphonia or laryngeal pathology is not well-documented. We therefore sought to describe the spectrum of laryngeal disorders present in myositis patients, evaluate whether any specific conditions are overrepresented among these patients compared to a large treatment-seeking population, and examine the clinical course and outcomes of these symptoms.

Materials And Methods: This was a retrospective chart review, including all patients seen at the Johns Hopkins Voice Center between January 2016 and December 2017. Demographic data, comorbidities, and laryngeal diagnoses were extracted from the electronic medical record. The charts of patients with myositis were reviewed further to ascertain details of their laryngeal symptoms and myositis disease course. Associations between myositis and dysphonia/dysphagia were evaluated using binary regression and multinomial logistic regression models to adjust for age, sex, race, and smoking status.

Results: Of 4252 patients, sixteen had myositis. Compared to 4236 controls, these patients had significantly higher odds of presenting with muscular voice disorders (adjusted odds ratio (OR*) = 4.503, p* = 0.005) and dysphagia (OR* = 6.823, p* < 0.001). A majority (64.3%, CI:35.6-93.0%) of myositis patients had laryngeal pathology among the presenting symptoms of their myositis. Across all diagnostic categories, there was a non-significant trend towards better outcomes in patients receiving specific interventions for their laryngeal symptoms.

Conclusions: Muscular voice disorders and dysphagia are significantly overrepresented in myositis patients presenting to a laryngology clinic, and in these patients, both are frequently among the presenting symptoms of myositis.
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http://dx.doi.org/10.1016/j.amjoto.2020.102747DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722093PMC
April 2021

Nonepithelial Tumors of the Larynx: Single-Institution 13-Year Review with Radiologic-Pathologic Correlation.

Radiographics 2020 Nov-Dec;40(7):2011-2028. Epub 2020 Oct 9.

From the Russell H. Morgan Department of Radiology and Radiological Science (A.C.O., E.H.H., A.J.M., N.A., M.A.K.), Department of Pathology (L.M.R.), and Department of Otolaryngology-Head and Neck Surgery (L.M.A., S.R.B.), Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore. MD 21287.

Nonepithelial tumors of the larynx are rare and represent a minority of all laryngeal neoplasms. Imaging has an important role in the diagnosis, treatment planning, and surveillance of these entities. However, unfamiliarity with these neoplasms can cause diagnostic difficulties for radiologists, especially because many of the imaging findings are nonspecific. By using a systematic approach based on clinical history, patient age and gender, lesion location, endoscopic results, and specific imaging findings, the differential diagnosis can often be narrowed. These tumors typically affect the submucosal layer, so if a tumor has an intact mucosa at endoscopy, a nonepithelial neoplasm is the most likely diagnosis. Nonepithelial tumors of the larynx can arise from the laryngeal cartilage or muscle or from the surrounding lymphoid tissue or blood vessels. Consequently, imaging findings typically correspond to the specific cell type from which it originated. Recognizing specific features (eg, metaplastic bone formation, macroscopic fat, or enhancement pattern) can often help narrow the differential diagnosis. In addition, identification of noncircumscribed borders of the lesion and invasion of the adjacent structures is key to diagnosis of a malignant process rather than a benign neoplasm. Understanding the pathologic correlation is fundamental to understanding the radiologic manifestations and is ultimately crucial for differentiation of nonepithelial laryngeal neoplasms. RSNA, 2020.
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http://dx.doi.org/10.1148/rg.2020190210DOI Listing
July 2021

Machine Learning in Laryngoscopy Analysis: A Proof of Concept Observational Study for the Identification of Post-Extubation Ulcerations and Granulomas.

Ann Otol Rhinol Laryngol 2021 Mar 14;130(3):286-291. Epub 2020 Aug 14.

Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA.

Objective: Computer-aided analysis of laryngoscopy images has potential to add objectivity to subjective evaluations. Automated classification of biomedical images is extremely challenging due to the precision required and the limited amount of annotated data available for training. Convolutional neural networks (CNNs) have the potential to improve image analysis and have demonstrated good performance in many settings. This study applied machine-learning technologies to laryngoscopy to determine the accuracy of computer recognition of known laryngeal lesions found in patients post-extubation.

