Publications by authors named "Philip Weissbrod"

44 Publications

Surgical wound classification in otolaryngology: A state-of-the-art review.

World J Otorhinolaryngol Head Neck Surg 2022 Jun 18;8(2):139-144. Epub 2022 Apr 18.

Department of Otolaryngology University of California San Diego La Jolla California USA.

Objective: To describe the issues related to the assignment of surgical wound classification as it pertains to Otolaryngology-Head & Neck surgery, and to present a simple framework by which providers can assign wound classification.

Data Sources: Literature review.

Conclusion: Surgical wound classification in its current state is limited in its utility. It has recently been disregarded by major risk assessment models, likely due to inaccurate and inconsistent reporting by providers and operative staff. However, if data accuracy is improved, this metric may be useful to inform the risk of surgical site infection. In an era of quality-driven care and reimbursement, surgical wound classification may become an equally important indicator of quality.
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http://dx.doi.org/10.1002/wjo2.63DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9242420PMC
June 2022

Transoral Laser Microsurgery With Neck Dissection Versus Radiotherapy for T2N0 Supraglottic Cancer.

Laryngoscope 2022 May 12. Epub 2022 May 12.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California-San Diego, La Jolla, California, USA.

Objectives: To compare overall survival outcomes associated with transoral laser microsurgery (TLM) with neck dissection versus definitive radiotherapy in the management of T2N0 supraglottic squamous cell carcinoma.

Methods: Data were extracted from the National Cancer Database concerning patients with cT2N0M0 supraglottic cancer treated with either TLM and neck dissection with minimum lymph node yield of 10 or definitive radiotherapy. Predictors of overall survival were assessed via Cox proportional hazards regression.

Results: Seventy-six cT2N0 supraglottic squamous cell carcinoma patients who underwent TLM with neck dissection (+/- adjuvant therapy) versus 991 patients who underwent radiotherapy. TLM was associated with an overall survival benefit (OR = 0.574; 95% CI 0.383-0.860) compared with radiotherapy. There was no difference in survival between TLM patients receiving adjuvant treatment and those receiving definitive radiotherapy.

Conclusions: An up-front, TLM-based surgical approach to cT2N0 supraglottic cancer may offer an overall survival benefit compared with definitive radiotherapy, and should receive more frequent consideration as a primary approach to this disease process.

Level Of Evidence: 3 Laryngoscope, 2022.
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http://dx.doi.org/10.1002/lary.30171DOI Listing
May 2022

Patient-worn endoscopy mask to protect against viral transmission.

Laryngoscope Investig Otolaryngol 2022 Feb 9;7(1):190-196. Epub 2021 Dec 9.

Department of Otolaryngology University of California-San Diego San Diego California USA.

Objectives: To design and evaluate patient-worn personal protective equipment (PPE) that allows providers to perform endoscopy while protecting against droplet and airborne disease transmission.

Study Design: Single subject study.

Methods: Mask efficacy was evaluated using a cough simulator that sprays dye visible under ultra-violet light. User-testing was performed on an airway trainer mannequin where each subject performed the endoscopy with and without the mask in random orders. Their time to completion and number of attempts before successful completion were recorded, and each subject was asked to fill out a NASA Task Load Index (TLX) form with respect to their experience.

Results: The mask has a filtration efficiency of 97.31% and eliminated any expelled particles with the cough simulator. Without the mask, a simulated cough is visualized as it progresses away from the cough origin. Subjects who performed trans-nasal endoscopy spent 27.8 ± 8.0 s to visualize the vocal cords for the no mask condition and 28.7 ± 13.6 s for the mask condition (mean ± SD,  > .05). There was no statistically significant difference found in the mental demand, physical demand, temporal demand, performance, effort, and frustration of endoscopy under the no mask and mask conditions (all  > .05).

Conclusion: The designed PPE provides an effective barrier for viral droplet and airborne transmission while allowing the ability to perform endoscopy with ease.

Level Of Evidence: 3 , 2021.
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http://dx.doi.org/10.1002/lio2.708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8823177PMC
February 2022

Clinicodemographic Predictors of Tracheotomy Tube Size and Decannulation: A Multiinstitutional Retrospective Cohort Study on Tracheotomy.

Ann Surg 2022 Jan 7. Epub 2022 Jan 7.

University of California San Diego, Department of Otolaryngology, La Jolla, CA University of Washington, Department of Otolaryngology, Seattle, WA University of Wisconsin, Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Madison, WI University of California, School of Medicine, La Jolla, CA Cleveland Clinic, Department of Otolaryngology, Cleveland, OH Medical University of South Carolina, Department of Otolaryngology, Charleston, SC Stanford University, Department of Otolaryngology, Palo Alto, CA Loma Linda University, Department of Otolaryngology, Loma Linda, CA University of Michigan, Department of Otolaryngology, Ann Arbor, MI University of Colorado, Department of Otolaryngology, Aurora, CA University of California Davis, Department of Otolaryngology, Sacramento, CA Mayo Clinic Arizona, Department of Otolaryngology, Phoenix, AZ.

