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-- Head and Neck Surgery

Laryngopharyngeal Reflux: Paradigms for Evaluation, Diagnosis, and Treatment

Zhen Gooi, Stacey L. Ishman, Jonathan M. Bock, Joel H. Blumin and Lee M. Akst
Otolaryngology -- Head and Neck Surgery 2013 149: P85
DOI: 10.1177/0194599813495815a156

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Oral Presentations P85
Objectives: 1) Determine the etiology of unilateral vocal fold
paralysis (UVFP) at a tertiary care institution over 10 years. 2)
Determine the length of time between onset of symptoms and
presentation/diagnosis of UVFP by an otolaryngologist at a
tertiary medical center.
Methods: Retrospective review of medical records of patients
with UVFP between 2002 and 2012 in a tertiary care institu-
tion. Patients were seen and evaluated over 10 years by the
Department of Otolaryngology at the Washington University
School of Medicine. Medical records were reviewed for infor-
mation relating to diagnosis, initial presentation date, date of
onset of symptoms, and etiology of UVFP.
Results: 938 patients were included in the study. 621 (66.2%)
patients had left sided UVFP. 581 (61.9%) patients had UVFP
due to iatrogenic effects related to surgery. 158 (27.2%) of
these were related to thyroid/parathyroid surgery. 357 patients
had UVFP due to reasons not related to surgery. 124 (34.7%)
patients had idiopathic UVFP. The median time to presenta-
tion from symptom onset until presentation to any otolaryn-
gologist was 2 months. There was a significant delay of 3.33
months between mean time to presentation to a community
otolaryngologist and subsequent referral and evaluation at a
tertiary medical center, P < 0.01.
Conclusions: Iatrogenic injury related to surgery is the most
common cause of UVFP. Thyroidectomy remains the leading
cause of surgically related UVFP. Patients are typically seen
within 4 months; however, a significant delay exists between
diagnosis and referral to a specialist.
The Incidence of Premalignant and
Malignant Disease in Reinke’s Edema
Shueh Y. Lim, MB, ChB, MRCP (presenter);
Phoebe C.Y. Sau; Lorna Cooper, MD; Allan
McPhaden, MD; Kenneth Mackenzie, MD
Objectives: Reinke’s Edema is a benign lesion of the vocal
folds affecting the subepithelial space. This condition occurs
almost exclusively in moderate to heavy smokers. As part of a
study of the management of Reinke’s Edema, we aimed to
determine the prevalence of dysplasia and malignancy in his-
tologically proven Reinke’s Edema.
Methods: A retrospective analysis of all laryngeal biopsies per-
formed in North Glasgow, United Kingdom, between 2001
and 2010 was carried out through the North Glasgow
Pathology Database. Clinical and pathological data from all
patients with histologically confirmed Reinke’s Oedema were
recorded with specific respect to the reporting of dysplasia
and malignancy.
Results: From the 10 year cohort, a total of 3902 laryngeal
biopsies were performed. 190 patients (19 males and 171
females) had histologically proven Reinke’s Edema. Of this
cohort, the pathologist commented on dysplasia in 172 (91%)
of patients. The remaining 18 (9%) patients subsequently had
their pathology reviewed. In the 190 patients who had Reinke’s
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Edema, 13 (8%) patients had mild dysplasia, 2 (1%) had mod-
erate dysplasia, and 1 (0.5%) had severe dysplasia. There was
no malignancy reported in the cohort.
Conclusions: In our predominantly female smoking population,
the epithelium appears to differentiate to benign Reinke’s
Edema rather than malignancy. Patients can be reassured with
regard to the very low risk of malignancy in classical Reinke’s
Edema. The principle indication for surgical intervention
should be the patient’s desire to improve their voice.
Laryngeal Muscle Activity in
Unilateral Vocal Fold Paralysis
Patients Using Electromyography and
Coronal Reconstructed Images
Tetsuji Sanuki, MD, PhD (presenter); Eiji
Yumoto, MD, PhD;Yoshihiko Kumai, MD;
Kohei Nishimoto
Objectives: Assess laryngeal muscle activity in patients with
unilateral vocal fold paralysis (UVFP) using laryngeal elec-
tromyography (LEMG) and coronal multi-planar recon-
structed images (coronal images).
Methods: Twenty-one patients suffering from paralytic dyspho-
nia, who had had onset of UVFP more than 6 months previously,
underwent LEMG, phonatory function, and coronal images. For
LEMG analysis, a four-point scale was employed to grade motor
unit (MU) recruitment; 4+: absent, 3+: greatly decreased, 2+:
moderately decreased, and 1+: mildly decreased (less than full
interference). Maximum phonation time (MPT) and mean air-
Laryngology
flow rate (MFR) were employed. Coronal images during phona-
tion and inhalation were assessed focusing on differences in
thickness and vertical position between the vocal folds during
phonation.
Results: MU recruitment results were three patients for 1+, five for
2+, six for 3+, and seven for 4+. MPT was positively correlated
with the MU recruitments (P = 0.011). The thinning of the
affected fold was evident during phonation in 20 of the 21 sub-
jects. All 8 subjects with MU recruitments 1+ and 2+ showed the
affected fold located at an equal level to the healthy fold. Twelve
of 13 subjects with MU recruitments 3+ and 4+ showed the
affected fold located at a higher level than the healthy fold. There
was a significant difference between MU recruitment and vertical
position of the affected fold (P = 0.001).
Conclusions: MU recruitments in patients with UVFP may be
related to phonatory function and the vertical position of the
affected fold. Synkinetic reinnervation may occur in some
cases with UVFP.
Laryngopharyngeal Reflux: Paradigms
for Evaluation, Diagnosis, and
Treatment
Zhen Gooi, MD (presenter); Stacey L.
Ishman, MD, MPH; Jonathan M. Bock, MD;
