Publications by authors named "Matthew R Hoffman"

96 Publications

The radial forearm snake flap: An underutilized technique for fasciocutaneous and osteocutaneous forearm flaps with primary closure.

Head Neck 2022 05 14;44(5):1106-1113. Epub 2022 Feb 14.

Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA.

Background: The radial forearm free flap (RFFF) is associated with troublesome donor site morbidity related to split thickness skin grafting (STSG). The radial forearm snake flap with primary closure of the donor site may reduce donor site complications.

Methods: Single institution, retrospective cohort study comparing rates of delayed donor site wound healing and tendon exposure in 52 patients undergoing radial forearm snake flap and 95 patients undergoing conventional RFFF with STSG closure of the donor site.

Results: Tendon exposure occurred in zero (0%) patients undergoing snake flap and four (4.2%) patients undergoing conventional RFFF (0/52 vs. 4/95; p = 0.297). Delayed wound healing occurred in zero (0%) patients undergoing snake flap and 19 (20.0%) patients undergoing conventional RFFF (0/52 vs. 19/95; p < 0.001).

Conclusions: The radial forearm snake flap provides an alternative to conventional RFFF harvest, which enables primary donor site closure with reduced rates of delayed donor site healing.
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http://dx.doi.org/10.1002/hed.27004DOI Listing
May 2022

The Voice Problem Impact Scales (VPIS).

J Voice 2021 Dec 18. Epub 2021 Dec 18.

UAB Voice Center, Otolaryngology Head and Neck Surgery, University of Alabama, Birmingham, Alabama. Electronic address:

Introduction: Patient-reported outcome measures (PROMs) are important for systematically assessing a person's perspectives and experiences with disease to inform clinical decision-making. However, PROMs can occasionally fail to capture subtle differences amongst subgroups. In response to this problem, the aim of the current study was to examine the convergent validity of four patient-reported voice activity and participation scales to better reflect and describe the impact of a voice problem in a patient's work, home, social and overall life. It was hypothesized that augmenting the validated PROM with a directed situational short instrument may enhance patient and clinician communication. This would allow for further description of individual areas of activity limitations or participation restrictions that are relevant to the patient, potentially informing therapeutic goals.

Methods: The Voice Problem Impact Scales (VPIS) were developed following the criteria outlined by Francis et al (2016). A retrospective chart review was completed for voice therapy treatment seeking patients at the USC Voice Center. Results from the Voice Handicap Index-10 (VHI-10) and VPIS scores were recorded at the time of the evaluation. Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) assessment was performed by an SLP with fellowship training in voice.

Results: Three hundred four charts were reviewed, and 198 met inclusion criteria. When considering all patients, VHI-10 scores were significantly correlated with each domain of the VPIS, including overall (R = 0.635, P < 0.001), work (R = 0.436, P < 0.001), social (R = 0.714, P < 0.001), and home (R = 0.637, P < 0.001). For females aged 18-39 and aged ≥60, the VHI-10 was correlated with all domains except work. CAPE-V score was significantly correlated with the social domain (R = 0.236, P = 0.001). Using the corrected significance level, it was not correlated with the overall (R = 0.165, P = 0.022), home (R = 0.197, P = 0.006), or work domains (R = 0.042, P = 0.567). The VHI-10 was not correlated with any of the VPIS domains for males aged 18-39, was correlated with all domains for males aged 40-59, and was correlated with all domains except work for males aged ≥60. Age was the only significant predictor of the work domain (β = -4.631 P < 0.001), with a model fit of R = 0.101.

Conclusions: Scores from each domain of the VPIS are significantly correlated with VHI-10 scores thus confirming the instrument's convergent validity. There are certain groups for which currently used questionnaires may underrepresent the impact of dysphonia on the patient's life. The VPIS represents a broad tool that might allow the patient to interpret each scale within their individual context and cultural background. The VPIS emphasizes the significance of the dysphonia on quality of life in four common environments. Using this instrument can augment questionnaires and initiate conversations between the provider and patient to determine the area(s) where voice impairment is most important enhancing shared decision-making on therapeutic goals for plan of care.
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http://dx.doi.org/10.1016/j.jvoice.2021.11.011DOI Listing
December 2021

Effect of Medialization on Dyspnea Index in Unilateral Vocal Fold Paralysis.

Otolaryngol Head Neck Surg 2021 Nov 9:1945998211056515. Epub 2021 Nov 9.

Department of Otolaryngology-Head and Neck Surgery, University of Alabama-Birmingham, Birmingham, Alabama, USA.

Objective: Patients with unilateral vocal fold paralysis commonly report dysphonia and dysphagia. Dyspnea also occurs, with studies on treatment-related change producing mixed results. Studies including patient-reported outcomes have focused on single-question global scales. The Dyspnea Index (DI) includes 10 questions, is specific to upper airway-related dyspnea, and may better capture these patients' symptoms. We evaluated change in DI after treatment.

Study Design: Retrospective review.

Setting: Academic medical center.

Methods: Forty-three patients with unilateral vocal fold paralysis underwent injection augmentation (n = 25) or framework surgery (n = 18). DI was recorded preprocedure, 2 to 4 weeks afterward, and at approximately 3 months afterward in 19 patients. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 were also recorded. Change in parameters and correlations were assessed. Obesity, cardiac disease, pulmonary disease, and procedure (injection vs framework surgery) were evaluated for effect on DI.

Results: Twenty-four patients had an abnormal baseline DI (>10). DI decreased from 14.9 ± 13.8 to 6.5 ± 9.3 after treatment ( < .001; 95% CI, 4.7-12.1). Twenty-eight scores decreased, 9 remained unchanged, and 6 increased. Change in DI was influenced by the presence of cardiac disease. Decreased DI persisted at 3-month follow-up. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 scores decreased and were correlated with change in DI.

Conclusion: Upper airway-related dyspnea is common in unilateral vocal fold paralysis, occurring in half of this cohort. Correcting glottic insufficiency may alleviate symptoms. Treatment decision making should consider postprocedural change in dyspnea, especially in patients for whom dyspnea is a motivating factor for seeking treatment.
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http://dx.doi.org/10.1177/01945998211056515DOI Listing
November 2021

Impact of Adjuvant Medical Therapies on Surgical Outcomes in Idiopathic Subglottic Stenosis.

Laryngoscope 2021 12 12;131(12):E2880-E2886. Epub 2021 Jun 12.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A.

