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Summary: Mucous membrane pemphigoid (MMP) is an autoimmune blistering, scarring and occasionally mutilating disease that may progress to blindness or airway obstruction. Over the past few years, rituximab (RTX) has emerged as a potential therapeutic solution for MMP; however, the literature regarding its efficacy in the treatment of severe MMP is sparse. We studied four patients with recalcitrant MMP who were treated with RTX. Three of these had recalcitrant laryngeal disease; two were unresponsive to RTX, while the third patient achieved complete remission (CR) but relapsed twice. The fourth patient, who had oral and ocular disease, also achieved CR. In addition, we reviewed 143 cases of MMP treated with RTX reported in the literature to date. Of these, 120 had late observation endpoints, of whom 81 (67.5%) achieved CR, 24 (20%) received partial remission and 15 (12.5%) had no remission. Based on this study, the presence of laryngeal MMP seems to predict refractoriness to RTX treatment. In conclusion, we found that RTX can ameliorate the MMP course and that laryngeal involvement, which is known to be a prognostic factor for severe MMP, may also predict poor response to RTX. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study is to compare the short-term effect of 7 versus 3 days of voice rest (VR) on objective vocal (acoustic) parameters following phonosurgery., Methods: A prospective randomized study conducted at a tertiary referral medical center. Patients with vocal fold nodules, polyps, or cysts and scheduled for phonosurgery were recruited from the Voice Clinic. They were randomized into groups of 7- or 3-day postoperative VR periods and their voices were recorded preoperatively and at 4-week postoperatively. A mixed linear model statistical analysis (MLMSA) was used to compare pre- and postoperative jitter, shimmer, harmonic-to-noise ratio, and maximum phonation time between the two groups., Results: Sixty-five patients were recruited, but only 34 fully complied with the study protocol, and their data were included in the final analysis (19 males, 20 females; mean age: 40.6 years; 17 patients in the 7-day VR group and 16 in the 3-day VR group). The groups were comparable in age, sex, and type of vocal lesion distribution. The preoperative MLMSA showed no significant group differences in the tested vocal parameters. Both groups exhibited significant (p < 0.05) and comparable improvement in all vocal parameters at postoperative week 4., Conclusions: A VR duration of 7 days showed no greater benefit on the examined vocal parameters than the 3-day protocol 4-week postoperatively. Our results suggest that a 3-day VR regimen can be followed by patients who undergo phonosurgery without compromising the vocal results. Larger-scale and longer-duration studies are needed to confirm our findings., Level of Evidence: 2 Laryngoscope, 134:4661-4666, 2024., (© 2024 The Author(s). The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: This study aims to examine the association between voice experience and levels of depression, anxiety, and stage of gender affirmation in transgender women., Study Design: A cross-sectional study., Methods: Adult transgender women attending a tertiary referral center were recruited between April 2022 and January 2023. They filled in a demographic and health survey, the Hebrew Trans Woman Voice Questionnaire (H-TWVQ), the Hebrew Patient Health Questionnaire, and the Hebrew version of the Generalized Anxiety Disorder Screener. Descriptive statistics and data regarding the associations between voice experience, grades of anxiety and depression, and stage of gender affirmation were compiled., Results: Sixty-seven transgender women were included (mean age 26.7 ± 7.78 years, mean time of presenting socially as a woman 5.2 ± 5.2 years). The median H-TWVQ score was 71 (maximal score 120). Most participants reported mild anxiety and mild depression levels. Those who reported a more positive voice experience (H-TWVQ score ≤71) had lower median depression and anxiety scores than participants with a less-positive voice experience (H-TWVQ score >71) (P = 0.028 vs P = 0.044, respectively), complained less of hoarseness (2.9% vs 19.4%, P = 0.045,) and more were employed (78.8% vs 41.9%, P = 0.003). No association was found between voice experience and cross-sex hormone treatment, affirmation surgery undertaken, or number of years presenting socially as a woman., Conclusions: We observed a potential association between better voice experience and lower anxiety and depression levels among transgender women. No association was found between voice experience and the stage of gender affirmation. Physicians treating this population should be aware of these associations and consider therapeutic means for voice adjustment., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Feminization laryngochondroplasty (FLC) methods have evolved from using a midcervical incision to a submental, less visible incision. The scar may be unacceptable to the patient because it signals gender reassignment surgery. An endoscopic transoral approach to FLC inspired by transoral endoscopic thyroidectomy was recently suggested to avoid the neck scar; however, it requires special equipment and has a long learning curve. A vestibular incision is used to approach the chin in lower-third facial feminization surgery. The authors propose that this incision may be extended to the thyroid cartilage in performing direct FLCs. The authors describe their experience with a novel, minimally invasive, direct transvestibular use of the chin-reshaping incision., Methods: The medical records of all patients who underwent direct transvestibular FLC (DTV-FLC) from December of 2019 to September of 2021 were retrieved and reviewed for this retrospective cohort study. Data on the operative, postoperative, and follow-up courses, complications, and functional and cosmetic results were retrieved., Results: Nine transgender women were included. Seven DTV-FLCs were performed during lower-third facial feminization surgery, and two were isolated DTV-FLCs. One was a revision DTV-FLC. Transient minor complications were encountered and resolved by the postoperative visit at 1 to 2 months. Vocal fold function and voice quality remained intact. Eight available patients were satisfied with the surgical results. A blinded assessment by eight plastic surgeons determined that seven procedures were successful., Conclusion: The novel DTV-FTLC approach either in isolation or as part of lower-third facial feminization surgery facilitated scar-free FLC with satisfactory cosmetic and functional results., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Objective: This study aimed to present our experience in treating laryngeal pemphigoid (LP) patients, including disease course, treatment and treatment response, and to search for predictors of response to treatment., Study Design: A retrospective cohort study., Methods: The medical records of all patients with LP from March 2013 to August 2020 were reviewed. Potential relationships between disease severity and response to treatment and demographics, diagnosis, extent of laryngeal and extra-laryngeal involvement, comorbidities, immunostaining, and serology profile were explored., Results: Eight patients were included in the study (seven females, one male, mean age 79 years, mean follow-up 22 months). Diagnoses included mucous membrane pemphigoid (MMP, n = 5), bullous pemphigoid (BP, n = 3). Two patients achieved complete laryngeal remission, four achieved partial remission, and two had no remission. The time to achieve laryngeal disease control was longer than for extra-laryngeal disease (P = 0.02). Potential associations were found between the absence of immunoglobulin G (IgG)-type auto-antibodies deposits in the basement membrane zone and a laryngeal disease that responded to topical corticosteroids and between the presence of BP180-C-terminal IgG auto-antibodies and a resistant rapidly progressive laryngeal disease., Conclusions: LP has a spectrum of severity, variable response and is more resistant to treatment. The absence of IgG-type auto-antibodies may indicate a response to topical corticosteroids. Based on our limited observation, the presence of IgG-type auto-antibodies that target BP180-C-terminal domain may indicate a more severe scarring disease. Early recognition of these "high-risk patients" will allow early initiation of advanced systemic treatment that may prevent the irreversible effects of scarring., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: Radiotherapy (RT) is widely used for early glottic cancer. Patients failing this treatment are referred to surgical management of their disease. Salvage partial laryngectomy (SPL) has the advantage of preserving laryngeal function with total laryngectomy (TL) remaining as a last resort. The purpose of this study was to determine the efficacy of SPL in preventing total laryngectomy, following failed RT, for early glottic cancer., Methods: A meta-analysis of all published English literature was performed. All publications that included patients undergoing SPL were reviewed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) reporting guidelines. The search strategy identified 154 relevant articles. A total of 15 retrospective studies that included 323 suitable patients were subsequently analyzed in this meta-analysis. The main outcome measure was the rate of laryngectomy-free survival (LFS) following SPL. The indications for salvage TL (i.e., disease recurrence and poorly functional larynxes) as well as subgroup analyses for open and trans-oral SPLs were also calculated., Results: The overall rate of LFS following SPL was 81.2% (fixed effects model range: 75.7-86.8%). Salvage TL following SPL were performed in 96.8% due to disease recurrence and in 3.2% to poorly functional larynxes. A subgroup analysis showed a 90.4% LFS after open SPL and 78.6% following trans-oral SPL., Conclusion: A high rate of successful salvage partial laryngectomies, regardless of surgical technique, is to be anticipated in well-selected patients after RT failure., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Preoperative planning of open laryngotracheal surgery is important for achieving good results. This study examines the surgeon's perception of the importance of using life size 3D printed models of the pediatric airway on surgical decision making., Methods: Life-size three-dimensional models of the upper airway were created based on CT images of children scheduled for laryngotracheal-reconstruction and cricotracheal resection with anastomosis. Five pediatric airway surgeons evaluated the three-dimensional models for determining the surgical approach, incision location and length, graft length, and need for single or double-stage surgery of seven children (median age 4.4 years, M:F ratio 4:3). They rated the importance of the three-dimensional model findings compared to the direct laryngoscopy videos and CT findings for each domain on a validated Likert scale of 1-5., Results: The mean rating for all domains was 3.6 ± 0.63 ("moderately important" to "very important"), and the median rating was 4 ("very important"). There was full agreement between raters for length of incision and length of graft. The between-rater agreement was 0.608 ("good") for surgical approach, 0.585 ("moderate") for incision location, and 0.429 ("moderate") for need for single- or two-stage surgery., Conclusion: Patient-specific three-dimensional printed models of children's upper airways were scored by pediatric airway surgeons as being moderately to very important for preoperative planning of open laryngotracheal surgery. Large-scale, objective outcome studies are warranted to establish the reliability and efficiency of these models., (© 2021. The Author(s).)