Objective: We aimed to discern clinico-demographic predictors of large (≥8) tracheostomy tube size placement, and, secondarily, to assess the effect of large tracheostomy tube size and other parameters on odds of decannulation before hospital discharge.

Summary Of Background Data: Factors determining choice of tracheostomy tube size are not well-characterized in the current literature, despite evidence linking large tracheostomy tube size with posttracheotomy tracheal stenosis. The effect of tracheostomy tube size on timing of decannulation is also unknown, an important consideration given reported associations between endotracheal tube size and probability of failed extubation.

Methods: We collected information pertaining to patients who underwent tracheotomy at 1 of 10 U.S. health care institutions between 2010 and 2019. Tracheostomy tube size was dichotomized (≥8 and <8). Multivariable logistic regression models were fit to identify predictors of (1) large tracheostomy tube size, and (2) decannulation before hospital discharge.

Results: The study included 5307 patients, including 2797 (52.7%) in the large tracheostomy cohort. Patient height (OR = 1.060 per inch; 95% CI 1.041-1.070) and obesity (1.37; 95% CI 1.189-1.579) were associated with greater odds of large tracheostomy tube; otolaryngology performing the tracheotomy was associated with significantly lower odds of large tracheostomy tube (OR = 0.155; 95% CI 0.131-0.184). Large tracheostomy tube size (OR = 1.036; 95% CI 0.885-1.213) did not affect odds of decannulation.

Conclusions: Obesity was linked with increased likelihood of large tracheostomy tube size, independent of patient height. Probability of decannulation before hospital discharge is influenced by multiple patient-centric factors, but not by size of tracheostomy tube.
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http://dx.doi.org/10.1097/SLA.0000000000005356DOI Listing
January 2022

An update on current treatment strategies for laryngopharyngeal reflux symptoms.

Ann N Y Acad Sci 2022 04 17;1510(1):5-17. Epub 2021 Dec 17.

Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California.

Laryngopharyngeal reflux (LPR) is a syndrome caused by reflux of gastric contents into the pharynx or larynx, which leads to symptoms of throat clearing, hoarseness, pain, globus sensation, cough, excess mucus production in the throat, and dysphonia. LPR is a challenging condition, as there is currently no gold standard for diagnosis or treatment, and thus this presents a burden to the healthcare system. Strategies for treatment of LPR are numerous. Medical therapies include proton pump inhibitors, which are first line, H2 receptor antagonists, alginates, and baclofen. Other noninvasive treatment options include lifestyle therapy and the external upper esophageal sphincter compression device. Endoscopic and surgical options include antireflux surgery, magnetic sphincter augmentation, and transoral incisionless fundoplication. Functional laryngeal disorders and laryngeal hypersensitivity can present as LPR symptoms with or without gastroesophageal reflux disease. Though there are minimal studies in this area, neuromodulators and behavioral interventions are potential treatment options. Given the complexity of these patients and numerous available treatment options, we propose a treatment algorithm to help clinicians diagnose and triage patients into an appropriate therapy.
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http://dx.doi.org/10.1111/nyas.14728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9012673PMC
April 2022

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review 2020.

OTO Open 2021 Oct-Dec;5(4):2473974X211057035. Epub 2021 Nov 10.

Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.

Objectives: To evaluate new drugs and devices relevant to otolaryngology-head and neck surgery that were approved by the US Food and Drug Administration (FDA) in 2020.

Data Sources: Publicly available device and therapeutic approvals from ENT (ear, nose, and throat), anesthesia, neurology (neurosurgery), and plastic and general surgery FDA committees.

Review Methods: Members of the American Academy of Otolaryngology-Head and Neck Surgery's Medical Devices and Drugs Committee reviewed new therapeutics and medical devices from a query of the FDA's device and therapeutic approvals. Two independent reviewers assessed the drug's or device's relevance to otolaryngology, classified to subspecialty field, with a critical review of available scientific literature.

Conclusions: The Medical Devices and Drugs Committee reviewed 53 new therapeutics and 1094 devices (89 ENT, 140 anesthesia, 511 plastic and general surgery, and 354 neurology) approved in 2020. Ten drugs and 17 devices were considered relevant to the otolaryngology community. Rhinology saw significant improvements around image guidance systems; indications for cochlear implantation expanded; several new monoclonal therapeutics were added to head and neck oncology's armamentarium; and several new approvals appeared for facial plastics surgery, pediatric otolaryngology, and comprehensive otolaryngology.