Objectives/hypothesis: Adjuvant medications including proton pump inhibitors (PPI), antibiotics (trimethoprim/sulfamethoxazole [TMP-SMX]), and inhaled corticosteroids (ICS) may be prescribed for patients with idiopathic subglottic stenosis (iSGS). We describe medication use with endoscopic dilation (ED) or endoscopic resection with medical treatment (ERMT) and evaluate impact on outcomes.

Study Design: International, prospective, 3-year multicenter cohort study of 810 patients with untreated, newly diagnosed, or previously treated iSGS.

Methods: Post hoc secondary analysis of prospectively collected North American Airway Collaborative data on outcomes linked with adjuvant medication utilization. Primary outcome was time to recurrent operation, evaluated using Kaplan-Meier curves and Cox regression analysis. Secondary outcomes of change in peak expiratory flow (PEF) and clinical chronic obstructive pulmonary disease questionnaire (CCQ) score over 12 months were compared.

Results: Sixty-one of 129 patients undergoing ED received PPI (47%), and 10/143 patients undergoing ED received ICS (7%). TMP-SMX was used by 87/115 patients (76%) undergoing EMRT. PPI use in the ED group did not affect time to recurrence (hazard ratio [HR] = 1.00, 95% confidence interval [CI]: 0.53-1.88; P = .99) or 12-month change in PEF (L/min) (median [interquartile range], 12.0 [10.7-12.2] vs. 8.7 [-5.1 to 24.9]; P = .59), but was associated with 12-month change in CCQ (-0.05 [-0.97 to 0.75] vs. -0.50 [-1.60 to 0.20]; P = .04). ICS did not affect outcome measures. TMP-SMX use in ERMT did not affect time to recurrence (HR = 0.842, 95% CI: 0.2345-3.023; P = .79), PEF at 12 months (75 [68-89] vs. 81 [68-89]; P = .92), or 12-month change in CCQ (0.20 [-1.05 to 0.47] vs. -0.30 [-1.00 to 0.10]; P = .45).

Conclusion: There is no standard practice for prescribing adjuvant medications. These data do not support that adjuvant medications prolong time to recurrence or increase PEF. Patients with iSGS and gastroesophageal reflux disease may experience some symptom benefit with PPI.

Level Of Evidence: 3 Laryngoscope, 131:E2880-E2886, 2021.
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http://dx.doi.org/10.1002/lary.29675DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8762605PMC
December 2021

Pre-tracheotomy for Potentially Emergent Airway Scenarios: Indications and Outcomes.

Laryngoscope 2021 11 22;131(11):E2802-E2809. Epub 2021 May 22.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A.

Objectives/hypothesis: Airway access in the setting of unsuccessful ventilation and intubation typically involves emergent cricothyrotomy or tracheotomy, procedures with associated significant risk. The potential for such emergent scenarios can often be predicted based on patient and disease factors. Planned tracheotomy can be performed in these cases but is not without its own risks. We previously described a technique of pre-tracheotomy or exposing the tracheal framework without entering the trachea, as an alternative to planned tracheostomy in such cases. In this way, a tracheotomy can be easily completed if needed, or the wound can be closed if it is not needed. This procedure has since been used in an array of indications. We describe the clinical situations where pre-tracheotomy was performed as well as subsequent patient outcomes.

Methods: Retrospective series of patients undergoing a pre-tracheotomy from 2015 to 2020. Records were reviewed for patient characteristics, indication, whether the procedure was converted to tracheotomy or closed at the bedside, and any post-procedural complications.

Results: Pre-tracheotomy was performed in 18 patients. Indications included failed extubation after head and neck reconstruction, subglottic stenosis, laryngeal masses, laryngeal edema, thyroid masses, and an oropharyngeal bleed requiring operative intervention. Tracheotomy was avoided in 10 patients with wound closed at the bedside; procedure was converted to tracheotomy in the remaining eight. There were no complications. Indications for conversion included failed extubation, intraoperative hemorrhage, significant stridor with dyspnea, and inability to ventilate.

Conclusion: Pre-tracheotomy offers simplified airway access and provides a valuable option in scenarios where tracheotomy may, but not necessarily, be needed.

Level Of Evidence: 4 Laryngoscope, 131:E2802-E2809, 2021.
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http://dx.doi.org/10.1002/lary.29612DOI Listing
November 2021

Spectral arc length as a method to quantify pharyngeal high-resolution manometric curve smoothness.

Neurogastroenterol Motil 2021 10 20;33(10):e14122. Epub 2021 Apr 20.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Background: Pharyngeal high-resolution manometry (HRM) has emerged over the last decade as a valuable assessment tool for oropharyngeal dysphagia. Data analysis thus far has focused primarily on measures of pressure and duration within key anatomic regions. We apply spectral arc length (SPARC), a dimensionless metric for quantifying smoothness felt to indirectly reflect neuromuscular coordination, as a new method of describing manometric curves. We then use it to distinguish swallows from healthy subjects and those with dysphagia related to stroke.

Methods: Previously collected pharyngeal HRM data from eight subjects with history of stroke and eight age- and sex-matched controls were reviewed. Receiver operating characteristic (ROC) analysis was used to optimize SPARC inputs. SPARC was then computed for the velopharynx, tongue base, hypopharynx, and upper esophageal sphincter (UES), and the values were compared between the two subject groups.

Results: Optimized parameter settings yielded an ROC curve with area under the curve (AUC) of 0.953. Mean SPARC values differed between control and stroke subjects for the velopharynx (t = 3.25, p = 0.0058), tongue base (t = 4.77, p = 0.0003), and hypopharynx (t = 2.87, p = 0.0124). Values were similar for the UES (t = 0.43, p = 0.671).

Conclusions: In this preliminary study, SPARC analysis was applied to distinguish control from post-stroke subjects. Considering alternative methods of analyzing pharyngeal HRM data may provide additional insight into the pathophysiology of dysphagia beyond what can be gleaned from measures of pressure and duration alone.
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http://dx.doi.org/10.1111/nmo.14122DOI Listing
October 2021

Pain Experience and Tolerance of Awake In-Office Upper Airway Procedures: Influencing Factors.

Laryngoscope 2021 05 16;131(5):E1580-E1588. Epub 2020 Nov 16.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A.

Objectives/hypothesis: Awake, unsedated in-office upper airway procedures are performed frequently and have high completion rates, yet less is known about the patients' pain experience and potentially influencing factors. It is also unclear if patients' pain experiences become worse with repeated procedures. We identified procedure- and patient-related factors that might influence procedural completion and pain scores.

Study Design: Retrospective chart review.

