THE PROGRAM OF THE ONE HUNDREDTH ANNUAL

MEETING OF

THE AMERICAN BRONCHOESOPHAGOLOGICAL

ASSOCIATION

Friday, April 24th, 2020 Virtual Meeting

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Contents

Purpose 4 Educational Objectives 4 Officers, Council Members, Committee Chairs, and Representatives 2019-2020 5 ABEA Past Presidents 7 Support the ABEA 8 ABEA 2020 Program Committee 9 ABEA Friday Virtual Meeting 10 ABEA Past Guests of Honor 14 ABEA 2020 COSM Program *Canceled due to COVID-19 16 Wednesday, April 22, 2020 16 Thursday, April 23, 2020 18 Friday, April 24, 2020 19 Manuscripts from the 100th Annual Meeting April 24, 2020 22 Broyles-Maloney Award Recipients 49 Chevalier Q. Jackson Award Recipients 51 Chevalier Q. Jackson Award Lecturers 52 Ellen M. Freidman Foreign Body Award Recipients 53 Seymour R. Cohen Award Recipients 54 Steven D. Gray Resident Award Recipients 55 Scientific Podium Manuscripts from COSM 2020 57 Membership in the ABEA 112 Active Members 113 Associate Members 117 Honorary Members 117 International Members 118 Post-Graduate Members 119 Resident Members 120 Senior Members 121

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The Laryngoscope is the official journal of ABEA

The Laryngoscope has been the leading source of information on advances in the diagnosis and treatment of head and neck disorders for nearly 120 years. The Laryngoscope is the first choice among otolaryngologists for publication of their important findings and techniques. Each monthly issue of The Laryngoscope features peer-reviewed medical, clinical, and research contributions in general otolaryngology, allergy/rhinology, otology/neurotology, laryngology/bronchoesophagology, head and neck surgery, sleep medicine, pediatric otolaryngology, facial plastics and reconstructive surgery, oncology, and communicative disorders. Contributions include papers and posters presented at the Annual and Section Meetings of the Triological Society, as well as independent papers, “How I Do It”, “Triological Best Practice” articles, and contemporary reviews. Theses authored by the Triological Society’s new Fellows as well as papers presented at meetings of the American Laryngological Association and American Broncho-Esophagological Association are published in The Laryngoscope.

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Purpose The purpose of this program is to provide Otolaryngologists-Head and Neck Surgeons, Pulmonologists, Gastroenterologists and other interested physicians, clinicians and scientists with an opportunity to update their knowledge of diseases involving the upper aerodigestive tract.

Educational Objectives The aim of these scientific sessions is to provide physicians with up-to- date information pertinent to the clinical evaluation and endoscopic management of laryngeal, tracheobronchial, and esophageal disorders.

This scientific program will provide attendees with an advanced understanding of current issues regarding the diagnosis and management of complex swallowing disorders, voice disorders, airway disorders and operative procedures used in the management of disorders of the upper aerodigestive tract.

Special focus will be placed on issues relevant to laryngology.

Attendees will also be provided with advanced knowledge and techniques enabling them to compare and refine their medical and surgical skills to include best practice performance and optimize patient outcomes. These outcomes will also introduce them to deficits in current knowledge and future research needs.

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Officers, Council Members, Committee Chairs, and Representatives 2018-2019 President: Albert Merati, MD – Seattle, WA

President – Elect: Karen Zur, MD – Philadelphia, PA

Secretary: Seth Dailey, MD – Madison, WI

Treasurer: Gresham Richter, MD – Little Rock, AR

Vice- President:Peter Belafsky, MD - Sacramento, CA

Editor: Mark Courey, MD – New York, NY

Councilors-At-Large: Michael Hinni, MD – Phoenix, AZ Michael Johns, III, MD – Los Angeles, CA

Immediate Past President: Milan Amin, MD – New York, NY

Resident Liaisons: Juliana Bonila-Velez, MD – Seattle, WA Saied Ghadershoi, MD – Chicago, IL

Liaisons and Representatives: AAO-HNS Representative: Lee Akst, MD – Baltimore, MA MDACS BOG Representative: Ian Jacobs, MD – Philadelphia, PA AAO-HNS Legislative Representative: Liz Guardiani, MD – Silver Springs, MD AAO-HNS Grass Roots Representative: Lee Akst, Baltimore, MA

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Chair, Awards and Thesis Committee: Milan Amin, MD – New York, NY

Chair, Community Outreach Committee: Joel Blumin, MD – Milwaukee, WI

Chair, Clinical Practice Committee: Edward Damrose, MD – Palo Alto, CA

Chair, Development Committee: Lee Akst, MD – Lutherville, MD

Chair, Difficult Airway and Foreign Body Accidents Committee: Mark Gerber, MD – Chicago, IL

Chair, Finance and Audit Committee: VyVy Young, MD – San Francisco, CA

Chair, International Relations Committee: Jacqui Allen, MD PhD – Auckland, New Zealand

Chair, Liaison Oversight Committee: David Rosow, MD – Miami, FL

Chair, Membership Committee: Elizabeth Guardiani, MD – Silver Springs, MD

Chair, Pharyngeal and Esophageal Committee: Maggie Kuhn, MD – Sacramento, CA

Chair, Research and Education Committee: Michael Pitman, MD – New York, NY

Chair, Scientific Program: Julina Ongkasuwan, MD – Houston, TX

Chair, Social Media Committee: Paul Bryson, MD –Cleveland, OH

ABEA Representative to The Laryngoscope: Associate Editor: Joel Blumin, MD – Milwaukee, WI Editorial Board: Jonathan Bock, MD – Milwaukee, WI Editorial Board: Julina Ongkasuwan, MD - Houston, TX

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ABEA Past Presidents

1917 Chevalier Q. Jackson, MD 1970 Richard W. Hanckel, MD 1918 Hubert Arrowsmith, MD 1971 John R. Ausband, MD 1919 John W. Murphy, MD 1972 John S. Knight, MD 1920 Henry L. Lynah, MD 1972 Richard A. Rassmussen, MD 1921 Harris P. Mosher, MD 1973 Gabriel F. Tucker, Jr., MD 1922 Samuel Iglauer, MD 1974 Howard A. Andersen, MD 1923 Robert C. Lynch, MD 1975 Walter H. Maloney, MD 1924 Ellen J. Patterson, MD 1976 Seymour R. Cohen, MD 1925 William B.Chamberlin, MD D. 1977 Paul H. Ward, MD 1926 Crosby Greene, MD 1978 James B. Snow, Jr., MD 1927 Sidney Yankauer, MD 1979 Joyce A. Schild, MD 1928 Charles J. Imperatori, MD 1980 Loring W. Pratt, MD 1929 Thomas E. Carmody, MD 1981 M. Stuart Strong, MD 1930 Henry B. Orton, MD 1982 Bernard R. Marsh, MD 1931 Louis H. Clerf, MD 1983 John A. Tucker, MD 1932 Richard McKinney, MD 1984 Frank N. Ritter, MD 1933 Waitmam F. Zinn, MD 1985 William R. Hudson, MD 1934 Henry Hall Forbes, MD 1986 David R. Sanderson, MD 1935 H. Marshall Taylor, MD 1987 C. Thomas Yarington, Jr., MD 1936 Joseph C. Beck, MD 1988 Robert W. Cantrell, MD 1937 Gordon Berry, MD 1989 H. Bryan Neel, III, MD 1938 John Kernan, MD 1990 Gerald B. Healy, MD 1939 Lyman Richards, MD 1991 Charles W. Cummings, MD 1940 Gabriel Tucker, MD 1992 Lauren D. Holinger, MD 1941 W. Likely Simpson, MD 1993 Haskins K. Kashima, MD 1942 Robert L. Morehead, MD 1994 Eiji Yanagisawa, MD 1943 Robert L. Morehead, MD 1995 Robert H. Ossoff, DMD, MD 1944 Carlos E. Pitkin, MD 1996 Stanley M. Shapshay, MD 1945 Carlos E. Pitkin, MD 1997 Rodney P. Lusk, MD 1946 Robert M. Lukens, MD 1998 W. Frederick McGuirt, Sr., MD 1947 Millard F. Arbuckle, MD 1999 Paul A. Levine, MD 1948 Paul H. Holinger, MD 2000 Ellen M. Friedman, MD 1949 Leroy A. Schall, MD 2001 Robin T. Cotton, MD 1950 Chevalier L. Jackson, MD 2002 Peak Woo, MD 1951 Herman J. Moersch, MD 2003 Charles N. Ford, MD 1952 Fred W. Dixon, MD 2004 Steven M. Zeitels, MD 1953 Edwin N. Broyles, MD 2005 Jonathan E. Aviv, MD 1954 Clyde A. Heatly, MD 2006 Gady Har-El, MD 1955 Daniel S. Cunning, MD 2007 Clarence T. Sasaki, MD 1956 Clarence W. Engler, MD 2008 Jamie A. Koufman, MD 1957 Walter B. Hoover, MD 2009 Andrew Blitzer, MD, DDS 1958 Francis W. Davidson, MD 2010 Michael Rothschild, MD 1959 Verling K. Hart, MD 2011 Gregory Postma, MD 1960 F. Johnson Putney, MD 2012 Peter J. Koltai, MD 1961 Alden H. Miller, MD 2013 Ellen Deutsch, MD 1962 Joseph P. Atkins, MD 2014 Gregory A. Grillone, MD 1963 Stanton A. Friedberg, MD 2015 J. Scott McMurray, MD 1964 Charles N. Norris, MD 2016 Dana M. Thompson, MD 1965 Daniel C. Baker, Jr., MD 2017 James Burns, MD 1966 Blair W. Fearon, MD 2018 Milan Amin, MD 1967 Francis E. LeJeune, MD 2019 Albert L. Merati, MD 1968 Charles F. Ferguson, MD

1969 Arthur M. Olsen,MD

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Support the ABEA

ABEA would like to thank the following gracious donors for con- tributing to the ABEA. Please consider making a contribution toward

sustaining the future of ABEA.

Platinum Supporters ($1,000) Marshall Smith Albert Merati Seth Dailey

Gold Supporters ($750) Karen Zur

Silver Supporters ($500) Michael Hinni Michael Johns Libby Smith Mike Rutter

Catherine Hart Julina Ongkasuwan

David Rosow Lee Akst

Paul Bryson Mark Gerber Milan Amin

Jacqueline Allen Gresham Richter

ABEA 100th Meeting Sponsors: Karl Storz

Bryan Medical Reflux Gourmet

To make your contribution to ABEA, visit www.abea.net and click on Donate or visit the registration desk.

Your support goes toward building resources for resident scholarships as well as research and educational programs for members.

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ABEA 2020 Scientific Program Committee

Julina Ongkasuwan, MD Program Chair

Committee Members: Milan R. Amin, MD Maggie Kuhn, MD Albert J. Merati, MD Doug Sidell, MD Karen Zur, MD

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ABEA Virtual Meeting Friday, April 24, 2020 11am EST – 4 pm EST; 8am PST – 1pm PST;

4pm – 9pm GMT

Friday, April 24th

11:00 – 11:20 am Welcome, Recognition, Appreciation Albert Merati, President ABEA

Recognition: Recognition of our colleagues and communities affected by the COVID pandemic

Program Committee: Julina Ongkasuwan (Chair), Maggie Kuhn, Doug Sidell, Karen Zur, Milan Amin

Guest of Honor: Robert Ossoff, DMD, MD

Presidential Citations: Robert Andrews, Milan Amin, Joel Blumin, Blake Simpson, Dana Thompson

Membership: Liz Guardiani, Chair

11:20 – 12:04pm Scientific Session 1 Moderated by: Anais Rameau, Rebecca Howell

11:20 – 11:26am Epiglottidectomy for treatment of dysphagia Presented by: Alden F Smith, Coauthor: Dinesh K Chhetri

11:26 – 11:32am Cervical Fibrosis as a Predictor for Dysphagia Presented by: Yuval Nachalon Coauthors: Lisa M Evangelista, Nogah Nativ-Zeltzer, Shumon I Dhar, Sharon J Lin, Shih Chieh Shen, Peter C Belafsky

11:32 – 11:38am Demographics & Incidence of Hypopharyngeal Diverticula: A Prospective Multi-Institutional Database Presented by: Rebecca J Howell Coauthors: Altaye Mekibib, Meredith Tabangin, Aaron Friedman, Sid Khosla, Sonya Yuen, Gregory Postma

The American Broncho-Esophagological Association

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11:38 – 11:44 am The Role of Vocal Fold Bowing on Cough and Swallowing Dysfunction in Progressive Supranuclear Palsy Presented by: Necati Enver Coauthors: James C Borders, James A Curtis, Jordanna S. S Sevitz, Nora Vanegas-Arroyave, Michelle S Troche

11:44 – 11:50 am Analyses of the profile of Laryngopharyngeal Reflux Patients at the Multi channel intraluminal impedance-pH monitoring and the relationship with pepsin saliva concentration Presented by: Jerome R Lechien Coauthors: Francois Bobin, Vinciane Muls, Mihaela Horoi, Charelle Salem, Didier Dequanter, Marie-Paule Thill, Alexandra Rodriguez, Sven Saussez

11:50 – 11:56 am Impact of FEES Outcomes and Dysphagia Management in Neurodegenerative Disease Presented by: Cooper Tye Coauthors: Philip Gardner, Gregory Dion, C Blake Simpson, Laura Dominguez

11:56 – 12:04 pm Discussion: Ashli O’Rourke

12:04 – 12:50 pm Scientific Session 2 Moderated by: Juliana Bonila-Velez, Romaine Johnson

12:04 – 12:10 pm National Inpatient Trends in Juvenile-Onset Recurrent Respiratory Papillomatosis Before and After the Human Papillomavirus Vaccine Presented by: Brooke M Su-Velez Coauthors: Eric K. Tran, Jennifer L. Long

12:10 – 12:16 pm Reflux as a risk factor for morbidity after pediatric tonsillectomy: A national cohort of inpatients Presented by: Stephen Reed Chorney Coauthor: Karen B. Zur, Adva Buzi

12:16 – 12:22 pm Organic vs. Inorganic Airway Foreign Bodies: Does Type or Duration Matter? Presented by: Charlotte K Hughes Coauthors: Christine L Christensen, Stephen C Maturo, Peter R O’Connor, Gregory R Dion

12:22 – 12:28 pm Urgency of Esophageal Foreign Body Removal: Differentiation Between Coins and Disk Cell Batteries Presented by: Arash R Safavi Coauthors: Christopher D Brook, Osamu Sakai, Bindu N. Setty, Ann Zumwalt, Mauricio Gonzalez, Michael P Platt

12:28 – 12:34 pm Importance of global foreign body injury reporting: Chevalier Jackson’s legacy carried to smartphone app Presented by: Kris R. Jatana Coauthors: Keith Rhoades, Gresham T. Richter, Craig S. Derkay, Diego Preciado, Ian N. Jacobs, James S. Reilly

12:34 – 12:40 pm Laryngeal Reconstruction Using Tissue Engineered Implants in Pigs: A Pilot Study Presented by: Sarah Brookes Coauthors: Sherry Harbin, Lujuan Zhang, Stacey Halum

12:40 – 12:50 pm Discussion: Alessandro Alarcon

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12:50 – 1:05 pm BREAK, Membership information, society announcements

1:05 – 2:05 pm COVID-19 DISCUSSION PANEL: Moderated by Maggie Kuhn

2:05 – 2:49 pm Scientific Session 3 Moderated by: Karla O’Dell, Joshua Bedwell

2:05 – 2:11 pm The Association of Diabetes on Treatment Outcomes for Subglottic Stenosis Presented by: Aisha Harun Coauthors: Thomas Edwards, Jeanne L Hatcher

2:11 – 2:17 pm Bigger is Not Always Better: Current Practices in Endotracheal Tube Size Selection Presented by: Austin Cao Coauthors: Shruthi Rereddy, Natasha Mirza

2:17 – 2:23 pm Postoperative use of Inhaled Corticosteroids Following Transoral Laser \ Surgery for Glottic Stenosis Reduces Rate of Granulation Tissue Formation Presented by: Alison Hollis, Coauthors: Ameer Ghodke, Douglas Farquhar, Robert A. Buckmire, Rupali N. Shah

2:23 – 2:29 pm In-office Steroid injection for Patients with Subglottic Stenosis: Effect Upon Intersurgical Interval and Characterization of Systemic Side Effects Presented by: Andrew Neevel, Coauthors: Ari D Schuman, Robert Morrison, Norman D Hogikyan, Robbi Ann Kupfer

2:29 – 2:35 pm The Impact of Socioeconomic and Insurance Status on Outcomes Following Tracheostomy Presented by: Rohini Bahethi, Coauthors: Christopher Park, Anthony Yang, Mingyang Gray, Kevin Wong, Alfred Iloreta, Mark Courey

2:35 – 2:41 pm Increased Expression of PD1 and PDL1 in Patients with Laryngotracheal Stenosis Presented by: Ruth J. Davis Coauthors: Dacheng Ding, Ioan Lina, Elizabeth L. Engle, Janis Taube, Alexander Gelbard, Alexander T. Hillel

2:35 – 2:41 pm Discussion: Dale Ekborn

2:49 – 3:33 pm Scientific Session 4 Moderated by: James Schroeder, Jeanne Hatcher

2:49 – 2:55 pm Comparing the Cost Effectiveness of Transoral Laser Surgery versus Radiation Therapy in the Primary Treatment of T1 Glottic Cancer Presented by: Caitlin Michelle Coviello Coauthors: Vincent D Cassidy, David E Rosow

2:55 – 3:01 pm Validation of the Communicative Participation Item Bank as an Outcome Measure for Spasmodic Dysphonia Presented by: Yin You Coauthors: Carolyn R. Baylor, Sandeep Shelly, Adam M. Klein, C. Gaelyn Garrett, Michael J. Pitman

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3:01 – 3:07 pm Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique Presented by: Brian A Nuyen Coauthors: Zhen J. Qian, Ross Campbell, Elizabeth Erickson-DiRenzo, James Thomas, C. Kwang Sung

3:07 – 3:13 pm Results of PCA Reinnervation with Phrenic Rootlet for BVFP Presented by: Randal C Paniello Coauthors: Marshall Smith, Paul Bryson

3:13 – 3:19 pm Pre-vascularized tracheal scaffolds using the platysma muscular flap for enhanced tracheal regeneration Presented by: Seong Keun Kwon Coauthors: Minhyung Lee, Ji Suk Choi, Su A Par

3:19 – 3:25 pm A MAUDE Database Analysis of Contamination Events Involving Upper Aerodigestive Endoscopy: Is Flexible Laryngoscopy Different? Presented by: Roy Jiang Coauthors: David Kasle, Nikita Kohli, Michael Lerner

3:25 – 3:33 pm Discussion: David Francis

3:33 – 3:51 pm Scientific Session 5 - Foreign Body

Moderated by: Marl Gerber 3:33 – 3:39 pm Endoscopic removal of a retained bullet within the larynx

Presented by: Punam A Patel Coauthors: Ahmed Soliman

3:39 – 3:45 pm 800 Gram Infant with A Bronchial Foreign Body Presented by: Yamilet Tirado Coauthors: Abdulmajeed Alruwaili, Heather C Smith, Alison Payson

3:45 – 3:51 pm Foreign Body Award Winner: Novel Use of an Arterial Embolectomy Catheter to Manage a Bronchial Foreign Body in a Patient with Trismus Presented by: Ryan Borek Coauthors: Luv Javia

3:51 – 4:00 pm Adjourn with Presidential Close, Introduction of President Karen Zur

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ABEA Past Guests of Honor 1951–2020

1951 Fernand Eeman, MD – Ghent, Belgium 1959 Louis Clerf, MD – Saint Petersburg, FL 1961 W. Likely Simpson, MD – Memphis, TN 1962 Edwin N. Broyles, MD – Baltimore, MD 1963 Sam E. Roberts, MD – Kansas City, MO 1964 Lyman Richards, MD – Wellesley Hills, MA 1965 Berling K. Hart, MD – Charlotte, NC 1966 Julius W. McCall, MD – Cleveland, OH 1967 Francis W. Davidson, MD – Danville, PA 1968 Dean M. Lierle, MD – Iowa City, IA 1969 Leroy A. Schall, MD – Barnstable,MA 1970 Herman J. Moersch, MD – Rochester, MD 1971 Louis Clerf, MD – Saint Petersburg, FL 1972 Joseph P. Atkins, MD – Philadelphia, PA 1973 Ricardo T. Acuna – Mexico City, Mexico 1974 Paul H. Holinger, MD – Chicago, IL 1975 Arthur M. Olsen, MD – Rochester, MN 1976 Francis LeJeune, MD – New Orleans, LA 1977 Alden H. Miller, MD – Los Angeles, CA 1978 Charles Norris, MD – Philadelphia, PA 1979 Charles F. Ferguson, MD – Osterville, OH 1980 Emily Lois Van Loon, MD – Philadelphia, PA 1981 Donald Proctor, MD – Baltimore, MD 1982 Frank D. Lathrop, MD – Pittsford, VT 1983 John E. Bordley, MD – Baltimore, MD 1984 Gabriel F. Tucker, MD – Chicago, IL 1985 Stanton A. Friedburg, MD – Chicago, IL 1986 F. Johnson Putney, MD – Charleston, SC 1987 Howard A. Anderson, MD – Rochester, MN 1988 John Paul Frazer, MD – Rochester, MN 1989 Paul H. Ward, MD – Los Angeles, CA 1990 D. Thane R. Cody, MD – Jacksonville, FL 1991 M. Stuart Strong, MD – Boston, MA 1992 Bruce Benjamin, MD – Sydney, Australia 1993 David R. Sanderson, MD – Scottsdale, AZ 1994 Michael E. Johns, MD – Baltimore, MD 1995 John A. Kirchner, MD – Woodbridge, CT 1996 Robert W. Cantrell, MD – Charlottesville, VA

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1997 Eiji Yanagisawa, MD – New Haven, CT 1998 Lauren Holinger, MD – Chicago, IL 1999 William R. Hudson, MD – Durham, NC 2000 Robert H. Ossoff, DMD, MD – Nashville, TN 2001Trevor J. I. McGill, MD - Boston, MA 2002 Flavio Aprigliano, MD – Rio de Janeiro, Brazil 2003 Stanley M. Shapshay, MD – Boston, MA 2004 Minoru Hirano, M.D. – Kurume, Japan 2005 R. Rox Anderson, MD – Boston, MA 2006 Hugh F. Biller, MD – Maine 2007 Frank W. Lucente, MD – Brooklyn, NY 2008 Marvin P. Fried, MD – Bronx, NY 2008 Marshall Strome, MD – Cleveland, OH 2009 James Pepa – Newark, NJ 2010 William Lawson, MD, DDS – New York, NY 2011 Robin Cotton, MD – Philadelphia, PA 2012 Kiminori Sato, MD, PhD – Kurume, Japan 2013 Byron J. Bailey, MD – Galveston, TX 2013 Steven M. Parnes, MD – Albany, NY 2013 Jerry C. Goldstein, MD – Wellington, FL 2013 Leora Loy – Salt Lake City, UT 2014 Ellen Friedman, MD, FACS - Houston, TX 2014 Peter Koltai, MD, FACS - Stanford, CA 2015 Stuart Strong, MD - Boston, MA 2016 Diane Bless, PhD - Madison,WI 2017 Robin Cotton, MD – Cincinnati, OH 2017 Kerry Olsen, MD – Rochester, MN 2018 Steven Zeitels, MD – Boston, MA 2019 Jamie Koufman, MD 2020 Robert Ossoff, DMD, MD

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ABEA Annual Meeting with COSM April 22-24, 2020 at Hilton Atlanta Atlanta, Georgia