Introduction: Direct laryngoscopy in children is usually performed with spontaneous ventilation and monitored by pulse oximetry. It is currently unknown if spontaneous ventilation has an effect on cerebral oxygenation. We hypothesized that cerebral oxygenation may be impeded during direct laryngoscopy with spontaneous ventilation in children., Objective: Our objective was to determine if children who undergo direct laryngoscopy under general anesthesia with spontaneous breathing experience significant reductions in cerebral oxygen saturation levels, and whether or not these reductions are accompanied by decreases in peripheral oxygen saturation levels., Methods: This pilot study included 16 consecutive children who underwent direct laryngoscopy under general anesthesia and spontaneous ventilation. The INVOS™ system, which is currently used to monitor cerebral oxygen saturation levels during neurosurgery and cardiothoracic surgery, consists of a processing unit and 2 sensors that are applied to the patient's forehead. We used it to record cerebral oxygenation levels throughout the procedure. Peripheral pulse oximetry was recorded simultaneously, and the results were compared to the levels recorded by the INVOS™ system., Results: Cerebral oxygen saturation levels decreased by more than 20% from baseline in 7/10 children with tracheostomy and in 2/6 children without tracheostomy, while peripheral oxygen saturation levels remained intact in all the children. The mean time from induction of anesthesia to significant decrease in the cerebral oxygenation level (rSO2) was 14 ± 6 min for the tracheostomy group and 14.5 ± 1.5 min for the no tracheostomy group., Conclusions: Children who undergo direct laryngoscopy under general anesthesia with spontaneous ventilation may display reductions in brain oxygenation levels that are not detected by standard pulse oximetry, which reflects only peripheral oxygenation levels. Further study is required to explore the possible effect of this phenomenon in children who undergo direct laryngoscopy., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: Acute supraglottitis (SG) can potentially lead to rapid airway obstruction. The last few decades have witnessed a shift towards a more conservative approach in airway management of adult SG. This study aims to evaluate this watchful approach based on a large case series combined with a high-level meta-analysis of all reports in the English literature., Methods: Retrospective case series and meta-analysis. The medical records of all adult patients diagnosed as having SG who were hospitalized in a large-volume tertiary referral center between January 2007 and December 2018 were reviewed. A meta-analysis was conducted on all English literature published between 1990 and 2018., Results: A total of 233 patients (median age 49.1 years, 132 males), were admitted due to acute SG during the study period. No airway intervention was required in 228 patients (97.9%). Five patients (2.1%) required preventive intubation, and two of them (0.9%) were later surgically converted to a tracheotomy. Patients who required airway intervention had higher rates of diabetes (P = .001), cardiovascular diseases (P = .036) and other comorbidities (P = .022). There was no mortality. The meta-analysis revealed that the overall intubation rates random effects model was 8.8% [95% confidence interval (CI) 4.6%-14.0%] and that the tracheotomy random effects model was 2.2% (95% CI; 0.5%-4.8%). The overall mortality rate was 0.89%., Conclusions: This study provides evidence of low rates of surgical airway intervention in patients diagnosed with SG worldwide. A conservative approach in adult SG is safe and should be advocated., Level of Evidence: 2., (Copyright © 2020. Published by Elsevier Inc.)