Implications For Practice: New technologies and pharmaceuticals offer the promise of improving how we care for otolaryngology patients. However, judicious introduction of innovations into practice requires a nuanced understanding of safety, advantages, and limitations. Working knowledge of new drugs and medical devices approved for the market helps clinicians tailor patient care accordingly.
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http://dx.doi.org/10.1177/2473974X211057035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8591653PMC
November 2021

YY1: A New Gene for Childhood Onset Dystonia with Prominent Oromandibular-Laryngeal Involvement?

Mov Disord 2022 01 7;37(1):227-228. Epub 2021 Oct 7.

Department of Neurosciences, University of California San Diego, La Jolla, California, USA.

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http://dx.doi.org/10.1002/mds.28813DOI Listing
January 2022

Patterns of Failure After Definitive Treatment of T4a Larynx Cancer.

Otolaryngol Head Neck Surg 2022 08 5;167(2):274-285. Epub 2021 Oct 5.

Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California, USA.

Objective: Recurrence is known to predict laryngeal squamous cell cancer (LSCC) survival. Recurrence patterns in T4a LSCC are poorly characterized and represent a possible explanation for observed survival discrepancies by treatment rendered.

Study Design: Retrospective database review.

Setting: Veterans Affairs national database.

Methods: Patients with T4a LSCC between 2000 and 2017 were identified and stratified by treatment (chemoradiotherapy [CRT] vs total laryngectomy + neck dissection + adjuvant therapy [surgical]). Primary outcomes were locoregional and distant recurrence. Secondary outcomes of overall mortality, larynx cancer mortality, and noncancer mortality were evaluated in Cox and Fine-Gray models.

Results: A total of 1043 patients had comparable baseline demographics: 438 in the CRT group and 605 in the surgical group. Patients undergoing CRT had higher proportions of node positivity (64.6% vs 53.1%, < .001). Locoregional and distant recurrence were less common in the surgical group (23.0% vs 37.2%, < .001; 6.8% vs 13.3%, < .001, respectively); however, distant metastatic rates did not differ within the N0 subgroup ( = .722). On multivariable regression, surgery demonstrated favorable locoregional recurrence (hazard ratio [HR], 0.49; 95% CI, 0.39-0.62; < .001), distant recurrence (HR, 0.47; 95% CI, 0.31-0.71; < .001), overall mortality (HR, 0.75; 95% CI, 0.64-0.87; < .001), and larynx cancer mortality (HR, 0.69; 95% CI, 0.56-0.85; < .001).

Conclusion: T4a LSCC survival discrepancies between surgical and nonsurgical treatment are influenced by varying recurrence behaviors. Surgery was associated with superior disease control and improved survival. Beyond the known benefit in locoregional control with surgery, there may be a protective effect on distant recurrence that depends on regional disease burden.
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http://dx.doi.org/10.1177/01945998211049211DOI Listing
August 2022

Reply to: "Laryngeal Movement Disorders in Multiple System Atrophy: A Diagnostic Biomarker?"

Mov Disord 2021 08;36(8):1999-2000

Department of Neurosciences, University of California San Diego, La Jolla, California, USA.

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http://dx.doi.org/10.1002/mds.28697DOI Listing
August 2021

Salvage Following Transoral Laser Microsurgery for Early Glottic Cancer in National Veteran Database.

Laryngoscope 2021 12 23;131(12):2766-2772. Epub 2021 Jul 23.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California-San Diego, San Diego, California, U.S.A.

Objectives: Transoral laser microsurgery (TLM) is commonly utilized for early glottic cancer and offers favorable oncologic and functional outcomes. However, the survival implications of salvage therapy for recurrent or persistent disease have not been definitively characterized.

Study Design: Retrospective, national database cohort study.

Methods: Data were extracted from Veterans Health Affairs (VHA) Informatics and Computing Infrastructure (VINCI) concerning the TLM-based management of T1-T2 glottic squamous cell carcinoma patients between 2000 and 2017. Patients were characterized as either requiring TLM-only, or in cases of persistent or recurrent local disease, TLM plus change in treatment modality (radiotherapy, chemoradiotherapy, or open surgery). Predictors of overall survival (OS), cancer-specific survival (CSS), and salvage-free survival were evaluated via Cox and Fine-Gray models.

Results: About 553 patients (70.9% T1a, 13.4% T1b, 15.7% T2) were included, with a median follow-up time of 74.5 months. The need for non-TLM salvage increased along with more advanced disease (11.7% T1a, 29.7% T1b, 32.2% T2). Compared to patients with T1a disease, those with T1b and T2 tumors initially treated with TLM had a significantly higher probability of receiving non-TLM salvage (T1b: HR 2.70, 95% CI: 1.61-4.54; T2: HR 3.02, 95% CI: 1.88-4.84). In a multivariable model, receipt of non-TLM salvage was not a significant predictor of either OS (HR = 0.91, 95% CI: 0.62-1.33, P = .624) or CSS (HR 1.21 95% CI 0.51-2.86, P = .667).