*This meeting was canceled due to COVID-19.*

Wednesday, April 22, 2020 (Grand Ballroom West)

7:00 – 7:45 am

7:55 – 8:00 am

8:00 – 8:15 am

8:15 – 8:50 am

8:50 – 9:22 am

9:22 – 10:00 am

ABEA Business Meeting and New Member Induction (MembersOnly)

Presidential Welcome: Introduction of Guests; Presidential Citations and Program

Presidential Keynote

Scientific Session 1 (Airway I) Moderated by: Dale Ekbom and Karla O'Dell

Laryngeal Reconstruction Using Tissue Engineered Implants in Pigs: A Pilot Study Presented by: Sarah Brookes Bigger is Not Always Better: Current Practices in Endotracheal Tube Size Selection Presented by: Austin Cao Increased Expression of PD1 and PDL1 in Patients with Laryngotracheal Stenosis Presented by: Ruth J Davis Preliminary Outcomes and Decannulation Rates of Glottic and Subglottic Stenosis Using a Self-Retaining Transglottic Stent Presented by: Joseph Choi Park Pre-vascularized tracheal scaffolds using the platysma muscular flap for enhanced tracheal regeneration Presented by: Seong Keum Kwon Q&A

Lecture 1 – Chevalier Jackson Lecturer: Dr. Lucian Sulica

Scientific Session 2 (Voice) Moderated by: Babek Sadoughi and Nazaneen Grant

Validation of the Communicative Participation Item Bank as an Outcome Measure for Spasmodic Dysphonia Presented by: Yin You Proposal of a Classification for Sulcus Vocalis following Microlaryngoscopy

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with a Study of the Results of a Laser Assisted Sulcus Release Surgery Presented by: Nupur Kapoor Nerukar Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique Presented by: Brian A. Nuyen Effect of Wendler Glottoplasty on Acoustic Measures of Voice Presented by: Joseph Chang Comparative Results of Vocal Fold Injury According to the Fiberoptic Laser in a Rabbit Vocal Fold Model Presented by: Seung-Won Lee Q&A

10:00 – 10:20 am

10:20 – 11:05 am

11:05– 11:10 am

Break

Scientific Session 3 (Broncho-Esophogalogy Part I) Moderated by: James Schroeder and JeanneHatcher

Analyses of the profile of Laryngopharyngeal Reflux Patients at the Multichannel intraluminal impedance-pH monitoring and the relationship with pepsin saliva concentration Presented by: Jerome R Lechien Pathophysiology of Dysphagia in those with Unilateral Vocal Fold Paralysis Presented by Etiology by: Maya Elena Stevens The Role of Vocal Fold Bowing on Cough and Swallowing Dysfunction in Progressive Supranuclear Palsy Presented by: Necati Enver Impact of FEES Outcomes and Dysphagia Management in Neurodegenerative Disease Presented by: Cooper Tye Deglutition and Respiratory Patterns during Sleep in the Aged with OSAS under CPAP Therapy Presented by: Kiminori Sato The Effect of Carbonation on Dysphagia for Liquids: A Prospective Study Using Fiber-Optic Endoscopic Evaluation of Swallowing Presented by: Yael Shapira- Galitz Q&A

Chevalier Jackson Award – Dr. Marshall Smith

11:10 am – 12:00 pm Panel 1: Reflux Management in 2020: What’s new from Alginates to Zantac

Moderated by: Libby J. Smith Panelists: Libby J. Smith, Rebecca B. Howell, Maggie A. Kuhn, Robbi Kupfer, Ashli O’Rourke

12 pm Adjourn with a Presidential Close

12pm Member Photograph– Location TBD

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Thursday, April 23, 2020 (Grand Ballroom West)

12:55 -1:00 pm

1:00 – 1:40 pm

1:40 – 2:15 pm

2:15 – 2:55 pm

2:55 – 3:15 pm

3:15– 3:55pm

Presidential Welcome

Scientific Session 4 (Cancer) Moderated by: Robbi Kupfer and John Paul Giliberto

Comparing the Cost Effectiveness of Transoral Laser Surgery versus Radiation Therapy in the Primary Treatment of T1 Glottic Cancer Presented by: Caitlin Michelle Coviello 1122: Oncological and Clinical Outcomes of Transoral Robotic Supraglottic Laryngectomy Presented by: Stephane Hans Laryngeal Chondrosarcoma: Clinicopathologic and Survival Characteristics Presented by: Roman Povolotsky The Role of Social Determinants of Health in Decision Making for Post- Laryngectomy Voice Rehabilitation Presented by: Christopher Boyd Is cone beam computed tomography with oral contrast more useful than videofluoroscopy for evaluation of pharyngeal leakage & fistula? Presented by: Mitsuyoshi Imaizumi Q&A Lecture 2 – Koufman Lecture – Dr. Peter Kahrilas

Scientific Session 5 (Airway II) Moderated by: Diana Kirke and Karthik Balakrishnan

Inhibition of TGF-β in a Murine Model of Subglottic Stenosis Presented by:

Tiffany N. Chao The Association of Diabetes on Treatment Outcomes for Subglottic Stenosis Presented by: Aisha Huron Genomic Methylation and Proteomic Signatures in Idiopathic Subglottic Stenosis Presented by: Greg Young Postoperative use of Inhaled Corticosteroids Following Transoral Laser Surgery for Glottic Stenosis Reduces Rate of Granulation Tissue Formation Presented by: Alison Hollis In-office Steroid injection for Patients with Subglottic Stenosis: Effect Upon Intersurgical Interval and Characterization of Systemic Side Effects Presented by: Andrew Neevel Q&A

Break with Exhibitors

Scientific Session 6 (Broncho-Esophogalogy Part II) Moderated by: Anais Rameau and Joe Bradley

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3:55– 4:45 pm

4:45 – 5:00 pm

5:00 pm

Presented by: Alden F. Smith Sarcopenia and Swallowing in Head and Neck Cancer Presented by: Samia Nawaz Cervical Fibrosis as a Predictor for Dysphagia Presented by: Yuval Nachalon Dysphagia Following Complex Anterior Cervical Spine Surgery Necessitating Otolaryngology Assistance Presented by: Sean M. McDermott Demographics & Incidence of Hypopharyngeal Diverticula: A Prospective Multi- institutional Database Presented by: Rebecca J. Howell Epiglottidectomy for treatment of dysphagia Q&A Panel 2: ALA/ABEA Combined Women in Laryngology Panel Moderated by: Nicole Maronian and Tanya Meyer

Ellen M. Friedman Foreign Body Award Session Moderated by: Mark Gerber

800 Gram Infant with A Bronchial Foreign Body Presented by: Yamilet Tirado Endoscopic removal of a retained bullet within the larynx Presented by: Punam A Patel

Ellen M. Friedman Foreign Body Award Winner: Novel Use of an Arterial Embolectomy Catheter to Manage a Bronchial Foreign Body in a Patient with Trismus Presented by: Ryan Borek

Adjourn with a Presidential Close (Reminder for Poster Reception at 5:30 pm)

Friday, April 24th, 2020 (Grand Ballroom West)

7:55 – 8:00 am

8:00 – 8:42 am

Presidential Welcome

Scientific Session 7 (Broncho-Esophogalogy Part III) and Koltai Award Moderated by: Jeanne Hatcher and Kaalan Johnson

Inflammatory Effects of Thickened Water on the Lungs in a Murine Model of Chronic Aspiration Presented by: Nogan Nativ Zeltzer Swallowing Outcomes following Laryngotracheoplasty with Posterior Grafting in Children Presented by: Yann-Fuu Kou Organic vs. Inorganic Airway Foreign Bodies: Does Type or Duration Matter?

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Presented by: Charlotte K. Hughes Urgency of Esophageal Foreign Body Removal: Differentiation Between Coins and Disk Cell Batteries Presented by: Arash E. Satavi

8:26 – 8:42 am

8:42 am – 9:32 am

9:32 – 10:10 am

10:10 – 10:30 am

10:30 – 11:10 am

Koltai Award Introduction and Koltai Award Paper Presentation

Importance of global foreign body injury reporting: Chevalier Jackson’s legacy carried to smartphone app. Presented by: Kris R. Jatana Q&A

Panel 3: Practical Approaches to Reducing Intubation Injury

Moderated by: David Rosow Panelists: David Rosow, Alexander Hillel, Elizabeth Guardiani, and Sunil Verma

Scientific Session 7 (Airway Part III) Moderated by: Nausheen Jamal and Romaine Johnson

Results of PCA reinnervation with Phrenic Rootlet for BVFP Presented by: Randal C. Paniello In Vitro Evaluation of the Diffusion of Dexamethasone Through the Cuff of an Endotracheal Tube Presented by: Luke Miller Pediatric Tracheal Reconstructive Procedures in the United States: Analysis

of a 12 year period Presented by: Alyssa Smith Impact of Social Determinants of Health on Surgical Outcomes in Idiopathic

Subglottic Stenosis Presented by: Jaclyn Lee The Impact of Socioeconomic and Insurance Status on Outcomes Following

Tracheostomy Presented by: Rohini Bahethi

Break with Exhibitors

Session 9 (The Big Picture) Moderated by: Catherine Hart and Ross Mayerhoff

A MAUDE Database Analysis of Contamination Events Involving Upper Aerodigestive Endoscopy: Is Flexible Laryngoscopy Different? Presented by: Roy Jiang Pain Experience During Office Laryngeal Procedures Presented by: Jonathan Lubin Costs in the management of paradoxical vocal fold motion disorder Presented by: Tadeas Lunga Reflux as a risk factor for morbidity after pediatric tonsillectomy: A

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national cohort of inpatients Presented by: Stephen Reed Chorney National Inpatient Trends in Juvenile-Onset Recurrent Respiratory Papillomatosis Before and After the Human Papillomavirus Vaccine Presented by: Brooke M. Su-Velez Q&A

11:10– 11:50 am Panel 4: Tracheostomy Transitions: Challenges and Pathways to Success as Children Enter Adulthood Moderated by: Joshua R. Bedwell Panelists: Joshua R. Bedwell, Libby Smith, Philip Weissbrod, Matthew Brigger

11:50am – 12:00 pm Adjourn with a Presidential Close and Introduction of New President

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Abstracts from ABEA 100th Annual Meeting April 24, 2020

Scientific Session 1

Abstracts from ABEA 100th meeting April 24, 2020

Moderated by: Anais Rameau, Rebecca Howell Epiglottidectomy for treatment of dysphagia Presented by: Alden F Smith Coauthor: Dinesh K Chhetri

Epiglottidectomy for treatment of dysphagia

Objectives: To review characteristics of patients with dysphagia due to epiglottic dysfunction, and to analyze outcomes of partial epiglottidectomy in dysphagia related to epiglottic dysfunction.

Study Design: Chart review and analysis of clinical data including pre- and post-operative dysphagia assessment for patients who underwent partial epiglottidectomy for treatment of dysphagia.

Methods: A retrospective review was performed of all patients who underwent partial epiglottidectomy for treatment of dysphagia at a single tertiary care referral center during a 4 year period. Objective pre- and post-treatment swallow findings including modified barium swallow study (MBSS), flexible endoscopic evaluation of swallowing (FEES), and progression of diet were reviewed.

Results: 90 patients underwent CO2 laser assisted partial epiglottidectomy during the study period. Ages ranged from 35 - 93 (average 68.2 years). 63% had a history of head and neck cancer, and 13% had a history of anterior cervical spine surgery or cervical osteophytes identified on preoperative imaging. Concurrent cricopharyngeal myotomy was performed in 36.9% of patients. Improvement in swallowing was seen in 77.2% of patients.

Conclusions: Epiglottic dysfunction can cause dysphagia in a variety setting including radiation for head and neck cancer and cervical spine disease. Partial epiglottidectomy is effective with minimal postoperative morbidity. Candidate selection includes patients with poor epiglottic inversion causing food bolus obstruction as noted on preoperative instrumental swallow assessments.

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Cervical Fibrosis as a Predictor for Dysphagia

Presented by: Yuval Nachalon

Coauthors: Lisa M Evangelista, Nogah Nativ-Zeltzer, Shumon I Dhar, Sharon J Lin, Shih Chieh Shen, Peter C Belafsky

Objective: Radiotherapy treatment damages key structures and causes dysfunction through radiation- induced fibrosis(RIF). We have hypothesized that the degree of cervical fibrosis is associated with swallowing dysfunction in persons having undergone RT for HNC. This study tries to evaluate the association between cervical fibrosis and swallowing dysfunction in patients after radiation therapy for HNC.

Method: Patients with dysphagia who were at least 1-year post radiation therapy for HNC underwent simultaneous cervical ultrasound(US) and videofluroscopic swallow study(VFSS). US determinants of fibrosis were measurements of sternocleidomastoid (SCM) fascia thickness bilaterally at cricoid level. Three measurements were obtained on each side and a mean(±SD) composite SCM thickness was calculated. Primary outcome variable on VFSS was pharyngeal constriction ratio, a validated measure of pharyngeal contractility. A qualitative assessment of lateral neck rotation was performed as a functional measure of neck fibrosis.

Results: Simultaneous cervical US and VFSS examinations were performed on 18 patients. The mean(±SD) age of the cohort was 65(±11) years. Mean time post-radiation was 6(±7) years. Mean SCM fascia thickness was 0.26mm(±0.04). Patients with moderate/severe restriction in lateral rotation of neck had thinner SCM fascia(0.23±0.03) compared to patients with normal/mild restriction(0.28mm±0.04)(p < 0.05). Patients with thinner SCM fascia had a higher pharyngeal constriction ratio, indicating poorer pharyngeal function(r=- 0.468,p<0.05).

Conclusion: Thinner sternocleidomastoid fascia on cervical ultrasound in patients having undergone radiotherapy for head and neck cancer was associated with reduced lateral neck movement and poorer pharyngeal constriction on swallowing fluoroscopy. The data suggest that cervical fibrosis is associated with swallowing dysfunction in head and neck cancer survivors.

24

Demographics & Incidence of Hypopharyngeal Diverticula: A Prospective Multi- Institutional Database

Presented by: Rebecca J Howell

Coauthors: Altaye Mekibib, Meredith Tabangin, Aaron Friedman, Sid Khosla, Sonya Yuen, Gregory Postma

Objective: To describe demographics, imaging, and patient-reported outcome measures (PROM) at presentation in a large patient population of hypopharyngeal diverticula. To define the relative incidence of Zenker’s Diverticula (ZD) versus non-ZD (Killian- Jameson (KJ), iatrogenic, traction, Laimer).

Method: Prospective, multicenter cohort study of 157 patients with hypopharyngeal diverticula using RedCap database. Demographic, imaging and PROM data will be summarized using means, medians, percentages and frequencies.

Results: 157 patients enrolled (57% male). Incidence data: CP bar (16), ZD (99), KJ (8), Laimer (0), traction(1), other (4). Symptom duration ranges: <1year (32,20.8%), 1-3years (64,41.6%), 3-10years (33,21.4%), and >10years (23,14.9%). PROM’s: Reflux Symptom Index: median 20, range 3-45; Eating Assessment Tool-10: median 15, range 0-39; and Voice Handicap Index-10: median 0, range 0-37. Esophagram sizing: <1cm (18,11.8%), 1-2cm (59,38.8%), 3-4cm (45,29.6%), 5-6cm (8,5.3%). 44 (28.4%) patients presented with a recurrence. Of the 28 patients that had undergone previous surgery for ZD the modalities attempted include: endoscopic laser (7,25%), endoscopic stapler (14,50%), open (7,25%), unknown (1,3.6%), other (3,10.7%).

Conclusion: This is the first study to describe incidence of non-Zenker’s diverticula. Herein we have identified 16 (18.4%) patients with CP bar (as an early ZD precursor), 99 (77.0%) ZD, 8 (5.6%) Killian Jameson. Patients with hypopharyngeal diverticulum are a heterogenous group with variable range of symptoms at presentation.

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The Role of Vocal Fold Bowing on Cough and Swallowing Dysfunction in Progressive Supranuclear Palsy

Presented by: Necati Enver

Coauthors: James C Borders, James A Curtis, Jordanna S. S Sevitz, Nora Vanegas- Arroyave, Michelle S Troche

Objective: Progressive supranuclear palsy (PSP) is a neurodegenerative disease which frequently results in cough and swallowing dysfunction and subsequent aspiration pneumonia. Relationships among vocal fold atrophy, cough, and swallowing have been previously identified in related diseases like Parkinson’s Disease, but remain unstudied in PSP. This study examined the influence of vocal fold bowing on cough and swallowing dysfunction in people with PSP.

Method: Twenty-three participants with PSP (16 males, mean age of 72 years, and mean disease duration of five years) completed measures of swallowing and cough function. Measures of vocal fold bowing (BI) and swallowing safety (PAS) were obtained using flexible endoscopy. Measures of cough effectiveness were obtained during spirometric testing of reflex and voluntary cough. Linear regressions were performed to assess the influence of BI on PAS and cough effectiveness, while controlling for age and sex.

Results: All participants demonstrated some degree of vocal fold bowing. BI significantly influenced reflex cough peak expiratory flow rise time (p = .04, R2 = .23), voluntary cough peak expiratory flow rise time (p =.02, R2 = .34), and voluntary cough volume acceleration (p = .04, R2 = .26). BI did not influence PAS (p > 0.05).

Conclusion: This study found vocal fold bowing to be common in PSP, and that these changes in vocal fold anatomy negatively influenced cough effectiveness. Future studies should continue to examine the relationships between laryngeal dysfunction and airway protective deficits in PSP and vocal fold atrophy as a possible target for behavioral and medical intervention.

26

Analyses of the Profile of Laryngopharyngeal Reflux Patients at the Multichannel Intraluminal Impedance-pH Monitoring and The Relationship with Pepsin Saliva Concentration

Presented by: Jerome R Lechien

Coauthors: Francois Bobin, Vinciane Muls, Mihaela Horoi, Charelle Salem, Didier Dequanter, Marie-Paule Thill, Alexandra Rodriguez, Sven Saussez

Objective: To investigate the profile of patients with laryngopharyngeal reflux (LPR) at the multichannel intraluminal impedance-pH monitoring (MII-pH) and the relationship between hypopharyngeal/proximal reflux episodes (HRE) and pepsin saliva concentration.

Method: Patients were recruited from four hospitals from January 2018 to October 2019. Patient benefited from MII-pH and pepsin saliva detection in the same time. Pepsin saliva concentration was measured after the breakfast, the lunch and the dinner. The LPR profile of patients was studied through a breakdown of the MII-pH findings over the 24-hour of testing. The relationship between the pepsin saliva concentration and the 24-hour HRE was studied through linear multiple regression.

Results: 126 patients were included. 71% of HRE occurred outside 1-hour post- meal times. 23.3% of HRE occurred during the 1-hour post-meal and only 4.6% of HRE occurred nighttime. 74 patients (58.7%) did not have nighttime HRE. There were no differences regarding the types of LPR (acid, nonacid, mixed). Patients with LPR and gastroesophageal reflux disease (GERD) mainly had acid LPR and patients with nonacid/mixed LPR had a low proportion of GERD. There were no significant associations between HRE and pepsin saliva concentration.

Conclusion: Unlike GERD, HREs occur less frequently after meals and nighttime. These information about the MII-pH profile of LPR patients have to be considered for future empirical therapeutic trial strategies.

27

Impact of FEES Outcomes and Dysphagia Management in Neurodegenerative Disease

Presented by: Cooper Tye

Coauthors: Philip Gardner, Gregory Dion, C Blake Simpson, Laura Dominguez

Objective: To determine the incidence of abnormal Fiberoptic Endoscopic Evaluation of Swallowing (FEES) findings in patients with progressive neurologic disorders and identify the most commonly implemented dysphagia management strategies.

Method: We conducted a retrospective review of patients with neurodegenerative disease who underwent FEES at a tertiary care center between 2008 and 2019. Patient demographics, diagnosis, and EAT-10 scores were recorded. Rates of penetration, aspiration, and functional change in management (FCIM) to include dietary modifications, home exercises, swallow therapy, surgical intervention (injection augmentation or esophageal dilation), or alternative means of nutrition (i.e. PEG tube) were calculated.

Results: 209 FEES were performed in 178 patients with a mean age of 64.8 years (SD= +/-14). The most common diagnoses were Amyotrophic Lateral Sclerosis (32%) followed by Parkinson’s disease or Parkinsonism (25%). FEES demonstrated penetration in 72.5% of patients and aspiration in 14.6%. Mean EAT-10 scores differed between patients with aspiration versus penetration versus normal FEES (no penetration or aspiration) (24.7 vs. 14.9 vs. 13.9, respectively, p<0.001). A FCIM was recommended in 88% of patients and most commonly included swallow therapy (34%). 4.5% of patients underwent surgical intervention. A PEG tube was recommended for either supplemental or sole form of nutrition in 19% of the entire cohort.

Conclusion: Most patients with neurodegenerative diseases presenting with dysphagia demonstrated abnormal FEES findings necessitating a FCIM, suggesting early dysphagia evaluation may be warranted in this cohort. These findings correlate with worsened EAT-10 scores in patients with aspiration or penetration on FEES.

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Scientific Session 2

Moderated by: Juliana Bonila-Velez, Romaine Johnson

National Inpatient Trends in Juvenile-Onset Recurrent Respiratory Papillomatosis Before and After the Human Papillomavirus Vaccine

Presented by: Brooke M Su-Velez

Coauthors: Eric K. Tran, Jennifer L. Long

Objective: The vaccine against human papillomavirus (HPV) was approved in the United States in 2006. Juvenile-onset recurrent respiratory papillomatosis (JORRP) is a rare but morbid condition caused by HPV types 6 and 11, which are covered by the vaccine. We aim to investigate changes in incidence of JORRP in relation to the HPV vaccine, using inpatient hospitalization for airway procedures as a proxy measure.

Method: Using years 2003, 2006, 2012, and 2016 of the Kids’ Inpatient Database (KID), we identified inpatient visits for presumed JORRP using the following criteria: ICD-9 or corresponding ICD-10 (for 2016) diagnosis codes for either “benign laryngeal neoplasm” or “HPV infection of unspecified site,” combined with procedure codes for laryngoscopy or tracheoscopy, endoscopic biopsy of larynx, or excision/destruction of lesion or tissue of the trachea or larynx. Demographic and utilization data were also extracted.

Results: The estimated number of cases of JORRP in 2003 and 2006 were 263 and 213 out of a total sample of over 7.5 million inpatient visits, respectively. In 2012 and 2016, the number of JORRP cases were 126 and 64, respectively, out of about 6 to 6.5 million visits. Overall, there was a decreasing rate of inpatient visits with airway procedures for JORRP (0.0036% in 2003, 0.0028% in 2006, 0.0019% in 2012, and 0.0010% in 2016).

Conclusion: The incidence of inpatient visits for JORRP demonstrates a downwards trend from 2003 to 2016. This trend may be attributable to increasing HPV vaccination rates after the vaccine was approved in 2006.

29

Reflux as a Risk Factor for Morbidity After Pediatric Tonsillectomy: A national Cohort of Inpatients

Presented by: Stephen Reed Chorney

Coauthors: Karen B. Zur, Adva Buzi

Objective: Gastroesophageal reflux (GER) has been identified as a risk factor for complications following pediatric tonsillectomy. The primary objective of this study was to examine outcomes after tonsillectomy among children with GER using a nationwide database. Secondary objectives included analyzing duration of hospitalization and total charges after admission.

Method: A cross-sectional review of the Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Databases (KID) from 2012 and 2016.