Introduction: Several surgical procedures have been described for the treatment of respiratory distress secondary to vocal fold immobility (VFI), but the contribution of posterior cordotomy (PC) to tracheostomy weaning or prevention has not been studied in depth, particularly in the acute setting. The objective of this study was to show the effectiveness of PC to relieve dyspnea, prevent the need for tracheostomy, and enable decannulation in patients with VFI., Methods: We conducted a retrospective study and reviewed the medical records of all patients whose dyspnea warranted surgical intervention from January 2013 to January 2018. Data were retrieved on epidemiology, etiology, and duration of VFI, tracheostomy dependence, success in decannulation from tracheostomy or respiratory relief, number of procedures until decannulation, and complications., Results: Twelve suitable patients were identified of whom eleven had bilateral VFI and one had unilateral VFI. Five were tracheostomy-dependent. Ten patients underwent unilateral PC, and two patients underwent bilateral PC. All the patients experienced respiratory relief, eleven after a single PC and one after two PCs. All tracheostomy-dependent patients were decannulated. The mean follow-up after PC was 24.55 months during which none of the patients required a re-tracheostomy and three patients required revision of the PC. There were no surgical complications. Postoperatively, eight patients (67%) experienced a breathy voice and three patients (25%) had dysphagia for fluids. No patient had aspiration pneumonia., Conclusions: We conclude that PC is an easy, safe, and effective procedure for tracheostomy weaning and respiratory relief in patients with VFI. A revision PC may be indicated in some patients. A breathy voice is to be expected, and a few patients will experience dysphagia to fluids that may be addressed by instructing the patient to use a fluid thickener and take small sips., Competing Interests: Conflict of interest: The authors declare that they have no competing interests. The Alma Pixel CO2 laser was on loan to our department from Alma Lasers., (©Copyright: the Author(s).)

Purpose: Acute supraglottic laryngitis (ASL) is manifested by supraglottic inflammation that has the potential for rapid and fatal airway obstruction. Complete/incomplete vocal fold immobility (VFIm) in the setting of ASL may contribute to airway obstruction. The rate of VFIm complicating ASL is not known, and it is not clear whether its occurrence alters the course and the management of ASL, particularly the need to secure the airway (by endotracheal intubation/tracheostomy). This study seeks to describe the natural history of VFIm associated with ASL (ASLIm) and to determine the added effect of VFIm on ASL severity, management, and the need for intervention to secure the airway., Methods: This is a retrospective cohort study in a tertiary referral center. The medical records of all patients hospitalized due to ASL between January 2007 and December 2016 were reviewed., Results: Of the 214 patients admitted due to ASL, VFIm was identified in 9 (4.2%). The VFIms resolved within 1-90 days in all 8 patients with available follow-up of 1-3 months. One patient required endotracheal intubation. The 9 ASLIm patients had significantly higher rates of hoarseness and a history of diabetes mellitus. There was no group difference in the need to secure the airway., Conclusions: VFIm is an apparently uncommon finding among patients with ASL. It appears to be usually transient, short-lasting, and full recovery can be expected. VFIm did not alter the ASL course, nor did it put our patients at increased risk for the need for intervention to secure the airway., Level of Evidence: 4.