Conclusion: The majority of patients with early glottic cancer that are managed with TLM do not require additional salvage therapy. When non-TLM salvage was required, there was no decrement in OS or CSS.

Level Of Evidence: 4 Laryngoscope, 131:2766-2772, 2021.
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http://dx.doi.org/10.1002/lary.29740DOI Listing
December 2021

Upper Esophageal Sphincter Compression Device as an Adjunct to Proton Pump Inhibition for Laryngopharyngeal Reflux.

Dig Dis Sci 2022 Jul 18;67(7):3045-3054. Epub 2021 Jul 18.

Division of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.

Background: The Reflux Band, an external upper esophageal sphincter (UES) compression device, reduces esophago-pharyngeal reflux events. This study aimed to assess device efficacy as an adjunct to proton pump inhibitor (PPI) therapy in patients with laryngopharyngeal reflux (LPR).

Methods: This two-phase prospective clinical trial enrolled adults with at least 8 weeks of laryngeal symptoms (sore throat, throat clearing, dysphonia) not using PPI therapy at two tertiary care centers over 26 months. Participants used double dose PPI for 4 weeks in Phase 1 and the external UES compression device nightly along with PPI for 4 weeks in Phase 2. Questionnaire scores and salivary pepsin concentration were measured throughout the study. The primary endpoint of symptom response was defined as reflux symptom index (RSI) score ≤ 13 and/or > 50% reduction in RSI.

Results: Thirty-one participants completed the study: 52% male, mean age 47.9 years (SD 14.0), and mean body mass index (BMI) 26.2 kg/m (5.1). Primary endpoint was met in 11 (35%) participants after Phase 1 (PPI alone) and 17 (55%) after Phase 2 (Device + PPI). Compared to baseline, mean RSI score (24.1 (10.9)) decreased at end of Phase 1 (PPI alone) (21.9 (9.7); p = 0.06) and significantly decreased at end of Phase 2 (Device + PPI) (15.5 (10.3); p < 0.01). Compared to non-responders, responders to Device + PPI had a significantly lower BMI (p = 0.02) and higher salivary pepsin concentration (p = 0.01).

Conclusion: This clinical trial highlights the potential efficacy of the external UES compression device (Reflux Band) as an adjunct to PPI for patients with LPR (ClinicalTrials.Gov NCT03619811).
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http://dx.doi.org/10.1007/s10620-021-07172-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286644PMC
July 2022

Distinct Clinical Physiologic Phenotypes of Patients With Laryngeal Symptoms Referred for Reflux Evaluation.

Clin Gastroenterol Hepatol 2022 04 20;20(4):776-786.e1. Epub 2021 May 20.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts; Division of Gastroenterology and Hepatology, Harvard Medical School, Boston, Massachusetts.

Background & Aims: Heterogeneous presentations and disease mechanisms among patients with laryngeal symptoms account for misdiagnosis of laryngopharyngeal reflux (LPR), variations in testing, and suboptimal outcomes. We aimed to derive phenotypes of patients with laryngeal symptoms based on clinical and physiologic data and to compare characteristics across phenotypes.

Methods: A total of 302 adult patients with chronic laryngeal symptoms were prospectively enrolled at 3 centers between January 2018 to October 2020 (age 57.2 ± 15.2 years; 30% male; body mass index 27.2 ± 6.0 kg/m). Discriminant analysis of principal components (DAPC) was applied to 12 clinical and 11 physiologic variables collected in stable condition to derive phenotypic groups.

Results: DAPC identified 5 groups, with significant differences across symptoms, hiatal hernia size, and number of reflux events (P < .01). Group A had the greatest hiatal hernia size (3.1 ± 1.0 cm; P < .001) and reflux events (37.5 ± 51; P < .001), with frequent cough, laryngeal symptoms, heartburn, and regurgitation. Group B had the highest body mass index (28.2 ± 4.6 kg/m; P < .001) and salivary pepsin (150 ± 157 ng/mL; P = .03), with frequent cough, laryngeal symptoms, globus, heartburn, and regurgitation. Group C frequently reported laryngeal symptoms (93%; P < .001), and had fewest esophageal symptoms (9.6%; P < .001) and reflux events (10.7 ± 11.0; P < .001). Group D commonly reported cough (88%; P < .001) and heartburn. Group E (18%) was oldest (62.9 ± 14.3 years; P < .001) and distinguished by highest integrated relaxation pressure.