Results: A total of 21,232 children had a tonsillectomy with or without adenoidectomy, with 1,683 (7.9%) diagnosed with GER. Average age for patients with reflux was 4.4 years and for those without was 5.6 years (p<.001). The rate of primary bleed was not statistically different between groups (p=.87). Patients with reflux were more likely to have respiratory complications (p=.03), aspiration pneumonitis (p<.001), and hypoxemia (p<.001) during their hospital course. Noninvasive ventilation and reintubation also occurred more frequently in this population (p<.001). Children with reflux had a longer duration of postoperative admission (3.8 vs. 2.3 days, p<.001) and higher total hospital charges (47,129 vs. 27,584 dollars, p<.001). A regression analysis determined that after controlling for reactive airway disease, reflux remained a statistically significant indicator of adverse outcomes.

Conclusion: Children with GER were significantly more likely to experience inpatient respiratory complications following tonsillectomy. Further, length of admission and total hospital charges were higher compared to children without reflux. These results suggest that children with GER experience poorer outcomes after tonsillectomy and highlight the role for appropriate preoperative counseling and planning in this patient population.

30

Organic vs. Inorganic Airway Foreign Bodies: Does Type or Duration Matter?

Presented by: Charlotte K Hughes

Coauthors: Christine L Christensen, Stephen C Maturo, Peter R O’Connor, Gregory R Dion

Objective: We sought to determine clinical and histologic differences between inorganic and organic airway foreign bodies over time.

Method: Twenty anesthetized Sinclair miniature swine (Sus scrofa domestica) were divided into 2 groups- inorganic or organic foreign bodies. Either an organic (peanut) or inorganic (Lego©) foreign body was placed within a bronchus and left for 3, 5, 7, 14 or 30 days. The airway was reassessed at the predetermined endpoint and endoscopic, gross, and histopathological findings were documented. Specimens were scored with a pathologic injury severity scoring system to assess injury severity from the foreign body.

Results: Foreign bodies were successfully placed in all 20 swine. Two animals required early euthanasia due to respiratory compromise. The foreign body was identified grossly in 8 (40%) of animals. An additional 3 (15%) had microscopic evidence suggestive of a previous foreign body of an undetermined duration. There was no difference in injury severity between organic and inorganic foreign bodies. The 3-day group had injuries limited to bronchial lining, whereas the longer groups had bronchial and adjacent lung parenchymal involvement. There was no difference in injury severity between days 5 - 30. The most common gross finding was a firm, purple focus in the lung surrounding the foreign body. The most common microscopic findings were intralesional bacteria, bronchial epithelial erosion, and suppurative bronchopneumonia.

Conclusion: Airway foreign bodies initially cause bronchial damage. After 5 days, the foreign body causes lung parenchymal changes. There was no difference in airway lesion severity between organic and inorganic foreign bodies.

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Urgency of Esophageal Foreign Body Removal: Differentiation Between Coins and Disk Cell Batteries

Presented by: Arash R Safavi

Coauthors: Christopher D Brook, Osamu Sakai, Bindu N. Setty, Ann Zumwalt, Mauricio Gonzalez, Michael P Platt

Objective: Coin-shaped disk battery ingestions have a similar initial presentation to coin ingestion, however, delayed retrieval of a battery from the esophagus can have devastating consequences. Variations in timing of retrieval for children with ingestion of coin foreign bodies have been reported. The study assesses the sensitivity and specificity of traditional and digital plain film X-ray to differentiate disk batteries from coin foreign bodies.

Study Design: A radiographic study of the 12 most common commercially available disk batteries and 67 coins of varying international origins was performed. Foreign bodies were placed in the cervical esophagus of a cadaver and anteriorposterior (AP) and lateral plain X-rays were taken using traditional film. Digital AP and lateral radiographs of standalone coins and batteries were also obtained. The images were blindly read by two otolaryngologists and two radiologists. Statistical analysis was performed to determine accuracy in identifying coins versus batteries.

Results: Using traditional film radiographs to identify disk batteries yielded a sensitivity = 0.88 and specificity = 0.92 (PPV=0.75, NPV=0.97). Digital radiography yielded an overall sensitivity = 0.98 and specificity = 0.97 (PPV=0.87, NPV=0.99). Features of disk batteries were only seen on AP traditional films using reverse contrast.

Conclusion: While digital imaging was more accurate in identifying disk batteries, neither modality had perfect accuracy. Features of international coins and common disc batteries were identified which may aid in diagnosis. With devastating consequences of retained disk battery ingestion in the esophagus, emergent removal of any possible disc battery foreign body should be considered.

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Importance of global foreign body injury reporting: Chevalier Jackson’s legacy carried to Smartphone App

Presented by: Kris R. Jatana

Coauthors: Keith Rhoades, Gresham T. Richter, Craig S. Derkay, Diego Preciado, Ian N. Jacobs, James S. Reilly

Objective: Chevalier Jackson, MD pioneered aerodigestive foreign body (FB) and caustic injury management and developed his own repository of data. Current hazards, such as button batteries, high-powered magnets, toys, food aspiration, and detergent- related caustic injury incidence and severity have not been reliably captured. Therefore, this study describes: 1) reasons for centralized injury data collection, 2) limitations to existing reporting platforms, 3) international outreach to drive global injury prevention efforts.

Method: Dedicated ABEA Button Battery Task Force members explored technologies that could better capture FB and caustic injury events. This team of engineers and medical experts determined an innovative solution was warranted.

Results: A novel reporting mechanism and global injury database was established via a new dedicated nonprofit organization, the Global Injury Research Collaborative (GIRC, www.globalirc.org). This platform allows for efficient submission of FB photos, and relevant initial and follow-up clinical data not captured elsewhere. An iOS based “GIRC App” is available to medical professionals for no charge on the App Store and soon to be Android version launched in GooglePlay. This allows for a rapid, anonymous, de- identified (HIPPA compliant), secure electronic mechanism for reporting injuries and optimizing treatment algorithms.

Conclusion: Prior mechanisms have not captured the cumulative data needed to drive adequate product safety changes across industry and regulatory levels. A smartphone app was created and represents an innovative approach to documenting injury events building on the legacy of Dr. Jackson. All otolaryngologists should be aware of this injury reporting mechanism and contribute to this global research database.

33

Laryngeal Reconstruction Using Tissue Engineered Implants in Pigs: A Pilot Study

Presented by: Sarah Brookes

Coauthors: Sherry Harbin, Lujuan Zhang, Stacey Halum

Objective: There are currently no treatments available that restore dynamic laryngeal function after hemilaryngectomy . Previously, we have shown that dynamic function can be restored post hemilaryngectomy in a rat model. Here, we report in a first of its kind, proof of concept study, that this previously published technique is scalable to a porcine model.

Method: Muscle and fat biopsies were taken from Yucatan minipigs and muscle progenitor cells (MPCs) and adipose stem cells (ASCs) were isolated and cultured for 3 weeks. The minipigs underwent a laterovertical partial laryngectomy sparing the left arytenoid cartilage with recurrent laryngeal nerve transection. Each layer was replaced with a tissue engineered implant: (1) an acellular epithelial layer composed of densified Type I collagen, (2) a skeletal muscle layer composed of autologous MPCs and aligned collagen differentiated and induced to express motor endplates (MEE), and (3) a cartilage layer composed of autologous ASCs and densified collagen differentiated to cartilage. Healing was monitored at 2 and 4 weeks post-op, with an 8 week study endpoint.

Results: Animals demonstrated appropriate weight gain, no aspiration events, and audible phonation. Video laryngoscopy showed progressive healing with vascularization and re-epithelialization present at 4 weeks. On histology, there was no immune reaction to the implants and there was complete integration into host tissue with nerve and vascular ingrowth.

Conclusion: This pilot study represents a first of its kind technique in which a transmural vertical partial laryngectomy was performed and successfully repaired with a customized, autologous stem cell-derived multi-layered tissue engineered implant.

34

Scientific Session 3

Moderated by: Karla O’Dell, Joshua Bedwell

The Association of Diabetes on Treatment Outcomes for Subglottic Stenosis

Presented by: Aisha Harun

Coauthors: Thomas Edwards, Jeanne L Hatcher

Objective: Patients with subglottic stenosis have been found to have a higher prevalence of diabetes. The impact of diabetes on the clinical course of these patients has not been fully elucidated. The goal of the current study was to evaluate the association of diabetes on subglottic stenosis treatment outcomes.

Method: A retrospective chart review was conducted for all patients evaluated for subglottic stenosis between 2017 to 2018 with follow-up for at least 12 months. Demographic variables, etiology of stenosis, comorbidities, hemoglobin A1c (a measure of blood glucose control), and treatment strategies were collected.

Results: There were 137 patients included in the study, and 24 individuals with diabetes (17.4%). Individuals with diabetes were over twice as likely to have a tracheostomy tube during follow up, and this approached significance (OR 2.62, p=0.058, 95% CI 0.97 to 7.13). Increasing hemoglobin A1c was associated with decreased odds of tracheostomy tube decannulation (OR -0.14, p=0.012, 95% CI -0.24 to -0.06). There was no significant association with diabetes on mean number of interventions or mean time between interventions.

Conclusion: We observed notable associations with diabetes and tracheostomy tube outcomes in patients with subglottic stenosis. These observations may help inform treatment course when counseling diabetic patients.

35

Bigger is Not Always Better: Current Practices in Endotracheal Tube Size Selection

Presented by: Austin Cao

Coauthors: Shruthi Rereddy, Natasha Mirza

Objective: Intubation with inappropriately sized endotracheal tubes (ETT) can cause long-term tracheal and laryngeal injuries often requiring surgical intervention. While tracheal size has been demonstrated to vary based on height and sex, it is unclear whether these guidelines are regularly implemented in patients undergoing endotracheal intubation. The objective of this study is to determine the rate of appropriate ETT size selection in patients undergoing intubation and assess provider decision making in ETT size selection.

Method: The study population was all patients who underwent endotracheal intubation over a two-week period at a tertiary academic medical center. Data were collected on patient age, gender, height, BMI, comorbidities, ETT size, duration of intubation, bronchoscopies, and type of practitioner who performed the intubation. A survey of providers who regularly intubate patients was carried out to gain insight into the decision-making process for ETT size selection.

Results: 131 patients were intubated over a two-week period. Compared to an ETT size selection model based on height, only 58% of intubations were sized appropriately. ETT were more frequently larger than appropriate in females (p<0.0001), patients with normal BMI (p=0.0415), and patients with shorter than average height (p<0.0001). Rates of bronchoscopy did not vary significantly between patients with appropriately sized tubes and those with larger than recommended tubes.

Conclusion: Guidelines on ETT size selection based on height have yet to be widely implemented. This is an area with significant scope for improvement and implementation of quality metrics.

36

Postoperative use of Inhaled Corticosteroids Following Transoral Laser Surgery for Glottic Stenosis Reduces Rate of Granulation Tissue Formation

Presented by: Alison Hollis,

Coauthors: Ameer Ghodke, Douglas Farquhar, Robert A. Buckmire, Rupali N. Shah

Objective: Transoral laser surgery for glottic stenosis (transverse cordotomy and anteromedial arytenoidectomy (TCAMA) is often complicated by granulation tissue (GT) formation. GT can cause dyspnea and may require surgical removal to alleviate airway obstruction. Inhaled corticosteroids (ICS) have been shown to reduce benign vocal fold granulomas, however its use to prevent GT formation has not been described. We aimed to analyze the effect of immediate postoperative ICS on GT formation in patients undergoing transoral laser surgery for glottic stenosis.

Method: A retrospective analysis of patients that had transoral laser surgery for glottic stenosis from 2000- 2019 was conducted. Demographics, diagnosis, comorbidities, intraoperative adjuvant therapy, and perioperative medications were collected. Surgical instances were grouped into those that received postoperative ICS and those that did not. Differences in GT formation and need for surgical removal were compared between groups. A multivariate exact logistic regression model was performed.

Results: Forty-four patients were included; 16 required 2 glottic airway surgeries (60 surgical instances). Of 23 that received immediate postoperative ICS, 0 patients developed GT; and of 37 that did not receive postoperative ICS, 15(40.5%) developed GT (p=<0.0001). Eight (53.3%) of these cases returned to the OR for GT removal. ICS use was solely associated with the absence of GT formation (p=0.042) in the multivariate analysis.

Conclusion: Immediate postoperative ICS use after transoral laser surgery for glottic stenosis effectively reduces the rate of GT formation. This avoids additional operative interventions and associated risks. Effects on cost and outcomes are yet to be determined.

37

In-office Steroid injection for Patients with Subglottic Stenosis: Effect Upon Intersurgical Interval and Characterization of Systemic Side Effects

Presented by: Andrew Neevel,

Coauthors: Ari D Schuman, Robert Morrison, Norman D Hogikyan, Robbi Ann Kupfer

Objective: In-office steroid injection (ISI) has become a commonly-used treatment for subglottic stenosis (SGS). This case series characterizes impact of ISI on time between operating room (OR) visits as well as systemic side effects of glucocorticoids.

Method: Retrospective chart review of patients with SGS receiving ISI at one institution from 1996-2018. Intersurgical interval was compared using paired t-tests. Mean intersurgical interval across patients was calculated using Kaplan-Meier methodology. Incidence and nature of systemic side effects were recorded.

Results: Eighteen patients and 135 procedures were included. The majority of patients were white (94%), female (100%), and had idiopathic SGS (61%). Mean follow-up time was 1042 days (95% CI 584-1500). Including patients who did not return to OR, mean OR-free interval was 265 days (95% CI 169-361) before initiating ISI and 454 days (95% CI 303-605) after initiating ISI. Among 9 patients who returned to OR after initiating ISI, mean increase in OR-free interval was 82 days (95% CI -46 to 209). Systemic side effects, including Cushing’s syndrome, increased intra-ocular pressure, new insulin requirement in the setting of diabetes, and new facial acne, occurred in four patients (22%) at a mean of 68 days (95% CI -52 to 188) from first injection.

Conclusion: Mean interval without OR intervention increased by 82 days among patients who initiated ISI and had a subsequent return to the OR. Systemic side effects of glucocorticoids occurred in 22% of patients after initiating ISI. This should be considered in pre-procedure counseling and monitoring for side effects during treatment.

38

The Impact of Socioeconomic and Insurance Status on Outcomes Following Tracheostomy

Presented by: Rohini Bahethi,

Coauthors: Christopher Park, Anthony Yang, Mingyang Gray, Kevin Wong, Alfred Iloreta, Mark Courey

Objective: To determine the association between socioeconomic status (SES) with hospital length of stay (LOS), intensive care unit (ICU) LOS, and in-hospital, 30-day, and 90-day mortality following tracheostomy at one tertiary-care academic hospital.

Method: A retrospective analysis of all patients who underwent tracheostomy at an urban tertiary-care academic hospital from 2016 to 2017 was performed. Using 2010 US Census data, patients were aggregated by zip code into low, middle, and high- income area brackets as a proxy for SES. Other independent variables included age, sex, race, ethnicity, BMI, and Charlson Comorbidity Index (CCI). Outcomes were hospital LOS, intensive care unit LOS, and in-hospital, 30-day, and 90-day mortality following tracheostomy.

Results: Of the 652 records reviewed, 503 had complete data. Patients from high income areas were more likely to be male, (p<0.01) white (p<0.01), and have lower BMI (p=0.04). Notably, patients from a higher income area also had a longer hospital LOS (p<0.01) and ICU LOS (p=0.05). Multiple regression analysis showed Hispanic ethnicity and higher CCI were associated with an increased odds of 30-day (p=0.02 and 0.05, respectively) and 90-day mortality (p=0.04 and 0.02, respectively), but other patient factors were not independently associated with outcomes.

Conclusion: In this patient group, lower SES, as determined by geographic estimation, was not associated with increased morbidity or mortality from tracheostomy. Higher SES patients had longer ICU and hospital LOS. Regardless of SES, ethnicity and higher CCI were associated with higher mortality. Future studies are needed to assess the effects of ethnicity, race and gender.

39

Increased Expression of PD1 and PDL1 in Patients with Laryngotracheal Stenosis

Presented by: Ruth J. Davis

Coauthors: Dacheng Ding, Ioan Lina, Elizabeth L. Engle, Janis Taube, Alexander Gelbard, Alexander T. Hillel

Objective: Expression of the PD1 immune checkpoint on CD4 T-cells has been shown to contribute to the pathogenesis of idiopathic pulmonary fibrosis, but has never been evaluated in laryngotracheal stenosis. This study aims to describe expression of PD1 and its ligand, PDL1, in patients with idiopathic subglottic stenosis (iSGS) and iatrogenic laryngotracheal stenosis (iLTS) compared to normal controls.

Method: Expression of PD1, PDL1, CD4, and CD8 were evaluated using immunohistochemical staining of cricotracheal resections specimens from iLTS and iSGS patients compared to rapid autopsy controls with normal airways (n=8 per group). Quantitative real-time polymerase chain reaction (qRT-PCR) was also used to assess PD1 and PDL1 expression in brush biopsies from LTS scar compared to areas of healthy trachea.

Results: iLTS and iSGS specimens both exhibited increased expression of PD1, PDL1, and CD4 (all p < 0.05) compared to controls. No significant difference was observed in CD8 expression between iLTS patients and controls. PD1, PDL1, and CD4 showed similar regional patterns of expression within the diseased samples, suggesting possible receptor-ligand interaction or co-expression of these markers.

Conclusion: Expression of both PD1 and its ligand, PDL1, are significantly greater in patients with iLTS and iSGS compared to controls. This appears to correlate with CD4 expression, which has previously been implicated in the pathogenesis of LTS and suggests a possible role for checkpoint inhibitors targeting PD1/PL1 in the treatment of LTS.

40

Scientific Session 4

Moderated by: James Schroeder, Jeanne Hatcher

Comparing the Cost Effectiveness of Transoral Laser Surgery versus Radiation Therapy in the Primary Treatment of T1 Glottic Cancer

Presented by: Caitlin Michelle Coviello

Coauthors: Vincent D Cassidy, David E Rosow

Objective: The treatment of T1 glottic cancer can be performed with either radiation therapy (RT) or transoral laser microsurgery (TLM) and studies have shown no significant difference in treatment effectiveness between the two. With the rising costs of healthcare, it is increasingly important to understand the cost implications of treatment options available to patients. Cost-effectiveness analysis compares relative health outcomes and their associated costs and can guide decision makers in healthcare resource allocation. Our objective is to determine whether TLM or RT is more cost- effective for treatment of T1 glottic cancer among adult patients.

Method: A Markov model with microsimulation was constructed from the US payer perspective comparing TLM and RT. Transition probabilities and health utilities were derived from the literature. Cost data was derived from Medicare Provider Utilization and Payment Data for 2012-2017, filtering by specialty and procedure code. Health outcomes were measured as quality-adjusted life-years (QALYs). Costs were modeled for a 5-year period after receipt of treatment. Utilities and costs were discounted in the model at 3% annually. Probabilistic sensitivity analysis was conducted.

Results: The average cost and effectiveness for TLM and RT were $8,473.90 for 3.40 QALYs and $14,463.24 for 3.28 QALYs., respectively. Compared to RT, TLM was the dominant strategy with greater effectiveness at lower cost for 88% of the trials modeled.

Conclusion: Based on our model, TLM is more cost-effective for the treatment of T1 glottic cancer.

41

Outcome Measure for Spasmodic Dysphonia

Presented by: Yin You

Coauthors: Carolyn R. Baylor, Sandeep Shelly, Adam M. Klein, C. Gaelyn Garrett, Michael J. Pitman

Objective: Current patient-reported outcome measures do not adequately capture the impact of spasmodic dysphonia (SD) on communication in daily life situations. The aim of this study was to validate the Communicative Participation Item Bank (CPIB), which specifically measures a disease’s impact on daily conversational situations, as an outcome measure for SD.

Method: A prospective study was conducted with administration of the 46-question CPIB and the Voice Handicap Index-10 (VHI-10) to 130 participants with SD before (time 1) and after (time 2) botulinum toxin injection. Pearson correlations were calculated between the CPIB and VHI-10. Differential item function (DIF) analyses will be performed to validate responses in SD compared to the original calibration sample of communication disorders.

Results: CPIB scores were a mean of T=46.9 (SD 9.2, n=130) at time 1 and T=44.9 (SD 9.6, n=76) at time 2. Participants used the full range of CPIB scores available. 41% of participants reported a score change of 0.5 standard deviations or greater between the two time points. Correlations between the CPIB and VHI-10 were r=-.68 at time 1 and r=.64 at time 2.

Conclusion: Preliminary analyses suggest the CPIB portrays a wide range of the construct of communicative participation in adults with SD and is capable of capturing clinically significant changes. The moderate correlations with VHI-10 suggest the CPIB captures a similar but not identical construct, which is anticipated as the CPIB seeks to quantify the ‘success’ of communication in real life situations rather than their functional, physical and emotional impact.

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Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique

Presented by: Brian A Nuyen

Coauthors: Zhen J. Qian, Ross Campbell, Elizabeth Erickson-DiRenzo, James Thomas, C. Kwang Sung

Objective: Feminization laryngoplasty (FL) is a gender-affirming surgery developed to increase vocal pitch, as well as alter vocal resonance and laryngeal cosmesis. The purpose of this study was to appraise FL’s long- term safety and acoustic and perceptual voice outcomes across a 17-year review period, and to discuss the surgical technique.

Method: Charts for FL patients were reviewed across a 17-year period. Demographic information and voice data (speaking pitch, lowest pitch, highest pitch, pitch range in both Hertz (Hz) and semitones, and maximum phonation time) were collected and assessed statistically. Additionally, perceptual self- assessment of voice femininity and complications were documented.

Results: Of 162 patients, all were transfeminine women, with a mean age of 40.4 years and mean follow-up of 35.7 months. There was a significant increase in mean speaking pitch (Δ=50±30 Hz, Δ=6±3 semitones; p<0.001) and mean change in lowest pitch (Δ=58±31 Hz, Δ=8±4 semitones; p<0.001). There was no significant difference in mean change in highest pitch or maximum phonation time. There was a significant improvement (Δ=60±39%; p<0.001) in perceptual self-assessment of vocal femininity. There was a 1.2% rate of major postoperative complications requiring inpatient admission or operative intervention. There were no differences in vocal outcomes between those patients who had less than one-year follow-up and those who had five- year follow-up, or based on age grouping.

Conclusion: FL is a safe and effective technique for increasing mean speaking pitch, mean lowest pitch, and voice gender perception over a prolonged follow-up period.

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Results of PCA Reinnervation with Phrenic Rootlet for BVFP

Presented by: Randal C Paniello

Coauthors: Marshall Smith, Paul Bryson

Objective: JP Marie found that a single phrenic rootlet (C3 or C5) can be used for laryngeal abductor reinnervation while maintaining diaphragmatic function. We reviewed our experience with this technique for treating bilateral vocal fold paralysis (BVFP).

Method: Retrospective chart review.

Results: Twenty cases met inclusion criteria. 12/20 (60%) were decanulated at one year post-op. Most of the cases had little or no arytenoid motion, but improved abductor tone was observed that prevented collapse on inspiratory negative pressure, typically starting 6-9 months post-op. Most, but not all, patients also retained diaphragm function. Voice quality was generally excellent.

Conclusion: Phrenic nerve rootlet of the PCA muscle can produce outstanding results for patients with BVFP, but seems to be effective in about half of patients. Most patients in this series did not regain abductor motion, but improved tone enabled decanulation and improved quality of life with good voice quality. This procedure is technically difficult, but within the capability of most laryngologists, and should be considered for patients with BVFP.

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Pre-vascularized Tracheal Scaffolds Using the Platysma Muscular Flap for Enhanced Tracheal Regeneration

Presented by: Seong Keun Kwon

Coauthors: Minhyung Lee, Ji Suk Choi, Su A Par

Objective: One of the biggest hurdles in tracheal tissue engineering is insufficient vascularization, which leads to the delayed mucosal regeneration, granulation formation, and restenosis. This study investigated whether pre-vascularized segmental tracheal substitute using platysma enhance the tracheal mucosal regeneration.

