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Purpose To this day, there is no cure for recurrent respiratory papillomatosis (RRP). Multiple surgical procedures are performed to achieve symptom relief and prevention of airway obstruction. A promising drug for RRP is the vascular endothelial growth factor (VEGF) binding antibody bevacizumab. This chemotherapeutic agent has an angiogenesis-inhibiting effect which inhibits tumor growth. The objective of this review was to investigate the efficacy of bevacizumab as treatment option for RRP, and to explore the difference of its effects between intralesional and systemic treatment. Methods A systematic search was conducted in Cochrane, PubMed, and Embase. Articles were included if bevacizumab treatment was given intralesionally and/or systemically. The methodological quality of the studies was assessed using the CAse REport (CARE) guidelines. Results Of 585 unique articles screened by title and abstract, 15 studies were included, yielding a total of 64 patients. In 95% of the patients treated with systemic bevacizumab, the post-bevacizumab surgical interval was considerably prolonged. More than half of them did not need any surgical intervention during mean follow-up of 21.6 months. Treatment with intralesional bevacizumab showed a lower efficacy: in 62% of the patients, the post-bevacizumab surgical interval (mean, 1.8 months follow-up) was extended when compared to the interval before the treatment. Conclusion Systemically and intralesionally administered bevacizumab are effective treatment options for severe RRP. A systemic administration might be the treatment of first choice. Further prospective research with long term follow-up is advocated to elucidate this important topic.

Objective: To characterize the efficacy of human papillomavirus (HPV) vaccination as an adjuvant therapy in recurrent respiratory papillomatosis (RRP). Data Sources: PubMed, Embase, Cochrane, Google Scholar, ClinicalTrials.gov, and Web of Science databases were queried for articles published before April 2021. Review Methods: All retrieved studies (n?=?870) were independently analyzed by two reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement using predefined inclusion and exclusion criteria.?13 studies met inclusion criteria. A random-effects meta-analysis was performed to study intersurgical interval (ISI) and number of surgical procedures per year before and after vaccination. Results: The systematic review included 13 studies, comprising 243 patients. All studies utilized the Gardasil? quadrivalent vaccine, and one study (Yiu et al. 2019) utilized both the quadrivalent and Gardasil? 9-valent vaccines. Our meta-analysis included 62 patients with ISI data across 4 studies, and 111 patients with data on the number of surgical procedures per month across 7 studies. The mean number of surgical procedures decreased by 4.43 per year after vaccination (95% CI, ?7.48 to ?1.37). Mean ISI increased after vaccination, with a mean difference of 15.73 months (95% CI, 1.46?29.99). Two studies reported on HPV sero-conversion, with HPV seropositivity of 100% prior to vaccination and 25.93% after vaccination. Conclusion: The addition of HPV vaccination was associated with an increase in time between surgeries and reduction in the number of surgical procedures required. HPV vaccination may be a beneficial adjuvant treatment for RRP. Level of Evidence: N/A Laryngoscope, 2023.

Introduction Informed consent for any surgical intervention is necessary, as only well-informed patients can actively participate in the decision-making process about their care, and better understand the likely or potential outcomes of their treatment. No consensus exists on informed consent for suspension microlaryngoscopy (SML). Materials and methods Informed consent procedures in nine countries on five continents were studied. Results Several risks can be discerned: risks of SML as procedure, anesthesiologic risks of SML, specific risks of phonosurgery, risks of inadequate glottic exposure or unexpected findings, risks of not treating. SML has recognized potential complications, that can be divided in temporary (minor) complications, and lasting (major) complications. Conclusion SML is a safe procedure with low morbidity, and virtually no mortality. Eleven recommendations are provided.

Objective: To compare short-term and long-term outcomes after transcanal endoscope-assisted with microscope-assisted ossiculoplasty using the Fisch titanium total prosthesis (FTTP). Study Design: Retrospective chart review. Setting: Tertiary referral center. Patients Pediatric ( 0.05). Three months postoperative endoscopic air conduction PTA0.5-2kHz was 37.6 ± 17.4 dB (14.5 dB improvement) and 44.6 ± 19.9 dB (7.6 dB improvement) in the microscopic group (p > 0.05). Three months postoperative endoscopic PTA0.5-2kHz ABG was 26.8 ± 16.6 dB and 28.4 ± 14.7 dB in the microscopic group (p > 0.05). Latest follow-up endoscopic air conduction PTA0.5-2kHz audiogram (mean follow-up, 20.6 ± 10.4 mo) was 36.1 ± 18.2 dB (16.0 dB improvement) and 40.1 ± 16.8 dB (12.1 dB improvement) in the microscopic group (mean follow-up, 19.9 ± 10.3 mo)(p > 0.05). For endoscopic air conduction PTA0.5-2kHz, between the 3 months and latest follow-up audiogram, 25.0% showed improvement, 50.0% remained stable, and 25.0% deteriorated. In the microscopic group, 26.7% improved, 46.6% remained stable, and 26.7% deteriorated (p > 0.05). Conclusion: Our study shows that hearing results with the Fisch titanium total prosthesis are in line with literature. Endoscope-assisted total ossiculoplasty proves to be a suitable technique with comparable results to the microscopic approach.