Conclusions: DAPC identified distinct clinicophysiologic phenotypes of patients with laryngeal symptoms referred for reflux evaluation: group A, LPR and gastroesophageal reflux disease (GERD) with hiatal hernia; group B, mild LPR/GERD; group C, no LPR/No GERD; group D, reflex cough; and group E, mixed/possible obstructive esophagogastric junction. Phenotypic differences may inform targeted clinical trials design and improve outcomes.
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http://dx.doi.org/10.1016/j.cgh.2021.05.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8715518PMC
April 2022

Association of race and health care system with disease stage and survival in veterans with larynx cancer.

Cancer 2021 08 2;127(15):2705-2713. Epub 2021 Apr 2.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California.

Background: Black patients with laryngeal squamous cell carcinoma (LSCC) historically have inferior outcomes in comparison with White patients. The authors investigated these racial disparities within the Veterans Health Administration (VHA), an equal-access system, and within the Surveillance, Epidemiology, and End Results (SEER) program, which is representative of the US hybrid-payer system.

Methods: Patients with invasive (T1 or greater) LSCC were included from SEER (2004-2015) and the VHA (2000-2017). The primary outcomes of overall survival (OS) and larynx cancer-specific survival (LCS) were evaluated in Cox and Fine-Gray models.

Results: In the SEER cohort (7122 patients: 82.6% White and 17.4% Black), Black patients were more likely to present with advanced disease and had inferior OS (hazard ratio [HR], 1.37; 95% CI, 1.26-1.50; P < .0001) in a multivariable analysis. Black LCS was worse in a univariable analysis (HR, 1.42; 95% CI, 1.27-1.58; P < .0001), but this effect was attenuated by 83% when the authors controlled for the TNM category and was found to be insignificant in a multivariable analysis (HR, 1.05; 95% CI, 0.93-1.18; P = .42). In the VHA cohort (9248 patients: 79.7% White and 20.3% Black), the 2 racial cohorts presented with similar tumor characteristics and similar OS (HR, 0.95; 95% CI, 0.89-1.02; P = .14). Black LCS was similar in univariable (HR, 1.10; 95% CI, 1.00-1.22; P = .05) and multivariable analyses (HR, 1.02; 95% CI, 0.92-1.14; P = .67).

Conclusions: Black patients with LSCC had a tumor burden at diagnosis and survival outcomes comparable to those of White patients within the VHA; this was counter to what was observed in the SEER analysis and prior national trends. This study's findings point toward the notable role of health care access in contributing to racial health disparities in the realm of larynx cancer.
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http://dx.doi.org/10.1002/cncr.33557DOI Listing
August 2021

Preclinical experience with a novel single-port platform for transoral surgery.

Surg Endosc 2021 08 12;35(8):4857-4864. Epub 2021 Mar 12.

Division of Head and Neck Surgery, Department of Surgery, University of California San Diego, San Diego, CA, USA.

Background: We investigated a novel minimally invasive surgical platform for use in the oropharynx, hypopharynx, and larynx for single-port transoral surgery used in concert with standard transoral laryngeal and pharyngeal instrumentation.

Methods: The preclinical investigational device by Fortimedix Surgical B.V. (Netherlands) features two channels for manually controlled flexible articulating surgical instruments. A third central channel accepts both rigid and flexible endoscopes. The system is coupled to a standard laryngoscope for transoral access. In three cadaver models, we evaluated the surgical capabilities using wristed grasping instruments, microlaryngeal scissors, monopolar cautery, and a laser fiber sheath. Procedures were performed within the oropharynx, supraglottis, glottis, subglottis, and hypopharynx.

Results: Within the oropharynx, we found adequate strength, range of motion, and dexterity to perform lateral oropharyngectomy and tongue base resection. Within the larynx, visualization was achieved with a variety of instruments including a flexible, 0° and 30° rigid endoscope. The glottis, supraglottis, pyriform sinuses, post-cricoid space, and esophageal inlet were readily accessible. Visualization and manipulation of grasping, laser, and monopolar cautery instruments were also possible within the subglottis. Instrument reach and accuracy facilitated completion of a delicate micro-flap on the true vocal fold. Other procedures included vocal fold resection, cricopharyngeal myotomy, and resection of subglottic mucosa.

Conclusions: From this initial proof of concept experience with this novel platform, we found a wide range of procedures within the oropharynx, larynx, and hypopharynx to be feasible. Further work is needed to evaluate its applicability to the clinical setting. The ability of this platform to be used with conventional instrumentation may provide an opportunity for complex transoral surgery to be performed in a facile manner at greatly reduced cost.
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http://dx.doi.org/10.1007/s00464-021-08420-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263430PMC
August 2021

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis.

Ann Otol Rhinol Laryngol 2021 Oct 25;130(10):1116-1124. Epub 2021 Feb 25.

Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, CA, USA.

Objectives: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients.

Methods: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence.

Results: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression.