Method: 3D printed scaffolds with (group 1) or without (group 2) Matrigel coating were implanted under the feeding vessels of the platysma flap of New Zealand White rabbits (n=3) to induce vascularization of the scaffolds. After 1 and 2 weeks, tracheal defect was created and vascularized scaffolds with feeders of the platysma were transplanted as a rotator flap. As control group, a scaffold with or without Matrigel coating was directly transplanted to a tracheal defect without pre-vascularization (0 week). Airway patency and epithelization were observed using rigid bronchoscope at every 2 weeks. Survivors were euthanized at 24 weeks, then micro-computed tomography and histological evaluation were performed.

Results: Animals with 2-weeks of pre-vascularization showed a longer survival period compared to animals with 0- and 1-week regardless of the Matrigel coating. However, wider airway patency was observed at group 1 than group 2. Moreover, group 1 showed migration of epithelium over the scaffold from 4 weeks after transplantation and complete coverage with epithelium at 12 weeks, while group 2 showed the migration of epithelium from 14 weeks and incomplete coverage with epithelium even at 24 weeks.

Conclusion: This two-step approach, utilizing the platysma muscular flap as in vivo bioreactor is a promising approach with long-term survival, enhanced luminal patency and mucosal regeneration.

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Flexible Laryngoscopy Different?

Presented by: Roy Jiang

Coauthors: David Kasle, Nikita Kohli, Michael Lerner

Objective: Several recent studies have shown a high incidence of microbial contamination for duodenoscopes and an association of contamination with healthcare- acquired infections. The purpose of this study was to quantify nasopharyngoscope microbial contamination relative to other commonly used endoscopes and characterize the manufacturers, outcomes and microbes associated with these cases.

Method: Adverse device events (3,865 total) were collected from 2013-2019 using the FDA Manufacturer and User Facility Device Experience (MAUDE) database. The fraction of total device failures associated with contamination was quantified for nasopharyngoscopes, bronchoscopes, duodenoscopes and gastroscopes. Odds ratios of nasopharyngoscope contamination compared to that of bronchoscopes, duodenoscopes or gastroscopes were calculated, and significance was assessed using Chi-square analysis. Kruskall-Wallis was used for non-parametric testing of significance.

Results: Nasopharyngoscope device failures were reported to MAUDE at an incidence of 0.672 per month; 32.6% involved contamination, comparable to the frequency observed for bronchoscopes (21.9%, P=0.100), duodenoscopes (29.2%, P=0.631) and gastroscopes (43.2%, P=0.189). The frequency of device incidents involving microbial contamination was also observed to be significantly higher for a specific scope manufacturer regardless of endoscope category (Kruskall-Wallis P=0.021). For cases involving contamination, nasopharyngoscope cases were significantly less associated with injury or death than bronchoscope cases (OR=10.1) and duodenoscope cases (OR=4.81).

Conclusion: While the rates of contamination were comparable across all endoscope categories, nasopharyngoscope contamination was less commonly associated with injury or death. Steps should be taken to further assess whether current disinfection standards for nasopharyngoscopes are aligned with actual patient safety data, taking into account overall rising healthcare costs.

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Scientific Session 5 – Foreign Body

Moderated by: Mark Gerber

Endoscopic removal of a retained bullet within the larynx

Presented by: Punam A Patel, Coauthors: Ahmed Soliman

Objective: To present a case of an intralaryngeal foreign body removed endoscopically.

Method: Case Report.

Results: A 21-year old male presented to the Emergency Department after enduring 11 gunshot wounds through the neck, chest, and abdomen. He was initially breathing comfortably but was intubated in the trauma bay after he developed hemoptysis. Computed tomography of the neck demonstrated a retained bullet medial to the right thyroid cartilage. The Otolaryngology service was consulted intra-operatively. Direct laryngoscopy, bronchoscopy, and esophagoscopy revealed significant edema of the false and true vocal folds with no visible foreign body. Neck exploration including examination of the paraglottic space through a right thyroid cartilage fracture line also failed to identify the foreign body. Postoperative repeat computed tomography however demonstrated the bullet to now be within the right false vocal fold. The patient was taken back the following day for repeat direct laryngoscopy where a right false vocal fold laceration was noted, deep to which the bullet was palpated. The bullet was dissected free using angled probes and was delivered through the laryngoscope using alligator forceps. Six weeks post-operatively, the patient was doing well without any complaints. Flexible laryngoscopy revealed only mild edema of the false vocal folds bilaterally. Having tolerated capping for 2 weeks before his visit, he was also decannulated.

Conclusion: Endoscopic removal of an intralaryngeal foreign body may be successful when a transcervical approach has failed.

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800 Gram Infant with A Bronchial Foreign Body

Presented by: Yamilet Tirado

Coauthors: Abdulmajeed Alruwaili, Heather C Smith, Alison Payson

Title: 800 Gram Infant With A Bronchial Foreign BodyBackground: Foreign body (FB) aspiration is common in pediatrics, but rare in premature, very low birth weight neonates.

Case Presentation: A 2 week-old, ex 25.1-week, female weighing 820 grams was transferred to a tertiary children’s hospital for concerns of airway FB. She was intubated in the delivery room, received surfactant, and on day of life 7 had pulmonary hemorrhage requiring deep suction. Repeat x-ray showed a FB in the right main stem bronchus. Interventional radiology and ENT attempted removal via the endotracheal tube (ETT), using fluoroscopy and bronchoscopy but were unsuccessful due to equipment size. Patient was transferred on high frequency oscillator ventilation and stabilized. CT Angiogram re-demonstrated a small, opaque tube from the carina to the right lower lobe segmental bronchus with collapse of the right lung. At bedside, ENT obtained direct visualization of the object through the 3.0 ETT via a neonatal flexible scope and measured the distance to the FB. Flexible biopsy forceps were introduced to the same previously measured distance and a portion of a 6-french suction catheter was retrieved.

Discussion: Micro-premature infants have smaller caliber airway and tenuous respiratory systems, making removal of an airway FB challenging. Equipment limitations, size of ETT, and lack of precision in determining nature and etiology of the foreign body can make intervention difficult in this population.

Conclusion: Optimizing respiratory status, obtaining appropriate preoperative imaging, and having instruments outside of the normal armamentarium, can assist in surgical planning and lead to a successful outcome.

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Foreign Body Award Winner: Novel Use of an Arterial Embolectomy Catheter to Manage a Bronchial Foreign Body in a Patient with Trismus

Presented by: Ryan Borek

Coauthors: Luv Javia

Objective: To describe the presentation and management of a bronchial foreign body with an arterial embolization catheter in a patient with trismus.

Method: Case Report

Results: A four year old male presented as a transfer from an outside hospital for choking and apneic episodes requiring endotracheal intubation. The patient has known 1-2 fingerbreadth trismus with a difficult airway designation. Outside hospital imaging reported a foreign body in the right bronchus. The patient was taken to the OR for endoscopic removal. Flexible bronchoscopy demonstrated a small plastic bead with a hollow lumen. Rigid bronchoscopy was attempted but due to the trismus the bronchoscope could not be advanced to the level of the foreign body. A 2.2 mm flexible bronchoscope was placed through the ETT alongside a 3 French Fogerty Catheter. The catheter was threaded through the lumen of the bead and inflated. The inflated catheter, bronchoscope and ETT were then pulled to the level of the glottis. The bead became obstructed at the glottis and the inflated catheter pulled through the lumen. A curved forceps was then used to ultimately remove the bead from the glottis.

Conclusion: This foreign body was treated successfully using the novel technique of an arterial embolectomy catheter, thus saving this patient from a tracheotomy in the setting of trismus and inability to perform rigid bronchoscopy.

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Broyles-Maloney Award The Broyles-Maloney Award was established to encourage advancement of the art and science of bronchoesophagology and closely related subjects. Competition for the award is limited to persons whose abstracts are submitted for inclusion in the Annual Scientific Program. The award is given for outstanding manuscript, thesis or accomplishments in bronchoesophagology, laryngology or related science.

RECIPIENTS OF THE BROYLES- MALONEY AWARD:

2000 Asif Amirali, MD

Greg Tsai, MD Nicole Schrader, MD Donald Weisz, PhD Ira Sanders, MD

2001 (no award) 2002 Shin-ichi Kanemaru

Hisayoshi Kojima, MD Akhmar Magrufov, MD Koichi Omori, MD Yasuyuki Hiratsuka, MD Shigeru Hirano, MD Juichi Ito, MD Yasuhiko Shimizu, MD

2003 Ira Sanders, MD 2004 Clarence T. Sasaki, MD 2005 Tomoko Tateya, MD

Ichiro Tateya, MD, PhD Diane M. Bless, PhD*

2006 (No award) 2007 J. Scott McMurray, MD

Charles N. Ford, MD Nadine P. Conner, MD Joseph E Kershner, MD Nikki Johnston, PhD

1988 Richard A. Kosarek, MD 1989 (no award) 1990 Thomas F. Dowling, MD 1991

Jamie Koufman, MD (no award)

1992 (no award) 1993 Jos. van Overbeek, MD 1994 Steven D. Gray, MD 1995 1996

Jonathan E. Aviv, MD John H. Martin, PhD Ralph Sacco, MD Beverly Diamond, PhD Andrew Blitzer, MD, DDS (no award)

1997 Ira Sanders, MD 1998

Liancai Mu,PhD Nancy M. Bauman, MD

1999

Degiang Wang, MD Eric S. Luschei, PhD Debra M. Jaffe, MD Robert Berkowitz, FRACS

Qi-Jian Sun, PhD John Chalmers, PhD

Paul Pilowsky, PhD

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5

2008

2009

2010

2011

2012

2013

Tina L. Samuels, MS Ethan Handler*, BS Michael L Syring, BS Joel H Blumin, MD Joseph E Kershner, MD Nikki Johnston, PhD Nikki Johnston, PhD Clive W. Wells Tina Samuels, MS Joel Blumin, MD Sandeep Karajanagi, PhD Gerardo Lopez-Guerra, MD Hyoungshin Park, PhD James B. Kobler, PhD Daryush D. Mehta, SM Yoshihiko Kumai, MD, PhD James T. Heaton, PhD Victoria L. M. Herrera, MD Robert E. Hillman, PhD Steven M. Zeitels, MD Mikhail Wadie, MD Juan Li, MD Clarence T. Sasaki, MD Satoshi Ohno, MD Shigeru Hirano, MD, PhD Shin- ichi Kanemaru, MD, PhD Masanobu Mizuta, MD Tina Samuels, PhD Nikki Johnston, MD Gary Stoner, MD Steven M. Zeitels, MD James Burns, MD Stacey Halum, MD

2018

2019

2020

Rachel Anfang, MD Kris Jatana, MD Rebecca Linn, MD Keithg Rhoades, MD Jared Fry, MD Ian Jacobs, MD Seong Keun Kwon, MD Jungirl Seok, MD Minnyung Lee, MD Young Kang, MD Seulki Song, MD Kiminori Sato MD, Chun-ichi Chitose, MD, Fumihiko Sato, MD Takeharu Ono, MD Hirohito Umeno, MD

2014

2015

2016

2017

Khadijeh Bijangi-Vishehsaraei,PhD Hongji Zhang, MD John Sowinski, BS Marco Bottino, DDS, MSc, PhD Abie H. Mendelsohn, MD Zhaoyan Zhang, MD Georg Luegmair, MD Michael Orestes,MDD Gerald S. Berke, MD Seong Keun Kwon, MD Hyun-Woo Shin, MD James Kobler, PhD Steven Zeitels, MD James Heaton, PhD Sandeep Karajanagi, MD Jamie Bothello Patrick Lombardo Robert Hillman, PhD

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Chevalier Q. Jackson Award Recipients

1988 Charles W. Cummings, MD 2019 2020

Gregory Postma, MDMarshall Smith, MD

1959 Louis H. Clerf, MD 1989 Bernard R. Marsh, MD 1960 (no award) 1990 David R. Sanderson, MD 1961 Herman J. Moersch, MD 1991 William W. Montgomery, MD 1962 Paul H. Holinger, MD 1992 John A. Tucker, MD 1963 Edwin N. Broyles, MD 1993 Gerald B. Healy, MD 1964 Leroy A. Schall, MD 1994 Vincent J. Hyams, MD 1965 Herbert W. Schmidt, MD 1995 Lauren D. Holinger, MD 1966 Paul G. Bunker, MD 1996 Stanley M. Shapshay, MD 1967 Joel Pressman, MD 1997 Robert H. Ossoff, MD 1968 Verling K. Hart, MD 1998 John Frederickson, MD 1969 Joseph P. Atkins, MD 1999 Eiji Yanagisawa, MD 1970 Anderson C. Hilding, MD 2000 William W. Montgomery, MD 1971 Robert M. Lukens, MD 2002 Jack L. Gluckman, MD 1972 Charles M. Norris, MD 2003 Ellen M. Friedman, M.D. 1973 Arthur M. Olsen, MD 2004 Robin T. Cotton, M.D. 1974 Charles F. Ferguson, MD 2005 Charles W. Vaughn, MD 1975 Shigeto Ikeda, MD 2006 Andrew Blitzer, MD, DDS 1976 Blair W. Fearon, MD 2007 Gayle E. Woodson, MD 1977 Francis W. Davidson, MD 2008 Robert J. Toohill, MD 1978 Seymour R. Cohen, MD 2009 Peter Koltai, MD 1979 M. Stuart Strong, MD 2010 Clarence T. Sasaki, MD 1980 DeGraff Woodman, MD 2011 Peak Woo, MD 1981 Albert H. Andrews Jr., MD 2012 W. Frederick McGuirt, Sr.,MD1982 Gabriel F. Tucker, Jr., MD 2013 Seth Pransky, MD1983 Howard A. Andersen, MD 2014 Michael Rothschild, MD1984 Paul H. Ward, MD 2015 Steven Zeitels, MD1985 Bruce N. Benjamin, MD 2016 Charles N. Ford, Jr., MD1986 Loring W. Pratt, MD 2017 Jamie Koufman, MD1987 Robert S. Fontana, MD 2018 Ellen Deutsch, MD

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Chevalier Q. Jackson Lecturers The ABEA established in 1964 the “Chevalier Q. Jackson Lecture” to honor the memory of the Doctors Jackson, father and son. These two physicians were uniquely gifted in the development of new information and techniques. The Doctors Jackson were dedicated and gifted in the teaching of broncho- esophagology.

1964 D. F.N. Harrison, MD 1965 Eric Carlens, MD 1966 John L. Pool, MD 1967 Eelco Huzinga, MD 1968 Paul H. Holinger, MD 1969 Plinio deMattos Barretto, MD 1970 James R. Jude, MD 1971 Jo Ono, MD 1972 G. Gordon McHardy, MD 1973 Hermes C. Grillo, MD 1974 John R. Gutelius 1975 Donald O. Castell, MD 1976 Paul Moore, PhD 1977 Mary Ellen Avery, MD 1978 George Berci, MD 1979 Gabriel F. Tucker, Jr, MD 1980 Flvaio Aprigliano, MD 1981 Peter Stradling, MD 1982 Arthur M. Olsen, MD 1983 Bruce N. Benjamin, MD 1984 Ronan O’Rahilly, MD 1985 John A. Tucker, MD 1986 William G. Anlyan, MD 1987 Tu Guy-Yi, MD 1988 Lucius Hill, Md 1989 Bernard R. Marsh, MD 1990 David R. Sanderson, MD 1991 Michael E. Johns, MD 1992 Whitney Addington, MD

1993 Henry J. Heimlich, MD 1994 John A. Kirchner, MD 1995 Minoru Hirano, MD 1996 Harold C. Pillsbury, III, MD 1997 Gerald Healy, MD 1998 Robin T. Cotton, MD 1999 Jamie Koufman, MD 2000 Stanley Shapshay, MD 2001 Paul A. Levine, MD2002 Steven D. Gray, MD2003 Wolfgang Steiner, MD 2004 Jonathan Aviv, MD2005 John Ward, PhD2006 Steven Zeitels, MD2007 Peak Woo, MD2008 Clarence Sasaki, MD 2009 Jamie Koufman, MD 2010 Marshall Strome, MD 2011 Jeffrey Laitman, MD 2012 Martin Birchall, MD2013 Nelson Powell, MD2014 Katherine Kuchenbecker, PhD 2015 Bert O’Malley, MD2016 Nathan V. Welham, PhD 2017 Nicholas LaRusso, MD 2018 Robert Hillman, PhD2019 Ryan Branski, MD2020 Lucian Silica, MD

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Ellen M. Friedman Foreign Body Award The Ellen M. Friedman Foreign Body Award is given to an accepted abstract in recognition of excellence in innovation, skill and education in the management of aero-digestive foreign bodies. It is intended to encourage continued leadership in the art of endoscopic foreign body management.

RECIPIENTS OF THE ELLEN M. FRIEDMAN FOREIGN BODY AWARD:

1997

1998

Ellen Deutsch, MD Garth Good, MD Kevin McLaughlin, MD

2012 Corbin Sullivan, MD Maria Wittkopf, MD William Clarke, MD

Ian Jacobs, MD Stephen Conley, MD 1999 James A. Stankiewicz, MD 2013 David Rosow, MD 2000 Aaron Chidekel, MD Si Chen, MD

John Moore, MD 2014 Matthew Naunheim, MD Ellen Deutsch, MD Matthew Dedmon, MD 2001 (no award) Matthew Mori, MD 2002 Benjamin B. Cable, MD Ahmad Sedaghat, MD

Dawn N. Boswell, MD Jayme Dowdall, MD 2003 Glenn Isaacson, MD 2015 Phillip Chaffin, MD 2004 Joseph Kerschner, MD Ian N. Jacobs, MD 2005 Matthew Bolinger, MD Kris R. Jatana, MD

Stacey L. Hallum, MD 2016 Meghan Wilson, MD Gregory N. Postma, MD Ryan Borek, MD 2006 Thomas Andrews, MD Ian N. Jacobs, MD

James Quintessenza, MD Luz Javia, MD Jeffrey Jacobs, MD 2017 Krista Kiyosaki, MD Richard Harmel, MD Varun Vendra, MD 2007 Aaron D. Friedman, MD Douglas Sidell, MD

Keiko Hirose, MD 2018 David R. Lee, MD Peter J. Koltai, MD Erin A. Harvey 2008 Glenn Isaacson, MD John Paul Giliberto, MD

Jeffrey Bedrosian 2019 Sarah Hodge, MD 2009 Steven Feinberg, MD Lauren Kilpatrick MD

Gerardo Lopez Guerra, MD Carlton Zdanski Steven M. Zeitels, MD 2020 Ryan Borek, MD 2010 Vartan A. Mardirossian, MD Luv Javia, MD

Timothy Anderson, MD Joyce Colton-House, MD

2011 Michael Joshua Wilhelm MD Benjamin Westbrook, MD Joseph Shvidler, MD

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Seymour R. Cohen Award The Seymour R. Cohen Award for Pediatric Laryngology and Bronchoesophagology Is presented to any resident, fellow or practicing physician who submits the best original paper in either basic research or clinical investigation pertaining to pediatric laryngology and bronchoesophagology.

RECIPIENTS OF THE SEYMOUR R. COHEN AWARD:

1979 Timothy A. Lim, MD 2003 (no award) 1980 Lauren D. Holinger, MD 2004 James M. Ridgeway, MD 1981 Bruce N. Benjamin, MD 2005 Richard D. Wemer, MD 1982 John A. Tucker, MD Robert A. Weatherly, MD 1983 John S. Supance, MD Michael S. Detamore, PhD 1984 Judson R. Belmont, MD 2006 Kiminori Sato, MD, PhD

Kenneth M. Grundfast, MD Hirohito Umeno, MD 1987 Ellen M. Friedman, MD Tadashi Nakashima, MD 1990 Glenn C. Isaacson, MD Satoshi Nonaka, MD 1991 Eric Mair, MD Yasuaki Harabuchi, MD

Davis D. Parson, MD 2010 (no award) 1992 (no award) 2011 (no award) 1993 Steven C. Marks, MD 2012 (no award)

Bernard Marsh, MD 2013 Kevin Huoh, MD 1994 (no award) Peter Koltai, MD 1995 John P. Bent, III, MD 2014 David Horn, MD

William Smits, MD Kimberley DeMarre, MD Richard J. H. Smith, MD Sanjay Parikh, MD Nancy M. Bauman, MD 2015 (no award) John W. Kim, MD 2016 Kris Jatana, MD 1996 (no award) Keith Rhoades, MD 1997 Robert F. Ward, MD Scott M. Milkovich, MD

Max M. April, MD Ian N. Jacobs, MD Dimitry Rabkin, MD 2017 Ravi W Sun, MD 1998 Brian S. Jewett, MD Adam B Johnson, MD

Raymond D. Cook, MD Juliana Bonilla-Velez, MD Kenneth L. Johnson, MD Robert D Pesek, MD Thomas C. Logan, MD Gresham T Richter, MD Kristina W. Rosbe, MD 2018 Steven Coppess, JD, MBA Suresh K. Mukherji, MD Jennifer Soares, MD William W. Shockley, MD Bianca Frogner, PhD 1999 Ryan R. Stevens, MD Kimberley DeMarre,MD

Geoffrey A. Lane, MD Amy Faherty, MD Scott M. Milkovich, PhD Jennifer Hoang, MD Daniel Stool Mahek Shah, MD Gene Rider 2019 Matthew MacKinnon, MD Sylvan E. Stool, MD Kaalan Johnson, MD 2000 (no award) 2020 Charlotte Kaplan Hughes, 2001 Nancy M. Bauman, MD Christine L. Christensen,

Deqiang Wang, MD Stephen Maturo, Erich Luschei, MD Peter R. O’Conner, Robert G. Berkowitz, MD Gregory R. Dion 2002 Ravindhra G. Elluru, MD

Jeffrey A. Whitsett, MD

55

5

Steven D. Gray Resident Award The Steven Dean Gray Resident Award was established as part of the continuing legacy of Dr. Gray in order to recognize excellence in resident research in both laryngology and bronchoesophagology.

RECIPIENTS OF THE STEVEN D. GRAY RESIDENT AWARD

2003 Sarah Hodges, MD 2003 Randal Leung, MBBS 2004 Seth Cohen, MD 2004 Jonathan P. Lindman, MD 2005 Grace SY Yang, MD 2006 None 2007 Tsunehisa Ohno, MD 2008 J. Matthew Dickson, MD 2009 Wataru Okano, MD 2010 None 2011 Richard Turley, MD 2012 Koshi Otsuki, MD 2013 Mitsuyoshi Imaizumi, MD 2014 None 2015 Yuta Nakaegawa, MD 2016 Neel Bhatt, MD 2017 Neel Bhatt, MD 2018 Andrew Redmann, MD 2019 Kathleen Sarber, MD

Lauren Tracy, MD 2020 Yael Shapira-Galitz

56

57

Scientific Podium Abstracts from COSM 2020 planned meeting April 22-24, 2020 Abstract submissions that were accepted for podium presentations at the COSM 2020 ABEA meeting that was canceled due to COVID 19 appear in this booklet.

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Cost Savings of Using Fluorescein Strips in Laser Laryngoscopy Surgery

Michael Gebhard, Neil Chheda

Objective: Publicizing an approach to endotracheal cuff inflation in laryngological laser surgery that will result in significant cost savings for hospitals and patients.

Method: Literature search of fluorescein. Pricing information obtained from a tertiary care hospital’s operating room pharmacy.

Results: The average acquisition cost for 10 milliliters (mL) of 1% methylene blue is $178.98. An entire bottle of methylene blue must be discarded after each case. The average acquisition cost of a 5 mL vial of 10% fluorescein is $22.78. The average acquisition cost of a box of 100-count ophthalmic fluorescein strips is $15.97. An open box of strips is able to be stored and reused, making the average cost per procedure $0.64. Therefore, by using fluorescein strips, laser laryngeal surgeries can realize a 99.64% savings of the balloon cuff component of the procedure.