Background: Huntington's disease (HD) is a neurodegenerative disease characterized by increasing dysphagia as the disease progresses. Specific characteristics of the HD dysphagia are not well defined., Objective: To characterize the swallowing disturbances of HD patients, to evaluate the feasibility of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in assessing dysphagia in HD patients, and to discern the relation between FEES findings and patients' self-report on dysphagia symptoms and swallowing related quality of life (SWAL-QOL)., Method: A retrospective case series in a tertiary referral center. All recruited HD patients underwent Bed Side Swallowing Evaluation (BSE), FEES, the Unified Huntington's Disease Rating Scale (UHDRS), and the Montreal Cognitive Assessment (MoCA). All completed the Swallowing Disturbances Questionnaire (SDQ) and the SWAL-QOL questionnaire., Results: Fourteen HD patients were recruited. All were able to complete the FEES study. The FEES demonstrated delayed swallowing reflex, solid food residues, and pre/post swallowing spillage in most patients (50%, 53.5%, 83.3%, and 87.5%, respectively). The mean SDQ score was 13.2. Significant correlations were found between the SWAL-QOL fear of eating score; the SDQ oral, pharyngeal, and total scores; and the FEES parameters of pureed and solid food bolus flow time. Significant correlations were also found between the total UHDRS score, the volitional cough score, and the SWAL-QOL disease burden score., Conclusion: HD patients exhibit prominent unique oropharyngeal dysphagia features that may serve as a marker of disease progression. The FEES and the SDQ are valuable tools for detecting these features in HD patients with swallowing disturbance.

Importance: The rate of skip metastasis to neck level IV in patients with clinically node-negative neck (cN0) oral cavity squamous cell carcinoma (OCSCC) remains controversial., Objective: To provide a high level of evidence using a meta-analysis on the rate of skip metastasis to level IV in this subset of patients., Data Sources: The Embase, PubMed, and Google Scholar databases were searched for articles published during the period of January 1, 1970, through December 31, 2017, using the following key terms: neck dissection, N0 neck, squamous cell carcinoma, skip metastasis, radical neck dissection, lymph node management, neck metastasis, oral cavity cancer, and tongue cancer. Some terms were also used in combination, and the reference section of each article was searched for additional potentially relevant publications. Data were analyzed from January 8 through 11, 2018., Study Selection: Inclusion criteria were all cohorts, including from any randomized clinical trial, case-control study, case study, and case report; studies of patients with the histopathologic diagnosis of OCSCC; and studies that differentiated data between skip metastasis and sequential metastasis to neck level IV. Of the 115 articles retrieved from the literature, 11 retrospective studies and 2 prospective randomized clinical trials (n = 1359 patients) were included., Data Extraction and Synthesis: Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Fixed-effects model and 95% CIs were estimated, and data of included studies were pooled using a fixed-effects model., Main Outcomes and Measures: Overall proportion of neck involvement and the rate of level IV skip metastasis. Subgroup analysis for primary site and tumor staging., Results: The rate of level IV involvement in patients with cN0 ranged between 0% and 11.40% with a fixed-effects model of 2.53% (95% CI, 1.64%-3.55%). The rate of skip metastasis ranged from 0% to 5.50% with a fixed-effects model of 0.50% (95% CI, 0.09%-1.11%). The rate of level IV skip metastasis did not increase significantly in cases that involved neck levels I through III. Tumor staging and primary site tumor did not significantly affect the rate of skip metastasis., Conclusions and Relevance: This meta-analysis showed very low rates of skip metastasis to neck level IV in patients diagnosed with cN0 OCSCC. Encountering an allegedly positive lymph node during neck dissection does not portend high rates of level IV involvement. Supraomohyoid neck dissection is therefore adequate for this subset of patients.

Introduction: Endoscopic balloon dilation (EBD) is the mainstay of endoscopic therapy for laryngotracheal stenosis (LTS), although there is no evidence that it achieves better results than traditional rigid laryngeal dilators. Rigid bougie dilators are less expensive and easier to use, and confer the advantage of providing tactile information about the stenosis to the surgeon. We analyzed the outcome of endoscopic rigid bougie dilatation of LTS in a large series of children and compared it to the reported results of EBD in the same setting., Patients and Methods: All cases of pediatric LTS treated by endoscopic rigid dilatation in a tertiary referral center between 2006 and 2015 were retrospectively studied. They were divided into a primary dilatation group (PDG) and a post-reconstruction dilatation group (PRG). The PDG children had no history of reconstructive airway surgery, and dilatation was the major treatment approach. The PRG children underwent dilatations after airway reconstruction surgery as part of routine postoperative management. A successful primary outcome was defined as improvement of dyspnea and achievement of a functional airway without reconstructive laryngotracheal surgery or need for a tracheostomy at final follow-up., Results: Sixty-two children (68 cases, mean age 5.1 years, range 0.7-17.2) underwent 156 endoscopic rigid dilatations. Successful outcome was achieved in 48 cases (70.6%), 73.0% in the PDG and 67.7% in the PRG. There were no procedure-related adverse events., Conclusions: Endoscopic rigid dilatation is a relatively inexpensive and efficacious tool in endoscopic management of pediatric LTS. Its success rates are in the same range as those of EBD.