Conclusions: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.
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http://dx.doi.org/10.1177/0003489421995283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8762607PMC
October 2021

Prognostic Significance of HPV Status in Laryngeal Squamous Cell Carcinoma: A Large-Population Database Study.

Otolaryngol Head Neck Surg 2021 07 1;165(1):113-121. Epub 2020 Dec 1.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California-San Diego, San Diego, California, USA.

Objective: To explore the survival implications of human papillomavirus (HPV) positivity and subtype in larynx cancer through a national cancer database. To investigate staging discrepancies in larynx cancer associated with HPV status.

Study Design: Retrospective observational cohort study.

Setting: National Cancer Database.

Methods: Data were extracted concerning adults with known HPV status who were treated between 2010 and 2016 for laryngeal squamous cell carcinoma. Patients without known HPV subtype were excluded. Cox multivariable regression models were fit to evaluate the survival impact of HPV status, characterized as a binary variable (HPV+ vs HPV-) and by subtype. Two- and 5-year survival rates were calculated via the Kaplan-Meier method and compared by stage between the HPV+ and HPV- cohorts per the log-rank test.

Results: Patients with HPV+ larynx cancer were younger (60.5 vs 64.3 years, < .001), more likely to have private insurance (37.2% vs 31.2%, < .001), more commonly White (84.6% vs 82.4%, = .013), and more likely to present with nodal disease (42.6% vs 33.0%, < .001). HPV positivity and HPV subtype 16 were associated with improved overall survival. One-stage discrepancies in 5-year survival were observed between the HPV+ and HPV- cohorts: stage II HPV+ (69.45%) vs stage I HPV- (65.77%); stage IV HPV+ (47.67%) vs stage III HPV- (46.80%).

Conclusions: HPV positivity and infection with HPV subtype 16 are correlated with improved overall survival in patients with laryngeal squamous cell carcinoma, manifesting with a 1-stage incremental survival advantage. Future prospective studies are indicated to corroborate the findings from this large-population database retrospective study.
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http://dx.doi.org/10.1177/0194599820976178DOI Listing
July 2021

In reply: Zenker's diverticulotomy with bipolar tissue sealer: Retrospective review of safety and short-term outcomes.

Am J Otolaryngol 2021 Jan - Feb;42(1):102774. Epub 2020 Oct 27.

Division of Otolaryngology, Department of Surgery, University of California San Diego, United States of America.

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http://dx.doi.org/10.1016/j.amjoto.2020.102774DOI Listing
February 2021

Surgical management of recurrent Zenker's diverticulum: A multi-institutional cohort study.

Am J Otolaryngol 2021 Jan - Feb;42(1):102755. Epub 2020 Oct 17.

UCI Health Voice and Swallowing Center, Department of Otolaryngology Head and Neck Surgery, University of California Irvine School of Medicine, CA, United States of America. Electronic address:

Objective: This study identifies how recurrent Zenker's diverticula are treated.

Methods: A retrospective chart review was performed from four tertiary referral academic voice and swallowing centers to identify individuals who underwent surgery for recurrent Zenker's diverticulum. Demographic data, surgical modalities for primary and revision surgery, symptoms pre and post revision and complications were recorded.

Results: 56 individuals met inclusion criteria. Primary surgery was open in 30.3% (n = 17) and endoscopic in 69.6% (n = 39). Revision surgery was performed via an open approach in 37.5% of cases (N = 21) and via an endoscopic approach in 62.5% of cases (N = 35). Revision surgical technique was based on pouch size, patient age and comorbidities, as well as patient and surgeon preference. There were no major complications and few minor complications.

Conclusion: Zenker's diverticulum symptoms can recur regardless of primary treatment modality. Both endoscopic and open approaches can safely treat recurrent Zenker's diverticula.
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http://dx.doi.org/10.1016/j.amjoto.2020.102755DOI Listing
April 2021

Changes in treatment trends in the early glottic cancer population after the Affordable Care Act.

Head Neck 2021 01 18;43(1):137-144. Epub 2020 Sep 18.

Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of California - San Diego, San Diego, California, USA.

Background: The clinical impact of Medicaid expansion in otolaryngology is uncertain. Herein, we evaluate the impact of Medicaid expansion on treatment patterns (primary radiotherapy vs surgery) in the early glottic cancer population.

Methods: Data regarding adults with Tis-T2N0M0 glottic cancer that were treated with either surgery or radiotherapy between January 2010 and December 2016 were obtained from the Surveillance, Epidemiology, and End Results (SEER) cancer database. Changes in treatment trends and survival in the Medicaid expansion setting were discerned.