Conclusion: We propose this innovation of using fluorescein dye in place of methylene blue for endotracheal cuffs in laryngological laser surgery. This change is easy to implement and will result in immediate, significant cost savings for both patients and hospitals.

Cervical Esophagostomy for Application of Intraluminal Negative Pressure Therapy Ricardo Aulet, William Brundage

Objective: Esophageal perforation is a very serious condition carrying a mortality rate of 10-25%. Historically, primary treatment was an open approach, but over the last two decades minimally invasive treatments have been employed. Intraluminal negative pressure wound therapy has shown promise for esophageal perforation. We present a case of intraluminal negative pressure therapy through a novel approach.

Method: Case report

Results: 55yo M presented in respiratory distress and intubated for airway protection. Outside hospital CT scan showed evidence of esophageal perforation. He underwent an esophageal stent placement by gastroenterology for a distal perforation. After extubation on HD#4, he did not tolerate his NG tube and it was removed. His perforation failed to close despite stent placement, mediastinal drains and chest tubes. On HD#16 his swallow study showed persistent perforation, but the patient adamantly refused having an NG tube placed for decompression. On HD#17 a left sided cervical esophagostomy was performed in the operating room through a lateral neck incision. The pyriform sinus mucosa posterior to the thyroid cartilage was incised, retracted laterally, and sutured to the lateral neck skin. A polyurethane sponge sutured to an NG tube was placed through the esophagostomy and advanced to the site of the perforation under fluoroscopic guidance. This was connected to continuous low suction. The sponge was changed weekly through the esophagostomy without difficulty. On HD#31 the leak had resolved and the sponge was removed. The esophagostomy was closed at bedside.

Conclusion: Esophagostomy offers safe access for intraluminal negative pressure therapy for esophageal perforations.

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A Toilet Paper Holder Removed from the Upper Aerodigestive Tract of a Patient with Self-Harm Syndrome:

A Case Report and Literature Review Michael Lai, Jace Morganstein, Nathan Deckard, Yekaterina Koshkareva

Objective: To present a case of an unusually large foreign body (FB) extraction in a patient with multiple psychiatric disorders. Due to its size and irregular shape, removal of the object was challenging and carried a high risk of complications.

Method: Case report and literature review.

Results: A 32-year-old female with a history of bipolar disorder and schizophrenia presented to our hospital after ingesting a FB. Chest x-ray revealed a 7.5cm x 5.4cm x 5.4cm object with a 2.6cm screw pointing superiorly in the upper aerodigestive tract. The patient was brought to the operating room (OR) and a Dedo laryngoscope was inserted for larynx visualization. The object was found to be caught superiorly by the soft palate and inferiorly by hypopharyngeal tissue. A hemostat was used to gently retract the soft palate cephalad. Another hemostat was clamped onto the rim of the object for leverage and the FB was extracted with alternate pulling on the two sides of the object. The FB was deemed to be a metal bracket for a toilet paper holder with a screw still attached.

Conclusion: Literature review revealed that most upper aerodigestive tract FBs are less than 4cm, and our case describes the removal of the largest object from the upper aerodigestive tract in peer-reviewed literature. One report suggested that 18% of adult patients with FB ingestion had primary neuropsychiatric disorders. Our patient’s psychiatric disorder was a major underlying factor leading to the ingestion, with our patient reporting hallucinations instructing her to ingest household objects.

Embryology of Tracheal Rings

Matthijs Fockens, Bernadette S de Bakker, Frederik G Dikkers

Objective: The trachea derives its shape from horseshoe shaped cartilage rings and a continuous membranous dorsal part. When tracheal rings are circular instead of horseshoe shaped, a stenosis occurs, mostly located mid- tracheally. The diagnosis complete tracheal rings (CTR) is the most common cause of congenital tracheal stenosis. The cause of CTR is unknown. In this study, the embryological development of tracheal rings is investigated in order to form a hypothesis on the occurrence of CTR.

Method: The development of tracheal rings was examined by studying the trachea in histological slides of 14 healthy embryos from the Carnegie collection. Embryos were Carnegie stages 17- 23, corresponding to 42 to 58 days of embryological development.

Results: At Carnegie stages 17-19 (42-51 days), a continuous mesenchymal condensation was observed ventral to the tracheal lumen. At stages 20 and 21 (51-54 days), this pre- tracheal mesenchymal condensation showed an intermittent pattern with signs of future tracheal rings. Also, both proximally and distally in the trachea, mesenchymal growth centers were identified. The typical horseshoe shape became apparent at Carnegie stages 22 and 23 (54-58 days). No CTR were observed.

Conclusion: In healthy embryos, tracheal rings arise from growth centers in the pre-tracheal mesenchyme

60

at approximately 51 to 54 days of embryological development. Strikingly, the development gradient seems to occur in a centripetal fashion. Although the cause of CTR remains unknown, we assume the centripetal development gradient may be of influence to the mid-tracheal occurrence of CTR.

Residual Glottic Web in DiGeorge Syndrome: A Risk Factor for Successful Extubation? Tyler Okland, Osama Hamdi, Noel Ayoub, Kara Meister, Ritu Asija, Douglas Sidell

Objective: Residual glottic webs (RGW) are an underdiagnosed laryngeal anomaly associated with DiGeorge syndrome. Patients with DiGeorge syndrome often require operative repair of cardiac defects, and may require prolonged intubation. When RGW are present, the potential for airway symptoms following extubation is considered. To date, the perioperative impact of glottic web on airway management and successful extubation has not been established.

Method: Patients with DiGeorge Syndrome undergoing cardiac surgery with concurrent laryngoscopy and bronchoscopy between 2010-2019 were reviewed. Extracted data included demographics, comorbidities, cardiac defect and repair, airway findings, hospital and ICU duration, total ventilator days, peri- extubation symptoms, and reintubation rates. Patients were evaluated using multivariate analysis to assess for differences in perioperative reintubation rates, ventilator days, and hospital/ICU duration.

Results: Forty-one DiGeorge patients were included, with a mean age of 10 months at time of surgery. Twelve (29%) had RGW, one of whom (8.3%) required reintubation immediately following extubation, compared to 9 (31%) patients without RGW (p = 0.124). There was no difference in mean hospital stay (33 vs 55 days, p = 0.621), mean ICU stay (20 vs 48, p = 0.288), or number of days on ventilator (9 vs 11, p = 0.864) between patients with and without RGW. A multivariate analysis was performed to control for comorbidities.

Conclusion: The presence of residual glottic web does not appear to jeopardize successful extubation following cardiac repair. There was no difference in reintubation rates, hospital or ICU stay length, or number of days on the ventilator for RGW patients.

Contralateral Modulation to Swallowing Interneurons in the Dorsal Medulla in Perfused Rats Yoichiro Sugiyama, Shota Kinoshita, Keiko Hashimoto, Shinya Fuse, Shigeyuki Mukudai, Toshiro Umezaki, Shigeru Hirano

Objective: A sequential movement of swallowing-related muscles during oropharyngeal swallow is precisely controlled by the swallowing central pattern generator in the medulla. However, little is known about the symmetrical coordination of bilateral swallowing pattern generation. The dorsal swallowing group located in the dorsocaudal medulla has a critical role in the motor pattern generation of swallowing. We investigated whether the swallowing interneurons, the kernel for the swallowing pattern generation, in the dorsal swallowing group could be affected by the crossing inputs from the contralateral swallowing motor circuitry.

Method: The arterially perfused juvenile rats were used in this study. The animals were maintained under eupneic respiratory conditions identified by the specific activities of the phrenic and vagus nerves. The vagus and hypoglossal nerves were also recorded to identify fictive swallowing elicited by electrical stimulation of the superior laryngeal nerve. The activity of the swallowing interneurons was recorded extracellularly and analyzed changes in the activity during swallowing before and after microinjection of GABA agonist muscimol in the

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contralateral dorsal medulla.

Results: After the injection of muscimol, the outputs of the vagus and hypoglossal nerves during swallowing were attenuated unilaterally to the injection site. Although the essential activity patterns of swallowing interneurons were maintained after the injection, the excitatory or inhibitory modulations of these neurons were observed.

Conclusion: Albeit the unilateral swallowing circuitry would mainly control swallowing movements ipsilaterally, the mutual coordination by crossing signals from bilateral swallowing motor circuitry could influence swallowing pattern generation including synthesis of the synchronized swallowing motor activities.

Feasibility and efficacy of TCS (docetaxel, carboplatin, TS-1) as induction chemotherapy for locally advanced head and neck squamous cell carcinoma Kohei Yamahara

Objective: Combination of Docetaxel, Cisplatin, 5-FU (TPF) is regarded as the current standard regimen as induction chemotherapy (ICT) for locally advanced head and neck squamous cell carcinoma (LAHNSCC). However, toxicity with TPF is a very important issue and toxic death rates were reported as being between 2% and 7%. Moreover, the continuous infusion of 5-FU combination reduces quality of life. We thus developed a new ICT regimen, TCS (docetaxel, carboplatin, TS-1) and tested this scheme on LAHNSCC.

Method: Between 2010 and 2018, the file of 39 patients treated for stage III/IV LAHNSCC with TCS were retrospectively collected. The efficacy and the adverse events of TCS regimen were examined using RECIST and CTCAE.

Results: Thirty-six patients (92.3%) completed 2 cycles or more than 2 cycles of TCS. The overall response rate of TCS was 80%, of which 19% were complete responses and 61% partial responses; 17% of patients had stable disease, and 3% progressed on treatment. The major toxicities of TCS were hematologic, with 24 cases (67%) of grade 3-4 neutropenia. Grade 3 febrile neutropenia was observed in 5 patients (14%). However, we observed no toxic deaths due to TCS. In the total cohort, the 5- year overall survival rates, the 5- year disease- free survival rates were 73.6%, 70.8%, respectively.

Conclusion: TCS showed comparable effects to TPF with less toxicity. TCS is safe and effective and could become a new option in ICT for patients with LAHNSCC.

Metastatic renal cell carcinoma presenting as a rapidly enlarging endotracheal mass due to hyper- progression on anti- PD1 immunotherapy Steven Hoshal, Peter C Wickwire, Regina F Gandour-Edwards, Prabhu Rajappa, Daniel J Cates

Objective: Tracheal tumors can present as life-threatening airway emergencies. Renal cell carcinoma (RCC) metastasis to the trachea is exceedingly rare with few reported cases in the literature. Anti-PD1 immunotherapy for metastatic RCC may be complicated by hyper-progression secondary to a robust immunologic response. The authors present a case of metastatic RCC presenting as a rapidly enlarging endotracheal mass due to hyper- progression on anti-PD1 immunotherapy. Treatment challenges associated with this rare entity are discussed.

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Methods: Presenting symptoms, endoscopic exam findings, radiographic images, histopathologic slides, and treatment outcomes are reviewed.

Results: A 68-year-old male with a history of metastatic renal cell carcinoma undergoing anti-PD1 immunotherapy was found to have an incidental tracheal mass on surveillance imaging (CT Chest). Office bronchoscopy demonstrated an exophytic endotracheal mass. Over four weeks the tumor underwent rapid enlargement requiring urgent surgery and a total of three endoscopic interventions over eleven days. The primary surgery included endoscopic Nd:YAG laser and cryo-ablation with tumor debulking and use of advanced airway support techniques. At last outpatient visit the patient was breathing comfortably without stridor and with minimal residual disease. Despite the tracheal metastasis hyper-progression, his systemic disease burden has responded well to anti-PD1 therapy.

Conclusion: Tracheal involvement by metastatic renal cell carcinoma is rare. Tumor hyper-progression on anti- PD1 therapy is a poorly understood immunologic phenomenon that can result in life-threatening circumstances. Awareness of this clinical entity is important for the airway surgeon and treatment may require urgent intervention and tools outside the typical armamentarium of the Otolaryngologist.

Pharyngo-Esophageal duplication cysts as a cause of airway obstruction in young children. Report of three cases and review of the literature James Tansey, Rebecca Thompson, Jerome Thompson, Joshua Wood

Objective: To describe esophageal duplications in the cervical area, which are rare errors in embryologic development. Those that present as an obstructing pharyngo-supra glottic cyst are even more uncommon. Their management poses unique challenges, which are initially urgent, and life threatening. Subsequent long-term management requires risk benefit analysis.

Method: A case series of three patients who presented in respiratory distress from an obstructive airway to our institution. The cases were reviewed in the electronic medical records, and a thorough literature search was conducted.

Results: All three of our patients were initially diagnosed as vallecular cysts and underwent tracheostomy. One was born via EXIT. Once the large supra glottic cysts were laser debulked, it became apparent that the origin of the cysts were a cystic tube posterior to the cricoid yet not penetrating into the esophageal lumen. One became an isolated post-cricoid tubular cyst 1cm long in the tracheo-esophageal party membrane. The other remained open into the pharynx and extended 3 cm down the esophageal anterior wall. One case was also associated with a large non-contiguous right pulmonary cyst. Neither of the esophageal duplications have enlarged nor changed after one year. The third persisted and then resolved after several years.

Conclusion: Pharyngo-esophageal duplication cysts are very uncommon, but can present as airway or swallowing problems in the newborn period. This case series highlights the diagnosis and management of these rare lesions. Early management is paramount, and includes surgical excision. With proper treatment, these lesions have a low risk of recurrence.

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Flexible Endoscopic Treatment of Zenker’s Diverticulum by Otolaryngologists is Safe and Effective Joseph Bradley, Michael M Awad

Objective: Determine whether a flexible endoscopic approach to Zenker’s diverticulum (ZD) is safe and effective for patients and feasible for otolaryngologists.

Methods: Retrospective study examining all ZD subjects treated from 2014-2019 via open, rigid endoscopic (RE), or flexible endoscopic (FE) technique with 2 months of follow-up. Data analyzed using descriptive and non-parametric analyses.

Results: 20 subjects enrolled (4 FE, 3 RE, 13 open), 45% male, mean age 73.5 years (range 59.1-89.3). All subjects undergoing FE and RE had complete resolution of dysphagia symptoms at 2 months. Of subjects undergoing open treatment, 77% had complete resolution of symptoms. No subjects undergoing FE or RE experienced any post-operative complications. Subjects undergoing open treatment experienced a 30% complication rate (1 post-operative hematoma, 1 temporary vocal fold paresis, 1 intra-operative perforation, and 1 post-operative chest pain). Despite these complications, these 4 open subjects experienced complete resolution of dysphagia and their complications. Median (range) operative time (min) is 67.5 (59- 117) for FE, 39 (33- 46) for RE, and 108 (78-160) for open (p=0.006). All FE and RE subjects had a length of stay (LOS) of 1 day. Median (range) LOS for open patients was 2 (1-7).

Conclusion: Flexible endoscopic treatment of ZD is safe and effective at resolving dysphagia symptoms at 2 months without post-operative complications. This technique is easily mastered by laryngologists already experienced with flexible endoscopic interventional techniques. Future studies are necessary to determine long- term efficacy and risks of recurrence.

Laryngeal Rhabdomyosarcoma in an Adult: Diagnostic Pitfalls and Management with Long Term Organ Preservation Rebecca Nelson, Conor Devine, Paul Bryson

Objective: To present a clinical update to a case report of laryngeal rhabdomyosarcoma with durable favorable outcome with organ preservation therapy and to discuss diagnostic pitfalls and management of this rare clinical entity.

Method: Retrospective case report, literature review

Results: A female smoker in her fifth decade of life presented to a speech pathologist with three years of dysphonia and was noted to have a right true vocal fold mass on videostroboscopy. She had a previous negative biopsy at outside facility but presented to our practice with persistence of symptoms and was referred to a laryngologist. Though consistent with granuloma based on appearance, excisional biopsy was performed with pathology positive for spindle cell rhabdomyosarcoma. Negative margins were achieved via and endoscopic approach and after multidisciplinary discussion she underwent chemotherapy (vincristine, actinomycin D, cyclophosphamide, 6 cycles). She has been followed with videostroboscopic exams and scheduled imaging and has had no evidence of disease for 4.5 years from surgical resection. She never required a tracheostomy or feeding tube.

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Conclusion: Laryngeal rhabdomyosarcoma is a rare clinical entity and may present as a benign appearing lesion. In this case, it was successfully treated with endoscopic resection and adjuvant chemotherapy without necessitating open partial or total laryngectomy over several years.

Not Just for Kids: A Rare Case of Congenital Laryngeal Cleft in an Adult Christopher Xiao, Lucas J Schloegel, Nancy Jiang

Objective: This case report aims to increase awareness of the diagnosis of laryngeal cleft in adult patients and discuss their treatment options.

Method: Case report and review of the literature.

Results: We present a case of a 56-year-old male referred for hoarseness and chronic cough that was discovered to have a type 2 laryngeal cleft. He had chronic aspiration, recurrent pneumonia, and a hoarse voice for his entire life. In contrast to most described cases in adults, this patient was successfully treated with an endoscopic approach using absorbable suture.

Conclusion: Laryngeal clefts are uncommon and almost always detected in childhood, making adult laryngeal clefts extremely rare. Endoscopic repair is a feasible and successful treatment option in these cases.

Big brother is in Big trouble: a unique oropharyngeal foreign body Andrew Redmann, John Stafford, Michael J Rutter

Objective: 1) Describe removal of a rare foreign body from the oropharynx in an infant

Results: A 3 month old female presented to the emergency department with significant drooling and respiratory distress, worse with prone positioning. History revealed that the child’s brother had placed an unknown foreign body in the patient’s mouth, which the mother unsuccessfully tried to remove with a finger sweep. X-ray revealed a C-shaped radiopaque foreign body in the upper aerodigestive tract. The patient was taken to the operating room immediately with the child upright. Anesthesia was induced, and the patient was maskable. Utilizing a phillips laryngoscope for exposure, a metallic foreign body was found to be obstructing the larynx, and removal of the obstructing foreign body was attempted without intubation, but was not possible in a timely manner. At this point, the patient was intubated past the foreign body with some difficulty (requiring manipulation of the foreign body). After intubation, the foreign body was unable to be removed with simple manipulation, and was advanced into the esophagus then withdrawn carefully with a magill. The foreign body was noted to be a large metallic pendant of the letter “C”, which was identified as from as the older brother’s necklace. Esophagoscopy and bronchoscopy revealed minor excoriations of the upper aerodigestive tract, and the child’s respiratory status returned to normal upon extubation.

Conclusion: Prompt identification of foreign bodies introduced by siblings can lead to satisfactory results. Securing the airway provides time to manipulate and remove difficult foreign bodies.

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Comparison of oropharyngeal swallowing dysfunction in myasthenia gravis patients between neutral and chin down positions examined with high resolution manometry Yoshihiko Kumai, Takumi Miyamoto, Keigo Matsubara, Satoshi Yamashita, Yorihisa Orita

Objective: To compare prospectively, oropharyngeal swallowing dysfunction in myasthenia gravis (MG)patients presenting mild to moderate difficulty in swallowing between neutral and chin- down maneuvers examined with high resolution manometry (HRM).

Method: Swallowing studies of seven MG patients with mild to moderate difficulty in swallowing examined with videofuloroscopic (VF) and HRM in neutral and chin-down positions, were reviewed. These patients were consulted from department of neurology in our institution during Feb 2018 to Dec 2018. The assessment parameters on HRM are set as follows: maximum swallowing pressure (SP) at soft palate, meso-hypopharynx, and upper esophageal sphincter (UES), and duration of lowered SP at UES for each maneuver. Comparison of these parameters between two maneuvers and correlation between these parameters and pharyngeal clearance rated with three to five-point scale in VF, clinical neurological evaluation such as QMG score (total and neck muscle alone, respectively), and grip strength were statistically determined.

Results: Comparison with neutral maneuver, the maximum SP at meso-hypopharynx was significantly (p<0.05) increased, and the duration of lowered SP at UES was significantly (p<0.05) elongated with chin-down position. Interestingly, pharyngeal clearance examined with VF was significantly (p<0.05) correlated with the maximum SP at UES and meso-hypopharynx with chin- down position, however, no correlation was identified with clinical neurological evaluations.

Conclusion: Chin-down position is useful for the oropharyngeal swallowing dysfunction in MG patients for the improvement of pharyngeal clearance via increase of SP at meso-hypopharynx, lowering the SP at UES and elongating duration of lowered SP at UES, however, no correlation with clinical neurological evaluation was identified.

The Combined Approach of Subglottic laryngeal Closure and Selective Myotomy of Swallowing related Muscles Masaya Uchida

Objective: In patients with severe swallowing dysfunction, laryngeal closure alone does not improve swallowing function. There are few effective methods for improving patients’ swallowing function. Herein, we aimed to introduce a new procedure for severe aspiration patients who have some residual swallowing function. This operation was expected to improve swallowing function and effectively prevent aspiration using a simple, less invasive method by closing the subglottic region and simultaneously attempting to improve swallowing function improvement methods using several steps.

Method: The subjects were 13 patients who underwent the combined approach of subglottic laryngeal closure and selective myotomy of swallowing-related muscles (SLCM) procedure at our Hospital. The surgery was performed from June 2017 to December 2018. Prior to surgery, the swallowing function test was used to determine which swallowing-related muscles were to be cut during surgery. The surgical procedure involved

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the combined approach of the subglottic laryngeal closure at the tracheal window with the cricoid archand myotomies of the cricopharyngeal muscle, omohyoid muscle, stylohyoid muscle and stylothyroid muscle.

Results: The average operation time was 121 &#177;± 13 minutes, and the average bleeding volume was 31 &#177; ± 30 g. In all cases, there was no fistula identified, and all procedures succeeded in preventing aspiration. Ingestion &lt;and swallowing functions were also improved at each level in all 13 cases.

Conclusion: The data suggests that the SLCM procedure is capable of reliably preventing aspiration and providing better feeding function for patients with severe aspiration.

Modifying titanium bridges for type 2 thyroplasty to improve device mechanical and safety performance Tetsuji Sanuki, Tsutomu Nishimura

Objective: The titanium bridge is a hinged bridge made of titanium, used to keep the split thyroid ala apart in type 2 thyroplasty for adductor spasmodic dysphonia. Revision surgeries revealed that the bridge wing experienced failure at the area of the medial hole in multiple cases. The purpose of this study was to identify the rate and cause of device malfunctions and to develop an increasingly secure device.

Method: We conducted a questionnaire survey on the number of surgeries, revisions, and information about revision cases performed with titanium bridges. Furthermore, damage analysis was performed on the recovered fracture surface of the titanium bridge with a SEM.

Results: From 2002 to 2014, titanium bridges were clinically used in 385 cases. Revision surgery was performed in 19 patients. Revision surgeries revealed that the wing had broken in its medial hole in 11 patients. However, such fractures were not associated with any sign of recurrence or any adverse event. When the fracture surface was analyzed by a SEM, it was confirmed that the fatigue fracture was caused by repeated bending stress. From the results, the shape of the hole was changed from round to oval and changed to increase the wing thickness for the purpose of preventing breakage.

Conclusion: The wings of the titanium bridge may be broken without any symptom and tissue damages. Based on these malfunctions detected, and the analysis of the devices recovered due to malfunctions, the following specification changes were made for commercialization to proceed.

Type Diverticulum and Esophago-esophageal Fistula Presenting as Complications of Anterior Cervical Spine Surgery Pranati Pillutla, Kevin O Juarez, Alden F Smith, Aliza Zhukhovitskaya, Jennifer L Long, Dinesh K Chhetri

Objective: Report two unique cases of Zenker’s type diverticulum and esophago-esophageal fistulas after anterior cervical spine surgery.