Background: Direct laryngoscopy and rigid bronchoscopy are currently performed using 2-dimensional endoscopic systems. Our objective was to determine whether a 3-dimensional endoscopic system can enhance visualization of the surgical field in pediatric direct laryngoscopy and rigid bronchoscopy., Methods: A prospective cohort study was conducted. Thirty three children who underwent direct laryngoscopies in a tertiary referral children's hospital were enrolled. Direct laryngoscopy was performed using both 2- and 3-dimensional endoscopic systems, after which the surgeons scored the quality of the images obtained with each system on a scale from 1 (low) to 5 (high). Comparison of the scores obtained with the 2 endoscopic systems was performed., Results: The 33 study children (mean age 2.3 years, M:F ratio 1:1.6) underwent 47 direct laryngoscopies. The mean score for visualization of the glottis was 4.8 for the three-dimensional system compared to 4.0 for the two-dimensional system (P = .025), 4.7 vs. 3.8, respectively, (P = .019) for the subglottis, and 4.6 vs. 3.9, respectively (P = .031) for visualization of the proximal trachea. The mean score for visualization of the distal trachea was 3.0 vs. 3.7, respectively (P = .020). In a child with recurrent type 3 laryngotracheal cleft a residual tracheo-esophageal fistula could not be detected using the 2D system, but was immediately detected using the 3D system., Conclusions: Visualization of the glottis, subglottis and proximal trachea during direct laryngoscopy using a 3-dimensional endoscopic system was rated by the surgeons as being superior to the conventional 2-dimensional technique. Further outcome studies that will demonstrate the clinical advantage of the 3D technology are highly required., Level of Evidence: 2b., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The study aimed (1) to evaluate the prevalence of sulcus vocalis (SV) coexisting with vocal fold polyp (SV-VFP), and (2) to determine the effect of their coexistence on voice quality., Study Design: This is a retrospective cohort study in a tertiary referral center., Methods: The medical records of all patients who underwent micro direct laryngoscopy due to VFPs between January 2013 and April 2015 were reviewed. Patients with SV-VFP were identified and data of their demographics, medical history, habits, preoperative and intraoperative laryngeal findings, and pre- and postoperative GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) score, and compared with the data of patients with solitary VFPs (S-VFPs)., Results: Eighty-nine patients were diagnosed with VFPs, 14 (15.7%) of whom were diagnosed with SV-VFPs. Patients with SV-VFPs had significantly lower incidence of concurrent leukoplakia (P = 0.01), higher incidence of contralateral vocal fold lesions (P = 0.04), increased voice roughness score postoperatively (P = 0.01) on the GRBAS score, and had a lower rate of cigarette smoking (P = 0.02) compared with patients with S-VFPs., Conclusions: The possibility of a hidden SV should be considered when detecting VFPs, particularly in patients with contralateral vocal fold lesions and without cigarette smoking history. Because the group of patients with SV-VFP presented with unique features, we suspect that the coexistence of VFPs and SVs is not incidental and that SVs may contribute to the formation of VFPs, possibly by alternating glottic airflow., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Seven years after the introduction of the pneumococcal conjugate vaccines (PCV) in Israel, its effect on the incidence and severity of episodes of acute mastoiditis (AM) remains unclear. The primary objective of this study was to determine the incidence of AM and describe its clinical features in children during the years that followed the introduction of the PCV13 in comparison with the pre-PCV period., Methods: Included in this retrospective comparative case series were all pediatric patients diagnosed with AM between Jan. 2007 and Dec. 2015 in one tertiary medical center. The patients were divided into 3 groups: pre-PCV, post-PCV7 (July 2009 through Dec. 2010) and post-PCV13 (Jan. 2011 through Dec. 2015). The patients' medical records were reviewed, and data on age at presentation, gender, presenting signs, bacterial ear cultures, hospitalization course, complications, surgical interventions, inflammatory response and outcome were retrieved and compared between the groups. Comparison was made between the pre-PCV and the post-PCV13 groups., Results: 216 children were identified for analysis, 80 children in the pre-PCV period, 31 in the post-PCV7 period and 105 in the post-PCV13 period. Their mean age was 2.6 years. The number of AM cases per 1000 visits at the emergency room decreased by 46% in the post-PCV13 period compared to the pre-PCV period. There was no difference in the rate of AM between the post-PCV7 and post-PCV13 periods. No differences were found in age, gender, hospitalization length, C-reactive protein level, white blood cell count, rate of surgical interventions (mastoidectomy and incision and drainage) and rate of complications between the 3 groups., Conclusion: The incidence of AM was lower in the post-PCV13 period compared to the pre-PCV period. The rate of AM complications, however, has not changed, nor has the number of mastoidectomies., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Mucous membranous pemphigoid (MMP) is an autoimmune disease of the mucous membranes characterized by formation of subepithelial blisters. MMP commonly involves the ocular and oral mucosa. Laryngeal MMP is very rare, estimated as occurring in 1 of 10 million persons in the general population. It mostly affects the supraglottis, but may also involve other laryngeal sites as well as extralaryngeal areas. This report describes the clinical picture, workup to diagnosis, and differential diagnosis of an isolated epiglottic process in an elderly female who presented with isolated, long-standing, nonresolving epiglottitis, later diagnosed as MMP with epiglottal and oral involvement., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Informed consent is an important part of the surgical process. Based on our clinical experience, we hypothesized that parents providing consent for their children's tonsillectomy do not comprehend all the information that is given to them by the operating surgeon at the time of a conventional consent process., Materials and Methods: Parents whose children were scheduled for tonsillectomy with or without adenoidectomy and/or tympanostomy tubes insertion were enrolled. Within one hour after the consent process, they were asked to complete a questionnaire designed to collect demographic data and to evaluate how much of the information that was given to them was actually understood., Results: Ninety-seven parents were enrolled between October 2011 and March 2013. The average percentage of correct answers (score) for the 16 multiple-choice questions was 76.3%. The average scores were 84.8% for the native Hebrew-speaking parents and 71.9% for the parents whose first language was other than Hebrew (p < 0.01). The average scores were 83.3% for the parents who are healthcare system workers and 74.4% for those parents whose profession is not related to medicine (p < 0.05). Fifty parents (51.5%) responded incorrectly to at least one of two questions that we defined as essential: "What would you do if your child starts to bleed from the mouth" and "What kind of food is recommended for your child during the first week after the surgery"., Conclusion: The current conventional method of obtaining informed consent for tonsillectomy is inadequate, as reflected by the low level of parental comprehension of essential information. Further studies which will evaluate methods for improving the consent process are highly warranted., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Endoscopic stapler diverticulotomy (ESD) has become an accepted primary treatment for Zenker's diverticulum (ZD). Recurrence of symptoms after surgical treatment of ZD is not uncommon, and traditionally patients with recurrent symptomatic ZD were referred to revision surgery by the transcervical Zenker's diverticulectomy approach. Our objective was to evaluate the technical feasibility, safety and effectiveness of revision endoscopic stapler diverticulotomy (RESD) for recurrent ZD., Methods: A case series with chart review study conducted in a tertiary referral center. The records of all patients who underwent ESD at our institute between 2002 and 2013 were retrieved and those who underwent RESD were identified and screened for primary surgical history, symptoms of recurrent ZD, time to recurrence, intraoperative and postoperative RESD course, complications and symptom resolution. The surgical history and outcome results of RESD and primary ESD (PESD) patients were compared., Results: Eighty-nine ESDs were performed. Twenty were RESDs for recurrent ZD, and 69 were PESDs. Nine RESDs were performed for recurrent ZD after transcervical Zenker's diverticulectomy, 10 RESDs for recurrent ZD after ESD, and one initial surgical approach was unknown. The mean time from first operation for ZD to RESD was 4.7 years. The average RESD surgery time and hospital stay were 21.4 min and 2.8 days, respectively. Endoscopic stapling of the ZD was feasible in 19 of 20 RESDs. Relief of symptoms without recurrence was achieved after 18 RESDs. Four RESD patients experienced minor postoperative complications. There were no significant differences in operative time, technical feasibility, hospital stay and complication rate between the RESD and PESD groups (P > .05)., Conclusion: RESD for ZD is technically feasible, safe and effective. The results are comparable to those of PESD.