Methods: Pre-, intra-, and post-procedure pain scores were collected prospectively for awake unsedated upper airway procedures performed at a single institution over a 5-year period. Patient factors reviewed were demographics, body mass index, psychiatric and/or pain diagnosis, and related medications. Procedure factors reviewed were procedure type, route, side, and performance of the same procedure multiple times. Patients reported their pain level before, during, and after the procedure using a standard 0 to 10 scale. Maximum pain score change (PΔmax), or the difference between highest and lowest reported pain levels, was calculated. Descriptive and multivariate analyses were performed.

Results: Procedure completion was 98.7% for 609 first time patients and 99.0% in 60 patients undergoing 292 repeat procedures. PΔmax did not covary with age, gender, or BMI. PΔmax covaried with pain and psychiatric conditions and associated medications. PΔmax was highest for injection medialization and lowest for tracheoscopy. PΔmax decreased over time for those undergoing multiple identical procedures.

Conclusions: Procedures were performed with a very high completion rate and low pain scores. Age, sex, and BMI did not affect pain experience. A combination of pain and psychiatric conditions did. Injection medialization had the highest PΔmax and tracheoscopy the lowest.

Level Of Evidence: 4 Laryngoscope, 131:E1580-E1588, 2021.
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http://dx.doi.org/10.1002/lary.29238DOI Listing
May 2021

Pressure abnormalities in patients with Zenker's diverticulum using pharyngeal high-resolution manometry.

Laryngoscope Investig Otolaryngol 2020 Aug 4;5(4):708-717. Epub 2020 Aug 4.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery University of Wisconsin-Madison Madison Wisconsin USA.

Objectives: Zenker's diverticulum is associated with reduced cricopharyngeal compliance and abnormal intrabolus pressure. However, it is unclear how the pharynx compensates for these deficits. Developments in manometric technology have improved our ability to capture pharyngeal pressure events. This study aims to describe the pharyngeal-upper esophageal sphincter (UES) pressure profile during swallowing in patients with Zenker's diverticulum.

Methods: High-resolution manometry was performed on 11 patients with symptomatic Zenker's diverticulum and 11 age- and sex-matched healthy controls during 10 mL liquid swallowing tasks. Pharyngeal and UES pressure magnitudes, durations, and integrals were compared between patients and controls using independent tests. Other manometric parameters, including residual UES pressure at the time of maximum tongue base pressure and pharyngeal-UES pressure gradient, were also evaluated. A case example using three-dimensional high-resolution manometry is presented.

Results: Compared with healthy controls, patients with Zenker's diverticulum exhibited pressure abnormalities in the UES region. While baseline and pre-opening maximum pressures were not different, residual pressures were elevated ( = .001). Pharyngeal-UES pressure gradients did not differ between the two groups.

Conclusion: This study used high-resolution manometry to characterize pharyngeal pressure dynamics in patients with Zenker's diverticulum. The changes occurring at the cricopharyngeus appear to result in persistent UES pressurization during UES opening, rather than high tonic resting pressure. Pharyngeal-UES pressure gradients, critical to bolus passage, were also preserved in this patient population.

Level Of Evidence: 3b.
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http://dx.doi.org/10.1002/lio2.434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444802PMC
August 2020

Simulation of Pediatric Endoscopic Cricoid Reduction and Expansion.

OTO Open 2020 Jul-Sep;4(3):2473974X20946268. Epub 2020 Jul 31.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.

Endoscopic cricoid expansion and reduction are newer approaches to the management of pediatric bilateral vocal fold immobility and postlaryngotracheal reconstruction glottic insufficiency, respectively. These procedures offer a less invasive, endoscopic alternative to procedures that typically required open management with a more prolonged recovery. These technically demanding procedures are currently performed only in select centers, and there is no currently described training model for practicing them. We present a modification to a laryngeal dissection station that allows for simulation of endoscopic cricoid reduction and expansion with excised larynges. The model allows trainees to practice endoscopic posterior cricoid exposure, incision of the cricoid cartilage, placement of a simulated costal cartilage graft for expansion, and endoscopic suturing for reduction. Development of simulators for procedures that are infrequently performed have the potential to help trainees reach surgical competency faster and more safely.
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http://dx.doi.org/10.1177/2473974X20946268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416139PMC
July 2020

Office-Based Steroid Injections for Idiopathic Subglottic Stenosis: Patient-Reported Outcomes, Effect on Stenosis, and Side Effects.

Ann Otol Rhinol Laryngol 2020 Apr 20;129(4):361-368. Epub 2019 Nov 20.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.

Objective: Office-based steroid injection has shown promise for idiopathic subglottic stenosis (iSGS). It is important to understand safety and patient-lived experience. We report patient experience related to airway restriction, voice, and side effects.

Methods: Sixteen patients (51 ± 14 years) with mild-moderate (20-50%) stenosis undergoing office-based transnasal steroid injections were included; fourteen had prior operations. Patients typically underwent three injections, 1 month apart, followed by transnasal tracheoscopy 1 month later to evaluate outcome; number of injections can vary based on disease severity and response. Outcomes were Dyspnea Index (DI), Modified Medical Research Council (MMRC) dyspnea scale, voice handicap index-10 (VHI-10), and degree of stenosis (estimated from procedural video). At each visit, patients were queried about post-injection airway restriction and side effects. Paired -tests compared values at baseline versus follow-up tracheoscopy.

Results: DI decreased ( = 3.938,  = 0.0013), as did MMRC ( = 2.179,  = 0.0457). There was no change in VHI-10 ( = 1.354;  = 0.1957) scores. Airway stenosis decreased ( = 4.331;  = 0.0006); this was not correlated with change in DI ( = 0.267,  = 0.318). Side effects included airway restriction lasting <48 hours (n = 5), cough (n = 3), and nasal pain (n = 2).

Conclusion: Steroid injections improved upper airway symptoms. Side effects were mild and transient. Improvement in DI did not correlate with percent stenosis.
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http://dx.doi.org/10.1177/0003489419889066DOI Listing
April 2020

Measurement Reliability of Laryngeal Resistance and Mean Flow Rate in Pediatric Subjects.

J Voice 2020 Jul 19;34(4):590-597. Epub 2019 Feb 19.

University of Wisconsin School of Medicine and Public Health, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Madison, Wisconsin. Electronic address:

Objective: Mean flow rate (MFR) and laryngeal resistance (R) are sensitive to changes in glottal configuration and biomechanics. There is little reported on aerodynamic parameters in children. We conducted a pilot study to evaluate MFR and R measurement reliability in a pediatric population using labial and mechanical interruption methods.