Method: Chart review of cases and a literature review of patients with pharyngoesophageal diverticulum and a history of anterior cervical disc fusion (ACDF).

Results: Two unique cases were identified from a dataset of patients undergoing treatment for upper esophageal

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diverticulum. Both had a history of esophageal perforation after ACDF surgery and were treated with removal of cervical hardware. Subsequently dysphagia persisted and radiological and endoscopic examinations revealed Zenker’s diverticulum and associated esophagoesophageal fistula extending from the apex of the diverticulum to several centimeters below into the esophagus. Both cases were treated with endoscopic laser diverticulotomy and esophageal dilation with subsequent long- term improvement in dysphagia symptoms. Both had gastric tubes that were subsequently removed. Literature review identified 13 cases of hypopharyngeal or esophageal diverticula formation in the setting of ACDF surgery. Age distribution of patients was bimodal, with a younger patient population (mean age 36.6 years) presenting after ACDF for trauma, and older patients (mean age 57 years) presenting after ACDF for degenerative cervical spine disease. The mean time to presentation was 4.6 years. Majority of cases (91%) were treated with open surgical management. There were no reports of esophago-esophageal fistula.

Conclusion: Zenker’s type diverticulum esophageal fistulas can develop in the setting of ACDF surgery following hardware removal for esophageal perforation. Endoscopic treatment is a viable and less morbid approach to treatment of dysphagia in this setting.

Role of Voice Therapy in Adherence to Voice Rest after Office- Based Vocal Fold Procedures Renee King, Seth Dailey, Susan Thibeault

Objective: Patients undergoing vocal fold operations and procedures significantly reduce but often do not cease voice use during absolute postprocedure voice rest. Both preprocedure voice therapy with a speech-language pathologist (SLP) and adherence to voice rest improve treatment outcomes. We hypothesized that patients who completed a greater number of preprocedure voice therapy sessions would increase adherence to postprocedure voice rest.

Method: Patients scheduled for office-based vocal fold laser, injection, and biopsy procedures, absolute postprocedure voice rest, and either one counseling session (“Counseling”) or multiple voice therapy sessions (“Therapy”) preprocedure were recruited. Self-reported talking on 100-mm visual analog scale was collected for up to three days both pre- and postprocedure. Patients with preprocedure voice evaluation only (“Evaluation”) were recruited on the procedure date. All participants completed a questionnaire after voice rest including various voice use measures. Demographic and clinical data, Voice Handicap Index (VHI), and Eating Assessment Tool (EAT-10) were collected.

Results: Talking decreased postprocedure by a median of 74/100mm in the Counseling group (n=31) and 71 in the Therapy group (n=35; p>.05). Greater decrease in self-reported talking was associated with more talking preprocedure (p<.0001), recurrent respiratory papillomatosis diagnosis (p<.01), and potassium titanyl phosphate laser treatment (p<.001). Less decrease in talking was associated with higher EAT-10 scores (p<.001), paralysis (p<.05), and injection laryngoplasty (p<.01). In the Evaluation group (n=21), talking decreased by median 39/100mm, less than Counseling and Therapy patients (both p<.01).

Conclusion: SLP voice care preprocedure may improve adherence to postprocedure voice rest. Adherence varies by diagnosis and procedure.

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Transgender Voice Feminization: Characteristics Outcomes Michelle Adessa, Zoe Weston, Jeffrey J. Russell, Paul C. Bryson

Objective: The primary aim of this study was to define characteristics of patients seen at our voice center for voice feminization. The secondary aim was to evaluate outcome measures for this cohort of voice feminization patients with: 1) voice therapy alone, 2) surgery alone, or a 3) combination of voice therapy and surgery.

Method: Patients seen in the outpatient voice center in a thirty month period who sought care for voice feminization were included. Patient demographic information, patient quality of life index scores (Male to Female Transgender Voice Questionnaire), and baseline acoustic data was collected. If patients had completed treatment, the same data points were collected.

Results: Eighteen patients were seen for evaluation. Fourteen patients began training with voice therapy. Five patients underwent Wendler glottoplasty. Seven patients had voice therapy alone; two patients underwent surgery alone; six patients had both voice therapy and surgical intervention. Pre and post treatment data was available for nine patients. Average pitch increase: with therapy alone was 51 Hz (n = 6); with surgery and voice therapy was 96 Hz (n= 3); overall average pitch increase of 66 Hz. Pre and post TVQ data was available for 2 patients who received therapy only and showed an average change of 60 points.

Conclusion: There is great variability in treatment course for patients seeking voice feminization. An eclectic approach to treatment may be useful to serve this population fully. Increased patient quality of life and increased speaking fundamental frequency were found in this patient cohort.

Transoral laser-assisted diverticulectomy: Swallow study results after complete endoscopic pouch excision for Zenker’s diverticulum Ryan McMillan, Michael L. Wells, Dale C. Ekbom

Objective: Transoral endoscopic laser-assisted diverticulotomy (TELD) with diverticulectomy and diverticuloplasty (TELD+DD) for the management of Zenker’s diverticulum (ZD) has been utilized by our institution since 2016 in attempts to reduce residual pouch size. This technique involves complete endoscopic pouch excision with advancement of mucosal flaps. Our study compares the subjective outcomes, objective outcomes, and complication rates between TELD and TELD+DD.

Method: A retrospective cohort study was performed on patients who underwent TELD or TELD+DD by a single surgeon at a tertiary academic center (2013-2019). Video swallow studies with esophagram, EAT- 10, Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and 3 month follow-up visits. A single blinded reviewer recorded height, width, and depth of pre and post- operative pouches with volumetric analysis performed assuming an ellipsoid shape. Comorbidities, complications, post-operative course, and recurrence were recorded.

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Results: Of the 75 patients that met criteria, 27 underwent TELD+DD and 48 underwent TELD, of whom 19 and 37 respectively had pre and post-operative swallow studies. TELD+DD and TELD had a 97±21% and 81±23% reduction in pouch volume, respectively (t-test|p=0.006). Complications (TELD+DD 7%|TELD 17%, Fisher’s exact|p=0.31) and final subjective outcomes after adjusting for initial were not significantly different between methods (EAT-10 with TELD+DD+1.3|p=0.18, RSI +1.4|p=0.29, FOSS -0.02|p=0.91). One short- term recurrence was reported with TELD.

Conclusion: TELD+DD has statistically significant decreased residual pouch size with no significant difference in short-term subjective outcomes. Complication rates and short-term recurrence rates are comparable. Long- term recurrence rates will require further studies to characterize.

Cricoid Chondritis -- A Rare and Reversible Etiology of Airway Stenosis Kershena Liao, Kathleen M. Tibbetts

Objective: Chondritis of the cricoid cartilage is a rare cause of airway stenosis that may occur after endotracheal intubation, particularly in the setting of trauma. Patients may present with significant airway compromise that is reversible if recognized and treated promptly.

Method: Case series.

Results: We report two cases of young gentlemen who presented with dyspnea, stridor, and dysphonia after prolonged endotracheal intubation for polytrauma. Both patients had findings of subglottic narrowing, vocal fold edema and erythema, and reduced vocal fold abduction on laryngoscopy. Computed tomography (CT) imaging revealed sclerosis and destruction of the cricoid cartilage. Both patients underwent a single endoscopic airway surgery with steroid injection and balloon dilation, with concurrent oral antibiotic therapy. They reported subjective improvement in their symptoms and had near complete resolution of their glottic and subglottic abnormalities on laryngoscopy. Neither patient has had recurrence of their stenosis at most recent follow up. We hypothesize that early intervention prevented maturation of the stenosis in these patients.

Conclusion: Chondritis of the cricoid cartilage may occur following prolonged intubation and presents with airway compromise that is reversible with treatment. Antibiotics should be considered in addition to surgical management.

The Association Between Hiatal Hernia and Esophageal Dysmotility Yuval Nachalon, Nogah Nativ-Zeltzer, Indulaxmi C Seeni, Peter C Belafsky

Objective: Hiatal hernia (HH) involves disruption of the functional components of the lower esophageal sphincter. The association between HH and gastroesophageal reflux disease (GERD) is well established. The association between HH and esophageal dysmotility remains uncertain and the purpose of the study was to evaluate the association between HH and esophageal dysmotility.

Method: All persons with a diagnosis of HH on video- fluoroscopic esophagram and ambulatory high-resolution manometry (HRM) between Jan 2016 and Sep 2018 were identified and were age and gender-matched to the studies of persons without HH. Manometric and pH measurements were compared between groups.

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Results: Twenty individuals with HH were matched to 20 individuals without HH. The mean(±SD) age of the entire cohort(N=40) was 60(±8.6) years. 60% was female. The percentage of weak or failed swallows was 43%(±45) for individuals with HH and 10%(±23) for individuals without HH(p<0.01). The mean distal contractile integral (DCI) was 1760(±931) mmHg-s-cm for individuals without HH and 1078(±917) mmHg-s- cm for individuals with HH(p<0.05). There was no difference in distal latency or lower esophageal sphincter integrated relaxation pressure between groups(p > 0.05). Mean composite pH score for patients with and without HH was 45(±36) vs. 16(±17) respectively(p<0.05).

Conclusion: The presence of hiatal hernia was associated with a significantly higher percentage of ineffective deglutitive esophageal contractions and weaker esophageal body peristalsis along with higher composite pH score. Although the study design precludes the assessment of causality, we hypothesize that chronic GERD in persons with HH may promote the development of ineffective esophageal motility.

Intermittent Vagal Nerve Stimulation-Associated Vocal Fold Movement Impairment Jennifer Yan, Julina Ongkasuwan, Elton M. Lambert

Objective: Vagal nerve stimulators (VNS) are an accepted therapy for refractory seizures. However, VNS have been shown to affect vocal fold function, leading to voice complaints of hoarseness. The objective of this study is to provide a case report of intermittent vocal fold lateralization and paralysis associated with vagal nerve stimulator activation and its consequences.

Method: Evaluation of medical record with endoscopic examination of swallowing, laryngeal stroboscopy, and acoustic vocal parameters.

Results: 13-year-old female presented with complaints of a raspy voice with VNS stimulation as well as after exertion with associated dyspnea. Full vocal fold mobility was seen with VNS off, while left vocal fold paralysis in lateral position and glottic gap was seen with VNS on and after exercise-induced exertion. Voice measures were performed demonstrating decreased phonation time, lower pitch, and decreased intensity of voice with VNS on. Flexible endoscopic evaluation of swallowing demonstrated deep penetration alone with VNS off and deep penetration with concern for aspiration with VNS on.

Conclusion: While the majority of cases of vocal fold movement impairment associated with VNS have been noted to have a medialized vocal fold with VNS activation, we describe a case of intermittent vocal fold lateralization associated with VNS activation with resultant voice changes and aspiration.

Comparison of Office-Based vs. Operative Settings for Esophageal Dilation: A Systematic Review and Meta- Analysis Nikita Kohli, Feng Dai, Alexandria Brackett, Michael Lerner

Objectives: Esophageal dilation (ED) may be performed in the office under local anesthesia or in a procedure/ operating room under general anesthesia or intravenous (IV) sedation. However, indications for type of anesthetic have not been established. The purpose of this review is to assess outcomes of esophageal dilation among different anesthetic types to assess the safety of office-based techniques.

Method: We conducted a systematic review and meta-analysis comparing the outcomes of anesthetic techniques for ED in adults. Exclusion criteria included reviews, small case series, stent, isolated diagnoses with high morbidity, and rare diseases. A comprehensive literature search of the PubMed, CINAHL, and EMBASE databases was performed for articles relating to esophageal dilation.

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Results: 876 papers were generated of which 164 full text studies were assessed and 20 were included in the analysis using the PRISMA guidelines. Data regarding demographics, dilation technique, and adverse events were extracted. Meta-analyses were performed to integrate quantitative findings. Random- effect models with inverse-variance weighting were fit to estimate the combined effects. The DerSimonian-Laird estimator was used to quantify the between-study variance. There were no statistically significant differences among mortality, perforation, or bleeding based on anesthetic. For bleeding, the 95% confidence interval was [0; 0.19] (P=0.20), indicating no significant difference in bleeding based on local, general or IV anesthesia.

Conclusions: With office-based procedures gaining popularity in laryngology, there is a need to profile their safety. Office-based ED appears to have equivalent safety to general and IV sedation, although further research is necessary to define indications favoring office-based techniques.

Patient Satisfaction with Methods of Interpretation in Otolaryngologic Clinic Helen Hyeon Soh, Matt L Rohlfing, Katherine R. Keefe, Alex D Valentine, Pieter J Noordzij, Chris D. Brook, Jessica R Levi

Objective: Effective communication between providers and patients is essential to patient care and to the patient-physician relationship. Studies have shown that patients with limited English Proficiency experience lower satisfaction and increased complications. Moreover, with the recent transition into Merit- based incentive payment system, understanding factors that may lower patient satisfaction has an increasing importance. This study seeks to explore the satisfaction of English speaking and limited English Proficiency patients with English speaking providers, focusing on interactions with different types of interpreters.

Methods: Patients with new and follow-up appointments in otolaryngology clinic were recruited to complete satisfaction surveys.

Results: A total of 209 patients were included in the final analysis. 65 utilized professional interpreter services, 9 used an ad-hoc interpreter, and 135 did not require an interpreter. Patients who used interpreter services demonstrated lower visit satisfaction compared with patients who did not (p&lt0.001). Patients expressed significantly greater preference for in-person interpreter (mean=9.73) or family member (mean=9.44) compared to telephone services (mean=8.50) (p=0.002). The overall survey scores, however, did not significantly differ between different interpreter types (p=0.157).

Conclusion: To our knowledge, there is no published study from the Otolaryngology clinic setting that defines limited English Proficiency patients’ satisfaction as it relates to interpreter services. Existing studies in other specialties have shown mixed outcomes. In this study, limited English Proficiency patients experienced lower visit satisfaction compared to language concordant patients. While the patients did prefer in-person interpreters, there was no significant difference in overall visit satisfaction between different types of interpreters.

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Race and Insurance Status on Laryngopharyngeal Reflux Symptomatology Eleni Varelas, Inna Husain

Objective: Laryngopharyngeal reflux (LPR) is an extraesophageal variant of gastroesophageal reflux disease associated with intermittent dysphonia, throat-clearing, and chronic cough. This study evaluates the impact of race and insurance status on presenting LPR symptomatology.

Method: A retrospective chart review of all patients diagnosed with LPR from 2017-2019 was performed at a tertiary care center. Diagnostic criteria included evaluation by a fellowship trained laryngologist, laryngoscopy, and Reflux Symptom Index (RSI) scores. Demographics, patient history, and insurance status were recorded. Descriptive statistics were calculated for each parameter with SPSS version 22.

Results: 170 patients (96 White, 44 Black, 26 Latinx, 4 Asian) met inclusion criteria. Black and Latinx patients reported higher RSI scores (26.7±8.6, p<0.05) relative to their White and Asian counterparts. Of the included cohort, 97 had private insurance,52 had Medicare, and 20 had Medicaid. RSI scores varied significantly (p<0.05) between all three insurance types. Medicaid patients reported higher RSI scores (28.7±10.1, p<0.05), while private insurance patients reported significantly lower scores (23.7±7.9, p<0.05). However, controlling for insurance type eliminated the association between RSI scores and Black and Latinx patients. Most notably within the Medicaid group, where Black, Latinx, and White patients did not have significantly different scores.

Conclusion: Black and Latinx patients present with more severe LPR symptoms than White and Asian patients. Additionally, Medicaid patients reported higher RSI scores than the Non- Medicaid cohort. These findings suggest that access to appropriate healthcare, due to varied insurance coverage, likely influences LPR symptomatology.

Extracranial Carotid Pseudoaneurysm Presenting with Ipsilateral Vagus and Spinal Accessory Nerve Dysfunction Justin Hall

Objective: Carotid pseudoaneurysms and dissections can rarely present with symptoms affecting the lower cranial nerves. Here we describe a case of an idiopathic carotid pseudoaneurysm which resulted in cranial nerve X and XI dysfunction.

Method: Case report and review of the literature.

Results: A 43 year old female initially presented to a laryngology clinic with the chief complaint of dysphonia, dysphagia, nasal regurgitation, and right neck and arm weakness. Examination showed palate and vocal fold paralysis associated with pooling of secretions in the ipsilateral pyriform sinus. While hand and arm strength was normal, ipsilateral shoulder dysfunction was noted. A CT Neck with contrast showed an Internal Carotid Artery pseudoaneurysm adjacent to the jugular bulb that was treated with endovascular embolization using a covered stent. Nasopharyngeal, Laryngeal and Upper Esophageal injections were performed. Shoulder dysfunction was treated with physical therapy. Six months after intervention, there was return of function of the vagus nerve. Nine months after intervention, there was return of function of the spinal accessory.

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Conclusion: While cranial nerve dysfunction can develop from the presence of carotid pseudoaneurysm, it is even more rare for this to be a patient’s presenting complaint. Close attention to the symptomatology and correlation with radiographic images is pertinent to ensure timely management of these patients.

Distribution of label retaining cells and their properties in the newborn vocal fold mucosa Kiminori Sato

Objective: There is growing evidence to suggest that the cells in the maculae flavae (MFe) are tissue stem cells of the vocal fold mucosa and the MFe are a stem cell niche. Distribution of label- retaining cells and their properties in the newborn vocal fold mucosawere investigated.

Method: Oral administration of bromodeoxyuridine (BrdU) was given to pregnant Sprague-Dawley rats and the label-retaining cells in the newborn vocal fold mucosa were observed by immunohistochemistry. Immunoreactivity to antibodies directed to Ki67 was studied to investigate the cell cycle.

Results: At day 0 after birth, BrdU positive cells were identified in the MFe, epithelium and lamina propria of the vocal fold mucosa. At day 56 after birth, the number of BrdU positive cells in the epitelium and lamina propria were lower compared to day 0 after birth. However, the number of BrdU positive cells remaining in the MFe was still high. The label-retaining cells were distributed throughout the MFe. Few Ki-67 positive cells were identified in the MFe indicating cells in the newborn MFe were resting cells in the cell cycle (G0-phase).

Conclusion: The results of this study are consistent with the hypothesis that the cells in the MFe are tissue stem cells. At birth, these cells are already present in the MFe of the newborn vocal fold and they are ready to start the growth and development of the vocal fold mucosa.

Robotic Epiglottopexy as a Method for Managing Adult Obstructive Sleep Apnea Jennifer Shehan, Michael Cohen

Objective: Patients who do not tolerate continuous positive airway pressure (CPAP) for treatment of obstructive sleep apnea (OSA) often seek surgical intervention for managing their symptoms. A variety of procedures exist to address the nasal passages, oropharynx, and hypopharynx. Diagnostic studies including drug-induced sleep endoscopy (DISE) have been helpful in identifying anatomical areas of obstruction in specific patients. One area evaluated during DISE is at the level of the epiglottis. This is the first report of epiglottopexy in the adult otolaryngology literature.

Methods: This is a case series of two patients with OSA who demonstrated epiglottis prolapse into the airway during DISE. They were evaluated based on their polysomnographic testing, Epworth Sleepiness scale, and physical exam. Given their epiglottic prolapse seen on DISE, they underwent transoral robotic epiglottopexy as a method to treat their OSA.

Results: Both patients had moderate to severe OSA pre- operatively. Both patients successfully underwent robotic epiglottopexy as a surgical intervention for their OSA. They tolerated the procedure well, and there have been no documented complications.

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Conclusion: There are many methods of surgical intervention for patients with OSA. These cases demonstrate the utility of DISE as a method for determining anatomic areas to target during surgical intervention. Epiglottopexy is one method for addressing collapse of the epiglottis and can be achieved successfully through trans-oral robotic surgery in adult patients with OSA.

Postoperative management after Tracheostomy and Laryngectomy: Improving patient care with bedside posters Sam DeVictor, Adrian Ong

Objective: To improve nursing staff understanding about the differences in post-operative management of patients undergoing tracheostomy and laryngectomy.

Method: A single center, prospective study in which ward and ICU nursing staff were initially surveyed on the management of patients undergoing tracheostomy and laryngectomy followed by a brief didactic lecture. An informational poster and anatomic diagram were then placed above the bed for each tracheostomy and laryngectomy patients over a six-month period. At the end of the six months, surveys were redistributed to the nursing staff.

Results: Fifty nurses completed the survey. Sixteen (32%) nurses believed oral ventilation is “sometimes” or “always” appropriate for laryngectomy patients prior to the study compared to zero nurses after the implementation of the posters (p<0.01). In addition, 58% of nurses believed that oral ventilation is “never” appropriate for patients with a tracheostomy compared to 8% following the 6-month period (p<0.01). The percentage of nursing staff reporting clear understanding of the patient care differences between laryngectomy and tracheotomy improved after poster implementation (16% pre-poster versus 80% post- poster, p<0.01).

The use of informational posters and anatomic diagrams significantly improves nursing staff understanding about the differences between tracheostomy and laryngectomy patients. Understanding the anatomical differences between these patient populations may improve patient care both during routine postoperative management and in airway emergency settings.

Channeled Flexible Laryngocopes for KTP Laser Ablation of Laryngeal RRP with Disposible Flexible Sheath Andrew Liu, Henry Hoffman

Objective: The channeled flexible laryngoscopes used for laser laryngeal may be damaged from disruption of the inner working channel from the pointed tip of the laser fiber during insertion. We present a novel technique employing the flexible hollow outer sheath of a sclerotherapy needle - routinely used to direct instillation of topical lidocaine - to protect the working channel during laser fiber insertion.

Method: Describe technique of laser fiber insertion during flexible trans-nasal laryngoscopy employing the KTP laser to treat laryngeal disease.

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Results: A flexible 25 gauge sclerotherapy therapy catheter with the internal needle in the retracted position is used to deliver topical anesthesia (4% lidocaine) to the larynx through the channel in the laryngoscope. This sclerotherapy catheter (1.8 mm outer diameter) is then cut to a length slightly longer than that of the working channel. The internal retractable needle removed from the sheath and replaced with the laser fiber. This sheath protects the working channel of the laryngoscope during laser fiber insertion and then is pulled back out of the working channel to provide room around the laser fiber to permit continuous suction to be applied for plume evacuation during laser activation. Still photos from a video documenting the process are provided.

Conclusion: A flexible sclerotherapy needle sheath may be used to protect the working channel of channeled flexible laryngoscope during insertion of a laser fiber and, by employing equipment already in use, adds no additional cost.

An Analysis of Tracheostomy Complications in Pediatric Patients with Scoliosis Swathi Appachi, Jessie Marcet-Gonzalez, Jennifer N Brown, Julina Ongkasuwan, Elton M Lambert

Objective: Analyze tracheostomy-related complications in pediatric patients with scoliosis.

Method: A single-institution, retrospective chart review of patients with tracheostomy and scoliosis was performed. Charts were reviewed for variables such as difficulties with tracheostomy tube changes, poor positioning of tracheostomy tube, abnormal tracheal appearance, and emergency room visits and admissions for tracheostomy complications. Decannulation rates were identified.

Results: 102 patients met inclusion criteria. 96 (94.12%) had scoliosis involving the thoracic spine, and 6 had lumbar scoliosis. 18 (17.65%) had reported difficulties with home tube changes, and 13 (12.75%) had documented poor positioning on tracheoscopy. 20 (19.61%) patients required at least one tracheostomy tube change due to poor positioning, with 7 (6.86%) requiring multiple changes. Custom length tracheostomy tubes were required in 9 patients (8.8%). 31 patients (30.39%) had at least one emergency room visit or admission for tracheostomy complications, such as accidental decannulation or bleeding from the tracheostomy. Abnormalities of the trachea, such as tortuosity, obstructive granulomas, or tracheomalacia, were seen in 31 patients (30.39%) on bronchoscopy. Scoliosis repair was performed in 18 patients (17.65%), of which one went on to be decannulated. 10 patients (9.8%) overall were decannulated.