Methods: This is a proof of concept study that used a convenience sample of transnasal, flexible, distal-chip laryngoscopy images from patients post-extubation in the intensive care unit. After manually annotating images at the pixel-level, we applied a CNN-based method for analysis of granulomas and ulcerations to test potential machine-learning approaches for laryngoscopy analysis.

Results: A total of 127 images from 25 patients were manually annotated for presence and shape of these lesions-100 for training, 27 for evaluating the system. There were 193 ulcerations (148 in the training set; 45 in the evaluation set) and 272 granulomas (208 in the training set; 64 in the evaluation set) identified. Time to annotate each image was approximately 3 minutes. Machine-based analysis demonstrated per-pixel sensitivity of 82.0% and 62.8% for granulomas and ulcerations respectively; specificity was 99.0% and 99.6%.

Conclusion: This work demonstrates the feasibility of machine learning via CNN-based methods to add objectivity to laryngoscopy analysis, suggesting that CNN may aid in laryngoscopy analysis for other conditions in the future.
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http://dx.doi.org/10.1177/0003489420950364DOI Listing
March 2021

Characterization of Geriatric Dysphagia Diagnoses in Age-Based Cohorts.

OTO Open 2020 Jul-Sep;4(3):2473974X20939543. Epub 2020 Jul 8.

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

Objective: An aging population requires increased focus on geriatric otolaryngology. Patients aged ≥65 years are not a homogenous population, and important physiologic differences have been documented among the young-old (65-74 years), middle-old (75-84), and old-old (≥85). We aim to analyze differences in dysphagia diagnoses and swallowing-related quality-of-life among these age subgroups.

Study Design: Retrospective chart review.

Setting: Tertiary care laryngology clinic.

Subjects And Methods: We identified chief complaint, diagnosis, and self-reported swallowing handicap (Eating Assessment Tool [EAT-10] score) of all new patients aged ≥65 years presenting to the Johns Hopkins Voice Center between April 2015 and March 2017. Dysphagia diagnoses were classified by physiologic etiology and anatomic source. Diagnostic categories and EAT-10 score were evaluated as functions of patient age and sex.

Results: Of 839 new patients aged ≥65 years, 109 (13.0%) reported a chief complaint of dysphagia and were included in this study. The most common dysphagia etiologies were neurologic and esophageal. Most common diagnoses were diverticula (15.6%), reflux (13.8%), and radiation induced (8.3%). Diverticula, cricopharyngeal hypertonicity, and radiation-induced changes were associated with higher EAT-10 score ( < .001). Significant differences by sex were found in anatomic source of dysphagia, as men and women were more likely to present with oropharyngeal and esophageal disease, respectively ( = .023). Dysphagia etiology and EAT-10 score were similar across age subgroups.

Conclusion: Important differences among dysphagia diagnosis and EAT-10 score exist among patients aged ≥65 years. Knowledge of these differences may inform diagnostic workup, management, and further investigations in geriatric otolaryngology.
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http://dx.doi.org/10.1177/2473974X20939543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346702PMC
July 2020

Involvement of Laryngopharyngeal Reflux in Select Nonfunctional Laryngeal Diseases: A Systematic Review.

Otolaryngol Head Neck Surg 2021 01 23;164(1):37-48. Epub 2020 Jun 23.

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

Objectives: To investigate the existing published evidence supporting the role of laryngopharyngeal reflux (LPR) in the development of the select nonfunctional laryngeal diseases of laryngotracheal stenosis, granuloma, leukoplakia, and laryngeal infections.

Data Sources: PubMed, Cochrane Library, and Scopus.

Review Methods: A systematic review was performed by 3 independent investigators for studies providing information about the prevalence and role of LPR in the development of laryngotracheal stenosis, granuloma, leukoplakia, and laryngeal infections. Diagnostic criteria and clinical outcome evaluation of included studies were analyzed with PRISMA criteria.

Results: Of the 64 relevant publications, 27 clinical and 4 basic science studies were included. Ten studies used objective reliable examinations for LPR diagnosis (eg, dual- or triple-probe or oropharyngeal pH monitoring, multichannel intraluminal impedance-pH monitoring, or pepsin detection). According to the bias analysis and the results of studies, the association between LPR and laryngotracheal stenosis, leukoplakia, laryngeal papillomatosis, or vocal fold granuloma remains poorly demonstrated. There is a notable heterogeneity among included studies regarding their inclusion criteria, diagnostic methods, and clinical outcome evaluation. Although some experimental findings support the involvement of bile salts and other gastroduodenal proteins active in alkaline pH, no included clinical studies assessed the role of nonacid and mixed reflux through multichannel intraluminal impedance-pH monitoring.