This guideline has been initiated by the task force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology, including physicians from all relevant disciplines and patient organizations. It is a S3 consensus‐based guideline that systematically reviewed the literature on mucous membrane pemphigoid (MMP) in the MEDLINE and EMBASE databases until June 2019, with no limitations on language. While the first part of this guideline addressed methodology, as well as epidemiology, terminology, aetiology, clinical presentation and outcome measures in MMP, the second part presents the diagnostics and management of MMP. MMP should be suspected in cases with predominant mucosal lesions. Direct immunofluorescence microscopy to detect tissue‐bound IgG, IgA and/or complement C3, combined with serological testing for circulating autoantibodies are recommended. In most patients, serum autoantibodies are present only in low levels and in variable proportions, depending on the clinical sites involved. Circulating autoantibodies are determined by indirect IF assays using tissue substrates, or ELISA using different recombinant forms of the target antigens or immunoblotting using different substrates. The major target antigen in MMP is type XVII collagen (BP180), although in 10–25% of patients laminin 332 is recognized. In 25–30% of MMP patients with anti‐laminin 332 reactivity, malignancies have been associated. As first‐line treatment of mild/moderate MMP, dapsone, methotrexate or tetracyclines and/or topical corticosteroids are recommended. For severe MMP, dapsone and oral or intravenous cyclophosphamide and/or oral corticosteroids are recommended as first‐line regimens. Additional recommendations are given, tailored to treatment of single‐site MMP such as oral, ocular, laryngeal, oesophageal and genital MMP, as well as the diagnosis of ocular MMP. Treatment recommendations are limited by the complete lack of high‐quality randomized controlled trials.

Objectives/hypothesis Assumed advantages of a minimally invasive endoscopic transmeatal approach in ear surgery are less postoperative pain, faster healing, and preservation of functional anatomy. We evaluated pain after ear surgery and compared endoscopic transmeatal, microscopic endaural, and retroauricular approaches. Study design Prospective cohort study. Methods A prospective evaluation of pain during 3 weeks after ear surgery was performed. Three groups were defined: endoscopic transmeatal, microscopic endaural, and retroauricular. Data from 20 fully completed questionnaires (Brief Pain Inventory-Short Form) per group were analyzed with Bayesian and frequentist statistics. Results For all approaches, low pain scores were found, not exceeding 4 on a scale of 0 to 10. Analysis of the worst, least, and average pain scores documented per 24 hours showed no statistically significant difference nor equality between groups. With Bayesian statistics, a Bayes factor of 1.07, 0.25, and 0.51 was found, respectively. With frequentist statistics a p value of .092, .783, and 0.291 was found, respectively. Small, but statistically significant, differences were found for sleep, natural sleeping position, normal work, and pain medication taken. The location of pain correlates with the incision site. Conclusions The results of this study show that the surgical approach has no clinically relevant influence on postoperative pain after ear surgery. The statistically significant differences on natural sleeping position, sleep, normal work, and amount of pain medication taken are small and should be interpreted with caution. Therefore, these should not be decisive factors in the choice of surgical approach in ear surgery. Level of evidence 3 Laryngoscope, 131:1127-1131, 2021.

ObjectiveThis study aimed to compare the necessary scutum defect for transmeatal visualisation of middle-ear landmarks between an endoscopic and microscopic approach.MethodHuman cadaveric heads were used. In group 1, middle-ear landmarks were visualised by endoscope (group 1 endoscopic approach) and subsequently by microscope (group 1 microscopic approach following endoscopy). In group 2, landmarks were visualised solely microscopically (group 2 microscopic approach). The amount of resected bone was evaluated via computed tomography scans.ResultsIn the group 1 endoscopic approach, a median of 6.84 mm3 bone was resected. No statistically significant difference (Mann–Whitney U test, p = 0.163, U = 49.000) was found between the group 1 microscopic approach following endoscopy (median 17.84 mm3) and the group 2 microscopic approach (median 20.08 mm3), so these were combined. The difference between the group 1 endoscopic approach and the group 1 microscopic approach following endoscopy plus group 2 microscopic approach (median 18.16 mm3) was statistically significant (Mann–Whitney U test, p < 0.001, U = 18.000).ConclusionThis study showed that endoscopic transmeatal visualisation of middle-ear landmarks preserves more of the bony scutum than a microscopic transmeatal approach.

Introduction Airway anomalies are accountable for a substantial part of morbidity and mortality in children with Down syndrome (DS). Although tracheal anomalies occur more often in DS children, a structured overview on the topic is lacking. We systematically reviewed the characteristics of tracheal anomalies in DS children. Methods A MEDLINE and EMBASE search for DS and tracheal anomalies was performed. Tracheal anomalies included tracheal stenosis, complete tracheal ring deformity (CTRD), tracheal bronchus, tracheomalacia, tracheal web, tracheal agenesis or atresia, laryngotracheoesophageal cleft type 3 or 4, trachea sleeve, and absent tracheal rings. Results Fifty‐nine articles were included. The trachea of DS children is significantly smaller than non‐DS children. Tracheomalacia and tracheal bronchus are seen significantly more often in DS children. Furthermore, tracheal stenosis, CTRD, and tracheal compression by vascular structures are seen regularly in children with DS. These findings are reflected by the significantly higher frequency of tracheostomy and tracheoplasty performed in DS children. Conclusion In children with DS, tracheal anomalies occur more frequently and tracheal surgery is performed more frequently than in non‐DS children. When complaints indicative of tracheal airway obstruction like biphasic stridor, dyspnea, or wheezing are present in children with DS, diagnostic rigid laryngotracheobronchoscopy with special attention to the trachea is indicated. Furthermore, imaging studies (computed tomography, magnetic resonance imaging, and ultrasound) play an important role in the workup of DS children with airway symptoms. Management depends on the type, number, and extent of tracheal anomalies. Surgical treatment seems to be the mainstay in severe cases.

This review focuses on the importance of oral and laryngeal HPV infection which is present in majority of sexually active individuals at least once in their lifetime. Despite testing, still little is known about prevalence rates, determinants and, especially, the concurrent HPV infection in head and neck, and genitals. The purpose of this review is to clarify some issues of oral HPV incidence, prevalence, and to demonstrate the difficulties in identification of asymptomatic oral HPV carriers. The main premise to take up this topic is the high and still increasing risk for development of oropharyngeal cancer, and potential benefit from screening strategies, education programs and HPV vaccination. Transmission of HPV to the oral cavity and oropharynx is hypothesized to occur mainly through sexual contact. The exposure of oropharyngeal mucosa to HPV infection with consequence of increased risk for oropharyngeal carcinoma depends on specific sexual behavior. Male gender, older age, race or ethnicity, oral hygiene and current cigarette smoking are independently associated with any prevalent oral HPV infection. (C) 2021 The Author(s). Published by Elsevier Ltd.