Conclusion: A portion of tracheostomy-dependent patients with scoliosis have anatomical abnormalities of the trachea and poor positioning of the tracheostomy tube. Decannulation rates are lower in this population compared to those seen in the literature, but the majority of these patients may have hypotonia secondary to neuromuscular scoliosis. Further work is required to elucidate if scoliosis pre-disposes patients towards tracheostomy-related complications.

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Management of Idiopathic Subglottic Stenosis During Pregnancy - A Support Group Survey Hilary McCrary, Vanessa Torrecillas, Catherine Anderson, Marshall Smith

Objectives: 1) To determine how pregnancy affects idiopathic subglottic stenosis (iSGS) symptoms. 2) To determine treatments (including operating room (OR) and in-office procedures) utilized for iSGS before, during, and after pregnancy.

Methods: A 19-question survey was distributed to an international iSGS support group to assess the patient experience of having iSGS during pregnancy. Descriptive statistics and chi2 analysis were completed.

Results: A total of 448 iSGS patients participated; 32.2% (n=144) of patients were diagnosed priorto menopause. A total of 24.4% (n=86) patients reported being diagnosed with iSGS while pregnant; 68.5% reported more severe airway symptoms during pregnancy. The proportion of patients that reported requiring ≥1 OR interventions (microlaryngoscopy/bronchoscopy, laser, balloon dilation, or steroid injection) before, during and after pregnancy was the following, respectively: 39.7%, 34.8%, 50%. Whereas the proportion of patients that reported requiring ≥1 in-office interventions (awake balloon dilation or steroid injection) before, during and after pregnancy was the following, respectively: 13.3%, 14.0%, 16.3%. Number of pregnancies and age of diagnosis was not related to severity of symptoms or requiring more airway interventions (p>0.05). The most common pregnancy complication was preeclampsia, affecting 22.1% (n=19) of patients. 39.5% (n=34) of patients stated their experience with iSGS adversely affected their decision to have children in the future.

Conclusions: The treatment of iSGS continues to evolve, with more in-office procedures available. This survey reveals worsening of symptoms during pregnancy, requiring interventions during and after pregnancy. Future avenues for research include optimizing management of airway symptoms during pregnancy to limit OR-based interventions.

Swallowing Symptoms in Patients Undergoing Thyroidectomy: A Prospective Cohort Study Michael Coulter, Tanner Miller, Kastley Marvin, Caroline Schlocker, Kevin Bach, Christopher Johnson

Objective: To assess pre- and post-operative swallowing symptoms in patients undergoing thyroid surgery and to correlate clinical and pathologic characteristics including high resolution manometry (HRM).

Method: Prospective cohort study of consecutive patients undergoing thyroidectomy procedures at a single institution over 2 years. All subjects completed pre-operative thyroid ultrasound, thyroid function testing, laryngoscopy, Voice Handicap Index-10 (VHI-10), and specific questions concerning dysphagia and globus. Positive swallowing symptoms were defined as at least weekly episodes of dysphagia or globus; HRM was offered to these subjects. Questionnaires were administered post-operatively at 3, 6, and 12 months.

Results: 87 patients met criteria for pre-operative analysis, and 70 for post-operative analysis. 36 (41.4%) had pre-operative swallowing symptoms. 14 (21.5%) were symptomatic at 3 months and 8 (12.7%) at 6 months. 6 (10.2%) were symptomatic at 12 months, of which 4 (6.8%) were new-onset from pre- operatively. Pre- and post-operative swallowing symptoms were not correlated, nor were they correlated with age, gender, dominant nodule size, thyroid volume, thyroid function labs,VHI-10, heartburn, thyroid cancer diagnosis, vocal fold paresis or extent of surgery. 18 (20.7%) patients underwent HRM, in which 12 (66.7%) had abnormalities. Only 1 (8.3%) of these had persistent post-operative swallowing symptoms.

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Conclusion: Pre-operative swallowing symptoms are common in those undergoing thyroid surgery, however this study could not correlate these symptoms to clinical or pathological characteristics related to their thyroid condition. Additionally, the presence of post-operative symptoms was not correlated with pre-operative symptoms. Regardless, these tend to improve with time, even in those with manometric abnormalities.

Diltiazem as a novel therapy for a chronic cough subtype Keith Conti, Aaron Jaworek, Ronak Modi

Objective: Chronic cough, defined as cough lasting longer than 8 weeks, contributes a substantial financial burden to the United States healthcare system and a psychological and emotional burden to the patient. Given suboptimal results with available treatment strategies in some cases, additional therapeutic options often are sought.

Method: The patient, a 72-year-old woman, was found to have a hypercontractile esophagus on high resolution manometry and was started on diltiazem after trials of other medications.

Results: Her cough improved by more than 50% after starting this medication.

Conclusion: We present, to our knowledge, the first case report of treating a patient with chronic cough using the non- dihydropyridine (DHP) calcium channel blocker (CCB), diltiazem. Historically, CCBs have been implicated in worsening reflux disease by relaxing the lower esophageal sphincter (LES). As a result, chronic cough due to reflux can be exacerbated with CCBs. In cases of esophageal hypercontractility concomitant with chronic cough, however, a trial of CCB like diltiazem should be considered as a potential therapeutic option.

Comorbid Dysphagia and Malnutrition in Elderly Hospitalized Patients Laura Bomze, Brianna Crawley, Andrea Cragoe, Cesar Luceno, Wilson Lao, Jordan Thompson, Nathan Lee

Objective: Elderly individuals account for one-third of all hospitalizations. The goal of this study was to evaluate the prevalence of dysphagia in elderly patients admitted to a tertiary care center. It also sought to investigate how dysphagia relates to comorbidities and to utilization of hospital resources.

Method: A retrospective chart review was performed. All patients older than 64 years admitted to a tertiary care center in January and February 2016 were included. Patients with primary psychiatric diagnoses and patients with head/neck malignancy were excluded. Data extraction included demographics, dysphagia, malnutrition, admission diagnoses and diet, speech language pathology (SLP) and dietician evaluations.

Results: 688 patients were identified. Mean age was 76.6 years. 24.4% (168 patients) were identified as having dysphagia at some point during their hospitalization. 44.3% (305 patients) were identified as having malnutrition. 13.5% (93 patients) had both dysphagia and malnutrition. 50% of patients who had malnutrition were seen by SLP. 100% of malnourished patients that saw SLP were identified as having dysphagia. 397 patients (57.8%) were seen by the dietician but not by SLP. Pre- hospitalization diet was identified in 59.4% (409 patients).

Conclusion: Approximately one quarter of elderly patients admitted to our tertiary care center have dysphagia. Dysphagia, especially when linked with malnutrition, has been shown to result in poorer outcomes and increased healthcare costs. Our data suggests a possible disconnect between malnutrition diagnosis and

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dysphagia identification. This is an important area of intervention that has the potential to improve the treatment and outcomes of these patients.

Vocal fold injection of basic fibroblast growth factor in patient with vocal fold scar, atrophy, and sulcus vocalis Shintaro Sueyoshi, Hirohito Umeno, Takashi Kurita, Syun-ichi Chitose

Objective: Fibrotic change of vocal fold is found in patient with vocal fold scar, atrophy, and sulcus vocalis, and often lead to voice disorder. So far, there is no reliable treatment for that property change of vocal fold. According to previous reports, basic fibroblast growth factor (bFGF) is supposed to improve that property change. In the present study, we examined voice outcome following bFGF injection into vocal fold.

Method: The bFGF injection was performed in nine patients in our institution. There were vocal fold scar in six patients, vocal fold atrophy in two patients and sulcus vocalis in one patient. Ten micrograms of bFGF was injected into each vocal fold. The injection was repeated four times. Aerodynamic, acoustic and stroboscopic examination were performed in each time point after surgery (1 month, 3 months, 6 months, 1 year, 2years, 3 years). Fundamental frequency, maximum phonation time (MPT), mean flow rate (MFR), amplitude perturbation quotient (APQ), and pitch perturbation quotient (PPQ) were examined in each time point.

Results: Voice quality has improved after treatment in most patient. They have kept their voice quality for a long time without recurrence. Aerodynamic assessment, MPT and MFR, improved from early, 1 month after treatment. Whereas, acoustic assessment, APQ and PPQ, improved from 6 months after treatment.

Conclusion: It took longer time to find acoustic improvement than aerodynamic improvement in the present study. That indicated that it took longer time to achieve the improvement of vocal fold vibration than to find mere volume change of vocal fold.

An Unusual Application of Transoral Robotic Surgery and Analysis of Coding and Billing Michael Lai, Yekaterina A. Koshkareva

Objective: To present a case of removal of a fully-embedded in the tongue base wire grill brush bristle, and to review coding and billing for this procedure.

Method: A 51-year-old female presented to our hospital with globus sensation and odynophagia after eating barbequed meat. Computed tomography (CT) of the neck demonstrated a 12mm radiopaque foreign body (FB) fully embedded in the left lingual tonsil. Intraoperative direct laryngoscopy revealed a site of entry, but no visible FB. Cup forceps were used to grab the soft tissue at the site of entry; however, nothing was removed, and the patient was awakened from anesthesia. Repeat CT confirmed persistence of the FB in the same location. The patient returned to the operating room for FB removal via transoral robotic surgery (TORS). Left tongue base tissue was resected using monopolar cautery with a zero-degree camera, but no FB was identified. A second deeper layer of the tongue base was resected using a 30-degree camera; the FB was visualized, removed, and deemed to be a wire grill brush bristle.

Results/Conclusion: There is one previous report in literature that used TORS to retrieve a FB in a similar anatomically difficult location. This unusual procedure presents a coding challenge, as our procedure was coded by the surgeon as a partial glossectomy (CPT41100 with S-2900 modifier), but the contracted coding team

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submitted it to the insurance company as an “unlisted procedure for tongue and mouth surgery” (CPT41599). As applications for TORS expand, coding challenges should be explored and addressed.

Unexpected Complication following Airway Surgery in a Patient with Granulomatosis with Polyangiitis (GPA) Nausheen Jamal, Zachary Keatts, Rachel Giese

Objective: Describe an unusual complication following airway surgery in a patient with GPA.

Method: Case Report

Results: A 40-year-old woman with granulomatosis with polyangiitis (GPA) presented for elective airway surgery. She underwent carbon dioxide laser incision, balloon dilation, and steroid injection of subglottic stenosis using jet ventilation, a surgery she had undergone multiple times previously. Intraoperative course was uncomplicated. After the procedure, the patient could not be extubated. Chest x-ray demonstrated bilateral pneumothoraces, necessitating chest tube placement with resolution. Despite weaning off sedation, the following morning the patient was slow to regain consciousness and demonstrated right-sided weakness. Initial brain computed tomography (CT) was unremarkable, but magnetic resonance imaging (MRI) performed that day showed multiple areas of abnormal T2 signaling in the bilateral parenchyma, suggestive of vasculitic versus embolic infarcts. Follow-up cerebral angiogram was not suggestive of vasculitis, but trans-esophageal echocardiogram demonstrated a mobile mass on the aortic valve consistent with a vegetation. The patient’s neurologic symptoms resolved quickly, and the patient was extubated and returned to baseline neurological function by hospital day 9.

Conclusion: Valvular vegetations are uncommon in GPA, and cardiac work-up is not routinely performed preoperatively. We suspect that with onset of bilateral pneumothoraces, there was a sudden increase of intrathoracic pressure that effectively simulated a Valsalva maneuver and precipitated a cardioembolic event. This case highlights the need for a high index of suspicion for cardiac involvement in the GPA population. Further studies are indicated to determine the value of routine preoperative cardiac work-up in patients with GPA.

Long-Term Follow-Up After Radiation Therapy for Laryngeal Amyloidosis Caitlin Bertelsen, Keith A Chadwick, John Holland, Joshua S Schindler

Objective: Laryngeal amyloidosis (LA) is a rare disease characterized by extracellular protein deposition within the larynx. Treatment is difficult due to the frequently submucosal and multifocal nature of disease. The mainstay of treatment has been surgical resection, however recurrence rates are high. In recent years, the use of radiotherapy (RT), either alone or as an adjuvant to surgery, for LA has been adapted from the management of extramedullary plasmacytoma and has been shown to provide good local disease control. Here we describe the experience with adjuvant RT for LA at our tertiary academic center.

Method: Institutional Review Board-approved retrospective study of patients with LA seen at a single tertiary academic institution between 2010 and 2019. Primary outcome measures included disease characteristics,

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recurrence rates, treatment modalities, and pre- and post-treatment voice handicap index (VHI).

Results: Ten patients met eligibility criteria. Mean follow up time was 62.0 ± 41.0 months; mean follow-up time after last treatment was 51± 55 months. All patients underwent surgical resection of their disease. Seven patients underwent subsequent RT. Of these seven, six underwent RT with a dose of 45 Gy at our institution. All seven completed RT without interruption due to toxicity. Patients undergoing RT underwent 2.1 ±1.3 surgical procedures prior to, and 0 ± 0 procedures after RT. Mean pre-treatment VHI was 22.9 ± 8.1 (range 2-32), and mean post-treatment VHI was 12.9 ±13.3.

Conclusion: RT after surgery for LA can provide good local control without unacceptable toxicity and may decrease the need for further surgery.

Let the Healer Beware Mursalin Anis, Stefania Goncalves, Opeoluwa Fawole

Objective: Awake injection medialization laryngoplasty is one of the most common therapeutic procedures done by laryngologists in the office or at the bedside. Complications of injection needle fracture are rarely reported.

Method: This is a case report of a 59-year-old male inpatient who developed left vocal fold immobility with significant glottic insufficiency after pneumonectomy for a large, left-sided lung cancer. During bedside injection medialization using thyrohyoid approach, the 25 G needle fractured at the hub and was embedded partly in pre-epiglottic space and partly overhanging rima glottidis. Needle fragment was successfully retrieved at the bedside with an endoscopic biopsy forcep using flexible bronchoscope.

Results: N/A

Conclusion: It is imperative to be aware of rare complications of routine procedures in order to manage them timely and effectively.

Pathophysiology of aspiration in piglets with unilateral superior laryngeal nerve injury using quantitative analysis of videofluoroscopy Maya Stevens, Christopher Mayerl, Laura Bond, Rebecca German, Julie Barkmeier-Kraemer

Objective: Increased incidence of aspiration was previously reported in piglets post-unilateral superior laryngeal nerve (uSLN) lesion. The purpose of this study was to elucidate the pathophysiology of aspiration in these previously studied piglets via videofluoroscopy quantitative measures used to assess swallow physiology in humans.

Method: Temporal measures were conducted on videofluoroscopy studies acquired from 13 female piglets ages 2-3 weeks (7 with uSLN lesion and 6 control). All videofluoroscopic studies were analyzed at 30 frames per second. Quantitative and temporal measures were conducted using published methodology for clinical assessment of adult and infant human videofluoroscopic studies. These measures included: 1. The number of linguapalatal contacts (i.e. pre- swallow), 2. total duration of swallow, as well as onset of: 3. upper esophageal sphincter (UES) opening, 4. maximum UES opening, 5. airway closure, and 6. maximum airway closure. Measures 3-6 were determined relative to onset of swallowing. Multi-level gamma regression analysis was used to compare continuous measures between lesioned and control groups. Ratings of bolus clearance were also

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recorded and analyzed using a multi-level multinomial distribution.

Results: The number of linguapalatal contacts (p=.006), pharyngeal swallow duration(p=.023) and timing of maximum airway closure (p=.041) were significantly greater or longer in the uSLN lesion than the control group.

Conclusion: Outcomes of this study replicated prior published findings and also newly identified pathophysiology placing uSLN lesioned piglets at greater risk for aspiration than control animals. Noteworthy was the use of clinically relevant quantitative videofluoroscopic measures in piglets that enable comparison to future studies in humans.

Development of Silent Aspiration in Patients with Head and Neck Squamous Cell Carcinoma Treated with Concurrent Chemoradiation Rafay Soleja, Zao Yang, Cherie Ann Nathan

Objective: To determine predictors of the time to developing post-treatment silent aspiration in patients with head and neck squamous cell carcinoma (HNSCC) treated with primary chemoradiation.

Method: Patients with HNSCC who were treated with chemoradiation from 2011 to 2019 and received a post- treatment modified barium swallow study (MBSS) were included in this single-institution retrospective cohort study. Primary outcome measures included the presence and onset of silent aspiration after chemoradiation based on speech language pathology MBSS reports. Clinical factors were evaluated for predictors of silent aspiration.

Results: 74 of 142 (52.1%) patients developed silent aspiration during the study period. The cohort included 35.5% oropharyngeal, 2.8% oral cavity, 15.6% hypopharyngeal, 16.3% glottic, and 29.8% supraglottic primaries. Stage IV cancers developed silent aspiration more quickly, with a hazard ratio (HR) of 3.35 (p = 0.047) at 5 months, 2.37 (p = 0.025 at 10 months), and 2.13 at 15 months (p = 0.03). Hypopharyngeal primaries are more likely to develop silent aspiration prior to 25 months compared to laryngeal primaries, with statistical significance across 5-year follow up (HR = 2.93, p = 0.018). Bilateral nodal disease was associated with silent aspiration between 10-15 months (HR 2.25, p = 0.034) when compared to no nodal disease.

Conclusion: Silent aspiration is common in patients with HNSCC treated with chemoradiation, and can develop several years after completion of treatment. Predictors of the timing of development of silent aspiration include stage IV disease, hypopharyngeal primary, and bilateral nodal disease.

Hope on the Horizon? Resolution of Severe Esophageal Button Battery Injury Following Removal with Acetic Acid Irrigation Ryan Borek, , Steve Sobol

Objective: Esophageal foreign body ingestion is often associated with severe injury beginning as little as one hour following ingestion and is a cause of significant morbidity and occasionally mortality. The objective of this report is to report on a case demonstrating positive resolution of an esophageal button battery with multiple day delay to treatment.

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Method: Case report with photo documentation. Results: A 16 month old female presented as an emergent transfer from an outside hospital with imaging findings consistent with an esophageal button battery ingestion. History was suggestive of ingestion four days prior to seeking medical treatment. On examination, the child presented with stridor, tachypnea and a hoarse cry. Esophagoscopy demonstrated a button battery at the cricopharyngeus with the anode facing anteriorly. Severe, circumferential esophageal necrosis, laryngeal edema and bilateral vocal fold paralysis was noted. Following removal, the esophagus was irrigated with 0.25% acetic acid and a feeding tube was placed. The patient remained intubated for a week. Repeat endoscopy prior to extubation demonstrated continued bilateral vocal fold immobility but near complete resolution of the esophageal injury. The patient was successfully extubated and discharged on a full oral diet. Repeat endoscopy at 3 months demonstrated compensated left sided vocal fold paralysis and normal esophagoscopy. Conclusion: This case demonstrates near complete resolution of severe injury resulting from delayed button battery ingestion. Acetic acid irrigation may be a promising adjunct to removal and should be considered.

Laryngeal Amyloidosis: Can it be Determined with Imaging? Emily Kay-Rivest, Juan Marquez Garcia, Jonathan Young, Francoise Chagnon, Carlos Torres, Karen Kost

Objective: The objective of this study was to review the imaging of patients diagnosed with laryngeal amyloidosis, in order to determine if any specific findings suggest the presence of this disease.

Method: A retrospective chart review of adult patients with confirmed histopathological diagnosis of laryngeal amyloidosis was performed, from January 2009 to March 2019. Clinico- demographic factors were collected. A fellowship-trained head and neck radiologist subsequently reviewed all computed tomography (CT) scans and magnetic resonance imaging (MR) findings within this cohort.

Results: Ten patients with histologically confirmed laryngeal amyloidosis were identified, with a total of 24 imaging studies analyzed. The most frequent location was combined glottic and supraglottic regions with involvement of the true and false vocal cords in seven patients. On CT, the most common finding was a submucosal soft tissue, homogenous and well-defined focal or diffuse mass with contrast enhancement. Punctate calcifications were only present in one case. Two patients showed multifocal disease. All cases with MR studies showed the same signal intensity, described as intermediate T1-weighted, low T2- weighted, with contrast enhancement. Diffusion weighted images (DWI) were obtained in every patient without evidence of diffusion restriction.

Conclusion: MR may be a more specific technique for the initial diagnosis of laryngeal amyloidosis.

Tracheal Lobular Capillary Hemangioma in a Pediatric Patient: A Case Report and Review of the Literature Ray Wang, Bruno Chumpitazi, Sarah Gitomer, Eric Chio, Julina Ongkasuwan

Objective: We describe a case of a posterior tracheal wall lobular capillary hemangioma (LCH) in a pediatric patient and review the literature regarding diagnosis and management of this rare mass.

Method: Case report of a patient with a tracheal LCH diagnosed at a tertiary children’s hospital.

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Results: A 10-year-old otherwise healthy female presented to a multidisciplinary aerodigestive clinic at a tertiary children’s hospital for evaluation of chronic cough, vomiting, and recurrent pneumonia. Rigid bronchoscopy demonstrated a subtle sessile lesion of the posterior tracheal wall, and CT of the neck demonstrated a 4mm x 2mm x 1cm mildly hyperdense mass of the posterior trachea at the level of C7. Biopsy of the lesion showed features consistent with lobular capillary hemangioma. She underwent rigid bronchoscopy and KTP laser ablation of the entire lesion without complications. At follow-up 1 month post- procedure the patient had significant improvement in her cough and vomiting. While cutaneous and mucosal LCHs are common, there are few case reports of tracheal LCHs, the majority of which are in adult patients. Presenting symptoms may include cough, hemoptysis, or airway obstruction from large lesions. Interventions including cold excision, electrocurettage, laser ablation, and cryoablation have been reported with good local control, albeit with limited follow-up.

Conclusion: Here, we present a unique case of a pediatric tracheal LCH--a rare cause of chronic cough. A high index of suspicion is required for diagnosis given their rarity and non- specific symptoms. Endoscopic KTP laser ablation may be a viable treatment option for these lesions in children.

Symptomatic Triticeous Cartilage Causing Thyrohyoid Syndrome with Successful Treatment Betty Yang, Timothy D Anderson

Objective: To describe a case of a symptomatic triteceous cartilage, treated successfully with steroid injection.

Method: Case report and review of the literature.

Results: We present the case of a 79 year-old gentleman who initially presented to the otolaryngology clinic with a chief complaint of right upper neck pain with ingesting solid foods. On physical exam, his discomfort localized to the right side, and he was tender at the level of the submandibular gland. A CT scan of the neck demonstrated “an asymmetrically elongated and curved right-sided triticeous cartilage” as well as “overlying asymmetric effacement of the right piriform sinus and mild asymmetric mucosal thickening presumably related to friction associated with this asymmetric anatomic variant”. The patient was observed for several weeks to see if his symptoms might resolve spontaneously. He returned with persistent discomfort. The clinical picture was consistent with thyrohyoid syndrome, possibly related to his asymmetric anatomic variant of a prominent triticeous cartilage causing soft tissue inflammation. The patient was taken to the operating room and underwent suspension microlaryngoscopy; no abnormalities were seen. Injection of depot steroid and local anesthetic was performed. He reported resolution of symptoms at 2 week follow-up and thereafter.

Conclusion: The triticeous cartilage is an often-overlooked element of the laryngeal framework with variable prevalence. Thyrohyoid syndrome is a clinical diagnosis that has been described as lacking any specific radiological findings. We present a case of thyrohyoid syndrome with radiologic findings of a prominent triticeous cartilage, which was successfully treated with steroid and anesthetic injection.

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Characteristics of Individuals with Idiopathic Subglottic Stenosis Managed Non-Surgically Aisha Harun, Thomas Edwards, Jeanne L Hatcher

Objective: Idiopathic subglottic stenosis is often managed by surgical intervention. However, a small subset of individuals are successfully treated with non-surgical management. We sought to define the characteristics of these patients.