Conclusion: The involvement of LPR in the development of leukoplakia, laryngotracheal stenosis, vocal fold granuloma, and laryngeal papillomatosis is currently not demonstrated. The potential relationship between LPR and these select nonfunctional laryngeal diseases must be confirmed through future clinical and experimental studies considering acid, nonacid, and mixed LPR.
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http://dx.doi.org/10.1177/0194599820933209DOI Listing
January 2021

Laryngeal Pathologies and Their Associations With Mental Health Disorders.

Laryngoscope 2021 01 8;131(1):E231-E239. Epub 2020 Jun 8.

Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, Sweden.

Objectives: Mental health disorders are very common. Understanding their clinical manifestations in terms of voice and laryngeal disorders (VLD) is important because they constitute a significant proportion of all patients seen by otolaryngology-head and neck surgery. In this study, we examine different mental disorders (MDs) and their presenting symptoms and diagnoses of VLD.

Methods: Case series study, retrospective chart review of patients seen between January 2016 and December 2017 at the Johns Hopkins Voice Center. Diagnoses, demographic data, and comorbidities were collected. VLD were grouped into categories (laryngeal pathology, functional voice disorders, airway, swallowing, other) for statistical analysis.

Results: Of a total 4,249 patients, 836 patients (19.7%) suffered from at least one MD. Those patients presented more frequently with swallowing problems (24.9% of all diagnoses in MD compared to 21.2% in control group; adjusted odds ratio [aOR] 1.280, 95% confidence interval [CI] 1.107-1.480, P = .001) and less frequently with vocal cord pathology (30.9% of all diagnoses in MD compared to 33.9% in control group, aOR 0.793, 95% CI 0.694-0.907, P = .001). Patients suffering from depression had significantly increased odds for dysphagia (aOR 1.570, 95% CI 1.216-2.026, P = .001). VLD clinical presentation profile was created for every MD studied.

Conclusion: Patients suffering from mental health disorders present more frequently with swallowing complaints, in particular for dysphagia. Awareness of this can guide appropriate referrals. Objective laryngeal findings are common in patients with substance abuse disorders. They should be screened with careful diagnostic laryngoscopy.

Level Of Evidence: 4 Laryngoscope, 131:E231-E239, 2021.
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http://dx.doi.org/10.1002/lary.28755DOI Listing
January 2021

Chronic Pain Syndromes and Their Laryngeal Manifestations.

JAMA Otolaryngol Head Neck Surg 2020 06;146(6):543-549

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

Importance: Fibromyalgia syndrome (FMS), irritable bowel syndrome (IBS), and chronic fatigue syndrome (CFS) are traditionally considered as distinct entities grouped under chronic pain syndrome (CPS) of an unknown origin. However, these 3 disorders may exist on a spectrum with a shared pathophysiology.

Objective: To investigate whether the clinical presentation of FMS, IBS, and CFS is similar in a population presenting with voice and laryngeal disorders.

Design, Setting, And Participants: This case series was a retrospective review of the medical records and clinical notes of patients treated between January 1, 2016, and December 31, 2017, at the Johns Hopkins Voice Center in Baltimore, Maryland. Patients with at least 1 CPS of interest (FMS, IBS, or CFS) were included (n = 215), along with patients without such diagnoses (n = 4034). Diagnoses, demographic, and comorbidity data were reviewed. Diagnoses related to voice and laryngeal disorders were subdivided into 5 main categories (laryngeal pathology, functional voice disorders, airway problems, swallowing problems, and other diagnoses).

Main Outcomes And Measures: Prevalence and odds ratios of 45 voice and laryngeal disorders were reviewed. Odds ratios (ORs) were calculated by comparing patients with CPS with control patients.