Method: Thirty-nine subjects aged 4-17 performed 10 trials per method. For labial interruptions, subjects produced five labial plosives at a comfortable amplitude. For mechanical interruptions, subjects maintained a steady /α/ while a balloon valve interrupted their airflow five times for 250 milliseconds each. MFR was measured as the flow through the interruption device between interruptions. R was calculated by dividing subglottal pressure (P) by MFR. The primary outcome measures of this study were the coefficients of variation of MFR and R. Paired t tests were used to compare each variable between the two methods. Pearson's correlation was used to analyze the relationship between each parameter and subject age.

Results: Mean P (t(38) = 2.966, P < 0.01) and R (t(38)=3.563, P < 0.01) were higher for labial interruptions while mean MFR (t(38) = -2.036, P < 0.05) was lower. Intrasubject coefficients of variation were higher for the labial technique for both MFR (t(38) = 4.939, P < 0.001) and R (t(38) = 3.439, P < 0.01) while there was no difference in P variability (P = 0.260). Mean MFR and R were related to age for both the labial (MFR: r = 0.588, P < 0.001; R: r = -0.468, p = 0.003) and mechanical trials (MFR: r = 0.534, P < 0.001; R: r = -0.496, P = 0.001). The coefficients of variation for R were negatively correlated with age for both labial (r = -0.415, P = 0.009) and mechanical trials (r = -0.471, P = 0.002). MFR was only correlated in the labial trials (r = -0.514, P = 0.001) and P was only correlated in the mechanical trials (r = -0.519, P = 0.001).

Conclusions: Differences in means and intrasubject variation are likely due to differences in task and measurement timing. Precision of MFR and R measurement in pediatric subjects was higher for mechanical interruption; further exploration of this method and its clinical utility is warranted. Measurement of aerodynamic parameters may be a useful addition to pediatric voice assessment.
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http://dx.doi.org/10.1016/j.jvoice.2019.02.005DOI Listing
July 2020

Measurement reliability of phonation threshold pressure in pediatric subjects.

Laryngoscope 2019 07 8;129(7):1520-1526. Epub 2018 Nov 8.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A.

Objectives/hypothesis: Phonation threshold pressure (PTP), the minimum subglottal pressure (P ) required for phonation, is sensitive to changes in laryngeal biomechanics and is often elevated with pathology. Little is reported on PTP in children; challenges with task performance and measurement reliability represent barriers to routine clinical assessment.

Study Design: Pilot study evaluating PTP and P measurement reliability in children using labial and mechanical interruption.

Methods: Twenty-two subjects aged 4 to 17 years (10.7 ± 3.9 years) participated. Ten trials were performed for each method; task order was randomized. For labial interruption, subjects produced /pα/ five times at softest (onset PTP) and comfortable amplitude. For mechanical interruption, subjects produced a sustained /α/ while a balloon valve interrupted phonation five times for 250 ms each; mechanical interruption was performed with a mouthpiece and mask. PTP was recorded as the difference between P and supraglottal pressure at phonation cessation (offset PTP). Mean PTP and P and intrasubject coefficients of variation were compared. Correlations with age were evaluated.

Results: Mean PTP (P < .001) and P (P = .005) were higher for labial interruption. Intrasubject coefficients of variation for PTP (P = .554) and P (P = .305) were similar across methods. Coefficient of variation was related to age for mechanical-mask trials only (r = -0.628, P = .00175).

Conclusions: Differences in means are likely related to differences in task and PTP hysteresis effect. Reliability is comparable with all methods; using a mouthpiece may be preferable to a mask for mechanical interruption. Measurement of PTP is noninvasive, reliable, and may be a useful adjunct in pediatric voice assessment.

Level Of Evidence: 3b Laryngoscope, 129:1520-1526, 2019.
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http://dx.doi.org/10.1002/lary.27418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506412PMC
July 2019

Idiopathic cervical tracheal stenosis in an 11-year-old male.

Int J Pediatr Otorhinolaryngol 2018 Oct 25;113:72-75. Epub 2018 Jul 25.

University of Wisconsin School of Medicine and Public Health, Department of Surgery - Division of Otolaryngology-Head and Neck Surgery, Madison, WI 53792, USA. Electronic address:

Idiopathic laryngotracheal stenosis is a fibroinflammatory stenosis in persons without alternative explanation such as trauma, intubation, or autoimmune disease. Patients are usually females of child-bearing age. We report on an 11-year-old male who developed progressive dyspnea and stridor. Bronchoscopy revealed 90% stenosis of the cervical trachea. He underwent serial balloon dilation with steroid injection; stenosis decreased to 20%. He had no history of intubation or trauma. Histologic and laboratory workup for autoimmune disease was negative. This report highlights occurrence of a well-known disease in an uncommon population, and alerts providers to consider this when seeing new pediatric patients with symptoms of progressive airway restriction.
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http://dx.doi.org/10.1016/j.ijporl.2018.05.013DOI Listing
October 2018

Delayed Presentation of Submucosal Retained Toothbrush from Self-Inflicted Injury in Patient with Schizophrenia.

Case Rep Emerg Med 2017 31;2017:2480140. Epub 2017 Dec 31.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Foreign body ingestion occurs in not only children but also adults, particularly those with history of neurologic disease, alcohol use, or psychiatric disease. We present the case of a 40-year-old male with schizophrenia who presented to the emergency room with a long history of pharyngeal foreign body sensation which had recently progressed to include trismus, odynophagia, and dyspnea. Flexible laryngoscopy demonstrated fullness of the right posterior pharyngeal wall and computed tomography (CT) showed a linear opaque foreign body extending from the level of the oropharynx to the thyroid ala. Further history elicited that he stabbed himself in the pharynx two years prior with a toothbrush following a command hallucination. The toothbrush was removed uneventfully via an external approach. The patient was discharged with psychiatry follow-up. This case is unusual due to the submucosal location of the foreign body and the length of retention. It demonstrates the atypical nature which patients with comorbid psychiatric illness may present following foreign body injury and the use of an external surgical approach for the removal of a retained foreign body based on CT reconstruction.
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http://dx.doi.org/10.1155/2017/2480140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804329PMC
December 2017

Simulation of KTP Laser-Based Zenker Diverticulotomy with a Porcine Model and Laryngeal Dissection Station.