OBJECTIVE: To assess the prognostic value of the ChOLE classification in predicting the severity of acquired cholesteatoma. METHOD: A retrospective chart review of patients undergoing primary cholesteatoma surgery in our tertiary referral center. The primary outcome measures were analyzed in three groups of follow up (FU): residual cholesteatoma in group A, FU > 52 weeks after last-look surgery or MRI-DWI; recurrent cholesteatoma in group B, FU > 52 weeks after last outpatient visit; and adverse events (AE) in group C, FU > 12 weeks after surgery. Cholesteatomata were staged according to the ChOLE classification. Kaplan-Meier curves were used to determine the prognostic value of the classification in predicting cholesteatoma severity, while correcting for FU. RESULTS: No significant differences were observed between the various stages of the ChOLE classification and residual or recurrent cholesteatoma rate, nor the occurrence of AE. Cholesteatoma extension to the sinus tympani or widespread in the mastoid, as well as absence of the stapes superstructure were predictive of residual disease. Sclerotic mastoids had a lower risk of residual disease than mastoids with good or poor pneumatization and ventilation. Poorly ventilated and poorly pneumatized mastoids were associated with increased risk of recurrence. Widespread cholesteatoma in the mastoid as well as presence of preoperative extracranial complications were correlated with an increased risk of AE. CONCLUSION: The ChOLE classification does not predict residual nor recurrent disease, nor the occurrence of AE, in our study population. Risk factors for severe cholesteatoma were identified, potentially useful for the development of future classifications.

The majority of sexually active individuals becomes infected with human papillomavirus (HPV) at least once in their lifetime. Pathways for HPV transmission vary across different mucosal sites per individual. They include autoinoculation within one host, direct transmission between individuals (including perinatal transmission and transmission during sexual activity), and indirect transmission through contact with hands. The authors aim to clarify the prevalence and route of transmission per anatomic site, inter- and intra-individually, using a narrative review of the literature. In conclusion, transmission of HPV to the oral cavity and oropharynx is hypothesised to occur mainly through sexual contact. Transmission of particles through saliva has not been proven and daily living activities are not a documented source of HPV infection. Oropharyngeal HPV related cancer survivors and their partners do not show increased risk of infection during sexual intercourse. Transmission of HPV to the oral cavity (autoinoculation with fingers or transmission through saliva in deep kissing) is probably of limited importance.

Introduction: The novel Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, may need intensive care unit (ICU) admission in up to 12% of all positive cases for massive interstitial pneumonia, with possible long-term endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common airway-related complications of such ICU maneuvers are laryngotracheal granulomas, webs, stenosis, malacia and, less commonly, tracheal necrosis with tracheo-esophageal or tracheo-arterial fistulae. Materials and methods: This paper gathers the opinions of experts of the Laryngotracheal Stenosis Committee of the European Laryngological Society, with the aim of alerting the medical community about the possible rise in number of COVID-19-related laryngotracheal stenosis (LTS), and the aspiration of paving the way to a more rationale concentration of these cases within referral specialist airway centers. Results: A range of prevention strategies, diagnostic work-up, and therapeutic approaches are reported and framed within the COVID-19 pandemic context. Conclusions: One of the most important roles of otolaryngologists when encountering airway-related signs and symptoms in patients with previous ICU hospitalization for COVID-19 is to maintain a high level of suspicion for LTS development, and share it with colleagues and other health care professionals. Such a condition requires specific expertise and should be comprehensively managed in tertiary referral centers.

Purpose To quantify changes in the perceived epithelial border with narrow band imaging (NBI) and white light imaging (WLI) during cholesteatoma surgery and to objectify possible benefits of NBI in otology. Methods Perioperative digital endoscopic images were captured during combined approach tympanoplasty at our tertiary referral center using WLI and NBI (415 nm and 540 nm wavelengths). Sixteen otologic surgeon defined the epithelial borders within 16 identical WLI and NBI photos. Pixels of these selections were calculated to analyze the quantitative difference between WLI and NBI. A questionnaire also analyzed the qualitative differences. Results Sixteen otologic surgeons participated in the study. Stratified per photo, only two photos yielded a significant difference: less pixels were selected with NBI than WLI. A Bland–Altman plot showed no systemic error. Stratified per otologist, four participants selected significantly more pixels with WLI than with NBI. Overall, no significant difference between selected pixels was found. Sub-analyses of surgeons with more than 5 years of experience yielded no additional findings. Despite these results, 60% believed NBI could be advantageous in defining epithelial borders, of which 83% believed NBI could reduce the risk of residual disease. Conclusion There was no objective difference in the identification of epithelial borders with NBI compared to WLI in cholesteatoma surgery. Therefore, we do not expect the use of NBI to evidently decrease the risk of residual cholesteatoma. However, subjective assessment does suggest a possible benefit of lighting techniques in otology. Level of evidence 3.

Purpose This study aims to analyse differences in fiberoptic laryngoscopy (FOL) versus high definition laryngoscopy (HDL) by examining videolaryngoscopy images by a large group of observers with different levels of clinical expertise in ear, nose and throat (ENT) medicine. Methods This study is a 111 observer paired analysis of laryngoscopy videos during an interactive presentation. During a National Meeting of the Dutch Society of ENT/Head and Neck Surgery, observers assessed both FOL and HDL videos of nine cases with additional clinical information. Observers included 41 ENT consultants (36.9%), 34 ENT residents (30.6%), 22 researchers with Head and Neck interest (19.8%) and 14 with unspecified clinical expertise (12.6%). For both laryngoscopic techniques, sensitivity, specificity, positive and negative predictive value and diagnostic accuracy were determined for identifying a normal glottis, hyperkeratosis, radiotherapy adverse effects and squamous cell carcinoma. The sensitivities for FOL and HDL were analysed with regard to the different levels of clinical expertise. Results The overall sensitivity for correctly identifying the specific histological entity was higher in HDL (FOL 61% vs HDL 66.3%, p p p = 0.02). Residents and researchers with Head and Neck interest diagnosed laryngeal lesions more correctly with HDL (p Conclusions In a large population of observers with different levels of clinical expertise, HDL is superior to FOL in identifying laryngeal lesions.