Results: The proportion of patients undergoing radiotherapy decreased from 64.8% to 59% after the Patient Protection and Affordable Care Act (PPACA) was implemented. State Medicaid expansion status was associated with reduced odds of radiation therapy (odds ratio [OR] = 0.66). Patients were diagnosed more often with earlier stage disease (20.6% vs 17.0% T2 diagnoses) in the Medicaid expansion cohort.

Conclusion: The implementation of the PPACA was associated with a significant increase in surgical therapy for and earlier diagnosis of glottic cancer.
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http://dx.doi.org/10.1002/hed.26463DOI Listing
January 2021

Mycosis Fungoides of the True Vocal Folds: A Case Report.

Ann Otol Rhinol Laryngol 2020 Sep 27;129(9):930-934. Epub 2020 Apr 27.

Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, UC San Diego, San Diego, CA, USA.

Objectives: To report a case of laryngeal involvement of mycosis fungoides and its symptomatic treatment with laser-assisted surgical ablation.

Methods: Case report and literature review.

Results: A 76-year-old woman with longstanding MF previously treated with Brentuximab Vedotin who developed persistent cough and dysphonia. The patient's laryngeal disease burden was treated with KTP-laser ablation and further reduced with doxorubicin and radiotherapy.

Conclusions: Although laryngeal, and especially glottic, involvement is a rare finding, suspicion should be maintained in symptomatic patients with cutaneous mycosis fungoides. This the first reported surgical laser treatment of laryngeal symptoms in this context, which can greatly improve a patient's quality of life.
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http://dx.doi.org/10.1177/0003489420916213DOI Listing
September 2020

An Atypical Cause of Difficulty Swallowing.

JAMA Otolaryngol Head Neck Surg 2020 05;146(5):501-503

Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of California, San Diego.

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http://dx.doi.org/10.1001/jamaoto.2020.0133DOI Listing
May 2020

What is the optimal timing for tracheostomy in intubated patients?

Laryngoscope 2020 05 12;130(5):1108-1109. Epub 2019 Nov 12.

Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.

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http://dx.doi.org/10.1002/lary.28382DOI Listing
May 2020

Critical Care and Postoperative Management of the Head and Neck Patient.

Otolaryngol Clin North Am 2019 Dec;52(6):1141-1156

Department of Anesthesiology and Critical Care, University of California San Diego, San Diego, CA, USA. Electronic address:

Head and neck surgical patients, at times, can represent a challenging population to manage in the intensive care unit postoperatively. Close interaction between the critical care and surgical teams, awareness of potential surgery-specific complications, and utilization of protocol-driven care can reduce risk of morbidity significantly in this population and enhance outcomes. Given the relative complexity of otolaryngologic surgery and the unique risk that head and neck pathologies can pose to patient airway, breathing, and circulation, these collective circumstances warrant detailed discussion in the interest of minimizing patient morbidity and mortality.
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http://dx.doi.org/10.1016/j.otc.2019.08.011DOI Listing
December 2019

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

JAMA Otolaryngol Head Neck Surg 2020 01;146(1):20-29

Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research.

Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease.

Design, Setting, And Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook.

Main Outcomes And Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications.

Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk.

Conclusions And Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.
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http://dx.doi.org/10.1001/jamaoto.2019.3022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824232PMC
January 2020

Flexible Endoscopic Zenker's Diverticulotomy with an Articulating Bipolar Energy Sealer.

Otolaryngol Head Neck Surg 2019 11 30;161(5):906-908. Epub 2019 Jul 30.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California San Diego, La Jolla, California, USA.

The surgical management of Zenker's diverticula is performed through open or endoscopic approaches. The purpose of this report is to review our early experience with flexible endoscopic diverticulotomy with an articulating bipolar energy sealer for cricopharyngeal and diverticular wall division in a series of 5 patients where transoral rigid access was not possible. In addition to technical details, safety and efficacy data are included. The average diverticulum size was 2.5 cm. All patients reported symptom resolution, and there were no surgical complications. Liquid diet was initiated on postoperative day 1 for all patients and solids on day 11.8 ± 14.4 (mean ± SD) per protocol. Results demonstrate that treatment of Zenker's diverticula can safely and successfully be performed with flexible endoscopic visualization and utilization of an articulating bipolar energy sealer to perform diverticulotomy in a population of patients where transoral diverticulotomy would not otherwise be feasible due to anatomic constraints. Early results support obtaining further experience to study this technology as an alternative to open surgery, especially when visualization and access are suboptimal with rigid endoscopy.
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http://dx.doi.org/10.1177/0194599819865468DOI Listing
November 2019

Adverse Events after Rigid and Flexible Endoscopic Repair of Zenker's Diverticula: A Systematic Review and Meta-analysis.

Otolaryngol Head Neck Surg 2019 09 23;161(3):388-400. Epub 2019 Apr 23.

12 San Diego Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of California, San Diego, California, USA.

Objective: To determine adverse events after endoscopic flexible vs endoscopic rigid cricopharyngeal myotomy for treatment of Zenker's diverticulum (ZD).