Results: In total, 4249 individuals were identified; 215 (5.1%) had at least 1 CPS and 4034 (94.9%) were control participants. Patients with CPS were 3 times more likely to be women compared with the control group (173 of 215 [80.5%] vs 2318 of 4034 [57.5%]; OR, 3.156; 95% CI, 2.392-4.296), and the CPS group had a mean (SD) age of 57.80 (15.30) years compared with the mean (SD) age of 55.77 (16.97) years for the control group. Patients with CPS were more likely to present with functional voice disorders (OR, 1.812; 95% CI, 1.396-2.353) and less likely to present with laryngeal pathology (OR, 0.774; 95% CI, 0.610-0.982) or airway problems (OR, 0.474; 95% CI, 0.285-0.789).

Conclusions And Relevance: The voice and airway presentation of patients with FMS, IBS, and/or CFS appears to be indistinguishable from each other. This finding suggests that these 3 diseases share upper airway symptoms.
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http://dx.doi.org/10.1001/jamaoto.2020.0530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7193518PMC
June 2020

CT Lung Screening in Patients with Laryngeal Cancer.

Sci Rep 2020 03 13;10(1):4676. Epub 2020 Mar 13.

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

Laryngeal cancer (LC) patients who meet the age and smoking criteria of the U.S. Preventive Services Task Force (USPSTF) for annual CT lung screening were analysed for pulmonary nodules (PN) detection and secondary lung cancer (SLC) diagnosis. This is a retrospective chart review of LC patients treated at Johns Hopkins Hospital from January 2010 to December 2017. The study population included patients who met USPSTF criteria by age and smoking history for annual chest screening and were followed for at least 3 consecutive years. A total of 998 LC patients' records were reviewed, of which 151 met the inclusion criteria. Inadequate follow-up period (37% of excluded cases) was the most common reason for exclusion, followed by not meeting USPSTF age criteria (27% excluded cases). In seventy-eight patients (n = 78, 52% of analysed patients) PN were reported. Nine individuals (6% of analysed patients) were diagnosed with SLC. Age over 70 (p = 0.003) was an independent predictor of malignancy. White race and smoking history over 40 pack-years were positively associated with a pulmonary nodule detection (p = 0.037 and p = 0.044, respectively). The incidence of PN and SLC in patients with LC is high. Many patients with laryngeal cancer meet the formal guidelines for USPSTF screening, and should be screened annually according to evidence-based medicine for the early detection of secondary lung cancers.
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http://dx.doi.org/10.1038/s41598-020-61511-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7070077PMC
March 2020

Is empirical treatment a reasonable strategy for laryngopharyngeal reflux? A contemporary review.

Clin Otolaryngol 2020 07 26;45(4):450-458. Epub 2020 Mar 26.

Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France.

Background: Diagnosis and treatment of presumed laryngopharyngeal reflux (LPR) remain controversial. Empiric medication trials remain widespread for suspected LPR despite emerging evidence against proton pump inhibitor (PPI) safety and for pepsin as a mediator of LPR symptoms. Ongoing concerns exist related to inaccurate diagnosis, the cost and morbidity of potentially unnecessary PPI prescriptions, and availability and interpretation of objective reflux testing.

Objectives: To review contemporary evidence that does and does not support empiric medication trials for presumed LPR.

Methods: PubMed, Scopus and Cochrane Library were searched for literature about benefits, limitations and alternatives to empiric medication trial for LPR, in order to present both sides of this debate and identify best practices.

Results: The majority of physicians perform prolonged empiric medication trial with PPIs for patients with suspected LPR. Because symptoms and signs of LPR are non-specific, empiric medication trials require exclusion of other conditions that can mimic LPR. Following a PPI empiric medication trial, over one-third of patients remain non-responders. The use of hypopharyngeal-oesophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) has benefits and limitations in objective diagnosis of LPR.

Conclusions: Use of PPIs for single-agent empiric medication trial does not account for possible non-responders with non-acid or mixed LPR. If LPR diagnosis remains uncertain, alginates can be added to PPI trials. HEMII-pH testing upfront is ideal for patients with suspected LPR, but not always practical; it is indicated when PPI and alginate empiric medication trials have failed or when comorbidities confuse the diagnosis. A more comprehensive, combination therapy empiric medication trial regimen may be needed.
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http://dx.doi.org/10.1111/coa.13518DOI Listing
July 2020

Sirolimus for the Treatment of Airway Obstruction due to Indolent T-Lymphoblastic Proliferation.

Case Reports Immunol 2019 9;2019:1724083. Epub 2019 Dec 9.