OTO Open 2017 Dec 16;1(4). Epub 2017 Oct 16.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Zenker's diverticulum is a rare cause of progressive dysphagia that is treated surgically. KTP laser-based diverticulotomy is one effective treatment. Developing a simulation model is helpful for rare conditions. Pigs have a natural hypopharyngeal pouch similar to a diverticulum. We present a model for performing rigid endoscopic KTP laser diverticulotomy in a porcine model using a laryngeal dissection station. Eleven pigs were examined to confirm presence of the hypopharyngeal pouch. A specimen was mounted on the modified laryngeal dissection station and a KTP laser-based diverticulotomy was performed. Novel aspects include use of the laryngeal dissection station and application of the model for simulating rigid endoscopic KTP laser diverticulotomy. This model allows trainees to practice equipment setup, positioning of the laryngoscope to isolate the cricopharyngeal bar, tissue handling, laser safety techniques, and use of the KTP laser through the laryngoscope under microscopic visualization.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751941PMC
http://dx.doi.org/10.1177/2473974X17736288DOI Listing
December 2017

Comparing Videostroboscopy and Direct Microlaryngoscopy: An Argument for Flexible Consent and Operative Plan.

J Voice 2019 Mar 27;33(2):143-149. Epub 2017 Nov 27.

University of Wisconsin School of Medicine and Public Health, Department of Surgery-Division of Otolaryngology-Head and Neck Surgery, Madison, Wisconsin. Electronic address:

Introduction: Office-based evaluation of glottic lesions has progressed significantly, but there can still be discrepancies compared with direct microlaryngoscopy (DML) in the operating room. We performed a prospective evaluation comparing diagnosis of epithelial and lamina propria glottic lesions on rigid telescopic strobovideolaryngoscopy (RTS) with DML.

Methods: Fifty subjects were enrolled and underwent RTS followed by DML. We compared presence and extent (unilateral or bilateral) of lamina propria and epithelial lesions. Primary (diagnoses motivating an operation) and secondary (diagnoses not requiring an operation) were considered. Changes in diagnosis and operative plan based on DML findings were evaluated.

Results: Sixty-eight lesions were identified on RTS, including 53 primary (15 epithelial, 38 lamina propria) and 15 secondary diagnoses. RTS was accurate in only 36% of subjects. Ten subjects had a different primary pathology identified on DML. A change in surgical management occurred in 16% of subjects.

Conclusions: This is the first prospective study evaluating how both diagnosis and operative plan for epithelial and lamina propria glottic lesions differ based on RTS and DML. Despite significant advances in office-based diagnosis of glottic lesions, there are still notable limitations. Clinicians should consider these findings when counseling patients on interpretation and plan for findings based on RTS. Obtaining a flexible surgical consent and counseling patients on the potential for new diagnoses and interventions based on DML is warranted.
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http://dx.doi.org/10.1016/j.jvoice.2017.10.005DOI Listing
March 2019

Idiopathic Supraglottic Stenosis Refractory to Multiple Interventions Improved With Serial Office-based Steroid Injections.

J Voice 2018 Nov 31;32(6):767-769. Epub 2017 Oct 31.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Electronic address:

Purpose: The objective of this study was to describe a patient with idiopathic supraglottic stenosis who experienced persistent disease despite multiple office-based and operative interventions, whose disease is now better controlled with scheduled serial office-based steroid injections.

Methods: This is a case report and literature review.

Results: A 42-year-old female was referred for worsening supraglottic stenosis despite systemic steroids. She underwent awake tracheotomy. A thorough historical, histologic, and laboratory workup did not reveal an etiology to her stenosis. She later underwent endoscopic partial laryngectomy and was able to be decannulated. She underwent a second endoscopic partial laryngectomy two years later for worsening disease and then was managed over the next seven years with intermittent systemic steroids. Over the last year, she has undergone eight office-based steroid injections with improvement in her degree of stenosis and symptom burden.

Conclusions: There are only four prior reported cases of idiopathic supraglottic stenosis, none of which has been managed with serial office-based steroid injections. This case report adds to the small body of literature on the management of this rare disease and proposes a new office-based treatment pathway that may help induce regression of stenosis.
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http://dx.doi.org/10.1016/j.jvoice.2017.09.016DOI Listing
November 2018

Lymph Node Yield in Therapeutic Neck Dissection: Impact of Dissection Levels and Prior Radiotherapy.

Ann Otol Rhinol Laryngol 2017 Nov 26;126(11):762-767. Epub 2017 Sep 26.

1 Department of Surgery-Division of Otolaryngology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Objective: Lymph node yield in therapeutic neck dissection is clinically significant and incompletely studied. We quantified node yield based on extent of neck dissection and presence of preoperative radiation. We also evaluated factors affecting incidence of extracapsular spread (ECS).

Methods: Retrospective review of 499 patients undergoing therapeutic neck dissection; 414 patients met inclusion criteria and were divided into 2 groups: neck dissection alone or before radiation (surgery first: 280 patients; 385 dissections) and primary radiation before surgery (radiation first: 134 patients; 157 dissections). Node yield relative to levels dissected and incidence of ECS were examined.

Results: Dissection-specific node yield was greater in the surgery first group for dissection of levels I-V (31.1 ± 16.7 vs 24.0 ± 14.7, P < .001) and levels II-V (26.7 ± 14.4 vs 21.1 ± 10.7). Extracapsular spread incidence was 32.1% (98/305) in the surgery first group and 15.4% (23/149) in the radiation first group ( P < .001).

Conclusion: This study clarifies anticipated node yield based on number of levels dissected and presence of preoperative radiation. Node yield and incidence of ECS are lower in patients undergoing preoperative radiation.
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http://dx.doi.org/10.1177/0003489417730839DOI Listing
November 2017

Excised larynx evaluation of subthyroid cartilage approach to medialization thyroplasty.

Laryngoscope 2018 03 11;128(3):675-681. Epub 2017 Sep 11.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A.

Objectives/hypothesis: To describe an alternative approach to medialization thyroplasty involving dissection underneath the thyroid cartilage with placement of a Gore-Tex implant, and to evaluate its effect on a range of phonatory measures using an excised canine larynx model.

Study Design: Animal model.

Methods: On each of eight excised canine larynges, the conditions of normal, paralysis, medialization thyroplasty by standard transthyroid cartilage approach, and medialization thyroplasty by experimental subthyroid cartilage approach were performed. Aerodynamic, acoustic, and mucosal wave parameters were measured for each condition.

Results: Compared to the vocal fold paralysis state, both the transthyroid and subthyroid approaches for Gore-Tex insertion resulted in significant decreases in phonation threshold pressure and phonation threshold flow. Both approaches also significantly decreased percent jitter, decreased percent shimmer, and improved signal-to-noise ratio. The mucosal wave was preserved after insertion of the Gore-Tex implant for both approaches. For all the phonatory measures except phonation threshold flow, there were no significant differences between the transthyroid and subthyroid approaches.