Data Sources: Systematic review of MEDLINE, Web of Science, CINAHL, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for all years according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional studies were identified from review citations and a by hand search of manuscripts referencing ZD.

Review Methods: A structured literature search was conducted to identify studies for this systematic review. Methodological Index for Non-randomized Studies (MINORS) criteria were applied to assess study quality. For inclusion, each study had to provide data for at least 10 adult patients who had undergone endoscopic ZD repair reporting clear association with the postprocedure course in each case. Data extracted included all reported adverse events, recurrences, follow-up, and operative times.

Results: In total, 115 studies were included. All but 8 were retrospective case series. Sixty-one reported series of patients after rigid endoscopic stapler repair, 31 after rigid laser repair, and 13 with other rigid endoscopic instruments. Twenty-nine flexible endoscopic studies were included. Mortality, infection, and perforation were not significantly more likely in either the rigid or the flexible group, but bleeding and recurrence were more likely after flexible endoscopic techniques (20% vs <10% and 4% vs 0%, respectively). Dental injury and vocal fold palsy were reported rarely in the rigid endoscopic groups.

Conclusions: Adverse events are rare after endoscopic Zenker's repair. The flexible approach minimizes exposure limitations and can be completed in some patients without general anesthesia. Transoral rigid approaches result in fewer revision surgeries compared with flexible diverticulotomy.
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http://dx.doi.org/10.1177/0194599819839991DOI Listing
September 2019

Bullous Pemphigoid Presenting as Oropharyngeal Hemorrhage.

JAMA Otolaryngol Head Neck Surg 2019 Mar;145(3):288-290

Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of California, San Diego.

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http://dx.doi.org/10.1001/jamaoto.2018.4051DOI Listing
March 2019

High-density surface electromyography: A visualization method of laryngeal muscle activity.

Laryngoscope 2019 10 21;129(10):2347-2353. Epub 2019 Jan 21.

Department of Surgery-Division of Otolaryngology, University of California, San Diego, California, U.S.A.

Objectives/hypothesis: Laryngeal muscle activation is a complex and dynamic process. Current evaluation methods include needle and surface electromyography (sEMG). Limitations of needle electromyography include patient discomfort, interpretive complexity, and limited duration of recording. sEMG demonstrates interpretive challenges given loss of spatial selectivity. Application of high-density sEMG (HD sEMG) arrays were evaluated for potential to compensate for spatial selectivity loss while retaining benefits of noninvasive monitoring.

Study Design: Basic science.

Methods: Ten adults performed phonatory tasks while a 20-channel array recorded spatiotemporal data of the anterior neck. Data were processed to provide average spectral power of each electrode. Comparison was made between rest, low-, and high-pitch phonation. Two-dimensional (2D) spectral energy maps were created to evaluate use in gross identification of muscle location.

Results: Three phonatory tasks yielded spectral power measures across the HD sEMG array. Each electrode within the array demonstrated unique power values across all subjects (P < .001). Comparison of each electrode to itself across phonatory tasks yielded differences in all subjects during rest versus low versus high, rest versus low, and rest versus high and in 9/10 subjects (P < .001) for low versus high phonation. Symmetry of HD sEMG signal was noted. Review of 2D coronal energy maps allowed for gross identification of cricothyroid muscle amidst anterior strap musculature.

Conclusions: HD sEMG can be used to identify differences in anterior neck muscle activity between rest, low-, and high-pitch phonation. HD sEMG of the anterior neck holds potential to enhance diagnostic and therapeutic monitoring for pathologies of laryngeal function.

Level Of Evidence: NA Laryngoscope, 129:2347-2353, 2019.
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http://dx.doi.org/10.1002/lary.27784DOI Listing
October 2019

Suture-ligature technique for the closure of tracheocutaneous fistula in adults.

Laryngoscope 2019 03 9;129(3):574-577. Epub 2018 Nov 9.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California-San Diego, San Diego, California.

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http://dx.doi.org/10.1002/lary.27448DOI Listing
March 2019

Inverted schneiderian papilloma of the supraglottis: Case report.

Laryngoscope 2017 12 12;127(12):2830-2832. Epub 2017 Jul 12.

Division of Otolaryngology Head and Neck Surgery.

Inverted schneiderian papillomas are rare benign tumors, most often arising from the sinonasal mucosa. We describe a case of a 59-year-old female with an inverted papilloma of the supraglottis. This is the first reported case of a supraglottic-presenting inverted papilloma. Although rare, this case demonstrates that these tumors should be considered during workup of supraglottic laryngeal masses. Laryngoscope, 127:2830-2832, 2017.
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http://dx.doi.org/10.1002/lary.26746DOI Listing
December 2017
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