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Introduction: Indolent T-lymphoblastic proliferation (iT-LBP) is a rare nonmalignant entity that presents as a proliferation of T-lymphoblasts. We report a first such case with a recurrent laryngeal obstruction presentation that was successfully controlled with Sirolimus.

Case Presentation: This is the case of a 29-year-old female who presented with a recurrent significant lymphoid hyperplasia in the adenoid and tongue base region as well as a right cervical lymph node. After repeated adenoidectomies and tonsillectomies, and based on pathological and clinical findings she was diagnosed with iT-LBP. Trials of radiotherapy and immunotherapy with cyclosporine and rituximab all failed to control the progression of the disease. Sirolimus was finally able to restrict the growth and improve her symptoms.

Conclusion: While It-LBP does not usually require treatment, it is important to report cases in which treatment was crucial for the survival of the patient, and the effective role of Sirolimus in doing so, without any major adverse effects.
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http://dx.doi.org/10.1155/2019/1724083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6959153PMC
December 2019

The Use of 532-Nanometer-Pulsed Potassium-Titanyl-Phosphate (KTP) Laser in Laryngology: A Systematic Review of Current Indications, Safety, and Voice Outcomes.

Ear Nose Throat J 2021 Feb 13;100(1_suppl):4S-13S. Epub 2020 Jan 13.

Department of Otolaryngology-Head and Neck Surgery, 1501Johns Hopkins School of Medicine, Baltimore, MD, USA.

Objective: To investigate the indications, efficacy, safety, and outcomes of potassium-titanyl-phosphate (KTP) laser procedures for treatment of laryngeal disease.

Methods: PubMed, Cochrane Library, and Scopus were searched for studies providing information about the indications, efficacy, and safety of both in-office and operative suspension microlaryngoscopy KTP laser procedure in treatment of laryngeal disease. Diagnostic criteria and clinical outcome evaluation of included studies were analyzed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.

Results: Of the initial screened 140 papers, 17 met our inclusion criteria. Six papers involved KTP laser procedures for benign and malignant vocal fold lesions in suspension microlaryngoscopy only, 10 papers focused on only in-office KTP laser procedures for benign vocal fold lesions, and 1 paper included both in-office and suspension microlaryngoscopy procedures. The following lesions may be considered as indications for KTP laser procedures: Reinke's edema, sulcus vocalis, vocal fold hemorrhage, polyp, granuloma, cyst, scar, papillomatosis, dysplasia, leukoplakia, and early vocal fold malignancies. Irrespective of the types of procedure (in-office vs suspension microlaryngoscopy), the KTP laser is associated with a low complication rate and overall good vocal fold vibration recovery. There is an important heterogeneity among studies concerning laser settings, indications, and outcomes used for the assessment of treatment effectiveness. There are no controlled studies directly comparing KTP laser with other lasers (ie, carbon dioxide laser).

Conclusion: The use of KTP laser procedures for treatment of laryngeal disease has increased over the past decade, especially for office-based management of vocal fold lesions. Future controlled studies are needed to compare the safety and outcomes of the KTP laser to other techniques.
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http://dx.doi.org/10.1177/0145561319899183DOI Listing
February 2021

Do Laryngologists and General Otolaryngologists Manage Laryngopharyngeal Reflux Differently?

Laryngoscope 2020 10 8;130(10):E539-E547. Epub 2020 Jan 8.

Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies, Paris, France.

Objective: To investigate current practices of laryngologists and non-laryngologists in management of Laryngopharyngeal Reflux (LPR).

Methods: An online survey was sent to members of otolaryngology societies about LPR, and subgroup analysis was performed between laryngologists and non-laryngologists. This survey was conducted by the LPR Study Group of Young Otolaryngologists of the International Federation of Otolaryngological Societies.

Results: A total of 535 otolaryngologists completed the survey. Among them, 127 were laryngologists and 408 were non-laryngologists. Collectively, symptoms most commonly attributed to LPR are cough after lying down/meal, throat clearing, and acid brash; most common findings are thought to be arytenoid erythema and posterior commissure hypertrophy. Respectively, 12.5% and 5% of non-laryngologists and laryngologists believe that ≥50% of LPR patients suffer from heartburn (P = .010). Non-laryngologists are more aware about some extra-laryngeal findings associated with LPR (eg, pharyngeal erythema) than laryngologists. Neither laryngologists nor non-laryngologists associated development of benign lesions of the vocal folds with reflux. The management of LPR substantially differs between groups, with laryngologists indicating increased awareness of (impedance)-pH monitoring as well as the prevalence and treatment of nonacid/mixed LPR. Conversely, non-laryngologists are much more likely to include gastroenterology referral in their management of presumed LPR. Respectively, 44.8% and 27.6% of non-laryngologists and laryngologists believe themselves not sufficiently knowledgeable about LPR.