Objectives/Hypothesis: Congenital auricular anomalies are common. Additionally, the auricle plays an important role in the staging of human embryos. However, little is known about the embryological development of the auricle. The most commonly reproduced developmental theory by His (1885) describes six hillocks; three on the first and three on the second pharyngeal arch. The aim of this study was to assess the validity of this theory by modern techniques and to expand the knowledge of the embryological development and morphology of the auricle. Study Design: 22 human embryos from the Carnegie collection between Carnegie stage 13 and 23 (28–60 days) were selected based on their histological quality. Methods: Histological sections of the selected embryos were examined. Three-dimensional (3D) reconstructions were prepared. Additionally, literature research was performed. Results: The hillocks were absent in most stages. Contrary to common knowledge, the auricle is almost entirely innervated by branches of the facial nerve. The branches of the trigeminal nerve only innervate the tragus and the anterior external auditory meatus (EAM). Consequently, this indicates that almost the entire auricle is derived from the second pharyngeal arch, with the exception of the tragus and the anterior EAM. Conclusions: The 3D reconstructions show the anatomy and development of the auricle to be different from concepts presented in current textbooks. As a consequence, we propose that preauricular sinuses should be classified as first pharyngeal arch anomalies. Level of Evidence: NA Laryngoscope, 130:2467–2474, 2020.

Airway surgery in pediatric patients is challenging with regard to balancing surgical exposure with ventilation requirements, as during the procedure the airway must be shared between laryngologist and anesthetist. For endoscopic laryngeal surgery, different methods of ventilation are used, among others jet ventilation via a specifically adapted suspension laryngoscope using a dual jet stream(Supraglottic Superimposed High Frequency Jet ventilation, SSHFJV) (1).High BMI and a history of pulmonary pathology proved to be factors contributing to failing of SSHFJV in adult patients (2). However, factors influencing the failure of SSHFJV in pediatric patients have never been described yet.

Objectives High definition laryngoscopy (HDL) could lead to better interpretation of the pharyngeal and laryngeal mucosa than regularly used fiberoptic laryngoscopy (FOL). The primary aim of this study is to quantify the diagnostic advantage of HDL over FOL in detecting mucosal anomalies in general, in differentiating malignant from benign lesions and in predicting specific histological entities. The secondary aim is to analyse image quality of both laryngoscopes. Design Retrospective paired analysis with multiple observers evaluating endoscopic videos simulating daily clinical practice. Setting A tertiary referral hospital. Participants In 36 patients, both FOL and HDL videos were obtained. Six observers were provided with additional clinical information, and 36 FOL and HDL videos were evaluated in a randomised order. Main outcome measures Sensitivity, specificity, positive and negative predictive value and diagnostic accuracy of observers using both flexible laryngoscopes were calculated for detection of mucosal lesions in general and uncovering malignant lesions. Sensitivities were calculated for prediction of specific histological entities. Image quality (scale 1-10) was assessed for both flexible laryngoscopes. Results HDL reached higher sensitivity compared to FOL for detection of mucosal abnormalities in general (96.0% vs 90.4%; P = .03), differentiating malignant from benign lesions (91.7% vs 79.8%; P = .03) and prediction of specific histological entities (59.7% vs 47.2%; P

Objectives: The primary goal was to study the diagnostic potential of narrow-band imaging (NBI), and the secondary goal was to evaluate the most common mistakes when using and interpreting NBI.Design: Retrospective study.Setting: University Medical Center Groningen, tertiary referral hospital, the Netherlands.Participants: Three hundred and seventy patients who underwent rigid endoscopy of the upper aerodigestive tract. Two observers assessed all lesions. Twelve observers assessed a selection of 100 lesions. All observers were provided with both white light imaging and NBI.Main outcome measures: Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and reasons for insufficient photograph quality.Results: When using NBI, the sensitivity, specificity, PPV, NPV and accuracy for detecting invasive carcinoma, carcinoma in situ or high-grade dysplasia were 92%, 68%, 61%, 94% and 77%, respectively. In multiple-observer analysis, values were 76%, 58%, 53%, 83% and 65% with the evaluation strictly based on type V patterns of Ni's classification, vs 83%, 68%, 64%, 85% and 74% when evaluation was also based on lesion-specific clinical characteristics. Lesions that caused misinterpretations were leukoplakia, papillomas and mucosal lesions after irradiation. In total, 185 photographs were assessed to be of suboptimal quality due to blurring (36%), bleeding (6%), insufficient zooming (15%) and/or insufficient lighting (17%).Conclusion: NBI is a relatively reliable screening method for detecting malignancy. Evaluation based on Ni's classification alone is not sufficient. To optimise NBI photograph quality, we recommend sufficient zooming and prevention of bleeding, blurring and inadequate lighting.