Conclusions: Gore-Tex implantation via a subthyroid approach in an excised canine larynx model can produce effective medialization, preserve the mucosal wave, and significantly improve aerodynamic and acoustic parameters without meaningful difference compared to a traditional transthyroid approach. The subthyroid approach does not require creation of a thyroid cartilage window and could be a potentially valuable alternative method of performing medialization thyroplasty.

Level Of Evidence: NA. Laryngoscope, 128:675-681, 2018.
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http://dx.doi.org/10.1002/lary.26852DOI Listing
March 2018

Extent of Endoscopic Resection for Anterior Skull Base Tumors: An MRI-Based Volumetric Analysis.

J Neurol Surg B Skull Base 2017 Jun 21;78(3):227-234. Epub 2016 Dec 21.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States.

 To determine the volume of ventral skull base tumor removed following endoscopic endonasal (EEA) resection using MRI-based volumetric analysis and to evaluate the inter-rater reliability of such analysis.  Retrospective case series.  Academic tertiary care hospital.  EEA patients November 2012 to August 2015.  Volumetric analysis of pre- and immediately postoperative MR imaging was performed independently by two investigators. The percentage of total tumor resected was evaluated according to resection goal and tumor type.  A total of 39 patients underwent resection. Intraclass correlation coefficients between the raters were 0.9988 for preoperative and 0.9819 for postoperative images. Tumors (and average percentage removed) included 17 nonsecreting pituitary adenomas (95.3%), 8 secreting pituitary adenomas (86.2%), 4 meningiomas (81.6%), 3 olfactory neuroblastomas (100%), 2 craniopharyngiomas (100%), 1 large B-cell lymphoma (90.5%), 1 germ cell neoplasm (48.3), 1 benign fibrous connective tissue mass (93.4%), 1 epidermoid cyst (68.4%), and 1 chordoma (100%). For tumors treated with intent for gross total resection, 96.9 ± 4.8% was removed.  EEAs achieved tumor resection rates of ∼97% when total resection was attempted. The radiographic finding of residual tumor is of uncertain clinical significance. The volumetric analysis employed in this study demonstrated high inter-rater reliability and could facilitate further study.
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http://dx.doi.org/10.1055/s-0036-1597137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461163PMC
June 2017

Serial office-based steroid injections for treatment of idiopathic subglottic stenosis.

Laryngoscope 2017 11 5;127(11):2475-2481. Epub 2017 Jun 5.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A.

Objectives/hypothesis: Current treatment options for idiopathic subglottic stenosis include endoscopic interventions, resection, and tracheotomy. Recently, serial office-based steroid injections were proposed as an alternative that may stabilize or induce regression of airway stenosis without the need for repeated operations. Procedure completion rate, pain, complications, effect on stenosis, time since the last operation, and limitations have not been described.

Study Design: Retrospective case series.

Methods: Retrospective series of 19 patients undergoing serial office-based steroid injection for idiopathic subglottic stenosis. Outcome measures included completion rate, procedure-related pain scores, complications, percentage of airway stenosis, and time since the last operative intervention.

Results: Procedure completion rate was 98.8%. Average pain score during the procedure was 2.3 ± 1.7 on a 10-point scale. There were no immediate complications. One patient underwent awake tracheotomy 8 days after her second injection and was later decannulated. Average stenosis decreased from 35% ± 15% to 25% ± 15% (n = 16; P = .086) over the first of three injections and 40% ± 15% to 25% ± 10% to 20% ± 10% (n = 8; P = .002) for those patients completing two sets of three injections. Fourteen of 17 patients undergoing at least three injections have not returned to the operating room since the first injection.

Conclusions: Office-based steroid injection represents a promising new treatment pathway for a disease that requires long-term management, offering a purely pharmacologic approach to a disorder that has traditionally been approached from a mechanical perspective. It is safe, well tolerated, and effective. Furthermore, it may help patients and physicians avoid repeated trips to the operating room and the associated risks.

Level Of Evidence: 4. Laryngoscope, 127:2475-2481, 2017.
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http://dx.doi.org/10.1002/lary.26682DOI Listing
November 2017

Endoscopic Management of Idiopathic Subglottic Stenosis.

Ann Otol Rhinol Laryngol 2017 Feb 19;126(2):96-102. Epub 2016 Nov 19.

1 Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Objective: To describe a homogeneous idiopathic subglottic stenosis (ISS) population undergoing endoscopic balloon dilation and evaluate factors affecting inter-dilation interval (IDI).

Methods: Retrospective review of 37 patients. Co-morbidity prevalence versus normal population was evaluated using chi-square tests. Correlations were evaluated using Pearson product moment tests. Independent samples t tests/rank sum tests assessed differences between groups of interest.

Results: All patients were female aged 45.9 ± 15.4 years at diagnosis. Four required a tracheotomy during management. Most prevalent co-morbidity was gastroesophageal reflux disease (GERD) (64.9%; P = .036). Body mass indices (BMI) at first and most recent dilation were 29.8 and 30.8 ( P = .564). Degree of stenosis before first dilation was 53 ± 14%. Patients underwent 3.8 ± 1.8 dilations (range, 1-11). Average IDI was 635 ± 615 days (range, 49-3130 days), including 556 ± 397 days for patients receiving concomitant steroid injection and 283 ± 36 for those who did not ( P = .079). Inter-dilation interval was not correlated with BMI ( r = 0.0486; P = .802) or number of co-morbidities ( r = -0.225, P = .223).

Conclusions: Most patients with ISS can be managed endoscopically, and IDI may be increased with steroid injection. Gastroesophageal reflux disease is a common co-morbidity. Body mass index did not change over time despite potential effects on exercise tolerance; BMI did not affect IDI. Methods to determine optimal timing for next intervention are warranted.
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http://dx.doi.org/10.1177/0003489416675357DOI Listing
February 2017

Voice Outcomes following a Single Office-Based Steroid Injection for Vocal Fold Scar.

Otolaryngol Head Neck Surg 2016 11 9;155(5):820-828. Epub 2016 Aug 9.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA

Objective: Persistent dysphonia from vocal fold scar remains a clinical challenge, with current therapies providing inconsistent outcomes. We evaluated voice outcomes after a single office-based steroid injection.

Study Design: Case series with chart review.

Setting: Academic medical center.