Background and Objectives: Dysphagia is a common disability with different etiologies. In order to measure dysphagia symptom severity and effects on quality of life, the Eating Assessment Tool (EAT-10) was developed and validated in the English language. We aimed to develop a Hebrew version of the EAT-10 and to evaluate its internal consistency, test-retest reliability, and validity in Hebrew-speaking adults with dysphagia., Subjects and Methods: The Hebrew EAT-10 (H-EAT-10) questionnaire was completed by 132 patients: 56 patients with dysphagia and 76 controls. Internal consistency analysis was calculated using Cronbach α, and test-retest reliability was calculated using intraclass correlation coefficient in order to assess clinical validity., Results: Internal consistency and test-retest reliability were found to be high in the H-EAT-10 (Cronbach α = 0.955 and intraclass correla tion = 0.98). In addition, H-EAT-10 scores in the dysphagia group were found to be significantly higher than those in the control group (p < 0.001)., Conclusion: This study demonstrated that H-EAT-10 is a reliable and valid tool that may be implemented for clinical practice and research on dysphagia in a Hebrew-speaking population., (© 2017 S. Karger AG, Basel.)

Objective: Laryngeal manifestations of stroke play a significant role in the morbidity and mortality among affected patients. The objective of this article was to describe unique myoclonic vocal fold movement disorder, which is an unusual post-stroke manifestation., Study Design: A retrospective case study., Setting: The study group included post-stroke patients with dysphagia who were referred to the Swallowing Clinic at Edith Wolfson Medical Center., Subjects and Methods: All patients underwent flexible laryngoscopy and flexible endoscopic evaluation of swallowing with sensory testing. The vocal fold movement was analyzed with the Sisson-Ammons video analysis system., Results: Three post-pontine stroke patients presented with vocal fold myoclonus (VFM). The myoclonus was spontaneous, unintentional, and irregular (19-420 jerks per minute). Two patients presented with unilateral myoclonus, ipsilateral to the brainstem stroke. One patient, who experienced subsequent pontine strokes, presented with bilateral VFM. When patients were asked to swallow or phonate, the myoclonus disappeared., Conclusion: Isolated VFM is an unusual manifestation of pontine injury, resulting in a sudden, involuntary, and non-rhythmic vocal fold movement. This laryngeal pathology is not associated with either dyspnea or dysphonia and most likely not with inefficient swallowing., (Copyright © 2013 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