Proper training and assessment of skill in flexible pharyngo-laryngoscopy are central in the education of otorhinolaryngologists. To facilitate an evidence-based approach to curriculum development in this field, a structured analysis of what constitutes flexible pharyngo-laryngoscopy is necessary. Our aim was to develop an assessment tool based on this analysis. We conducted an international Delphi study involving experts from twelve countries in five continents. Utilizing reiterative assessment, the panel defined the procedure and reached consensus (defined as 80% agreement) on the phrasing of an assessment tool. FIFTY PANELISTS COMPLETED THE DELPHI PROCESS. THE MEDIAN AGE OF THE PANELISTS WAS 44 YEARS (RANGE 33-64 YEARS). MEDIAN EXPERIENCE IN OTORHINOLARYNGOLOGY WAS 15 YEARS (RANGE 6-35 YEARS). TWENTY-FIVE WERE SPECIALIZED IN LARYNGOLOGY, 16 WERE HEAD AND NECK SURGEONS, AND NINE WERE GENERAL OTORHINOLARYNGOLOGISTS. AN ASSESSMENT TOOL WAS CREATED CONSISTING OF TWELVE DISTINCT ITEMS.: Conclusion The gathering of validity evidence for assessment of core procedural skills within Otorhinolaryngology is central to the development of a competence-based education. The use of an international Delphi panel allows for the creation of an assessment tool which is widely applicable and valid. This work allows for an informed approach to technical skills training for flexible pharyngo-laryngoscopy and as further validity evidence is gathered allows for a valid assessment of clinical performance within this important skillset

Purpose: Septic cavernous sinus thrombosis (CST) is a rare complication of infections in the head and neck area. CST is notorious for its bad prognosis, with high mortality and morbidity rates described in literature. However, these rates are based on old series. We question whether the prognosis of CST is currently still as devastating. The primary purpose of this study is to assess the mortality and morbidity of CST. Methods: Using the databases of all relevant specialties in our tertiary referral hospital, we collected all the patients treated for CST in the period 2005–2017. In addition, a PubMed search, using the mesh term ‘cavernous sinus thrombosis’, was performed. Results: We found 12 patients with CST in the study period. Of the 12 patients, 11 survived and 9 recovered without any permanent deficits. Seven patients were treated with anticoagulation, and in none of the patients we saw hemorrhagic complications. In literature, older articles describe higher mortality rates (14–80%), but more recent articles report mortality and morbidity rates similar to our results. Conclusions: The prognosis of CST nowadays is more favorable than previously described. Anticoagulation seems to be a safe addition to antibiotic and surgical treatment, at least in patients without central nervous system infection.

The hyoid-larynx complex is highly prone to anatomical variation. The etiology of anatomical variants such as Eagle's syndrome and the aberrant hyoid apparatus can be explained from embryonic development. Modern textbooks state that the hyoid bone body develops from the second and third pharyngeal arch cartilages, and that thyroid cartilage derives from the fourth and sixth arch cartilages. This description, however, is incompatible with various anatomical variants, and it is unclear whether it was based on observations in human embryos or on comparative embryology.14 human embryos from the Carnegie collection between Carnegie stage 17 and 23 (42-60 days) were selected based on their histological quality.Histological sections of the selected embryos were examined. Three-dimensional models were prepared in an interactive format. These anatomical models provide crucial spatial information and facilitate interpretation.We observed a less-complicated development of the hyoid-larynx complex than is currently described in textbooks. The body of the hyoid bone originates from a single growth center, without overt contributions from second and third pharyngeal arch cartilages. The fourth and sixth arch cartilages were not detected in human embryos; the thyroid and cricoid cartilages develop as mesenchymal condensations in the neck region.Despite new research techniques, theories about hyoid-larynx complex development from the beginning of the 20th century have not been refuted properly and can still be found in modern literature. Based on observations in human embryos, we propose a new and relatively simple description of the development of the hyoid-larynx complex to facilitate better understanding of the etiology of anatomical variants.NA Laryngoscope, 1829-1834, 2018.

BACKGROUND: The purpose of this study was to validate the prognostic value of adding narrow-band imaging (NBI) during transoral laser surgery (TLS) for early glottic cancer.METHODS: In 84 patients, 93 transoral laser resections were performed for carcinoma in situ (Tcis), T1, or T2 glottic cancer. TLS was preceded by intraoperative evaluation using traditional white-light imaging (WLI) in 51 cases. In 42 cases, NBI was used in addition to WLI. Local recurrence rate and recurrence-free survival were retrospectively compared between both groups.RESULTS: Local recurrences developed in 14% of the 93 cases: 12 of 51 patients (24%) were treated by TLS based on WLI alone, and in 1 of 42 patients (2%) in the NBI group (P < .01). Two-year recurrence-free survival was 82% in the WLI group and 98% in the NBI group (P < .05).CONCLUSION: Additional use of NBI during TLS for early glottic cancer significantly improves clinical outcome.

OBJECTIVES/HYPOTHESIS: Recurrent respiratory papillomatosis (RRP) is a disease with a high disease burden. Few studies have assessed quality of life (QoL) of RRP patients. This study compares QoL of these patients with controls. Associations between QoL and sociodemographic and illness-related factors are examined, as is uptake of psychosocial care and speech therapy. STUDY DESIGN: Prospective cross-sectional questionnaire research. METHODS: Ninety-one RRP patients (response = 67%) from two university hospitals in the Netherlands and Finland completed the following patient reported outcome measures: (HADS), 15-dimensional health-related quality-of-life scale (15D), Voice Handicap Index (VHI) and the RAND 36-item health-related quality-of-life survey instrument (RAND-36) assessing health-related QoL and voice handicap, and they provided sociodemographic, illness-related, and allied healthcare use. Descriptive analyses, χ(2) tests, t tests, analysis of variance tests, and Pearson correlations were computed to describe the study population and to examine differences between groups. RESULTS: RRP patients had significantly higher mean scores on depression, health-related QoL (15D) and on voice problems (VHI), and significantly lower mean scores on anxiety than controls. Dutch patients had more pain and a decreased general health perception (RAND-36) than controls. Dutch patients and older patients were more depressed, women were more anxious, older patients had lower health-related QoL, and smoking was significantly associated with voice handicap. Patients who had received psychosocial care had significantly higher HADS-depression mean scores than patients who did not receive psychosocial care. CONCLUSIONS: Having RRP has significant effect on voice-related QoL and depression, but has no negative effect on anxiety and health-related QoL. Risk factors for decreased functioning are different than previously hypothesized by many authors. Prevention should be aimed at these risk factors. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016.