Subjects And Methods: This study was based on pre- and postoperative analysis of patient-reported, perceptual, acoustic, aerodynamic, and videostroboscopic parameters. The sample comprised 25 patients undergoing office-based dexamethasone injection into the superficial lamina propria for mild/moderate vocal fold scar. Average follow-up was 13.7 ± 4.4 weeks; patients completed 3.5 ± 2.3 sessions of voice therapy between assessments. Complete data sets were not available for each parameter; sample size is noted with results.

Results: Voice handicap index (n = 24; P < .001) and glottal function index (n = 22; P < .001) decreased after injection. Total GRBAS score (grade, roughness, breathiness, asthenia, strain) decreased (n = 25; P < .001). Fundamental frequency range increased (n = 24; P = .024). Phonation threshold pressure decreased (n = 14; P = .017). Videostroboscopic parameters of vocal fold edge (P = .004), glottic closure (P = .003), and right mucosal wave (P = .016) improved after injection.

Conclusions: Office-based steroid injection combined with voice therapy for mild/moderate vocal fold scar is associated with improved patient-reported and functional voice measures. These findings provide preliminary support for this approach. Importantly, the procedure is low risk and can be performed in the office, thus offering a simple treatment alternative to patients with a disorder that has traditionally been difficult to manage. Prospective studies evaluating the effects of multiple injections are warranted.
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http://dx.doi.org/10.1177/0194599816654899DOI Listing
November 2016

Editorial response to "A novel approach to cricoarytenoid joint injections: An anatomic study".

Laryngoscope 2017 01 31;127(1):204-205. Epub 2016 Aug 31.

Division of Otolaryngology, Department of Surgery, University of Wisconsin, Madison, Wisconsin, U.S.A.

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http://dx.doi.org/10.1002/lary.26251DOI Listing
January 2017

Evaluation of type II thyroplasty on phonatory physiology in an excised canine larynx model.

Laryngoscope 2017 02 25;127(2):396-404. Epub 2016 May 25.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, U.S.A.

Objectives/hypothesis: Type II thyroplasty is an alternative treatment for spasmodic dysphonia, addressing hyperadduction by incising and lateralizing the thyroid cartilage. We quantified the effect of lateralization width on phonatory physiology using excised canine larynges.

Methods: Normal closure, hyperadduction, and type II thyroplasty (lateralized up to 5 mm at 1-mm increments with hyperadducted arytenoids) were simulated in excised larynges (N = 7). Aerodynamic, acoustic, and videokymographic data were recorded at three subglottal pressures relative to phonation threshold pressure (PTP). One-way repeated measures analysis of variance assessed effect of condition on aerodynamic parameters. Random intercepts linear mixed effects models assessed effects of condition and subglottal pressure on acoustic and videokymographic parameters.

Results: PTP differed across conditions (P < .001). Condition affected percent shimmer (P < .005) but not percent jitter. Both pressure (P < .03) and condition (P < .001) affected fundamental frequency. Pressure affected vibratory amplitude (P < .05) and intrafold phase difference (P < .05). Condition affected phase difference between the vocal folds (P < .001).

Conclusions: Hyperadduction increased PTP and worsened perturbation compared to normal, with near normal physiology restored with 1-mm lateralization. Further lateralization deteriorated voice quality and increased PTP. Acoustic and videokymographic results indicate that normal physiologic relationships between subglottal pressure and vibration are preserved at optimal lateralization width, but then degrade with further lateralization. The 1-mm optimal width observed here is due to the small canine larynx size. Future human trials would likely demonstrate a greater optimal width, with patient-specific value potentially determined based on larynx size and symptom severity.

Level Of Evidence: NA Laryngoscope, 2016 127:396-404, 2017.
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http://dx.doi.org/10.1002/lary.26017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123985PMC
February 2017

Extension and Application of High-Speed Digital Imaging Analysis Via Spatiotemporal Correlation and Eigenmode Analysis of Vocal Fold Vibration Before and After Polyp Excision.

Ann Otol Rhinol Laryngol 2016 Aug 10;125(8):660-6. Epub 2016 May 10.

Fudan University, Department of Otolaryngology-Head and Neck Surgery, EENT Hospital, Shanghai, China University of Wisconsin-Madison School of Medicine and Public Health, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Madison, Wisconsin, USA

Objectives/hypothesis: To evaluate the spatiotemporal correlation of vocal fold vibration using eigenmode analysis before and after polyp removal and explore the potential clinical relevance of spatiotemporal analysis of correlation length and entropy as quantitative voice parameters. We hypothesized that increased order in the vibrating signal after surgical intervention would decrease the eigenmode-based entropy and increase correlation length.

Study Design: Prospective case series.

Methods: Forty subjects (23 males, 17 females) with unilateral (n = 24) or bilateral (n = 16) polyps underwent polyp removal. High-speed videoendoscopy was performed preoperatively and 2 weeks postoperatively. Spatiotemporal analysis was performed to determine entropy, quantification of signal disorder, correlation length, size, and spatially ordered structure of vocal fold vibration in comparison to full spatial consistency. The signal analyzed consists of the vibratory pattern in space and time derived from the high-speed video glottal area contour.

Results: Entropy decreased (Z = -3.871, P < .001) and correlation length increased (t = -8.913, P < .001) following polyp excision. The intraclass correlation coefficients (ICC) for correlation length and entropy were 0.84 and 0.93.

Conclusion: Correlation length and entropy are sensitive to mass lesions. These parameters could potentially be used to augment subjective visualization after polyp excision when evaluating procedural efficacy.
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http://dx.doi.org/10.1177/0003489416644618DOI Listing
August 2016

Preliminary Evaluation of Functional Swallow After Total Laryngectomy Using High-Resolution Manometry.

Ann Otol Rhinol Laryngol 2016 Jul 11;125(7):541-9. Epub 2016 Feb 11.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA

Introduction: Understanding of swallowing pressures after total laryngectomy (TL) and what constitutes a "functional" swallow are limited. Mobile structures are altered or removed after TL, with consequent effects on pressure profiles. High-resolution manometry (HRM) can characterize these pressures.

Methods: Six TL subjects without dysphagia and 6 controls underwent pharyngeal HRM. Timing and pressure variables for the velopharynx, mesopharynx, and upper esophageal sphincter (UES) were compared. Changes in variables due to bolus volume were evaluated in TL subjects.

Results: The TL subjects had increased duration of velopharyngeal pressure (P = .012). Maximum mesopharyngeal pressure was lower versus controls (P = .003). Maximal and total pre-opening (P = .002, P = .002) and post-closure (P = .001, P = .002) UES pressures were lower. Maximum mesopharyngeal pressure (P = .032) decreased with increasing bolus volume.