Joel H. Blumin, MD; Lee M. Akst, MD
 P86 Otolaryngology–Head and Neck Surgery 149(2S)
Objectives: Describe current otolaryngologic paradigms for
diagnosis and treatment of laryngopharyngeal reflux (LPR)
and analyze differences between laryngologists and
non-laryngologists.
Methods: American Academy of Otolaryngology—Head and
Neck Surgery (AAO-HNS) and American Bronchoesophageal
Association (ABEA) members were invited to complete a
23-question online survey regarding evaluation, diagnosis, and
treatment of LPR in 2012. Subgroup analysis was performed to
identify differences between respondents who completed laryn-
gology fellowships (LL) and those who did not (NL).
Results: Of 159 respondents, 40 completed laryngology fel-
lowships. NL respondents had been practicing longer than LL
(19.6 vs. 11.4 years, P = 0.0001). Video-documentation of
laryngopharyngeal exams was almost universal in the LL
group (97% vs 38%, P < 0.0001); similarly, use of rigid
(100%, P = 0.002) and flexible distal-chip technologies (94%,
P = 0.004) were far more common in the LL group. Diagnostic
criteria were otherwise similar between the groups, with
symptoms of heartburn, globus, and throat clearing thought
most suggestive of LPR. Adjunctive tests most commonly
used were barium esophagram, dual-probe pH testing with
impedance, and esophagoscopy, although most ordered no ini-
tial testing. NL used dual pH probe with impedance more
often than LL (P = 0.004). LL were significantly more likely
to perform transnasal esophagoscopy in their office (P <
0.0001), to prescribe twice-daily proton pump inhibitors with
concurrent H2-blocker medication initially (P = 0.004), and to
treat for longer than 4 weeks (P = 0.0003).
Laryngology
Conclusions: Otolaryngologists are in broad agreement on
symptoms and physical features of LPR; however, significant
differences exist between laryngologists and non-laryngolo-
gists on the use of adjunctive testing and treatment strategy.
Lessons Learned from Endoscopic
Treatment of Early Glottic
Carcinomas: A Primer for the
General Otolaryngologist
Elazar Sofer, MD (presenter); Nausheen
Jamal, MD; Dinesh Chhetri, MD
Objectives: 1) Identify technical considerations involved in per-
forming oncologic resection while maintaining laryngeal
function. 2) Analyze on a case-by-case basis what type of
treatment protocol to implement and when lesions persist or
recur.
Methods: A retrospective review was performed to identify all
endoscopic laser resections of glottic carcinomas performed
over a 4-year period. Records were reviewed to identify tech-
nical factors that led to cure vs. recurrent disease; disadvan-
tages of extensive resection vs. adjuvant radiation; when and
how often patients returned to the operating room for further
resection; how to push surgical limits while maintaining good
functional results; and what to expect on examination in the
post-operative healing process.
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Results: Twelve patients were treated during the study period.
Difficult exposure was not a contraindication to endoscopic
resection, if the lesion did not extend to the anterior commis-
sure. For patients with deeply invasive disease who cannot
afford lengthy vocal downtime, radiation therapy is the
answer. However, radiation leads to dysphagia and contralat-
eral vocal fold injury that is avoided with surgery. Additionally,
good voice can be achieved in patients undergoing intramus-
cular cordectomy, but it does cause longer vocal downtime
compared to radiation. The key to optimal vocal results is
achieving glottal closure. Patients should be counseled pre-
operatively regarding the possibility of additional surgery.
Conclusions: Endoscopic resection can be tailored on an indi-
vidual basis based on both cancer stage and the patient’s per-
sonal needs. Patients should be counseled pre-operatively
regarding the advantages and disadvantages of surgery vs.
radiation, including side effects and voice results.
Management of Chronic Laryngeal
Neuropathy in the United States
versus Europe
J. Pieter Noordzij, MD (presenter);
Minyoung Jang, MD; Joseph Depietro, MD
Objectives: Analyze differences in the evaluation of laryngeal
neuropathy by laryngologists in the United States versus other
countries.
Methods: Members of the American Laryngology Society
(ALA) and the European Laryngological Society (ELS) were
surveyed. Questionnaires were emailed to 137 members of the
ALA and 324 members of the ELS. As laryngology fellow-
ships are less available outside the U.S., ELS members who
devoted more than 50% of their practice to laryngology were
identified as laryngologists for this study.
Results: Of the ELS members surveyed, 72 (22.2%) responded,
compared to 43 (24.5%) for ALA members. 56.9% of ELS
respondents identified as devoting more than 50% of their
practice to laryngology. Fellowship-level training in laryngol-
ogy was completed by 74.1% of ELS respondents and 79.5%
of ALA respondents. 11% of ELS respondents commented on
completing fellowships in phoniatry or phonosurgery, or the
absence of formal fellowships in their country. When compar-
ing comfort with the diagnosis of laryngeal neuropathy, ELS
laryngologists’ average comfort level was 4.33 on the Leikert
scale versus 6.1 for ALA laryngologists (P <.000002). When
asked if they were concerned about over-diagnosing gastro-
esophageal reflux disease (GERD)-related laryngitis, 73% of
ELS respondents vs. 40.9% of ALA respondents said yes (P =
0.0109).
Conclusions: Laryngologists in the United States vs. Europe
vary significantly in their familiarity with laryngeal neuropa-
thy. This could lead to differences in the workup of patients
with laryngopharyngeal symptoms, possibly resulting in inef-
fective treatments. These differences are likely amenable to
further education.