Purpose: Vocal fold scar is one the most challenging benign laryngeal pathologies. The purpose of this paper is to propose a classification that will allow for a common description of this entity between laryngologists, prevent discrepancies in interpretation, allow for comparison of related studies, and offer a training tool for young laryngologists. Methods/Results: Based on the depth and laterality of scarring, we propose 4 types: type I, characterized by atrophy of lamina propria with/without affected epithelium; type II, where the epithelium, lamina propria, and muscle are affected; type III, where the scar is located on the anterior commissure; type IV, which includes extended scar formation in both anteroposterior and rostro-caudal axis with significant loss of vocal fold mass. Conclusion: We believe that our proposal is comprehensive and encompasses all existing iatrogenic and non-iatrogenic etiologies in a simple and concise manner. It also serves its purpose as a descriptive, comparative, and training tool.

Objectives: The aim of this study was to determine and compare the incidence of long- and short-term complications of percutaneous dilatation tracheotomies (PDT) and surgical tracheotomies (ST). Design: A single-centre retrospective study. Participants: 305 patients undergoing a tracheotomy (PDT or ST) in the University Medical Center Groningen from 2003 to 2013 were included. Data were gathered from patient files. Main outcome measures: Short-term and long-term complications including tracheal stenosis. Results: The incidence of short- and long-term complications, including tracheal stenosis, was similar in both groups. Analysis of a small high-risk subgroup showed no difference in long-term complications. Conclusions: The rate of short- and long-term complications, including tracheal stenosis, is equal in PDT and ST. PDT is a safe alternative for ST in selected patients.

Thorough anatomic knowledge of the hyoid-larynx complex is necessary for forensic radiologists and ear-nose-throat surgeons, given the many anatomic variations that originate in embryology. In forensics the anomalies must be distinguished from fractures because the latter are indicative of violence on the neck. In this manuscript we describe the anatomical variations that can be found in the hyoid-larynx complex and explain their etiology. 284 radiological scans of excised hyoid-larynx complexes were examined with X-ray and CT. Some rare cases from literature and historical collections were added. Two third of the examined hyoid-larynx complexes deviated from the anatomical standard and showed uni- or bilateral ankylosis in the hyoid bone and/or so-called triticeal cartilages. In one fifth of the cases we found striking anatomical variants, mostly derived from the cartilage of the second pharyngeal arch. Anatomical variations of the hyoid-larynx complex can be explained by embryological development. The aberrant hyoid apparatus and the elongated styloid processes (Eagle syndrome) should be considered as one clinical entity with two different expressions as both anomalies are derived from the cartilage of the second pharyngeal arch. Several variants can mimic fractures in this region, so our study is important for radiologists and forensic experts assessing cases of possible violence on the neck.

Since 2015, the European Laryngological Society (ELS) has organized on a yearly basis the European Laryngological Live Surgery Broadcast. The goal of this paper is to demonstrate the increasing worldwide audience. The number of individual computers logged in, number of estimated audience, and number of countries with an active audience were calculated and compared to the numbers in 2015. In 2018, 19 live interventions were performed in three parallel sessions. The surgeons worked in 10 departments in 8 different countries. The number of individual computers logged in increased from 1000 in 2015 to 16000 in 2018. The estimated audience increased from 3000 to 32000 visitors. The number of countries with an active audience increased from 52 to 91. The amount of computers logged in is increasing year by year. The audience was presenting despite inconvenient broadcasting times, highlighting the educational importance. The teaching aspect remains visible on videos of this year’s and previous year’s interventions. They can be seen on website http://els.livesurgery.net/home.php . The organization of the European Laryngological Live Surgery Broadcast concurs to the idea that live broadcast of laryngologic surgery is feasible and attractive. Therefore, the ELS is going to continue to organize additional European Laryngological Live Surgery Broadcasts in the future.

OBJECTIVES/HYPOTHESIS: Antireflux therapy is incorporated in many treatment protocols for recurrent respiratory papillomatosis (RRP) because gastroesophageal reflux (GERD) is thought to worsen the disease course of RRP. It is unclear if GERD really aggravates the disease course. The aims of this systematic review were to 1) evaluate incidence of GERD among RRP patients and 2) report if GERD changes the clinical course or tissue properties of RRP. STUDY DESIGN: A search was conducted in PubMed, Embase, and Google Scholar, following the methods of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. METHODS: Articles with original data, published after January 1, 1990, on RRP with GERD as a determinant were eligible. There was no language restriction. Data on study design, study population, statistics, outcomes (incidence and influence of GERD), and risk of bias were collected and evaluated following PRISMA protocols. RESULTS: Of 1,277 articles, 19 were selected. Gastroesophageal reflux was objectified in 25% to 100% of RRP patients. Subjective GERD was present in 0% to 70% of patients. There is no proof that GERD aggravated the clinical course or tissue properties of RRP, as measured by the number of surgeries, severity scoring systems, or dysplasia. One study did find a higher chance of web formation in patients with anterior or posterior glottic papillomas who did not receive antireflux therapy, but these results should be interpreted with care due to the study's quality. CONCLUSION: There is insufficient proof that GERD does or does not aggravate the clinical course or tissue properties of RRP. Laryngoscope, 2016.