Objectives: We sought to determine the patient population that will benefit from surgical rehabilitation of voice and swallowing after jugular foramen tumor (JFT) resection., Methods: We performed a retrospective case study of patients with a history of JFT resection. The patients' files were reviewed for data on preoperative and postoperative function of cranial nerves VII and IX through XII, voice and swallowing function, and surgical procedures for voice and swallowing rehabilitation and their timing., Results: Twenty-one patients underwent JFT resection. Thirty-eight percent presented with deficits of cranial nerves VII and IX through XII, and 61% developed new postoperative deficits. Three patients recovered glossopharyngeal nerve function, 2 recovered vagus nerve function, and 1 recovered facial nerve function. Surgical rehabilitation procedures were undertaken in 8 patients. Patients who eventually underwent surgical rehabilitation procedures for voice and swallowing tended to have larger tumors, tumors within the nerve bundle in the jugular foramen, and multiple nerve deficits., Conclusions: Most patients with multiple deficits of cranial nerves VII and IX through XII after JFT resection are unlikely to regain spontaneous nerve function, will experience long-term dysphonia and dysphagia, and will elect to undergo corrective surgery to improve voice and swallowing. Preoperative evaluation and close postoperative follow-up can identify patients who would benefit from early surgical rehabilitation.

Objectives: We describe the clinical characteristics and management of vocal fold paralysis in infants who were born with a tracheoesophageal fistula (TEF)., Methods: This retrospective case series included all infants born with TEFs who presented to our pediatric otolaryngology unit and intensive care unit because of dyspnea or aphonia in the years 2005 and 2006, and who were found to have vocal fold paralysis., Results: Five boys and 1 girl were studied. One infant had stridor before TEF repair, and 5 after it. All children underwent flexible laryngotracheobronchoscopy and were treated in the pediatric intensive care unit before diagnosis of the vocal fold paralysis (5 bilaterally and 1 unilaterally) was made. The ages at diagnosis of paralysis ranged between 14 days and 14 months. Five infants required tracheostomy., Conclusions: Vocal fold paresis in infants is difficult to diagnose. The risk for recurrent laryngeal nerve injury associated with TEF and TEF repair should be emphasized in these children. We recommend that all newborns with TEF should be examined by an otolaryngologist before operation to confirm the mobility of the vocal folds and to rule out other associated airway malformations, and examined after operation if respiratory difficulties develop.

Objective: To review the current management of acute mastoiditis with critical emphasis on the role of myringotomy., Design: A retrospective chart review., Setting: Tertiary-care, university affiliated children's hospital., Patients: One hundred and forty-four consecutive children hospitalized for acute mastoiditis between the years 1991 and 2002., Interventions: All children were treated with parenteral antibiotics (conservative management). Myringotomy was performed at the discretion of the otolaryngologist on-call., Main Outcome Measures: Comparing outcomes of children with or without myringotomy regarding hospital stay, complications and the need for surgical interventions., Results: Myringotomy was performed in 34.6% of episodes. The children who underwent myringotomy were found to be significantly younger (22.4 compared to 28.8 months, p=0.028) and had more complications (n=17 vs. n=8, p<0.001). Complications overall occurred in 16.3% of episodes. Performing myringotomy had no significant effect on the duration of hospital stay. Children pretreated with antibiotics underwent significantly less myringotomies p=0.027. There were no significant differences between children who underwent myringotomy and those who did not with regard to WBC count, or ESR., Conclusions: These findings suggest that myringotomy may not be required in all cases of acute mastoiditis. Parenteral antibiotics is sufficient in most cases. Criteria for myringotomy may include a younger age. Conservative management resulted in good outcomes in this series.

We report a rare case of acute otitis media (AOM) complicated by arterial brain infarction, meningitis and orbital cellulitis. Computed tomography (CT) initially showed suspected epidural abscess, coalescent mastoiditis, and orbital cellulitis. Further clinical deterioration occurred following mastoidectomy and evacuation of the abscess. Magnetic resonance imaging (MRI) revealed subacute brain infarction and an extra-axial brainstem abscess. Revision of the initial CT revealed subtle signs suggestive of arterial brain infarction. Although CT with contrast is the standard of care for suspected AOM complications, MRI should be considered as an adjunct when CT is not definitive and neurological signs are present.

Objectives: Hyperkinetic laryngeal behaviors may be used to achieve glottal closure in the presence of vocal cord disorders. In adults, the Glottal Function Index (GFI) is a validated self-administered survey used to evaluate glottal insufficiency. In children, the relationships between glottal closure and vocal cord lesions have not been examined. We undertook to evaluate the efficacy of the GFI in detecting disorders of the vocal cords in children., Methods: We evaluated 100 consecutive children who underwent flexible fiberoptic laryngoscopy. A 4-item GFI questionnaire was administered to the parents of each study subject on study entry. The videotapes of the examinations were evaluated and scored by 3 investigators in a blinded manner. The GFI scores were compared in subjects with and without vocal cord findings., Results: The final analysis included 100 children 2 to 16 years of age. The-mean age of the study group was 7.3 years (+/-3.9 years). Of the 100 patients, 54 had vocal cord disorders. The most common was vocal cord nodules, in most cases combined with bowing of the vocal cords; the two variables were highly correlated (p << .01). We performed a receiver operating characteristics test between the presence of vocal cord disorders and the GFI score. We found that the "optimal" score, on which the sensitivity and specificity curves cross, was 3. Of the 54 patients who had vocal cord disorders, the index identified 38 patients (70%), whereas the patients' complaints identified only 30 patients (55.6%). This difference was statistically significant (p < .05)., Conclusions: The GFI is a reliable 4-item symptom index with excellent correlation to the presence of vocal cord lesions in children.