Conclusions: Significant differences exist between laryngologists and non-laryngologists in diagnosis and treatment of LPR. Overall only one-third of responders believe themselves to be sufficiently educated about LPR.

Level Of Evidence: 4 Laryngoscope, 130:E539-E547, 2020.
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October 2020

Microlaryngeal Teaching Courses: A National Survey on Prevalence, Value, and Barriers to Implementation.

Ann Otol Rhinol Laryngol 2020 Feb 15;129(2):101-109. Epub 2019 Sep 15.

Division of Laryngology, Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University, Suburban Hospital, Bethesda MD, Johns Hopkins Hospital, Baltimore, MD, USA.

Objective: To assess the prevalence of microlaryngeal teaching course in Accreditation Council for Graduate Medical Education (ACGME)-accredited otolaryngology residency programs in an effort to evaluate the nature, perceived value and barriers to implementation of microlaryngeal courses.

Method: A 14-question survey to all ACGME-accredited otolaryngology programs in the United States.

Result: Out of 119 ACGME-accredited otolaryngology programs identified on the ACGME Fellowship and Residency Electronic Interactive Database, responses were received from 67 programs (56%). Although 90% of respondents indicated that instruction courses in one discipline or another existed at their institution for their otolaryngology residents, only 33% indicated that their program offers a hands-on instruction course in microlaryngeal surgery. Of those programs that offered a microlaryngeal surgery course, 100% felt the residents appreciated the course; 95% of those programs that did not have a course felt their residents would appreciate a microlaryngeal course at their institution if they were able to offer one. Among programs without a microlaryngeal teaching course, the largest perceived barriers were cost and availability of appropriate equipment.

Conclusion: Microlaryngeal courses for otolaryngology residency training are limited in availability in the United States, and there is variability in training across the country. All respondents in our survey indicated the value in these courses for microlaryngeal surgical skill training. There is a clear role for increasing availability of low-cost microlaryngeal stations and courses.
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http://dx.doi.org/10.1177/0003489419876290DOI Listing
February 2020

Awareness of European Otolaryngologists and General Practitioners Toward Laryngopharyngeal Reflux.

Ann Otol Rhinol Laryngol 2019 Nov 1;128(11):1030-1040. Epub 2019 Jul 1.

Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS).

Objectives: To investigate the current trends in management of laryngopharyngeal reflux (LPR) among young European otolaryngologists and general practitioners (GP).

Methods: An international survey was sent to European general practitioners and all otolaryngologists under 45 years old from the 2017 IFOS meeting. This survey was conducted by the LPR Study Group of YO-IFOS (Young Otolaryngologists of the International Federation of Otolaryngological Societies).

Results: Among the 2500 attendees, 230 European otolaryngologists (response rate = 9%) completed the survey; an additional 70 GPs also completed the survey. GPs did not differentiate between gastroeosophageal reflux disease (GERD) and LPR, overstating GERD-related symptoms (ie, heartburn and regurgitations) in LPR clinical presentation and relying on gastrointestinal endoscopy for LPR diagnosis. Otolaryngologists also believe that GERD-related symptoms are prevalent in LPR. Knowledge of nonacid and mixed LPR and use of multichannel intraluminal impedance-pH monitoring are still limited in both groups. A therapeutic dichotomy exists between groups: GPs mainly use a 4-week once daily empiric proton pump inhibitors (PPIs) trial, while otolaryngologists use PPIs twice daily for a longer therapeutic period ranging from 8 to 12 weeks. More than 50% of GPs and otolaryngologists believe that they are not adequately knowledgeable and skilled about LPR.

Conclusion: The majority of GPs and otolaryngologists do not believe themselves to be sufficiently informed about LPR, leading to different practice patterns and grey areas. The elaboration of international recommendations in the management of reflux is needed to improve practices.
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http://dx.doi.org/10.1177/0003489419858090DOI Listing
November 2019
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