Objectives/Hypothesis: Visualization by endoscopy is essential in the diagnosis of upper aerodigestive tract lesions. Recent studies showed that narrow band imaging (NBI) increases the diagnostic potential of conventional white light imaging (WLI) by highlighting the superficial vessels. The objective of this study was to evaluate whether the use of NBI would influence inter- and intraobserver agreement while making diagnostic decisions using rigid endoscopy of the upper aerodigestive tract. Study Design: Retrospective study. Methods: One hundred routinely collected pictures of laryngeal, hypopharyngeal, and oropharyngeal lesions were used. Rigid endoscopies and patient data collection were performed according to standard protocol. Twelve observers, grouped in different levels of experience, assessed all lesions twice with a 2 to 4 week interval. Fleiss and Cohen's kappa (kappa) values were calculated to assess inter- and intraobserver agreement. Results: Overall interobserver agreement increased from kappa = 0.34 to kappa = 0.40 by adding NBI to WLI (WLI and WLI + NBI, respectively). In experienced observers, an improvement from kappa = 0.39 to kappa = 0.43 was observed; in less-experienced observers an improvement from kappa = 0.30 to kappa = 0.37 was observed. Overall intraobserver agreement increased from moderate (kappa = 0.54) to substantial (kappa = 0.63) with addition of NBI. lntraobserver agreement for less -experienced observers improved remarkably when WLI was combined with NBI (kappa = 0.51 vs. kappa = 0.67). Conclusions: Addition of NBI during rigid endoscopies of the upper aerodigestive tract led to improvement of both inter- and intraobserver agreement.

In the last decades new endoscopic tools have been developed to improve the diagnostic work-up of vocal fold lesions in addition to normal laryngoscopy, i.e., contact endoscopy, autofluorescence, narrow band imaging and others. Better contrasted and high definition images offer more details of the epithelial and superficial vascular structure of the vocal folds. Following these developments, particular vascular patterns come into focus during laryngoscopy. The present work aims at a systematic pathogenic description of superficial vascular changes of the vocal folds. Additionally, new nomenclature on vascular lesions of the vocal folds will be presented to harmonize the different terms in the literature. Superficial vascular changes can be divided into longitudinal and perpendicular. Unlike longitudinal vascular lesions, e.g., ectasia, meander and change of direction, perpendicular vascular lesions are characterized by different types of vascular loops. They are primarily observed in recurrent respiratory papillomatosis, and in pre-cancerous and cancerous lesions of the vocal folds. These vascular characteristics play a significant role in the differential diagnosis. Among different parameters, e.g., epithelial changes, increase of volume, stiffness of the vocal fold, vascular lesions play an increasing role in the diagnosis of pre- and cancerous lesions.

Adult and pediatric laryngotracheal stenoses (LTS) comprise a wide array of various conditions that require precise preoperative assessment and classification to improve comparison of different therapeutic modalities in a matched series of patients. This consensus paper of the European Laryngological Society proposes a five-step endoscopic airway assessment and a standardized reporting system to better differentiate fresh, incipient from mature, cicatricial LTSs, simple one-level from complex multilevel LTSs and finally "healthy" from "severely morbid" patients. The proposed scoring system, which integrates all of these parameters, may be used to help define different groups of LTS patients, choose the best treatment modality for each individual patient and assess distinct post-treatment outcomes accordingly.

Objective: Laryngomalacia is the most common cause of dyspnea and stridor in newborn infants. Laryngomalacia is a dynamic change of the upper airway based on abnormally pliable supraglottic structures, which causes upper airway obstruction. In the past, different classification systems have been introduced. Until now no classification system is widely accepted and applied. Our goal is to provide a simple and complete classification system based on systematic literature search and our experiences. Study Design: Retrospective cohort study with literature review. Methods: All patients with laryngomalacia under the age of 5 at time of diagnosis were included. Photo and video documentation was used to confirm diagnosis and characteristics of dynamic airway change. Outcome was compared with available classification systems in literature. Results: Eighty-five patients were included. In contrast to other classification systems, only three typical different dynamic changes have been identified in our series. Two existing classification systems covered 100% of our findings, but there was an unnecessary overlap between different types in most of the systems. Based on our finding, we propose a new a classification system for laryngomalacia, which is purely based on dynamic airway changes. Conclusion: The groningen laryngomalacia classification is a new, simplified classification system with three types, based on purely dynamic laryngeal changes, tested in a tertiary referral center: Type 1: inward collapse of arytenoids cartilages, Type 2: medial displacement of aryepiglottic folds, and Type 3: posterocaudal displacement of epiglottis against the posterior pharyngeal wall. (C) 2015 Wiley Periodicals, Inc.

Human papillomavirus (HPV) infections are well known causes of anogenital cancers. Recent studies show that HPV also plays a role in oropharyngeal cancer (OPC). A review on the role of HPV vaccination in the prevention of head and neck squamous cell carcinoma (HNSCC) with special emphasis on OPC was conducted and available vaccines and vaccination strategies in HNSCC and OPC are discussed. Prophylactic vaccination is known to be effective for prevention of anogenital HPV infection and precursor lesions in the cervix and anus. While the value of vaccination for prevention of OPC and possibly as an adjuvant treatment is still an open question, evidence to date supports the possibility that HPV vaccination may prove to be effective in reducing the incidence of this malignancy. (C) 2015 Elsevier Ltd. All rights reserved.

Objectives/HypothesisTo evaluate the short-term voice outcomes of vocal fold augmentation using fat compared to calcium hydroxylapatite product Radiesse Voice (Merz Aesthetics). Study DesignRetrospective study design. MethodsSixty-six consecutive patients with vocal fold insufficiency were recruited, including the final 33 patients treated with fat and all 33 patients treated with calcium hydroxylapatite product. Before April 2011, fat augmentation was the standard treatment; from April 2011, only calcium hydroxylapatite product was used. For all subjects, videolaryngostroboscopic evaluation, s/z ratios, and voice handicap index (VHI) were analyzed. MethodsTreatment outcomes were evaluated 3 months after the augmentation. Two patients augmented with fat (both after 6 months), versus four augmented with calcium hydroxylapatite product (mean after 7 months), needed reintervention. Mean VHI decreased from 18 points in the fat augmentation group compared to 17 points in the calcium hydroxylapatite group. Mean s/z ratio changed -0.33 in the fat augmentation group compared to -0.46 in the calcium hydroxylapatite group. ConclusionThis retrospective cohort demonstrates that there are no short-term differences in VHI outcome or number of reinterventions for augmentation with fat compared to calcium hydroxylapatite product Radiesse Voice (Merz Aesthetics). Level of EvidenceLevel 4. Laryngoscope, 125:1161-1165, 2015