Conclusions: Increased velopharyngeal pressure duration and total swallow duration reflect separation of the pharynx into distinct conduits for air and food, thus ensuring successful bolus passage without the need for respiration. Decreased UES pressure highlights the effects of disrupting the cricopharyngeal and rostral esophageal muscle fibers from their attachments to the larynx and performing a cricopharyngeal myotomy. Additional studies including subjects with dysphagia could further characterize the functional TL swallow and identify aspects susceptible to dysfunction.
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http://dx.doi.org/10.1177/0003489416629978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300062PMC
July 2016

Simulation study of high-dose-rate brachytherapy for early glottic cancer.

Brachytherapy 2016 Jan-Feb;15(1):94-101. Epub 2015 Nov 21.

Department of Human Oncology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI.

Purpose: External beam radiation therapy (EBRT) is effective for early glottic cancers, with cure rates of ∼90% for T1 tumors. EBRT has strengths but also disadvantages including radiation to healthy tissues and duration of 5-7 weeks. With advances in laryngeal framework surgery, new devices can provide reliable, minimally invasive access to the larynx. Such devices could be modified to insert brachytherapy catheters. Brachytherapy could provide focused radiation while limiting dose to normal structures in the larynx and neck. As a preliminary step, we performed simulations comparing EBRT to high-dose-rate brachytherapy to assess if this approach could provide dosimetric advantage.

Methods And Materials: One- and 2-catheter brachytherapy simulations were performed for 3 patients with T1 glottic carcinoma. Percentage of dose delivered to the target and adjacent structures was compared with conventional EBRT using 3D and intensity-modulated radiation therapy approaches.

Results: Percentage of structures exposed to 50% of the dose was lower for brachytherapy compared with 3D EBRT and intensity-modulated radiation therapy, particularly for the cricoid and contralateral arytenoid. Dose was also lower for the carotid-internal jugular vein complexes compared with 3D EBRT. Dose profiles did not differ significantly between 1- and 2-catheter simulations.

Conclusion: Brachytherapy can decrease radiation to normal tissues including laryngeal cartilages and carotid-internal jugular vein complexes. Recent advancements allowing catheter placement may afford the potential to decrease radiation to healthy tissues with decreased treatment time. However, careful, stepwise evaluation of feasibility and outcomes in model systems is required before recommending this approach for such high cure rate cancers in humans.
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http://dx.doi.org/10.1016/j.brachy.2015.10.007DOI Listing
September 2016

Effects of Balloon Dilation for Idiopathic Laryngotracheal Stenosis on Voice Production.

Ann Otol Rhinol Laryngol 2016 Jan 14;125(1):12-9. Epub 2015 Jul 14.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA

Objective: To evaluate the effects of balloon dilation for idiopathic laryngotracheal stenosis on voice production.

Methods: Retrospective review of 10 female patients with idiopathic laryngotracheal stenosis undergoing balloon dilation. Voice outcomes were evaluated by comparing pre- and posttreatment patient-reported, perceptual, aerodynamic, and acoustic parameters. Complete data sets were not available for all subjects; sample size for each parameter is reported with the corresponding result.

Results: Total Voice Handicap Index (VHI) decreased significantly (22.9 ± 13.5 to 6.8 ± 6.5; n = 8; p = .015), as did glottal function index (7.2 ± 4.9 to 1.5 ± 2.0; n = 6; p = .022). No changes were observed in the GRBAS (grade, roughness, breathiness, asthenia, strain) scale. Changes in aerodynamic parameters were not statistically significant. Percent jitter decreased (1.32 ± 1.37 to 0.60 ± 0.29; n = 7; P = .078), and fundamental frequency range was preserved (507 ± 325 to 612 ± 281; n = 7; P = .309).

Conclusions: Our sample of patients with idiopathic laryngotracheal stenosis had a mild-moderate dysphonia that improved with balloon dilation. Importantly, adverse effects on voice that can occur with open procedures were not observed. Patient perception of dysphonia improved while fundamental frequency range was maintained and aerodynamic parameters remained within or moved toward the normal range. Larger prospective studies are warranted to further evaluate changes in voice production associated with balloon dilation.
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http://dx.doi.org/10.1177/0003489415595425DOI Listing
January 2016

Functional and Histological Evaluation following Canine Vocal Fold Reconstruction Using Composite Thyroid Ala Perichondrium Flaps.

Otolaryngol Head Neck Surg 2015 Jul 16;153(1):79-87. Epub 2015 Apr 16.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA

Objectives/hypotheses: We evaluated the effects of vocal fold reconstruction using a composite thyroid ala perichondrium flap (CTAP) after unilateral vocal fold stripping in beagles. We hypothesized that CTAP would improve glottic closure, decrease phonation threshold pressure, and decrease perturbation. In addition, vocal folds with CTAP would exhibit neovascularization and fat with increased von Willebrand factor (vWF) and smooth muscle actin (SMA), reflecting neoangiogenesis and flap viability.

Study Design: Randomized controlled trial using beagles.

Setting: University laboratory.

Methods: Ten beagles underwent unilateral vocal fold stripping. Dogs in the scar-only group (n = 5) were sacrificed at 1 month. Dogs in the CTAP group (n = 5) underwent ipsilateral reconstruction with CTAP at 1 month and were sacrificed at 2 months. Excised larynx experiments evaluated vocal fold vibration using aerodynamic, acoustic, and mucosal wave measurements. Qualitative evaluation of vocal fold morphology and quantitative analysis of elastin, collagen, glycosaminoglycans, vWF, SMA, and hyaluronic acid were performed.

Results: Phonation threshold pressure (P = .005), percent jitter (P = .010), percent shimmer (P = .007), and open quotient (P = .007) were lower in the CTAP group. Neovascularization (P = .0079) and fat (P = .1667) occurred more with CTAP, although the difference in fat was not significant. von Willebrand factor was higher with CTAP vs contralateral normal fold (P = .110), although not statistically significant. Smooth muscle actin was higher with CTAP vs contralateral normal fold (P = .038) and scarred vocal folds (P = .022).

Conclusions: Composite thyroid ala perichondrium flap restored glottic closure and vibratory periodicity following vocal fold scarring. Additional investigation on biologic response is warranted. Composite thyroid ala perichondrium flap offers an autologous, vascularized implant that can improve both vocal fold structure and function.
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http://dx.doi.org/10.1177/0194599815578824DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6622179PMC
July 2015
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