The aim of the present study was to review our recent experience in the diagnosis and treatment of acute mastoiditis and its complications in a single tertiary-care, university-affiliated pediatric center. Ninety-eight children with 101 episodes of acute mastoiditis were included in the study. The mean interval from onset of illness to mastoiditis was 4.5 days. Ear cultures most often grew Streptococcus pneumoniae and Pseudomonas aeruginosa (23.7% each). Complications occurred in 15.8% of episodes. The only factor differentiating children with and without complications was white blood cell count. These findings indicate that acute mastoiditis not only is a complication of prolonged infection of the middle ear, but may also present as an acute infection of the mastoid bone that can progress within 48 hours. The complication rate remains high, and antibiotic treatment at the onset of symptoms does not prevent complications. A high white blood cell count on admission may serve as a predictive factor of complicated cases.

Objective: Facial palsy secondary to acute otitis media is rarely encountered today. The aim of the present study was to review the characteristics of the disease and propose the proper management., Study Design: File review. Setting University-affiliated tertiary referral center., Main Outcome Measures: Disease course, management and outcome were recorded., Results: Sixty-five children with facial palsy were identified, of whom 13 (20%) had acute otitis media. The otitis media preceded the facial palsy in all cases by 1 to 21 days (average 5 days). House-Brackmann grade ranged from 2 to 5 (average 3.5). The recovery period was varied and unpredictable, ranging in duration from 1 to 180 days (average 68 days). Treatment was conservative, except for insertion of a ventilation tube in 2 cases., Conclusions: Considering that all the patients recovered, conservative treatment, including myringotomy and intravenous antibiotics, may be the correct approach to facial palsy associated with acute otitis media.

Background: The determination of malignancy in follicular patterned thyroid lesions is based on postoperative histologic findings. Therefore, affected patients are referred for surgery, although only 20% will have a final diagnosis of malignancy. The aim of this study was to investigate the potential of galectin-3 as a marker of malignancy in these lesions., Methods: Fifty-four tissue specimens of follicular patterned thyroid lesions were immunohistochemically stained for galectin-3. Area and intensity scores were recorded., Results: Significant differences were found between the benign and malignant lesions. The sensitivity, specificity, positive predictive values, and negative predictive values of galectin-3 staining were 82%, 68%, 75%, and 77%, respectively (p=.0002). Significant differences were also found between the subgroups of benign and malignant lesions (p < or =.05)., Conclusions: Galectin-3 staining is highly sensitive for malignancy in follicular patterned thyroid lesions. Diagnostic problems may arise in the presence of Hurthle cell proliferation or minimally invasive follicular carcinoma.

Objective: Venous sinus thrombosis (VST) is the second most common intracranial complication of acute otitis media (AOM). There is some evidence that hereditary and acquired prothrombotic disorders are risk factors for VST. The aim of the present study was to evaluate whether children with AOM complicated VST have a prothrombotic tendency, which might have important therapeutic and preventive implications., Study Design: Retrospective., Methods: The files of children hospitalized at Schneider Children's Medical Center of Israel, a tertiary referral center, from 1999 to 2002, because of AOM complicated by acute mastoiditis and VST were reviewed. All children underwent laboratory work-up for hypercoagulability., Results: Seven children met the study criteria. Of these, five had prothrombotic disorders, namely elevated levels of lipoprotein apolipoprotein (Lp[a]) (n = 4), antibodies to beta 2-glycoprotein and to cardiolipin (markers of antiphospholipid syndrome) (n = 4), and heterozygosity for factor V Leiden mutation (n = 1). One child had three abnormalities, two children had two abnormalities, and two children had one abnormality., Conclusions: A prothrombotic tendency may exist in children with AOM complicated by mastoiditis and VST. Further studies are needed to evaluate its extent.

Squamous cell carcinoma of the hypopharynx is an aggressive tumor with a bad prognosis. When the tumor is resected it is necessary to reconstruct the hypopharynx and the esophagus. Today, reconstruction with a jejunal free flap is considered to be the preferred option. We present a series of five patients with squamous cell carcinoma of the hypopharynx operated on at the Department of Otolaryngology in the Rabin Medical Center. All underwent total laryngopharyngectomy and reconstruction with a jejunal free flap. Three patients resumed total enteral nutrition about two weeks post surgery. One patient suffered from a pharyngocutaneous fistula and continued parenteral nutrition via a jejunostomy. One patient suffered from necrosis of the flap, which necessitated its resection. Despite the morbidity which follows surgery of the hypopharynx and despite the low cure rates, a successful reconstruction with jejunal free flap enables the resumption of oral nutrition and improvement in the patients quality of life.