Objective Recurrent respiratory papillomatosis (RRP) is a rare disease for which a limited number of information sources for patients exist. The role of the Internet in the patient–physician relationship is increasing. More and more patients search for online health information, which should be of good quality and easy readable. The study aim was to investigate the quality and readability of English online health information about RRP. Study Design Quality and readability assessment of online information. Methods Relevant information was collected using three different search engines and seven different search terms. Quality was assessed with the DISCERN instrument. The Flesch Reading Ease Score (FRES) and average grade level (AGL) were determined to measure readability of the English websites. Results Fifty-one English websites were included. The mean DISCERN score of the websites is 28.1 ± 9.7 (poor quality); the mean FRES is 41.3 ± 14.9 (difficult to read); and the mean AGL is 12.6 ± 2.3. Conclusion The quality and readability of English websites about RRP is alarmingly poor. Level of Evidence NA. Laryngoscope, 127:2293–2297, 2017

Objective. There is no specific clinical tool for physicians to detect psychosocial and physical distress or health care need in patients with recurrent respiratory papillomatosis (RRP). The main aim of this study is to validate the RRP-adapted Distress Thermometer and Problem List (DT&PL).Study Design. Prospective cross-sectional questionnaire research.Setting. Academic tertiary care medical centers in Groningen, Netherlands, and Helsinki, Finland.Subjects and Methods. Ninety-one juvenile- and adult-onset RRP patients participated from the departments of otorhinolaryngology-head and neck surgery of the University Medical Center Groningen, Netherlands, and Helsinki University Hospital, Finland. The Hospital Anxiety and Depression Scale was used as the gold standard.Results. A DT cutoff score 4 gave the best sensitivity and specificity. Thirty-one percent of patients had significant distress according to the DT cutoff. Significantly more patients with a score above than under the cutoff had a referral wish. The PL appeared to be reliable. Patients' opinions on the DT&PL were largely favorable.Conclusion. The Dutch and Finnish versions of the DT&PL are valid, reliable screening tools for distress in RRP patients.

Acronyms and abbreviations are frequently used in otorhinolaryngology and other medical specialties. CO2 laser-assisted transoral surgery of the pharynx, the larynx and the upper airway is a family of commonly performed surgical procedures termed transoral laser microsurgery (TLM). The abbreviation TLM can be confusing because of alternative modes of delivery. Classification and definition of the different types of procedures, performed transorally or transnasally, are proposed by the Working Committee for Nomenclature of the European Laryngological Society, emphasizing the type of laser used and the way this laser is transmitted. What is usually called TLM, would more clearly be defined as CO2 laser transoral microsurgery or CO2 TOLMS or CO2 laser transoral surgery only (with a handpiece) would be defined as CO2 TOLS. KTP transnasal flexible laser surgery would be KTP TNFLS. Transoral use of the flexible CO2 wave-guide with a handpiece would be a CO2 TOFLS. One can argue that these clarifications are not necessary and that the abbreviation TLM for transoral laser microsurgery is more than sufficient. But this is not the case. Laser surgery, office-based laser surgery and microsurgery are frequently and erroneously interchanged for one another. These classifications allow for a clear understanding of what was performed and what the results meant.

Endoscopic sheaths covering the laryngoscope are advised to prevent cross contamination, but might hamper visualization as the most important tool in the diagnostic approach of laryngeal disease. We evaluated whether endoscopic sheaths change image quality and diagnostic accuracy of flexible distal chip laryngoscopy (DCL) and flexible fiberoptic laryngoscopy (FOL). Twelve healthy volunteers underwent a flexible laryngoscopy using a distal chip and a fiberoptic laryngoscope with and without endoscopic sheaths, and in this way 48 images were collected. To determine diagnostic accuracy, the 48 images were mixed with images of 40 patients. All images were randomly shown to four experts in the field of laryngology and head and neck oncology. Observers were asked to validate image quality, choose a diagnosis, and express their confidence level of that diagnosis. Image quality was validated better in DCL as compared to FOL (p

Background. Recurrent respiratory papillomatosis (RRP) is mainly associated with human papillomavirus (HPV) 6 or HPV11. The purpose of this study was to compare clinical outcome, aggressiveness, and treatment response between HPV6- and HPV11-associated RRP. Methods. A retrospective cohort of 55 patients with RRP (1974-2012) was used. Surgical interventions (n = 814) were analyzed, and complications scored. HPV6/11-specific polymerase chain reaction (PCR) was performed on RRP biopsies. Results. Seventy-six percent of patients (42 of 55) were infected with HPV6 and 24% (13 of 55) with HPV11. The HPV11 group had anatomically more widespread disease. The expected number of surgical interventions was higher in the younger age ( Conclusion. Anatomically, HPV11-associated RRP behaves more aggressively. Younger patients with HPV11 and older patients with HPV6 experience a worse clinical course of RRP. (C) 2014 Wiley Periodicals, Inc.

Laryngeal visualization is the hallmark in the diagnostic approach of laryngeal disease. In addition to fiberoptic techniques, digital distal chip technology has been developed to improve visualization. Endoscopic sheaths are used in daily clinical practice to prevent cross-contamination. The objective of the study was to evaluate diagnostic accuracy, image quality and interrater reliability of both flexible distal chip laryngoscopy (DCL) and flexible fiberoptic laryngoscopy (FOL) using contamination preventing endoscopic sheaths. In 53 cases both DCL and FOL images were collected during routine examination using endoscopic sheaths. All images were randomly shown to four experts in the field of laryngology and head and neck oncology. Observers were asked to choose a diagnosis, express their confidence level of that diagnosis and validate image quality: in this way 420 observations (four observers using two techniques) were analyzed. Accuracy in detecting laryngeal disease was 78 % (both DCL and FOL). Confidence level of diagnosis tended to be higher in DCL (p = 0.05). Image quality was validated better in DCL as compared to FOL (p