Method: A retrospective chart review was conducted for all patients evaluated between October 2014 to October 2019 for idiopathic subglottic stenosis with no prior surgical intervention for 4 or more years. Demographic variables, body mass index (BMI), treatment strategies, and quality of life indices, including the Reflux Symptom Index (RSI) and the Dyspnea Index (DI), were collected.

Results: There were 6 patients included in the study. Only one patient had an endoscopic airway dilation 4 years prior to presentation. Five patients underwent office-based steroid injections (average of 2.36 injections per year, range 1 - 4), whereas one was observed with no interventions. There was a significant change in reported reflux symptoms from baseline to last office visit (RSI 20.2 vs 10.8, p=0.04). There was no significant change in DI or BMI.

Conclusion: We observed that reported reflux symptoms decreased in patients managed non-surgically for idiopathic subglottic stenosis. Reflux management and office-based steroid injections may be considered in patients with mild dyspnea symptoms.

Risk of an Inferior Lesion for Recurrent Vocal Fold Leukoplakia Hisashi Hasegawa, Hiroumi Matsuzaki, Kiyoshi Makiyama, Anzuko Nakata, Takeshi Oshima

Objective: Previous studies have proposed various risk factors for recurrence of vocal fold leukoplakia becoming malignant transformation. This study aimed to analyze preventable risk factors during surgery for recurrence of vocal fold leukoplakia.

Methods: This study was a retrospective case series. Thirty-nine patients with vocal fold leukoplakia who were treated by cold instrument resection combined with a Holmium YAG laser (2006-2018) were evaluated. Patients who were diagnosed with carcinoma in situ and laryngeal cancer were excluded. The patients were divided into the non-recurrent and recurrent groups. We examined patients’ characteristics, surgical procedures, and associated pathology.

Results: Ten (25.6%) patients had recurrence. Six of 10 (60%) patients had an inferior lesion of the vocal fold at the first operation in the recurrent group (Odds ratio = 16, p = 0.0039), while none of the patients had an inferior lesion in the non- recurrent group. There were no significant differences in difficult laryngeal exposure (p = 0.15), the size of the lesion (≥50% vs <50%, p = 0.70), the site of the lesion (unilateral vs bilateral, p = 0.12), anterior commissure (p = 1.0), and pathological grade (no dysplasia and mild vs moderate and severe, p = 0.26) between the groups. There was no malignant transformation in the follow-up period (mean: 23.4 ± 25.9 months, range: 12-116 months).

Conclusion: An inferior lesion is a significant risk factor for recurrence of vocal fold leukoplakia.

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Quantifying Pharyngoesophageal Segment Distention in Patients Undergoing Cricopharyngeal Myotomy after Balloon Dilatation Gregory Dion, Natalie Jarvis, Alexandria E Gawlik, Ashley M Geer

Objective: Objective measures guiding selection of cricopharyngeal (CP) myotomy or CP balloon dilatation with/without botulinum toxin injection are lacking. We sought to characterize pharyngoesophageal segment (PES) distention on initial videofluoroscopy in these populations.

Method: Patients from a tertiary care laryngology practice over three years who underwent dilatation and/or myotomy for CP dysfunction were included. Maximum PES distention at narrowest location during a liquid cup sip trial and corresponding widest dimension in the same image were measured, with PES distension ratio calculated. Demographics, EAT-10 scores, time between procedures, and PES manometric pressures were recorded. Wilcoxon Rank Sum test compared measurements and chi-squared analysis was used for binomial variables.

Results: Forty-eight patients were identified, 10 additionally underwent CP myotomy. The narrowest PES dimension was smaller in myotomy patients (19.4 +/- 12.4mm vs 24.6 +/- 11.8mm, p = 0.029). Conversely, PES ratios did not differ in those undergoing myotomy (mean +/- SD = 0.61 +/- 0.17 vs 0.64 +/- 0.16, respectively, p = 0.46), nor did widest PES measurement (33.4 +/- 9.1mm vs 38.8 +/- 7.6mm, p = 0.54). EAT-10 scores did not differ between patients undergoing myotomy or not (19.5+/- 8.9 vs 14.7 +/- 9.0, p = 0.11). Age and gender were not predictive, and manometric pressures were elevated in those undergoing myotomy.

Conclusion: Patients who underwent CP myotomy had narrower PES distention measurements on VFSS, suggesting this measure may be an objective target for determination of patients that may benefit from an upfront CP myotomy.

Indications and prognosis of surgical procedures for laryngeal or tracheal stenosis: Descriptive study using Japanese claims database Kayoko Mizuno, Yuji Kanazawa, Masato Takeuchi, Yo Kishimoto, Koji Kawakami, Koichi Omori

Objective: Tracheal reconstruction is a rare surgical procedure and the actual incidence of or indications for this procedure have not been thoroughly elucidated. We performed the database analysis to clarify the real-world situation of airway stenosis surgery requiring cervical tracheal reconstruction.

Method:This descriptive study utilized data from the Diagnosis Procedure Combination inpatient database maintained by Medical Data Vision Co., Ltd. (Tokyo, Japan). The database includes 297 acute care hospitals in Japan. We identified patients registered with surgical treatments for laryngeal or tracheal stenosis from 2008 to 2016.

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Results: The study included 168 surgeries for 134 patients (75 males). Twenty patients (14.9%) had multiple surgical treatments and the median age at the initial surgery was 65.5 years. The most common indications for surgery was malignancy (n=61, 45.5%), and followed by complications caused by prolonged dependence for tracheotomy (n=23, 17.2%), trauma (n=6, 4.5%), malformation of the larynx and trachea (n=6, 4.5%), chronic inflammatory disease (n=4, 2.8%). Among the malignancy, thyroid cancer was the most common (n=39). The most common surgical procedure was surgery for releasing laryngostenosis (n=70, 41.7%), and followed by tracheal reconstruction (n=60, 35.7%), laryngo-tracheal reconstruction (n=17, 10.1%), and surgery for releasing trachealstenosis (n=21, 12.5%). Thirty-eight patients (28.4%) could not close the tracheal defect within 3 months and the mortality rate accounts for 9.7%.

Conclusion: This study using Japanese claims database provided a description of the clinical features of the patients who underwent surgery requiring cervical tracheal reconstruction.

Effects of Multiple Balloon Dilation on Subglottic Stenosis in an Animal Model Wei-Chung Hsu, Chun Kuo, Claudia Schweiger, Nicholas J. Roetting, Catherine K. Hart, Alessandro de Alarcon

Objective:To determine the optimum number of balloon dilations (BD) required to achieve a stable airway in an animal model of acute subglottic stenosis (SGS).

Method: We conducted a prospective study including 12 New Zealand white rabbits. Acute SGS was induced by Bugbee electrocautery to 75% of the circumference of the subglottis followed by 4-hour endotracheal intubation. After two weeks, the animals’ airways were sized by endotracheal tubes and serially dilated using an 8 mm balloon at 1 , 2, and 3 week intervals with 4 animals in each group. One week after the final BD procedure the airways were sized and the animals euthanized for further histopathological examination and microscopic measurement of cricoid lumen.

Results: Prior to dilation all animals were sized as grade 2 SGS using 2.5 endotracheal tubes without leak. The median cricoid lumen measured 16.52 mm2 in the single dilation group, 22.06 mm2 in the two dilation group

and 23.13 mm2 in the three dilation group. One cricoid fracture was noted in the two dilation group. There was no significant difference in lumen size between animals in the 2 dilations and 3 dilations groups.

Conclusion: In our study, we found that two weekly serial dilations was as effective as three weekly serial dilations in an acute rabbit SGS model. Multiple serial dilations was more effective than a single dilation in our model.

Evaluation of surgical management of pediatric grade III subglottic stenosis Amy Manning, Matthew M Smith, Jareen Meinzen-Derr, Catherine K Hart, Charles M Myer, IV, Michael J Rutter, Alessandro de Alarcon

Objective: 1. Describe outcomes for surgical management of grade III subglottic stenosis 2. Evaluate which risk factors predict the need for revision airway surgery.

Method: Retrospective case series of patients undergoing surgery for grade III subglottic stenosis at a tertiary academic children’s hospital from 2011-2018. Patients were divided into two groups: those that required revision airway reconstruction and those that did not require subsequent airway reconstruction. Chi-square test

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was used to examine categorical variables, including demographics, past medical history, type of operation, complications, and need for revision airway surgery.

Results: 118 patients underwent airway reconstructive surgery for grade III subglottic stenosis with 38 (32%) needing at least 1 revision airway reconstructive surgery. There was no significant difference between groups regarding demographics, past medical history, preoperative workup or complications. Properly treated MRSA colonization, GERD, eosinophilic esophagitis and glottic stenosis were not predictive of the need for revision airway reconstruction. Patients who underwent single-stage airway reconstruction were significantly less likely to require revision than those who underwent double-staged surgery (p = 0.04).

Conclusion: There were no significant risk factors identified which predicted the need for subsequent airway reconstruction after the initial airway surgery for grade 3 subglottic stenosis. Patients selected to undergo single- staged airway reconstruction had significantly fewer revision airway reconstructions compared those who underwent double-staged reconstruction, highlighting the importance of the surgeon’s judgment when selecting patients for single-staged procedures.

Minimally Invasive Epiglottoplasty Using a Trans-Cervical Barbed Suture Seth Kaplan, Yosef P Krespi, Victor Kizhner

Objective: Epiglottoplasty has been a reliable surgical intervention as a treatment for Obstructive Sleep Apnea secondary to a displaced, retroflexed, inverted, floppy or otherwise obstructing epiglottis. We describe a new minimally invasive technique without incision, using a trans-cervical insertion of a barbed suture to secure the epiglottis in a non- obstructing, anterior and upright position.

Methods: We treated 6 patients with known obstructive sleep apnea and findings consistent with an obstructing epiglottis. All patients underwent a minimally invasive procedure including transoral robotic demucosalization of the dorsal surface of the epiglottis as well as the corresponding surface of the base of tongue. Next, a loaded suture passer is placed trans-cervically just below the hyoid and passed through the base of tongue. A barbed suture is then guided robotically through the epiglottis. A second pass is placed above the hyoid, the suture is grasped through the cannula and withdrawn through the neck. Tension applied on the suture positions the epiglottis to the Base of Tongue.

Results: At the 3 month, post-operative visit all 6 patients had improvement in Polysomnogram, Epworth Sleepiness Scale, and Pittsburgh Sleep Quality Index, indicating both subjective and objective improvement in sleep quality.

Conclusion: A displaced epiglottis can be an underappreciated cause of Obstructive Sleep Apnea. Epiglottoplasty has been a mainstay of treatment for this type of obstruction. We propose a minimally invasive method for a robotic epiglottoplasty using a trans-cervical barbed suture. Both subjective and objective post- operative results have been encouraging.

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Predicting need for operative intervention in recurrent laryngotracheal stenosis using interoperative changes in spirometric measures Tyler Crosby, Lacy Adkins, Andrew McWhorter, Melda Kunduk

Objective: We sought to identify changes in spirometric values between surgical interventions in patients with recurrent laryngotracheal stenosis and assess the utility of tracking those changes in predicting the need to return to surgery.

Method: Charts from a 10 year period were reviewed, and 80 patients were identified with recurrent laryngotracheal stenosis and serial spirometry. Recorded FEV1 (forced expiratory volume in 1 second), FIV1 (forced inspiratory volume in 1 second), PEF (peak expiratory flow), and PIF (peak inspiratory flow) were tabulated. Calculations were then performed to determine changes in spirometric measurements between surgeries. We looked at time-dependent rates of change both in relative and absolute terms as well as time- independent changes. We separately calculated total change over an entire observation period as well as changes from one encounter to the next during an observation period. We then calculated receiver operating characteristic (ROC) curves for all calculated variables.

Results: Changes in PEF tended to have the greatest predictive value with AUCs greater than 0.82. Changes in PIF were less predictive with AUCs of greater than 0.80. All calculated variables related to FEV1 and FIV1 had AUCs less than 0.80. Time-dependent rates of change were generally not as predictive as time-independent degree of changes, with AUCs for rates of change of all variables being less than 0.80.

Conclusion: Change in PEF and PIF were the most sensitivity and specific indicators of need to return to surgery in our cohort. Rate of change was less sensitive and specific than time- independent amount of change. Management of an unusual infraglottic-pharyngeal fistula causing aspiration John Pang, Andrew Vahabzadeh-Hagh

Case Report: Spontaneous tracheo-esophageal fistulas are rare in adults. Here, we describe management of an unusual infraglottic-pharyngeal fistula (transcricoid) causing aspiration that has not previously been reported in the literature. The patient is a 57-year old male with paraplegia from remote cervical spine injury presenting to clinic with several months of worsening aspiration with liquids. Left true vocal cord paresis was noted on laryngoscopy and outside modified barium swallow (MBS) was suggestive of a Zenker’s diverticulum. Aspiration persisted despite in-office left vocal cord injection. Repeat MBS confirmed persistent aspiration. The patient refused a gastric feeding tube. Shortly thereafter the patient developed respiratory failure from aspiration pneumonia and received tracheostomy and gastrostomy tubes. Intraoperatively no diverticulum was appreciated. Repeat MBS was done and contrast extravasation from the upper esophageal sphincter region into the trachea was noted. On re-review of prior MBS, similar extravasation was appreciable but views were poor. Repeat operative direct laryngoscopy, esophagoscopy, and bronchoscopy was performed in collaboration with cardiothoracic surgery. With the infraglottis in view, air and irrigation were seen egressing from a left infraglottic mucosal defect. This was confirmed with application of methylene blue. A biopsy was taken and Dermabond bioglue was injected into the fistula tract using a laryngeal needle from both the infraglottic and pharyngeal surfaces. Here we review this unique case of an infraglottic fistula, its pathophysiology, treatment course and outcomes, and literature on spontaneous tracheoesphageal fistulas in adults.

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Airway Protection and Patterns of Dysphagia in Infants with Cerebral Palsy Amit Narawane, Christina Rappazzo, James Eng, Julina Ongkasuwan

Objective: Cerebral palsy in infants can affect oral motor function and lead to swallowing difficulties. This study aims to characterize this dysphagia and look for correlations with current metrics of cerebral palsy.

Method: This is a retrospective chart review of infants with cerebral palsy who underwent videofluoroscopic swallow studies (VFSS) between 6/2008 and 10/2018 at a tertiary children’s hospital. Demographic data and VFSS findings were collected and analyzed.

Results: 94 patients were identified. 41% of patients were female, and the average age at the time of VFSS was 4 months (range: 0.1 to 12 months). 76% of patients presented with oral dysphagia, and 78% with pharyngeal dysphagia. 53% of patients had laryngeal penetration and 39% of patients had tracheal aspiration. 69% of these aspirations were silent. At the time of VFSS, 55% of patients had a nasogastric tube, 11% had a gastrostomy tube, and 3% had a prior hospitalization for pneumonia. Rates of penetration and aspiration did not correlate with type of cerebral palsy (spastic, non-spastic, or mixed) or degree of paralysis (quadriplegic, hemiplegic, triplegic, or diplegic) (p > 0.05). Patients with penetration or aspiration did not have a statistically different Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), or Communication Function Classification System (CFCS) score than those without (p > 0.05).

Conclusion: Infants with cerebral palsy are at high risk for dysphagia and subsequent aspiration. The lack of correlation with current classifications of cerebral palsy suggests a need for independent swallowing evaluation in this patient population.

Transoral surgical anatomy of the cricopharyngeal bar under endoscopic visualization Shun-ichi Chitose, Kiminori Sato, Takashi Kurita, Mioko Fukahori, Shintaro Sueyoshi, Kiminobu Sato, Fumihiko Sato, Hirohito Umeno

Objective: Transoral laser microsurgery (TLM) is a modality for performing tumor resection or cricopharyngeal (CP) myotomy. The upper esophageal sphincter (UES) can be treated with TLM, but the CP bar confirmed by the postcricoid placement of a distending laryngoscope often confuses TLM surgeons due to its poorly understood submucosal structures such as muscles and blood vessels. This study aimed to clarify the transoral surgical anatomy of the CP bar under endoscopic visualization.

Method: A hypopharyngeal and laryngeal specimen was obtained from a surgical case. The lumen from the pharynx to esophagus was dilated by a balloon through the UES and fixed with formalin. After removing the balloon, the inside-out anatomy presented by submucosal dissection was observed using an endoscope. Muscle boundaries were confirmed by inserting several needles along the muscles from the outside into the lumen.

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Results: The mucosa of CP bar was thicker than other hypopharyngeal regions. The dorsally-confirmed CP bar was composed of the esophageal muscle and transverse and oblique parts of the CP muscle. The oblique part without the median pharyngeal raphe was located in the superior part of the CP bar. The submucosal venous plexus was confirmed on the center of this part. The oblique part with the median pharyngeal raphe was not included in the CP bar, but the superior-lateral sides were gently suspended. The esophageal muscle was confirmed in the inferior-middle part of the CP bar.

Conclusion: A precise understanding of the transoral surgical anatomy of the CP bar can contribute to successful TLM.

Revision thyroplasty for unilateral vocal fold paralysis Yo Kishimoto, Nao Hiwatashi, Tohru Sogami, Yoshitaka Kawai, Yasuyuki Hayashi, Koichi Omori

Objective: Sometimes revision thyroplasty is indicated for unilateral vocal fold paralysis. However, the outcomes of or indication for revision surgery have not been well documented. For the better understanding of the indication of the procedure and to achieve better phonatory outcomes, herein we performed the retrospective chart review of the patients who underwent revision thyroplasty for unilateral vocal fold paralysis.

Method: Of 149 total thyroplasties between October 2004 and October 2019, 21 revision thyropasty was performed in 19 patients. Patient self-assessment using the Voice Handicap Index-10 (VHI-10) questionnaire and objective aerodynamic and acoustic assessments performed pre- and post-operatively were analyzed using t-tests for paired comparisons.

Results: Revision techniques included type I thyroplasty, type IV thyroplasty and arytenoid adduction, and revision surgery was completed without any major complications in all the cases. Pre- and post-operative VHI- 10 score was available in 12 cases, and other parameters were available in 18 cases. Significant improvement was observed in VHI-10, MPT, MFR, AC/DC, APQ and PPQ.

Conclusion: Revision thyroplasty for unilateral vocal fold paralysis significantly improved phonatory outcomes even after multiple procedures. Revision surgery should be considered for the patients with not satisfying phonatory function after initial thyroplasty for unilateral vocal fold paralysis.

Predictors of Increased Surgical Drain Output following Type I Thyroplasty for Glottic Insufficiency Nicholas Lenze, Ameer Ghodke, Rupali Shah, Robert Buckmire

Objective: To determine predictors of increased drain output following type I thyroplasty for glottic insufficiency.

Method: A retrospective review was conducted for patients who underwent type I thyroplasty for glottic insufficiency from 2014 to 2019. The primary outcome was 24-hr drain output. Increased drain output was defined as >50th percentile for the sample. Univariate logistic regression models and linear regression models were used.

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Results: There were 84 patients with a mean age of 58.9 (+/- 16.9) years. 24-hr drain output ranged from 0 to 29 mL with a mean of 9.47 (+/- SD 6.49) mL. Patients with a history of tobacco use (OR 3.33 [95% CI 1.24-8.95]; p=0.017), and prior surgery of the head or neck (OR 5.29 [95% CI 1.91 to 14.63]; p=0.001) were significantly more likely to have increased drain output following surgery; these patients had a mean increase in total drain output of 3.51 mL (95% CI 0.52 to 6.51; p=0.022) and 4.00 mL (95% CI 1.10 to 6.90; p=0.007), respectively. There were non- significant trends towards more total drain output as age increased and less total drain output as BMI increased. Type of implant (Gore-Tex vs. Silastic) and operative technique (unilateral vs. bilateral) were not significantly associated with drain output.

Conclusion: History of tobacco use and prior surgery of the head or neck predict increased drain output following type I thyroplasty surgery. These patients may derive the most benefit from surgical drain placement. More research is needed to elucidate the mechanisms underlying these findings.

Functional Swallowing Outcomes following Surgery for Obstructive Sleep Apnea Alysha Rasool, Derrick R Randall, Jason KM Chau

Objective: Identification, evaluation, and management of pre and post-operative swallowing dysfunction in patients undergoing airway surgery for Obstructive Sleep Apnea (OSA) is limited. The aim of this study was to evaluate subjective swallowing function pre and post-operatively in patients undergoing multi-level pharyngeal sleep surgery.

Methods: A retrospective analysis of prospectively administered Eating Assessment Tool (EAT-10) scores was conducted among adult patients undergoing surgery for OSA in a tertiary sleep surgery clinic. Pre-operative and 1,3, and 6-month post- operative time points were assessed. Patients with elevated EAT-10 score (greater or equal to 3) at 6-months underwent videofluoroscopic swallow study (VFSS) examination.

Results: 114 patients were identified. Eighty-six participants were male (75.4%). There was a mean age and BMI of 42 (SD 14) and 30.3 (SD 6.57), respectively. The median pre-operative Apnea-Hypopnea Index was 18 (range 2-89). Thirty-seven patients underwent Phase I reconstruction. Among all participants, respective mean pre-operative and 6-month post- operative EAT-10 scores were 3.34 (SD 6.49) and 4.62 (SD 7.33) (p=0.45). Elevated EAT-10 scores were reported in 47.6% of patients at 6 months, with mean score 9.6 (SD=8.17). Mean 6- month EAT-10 score for Phase I reconstruction patients was 5.80 (SD 7.30) versus 4.33 (SD 8.20) for non-Phase I reconstruction (p=0.69). All patients who underwent VFSS had a penetration- aspiration scale scoreequal to 1.

Conclusion: Subjective dysphagia was found both at pre- operative and 6-month post-operative time points. Pharyngeal surgery resulted in no significant change in swallowing function. Subjective reports of swallowing function were discordant with objective testing. Further investigation into the cause for symptoms is needed.

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Sleep Outcomes of Concurrent Lingual Tonsillectomy and Epiglottopexy in Pediatric Patients

Matthew Maksimoski, Sarah Maurrasse, Jonathon Ida

Objective: Previous studies have examined the sleep outcomes of lingual tonsillectomy and other sleep surgeries beyond that of a simple adenotonsillectomy. However, the outcomes of concurrent lingual tonsillectomy and epiglottopexy have not been discussed, as this represents a unique combination of procedures which may relieve base of tongue obstruction of the pediatric airway.

Methods: Retrospective chart review was used to identify all patients who underwent lingual tonsillectomy, and all patients who underwent epiglottopexy at our tertiary-level care pediatric center from 2011-2019. These groups were then examined for patients who underwent both procedures simultaneously, and polysomnograms were reviewed with data collection.

Results: 16 patients were identified who underwent simultaneous lingual tonsillectomy and epiglottopexy over the time period of 2011-2019. Of these patients, 10 met inclusion criteria of both a pre- and post- procedural polysomnogram. The range of preoperative AHI was 1.6-79.7 events per hour (mean 19.9, median 10.6) and the range of postoperative AHI was 0.7-26.2 events per hour (mean 8.5, median 2.0). All patients except 1 had reductions in their AHI with an average absolute reduction of 11.3 (median 7.5) and relative reduction of 56.0% (median 75.1%, 95% CI 17.3%-84.1%). 9/10 patients had significant comorbidities.

Conclusion: Concurrent lingual tonsillectomy and epiglottopexy represents a single-stage treatment option in pediatric patients with sleep endoscopy-proven base of tongue airway obstruction. Our data show this is an effective treatment option for these patients with good results, even in the presence of comorbidities.

The tonsil microbiome is associate with the serum level of interleukin 10 in healthy weight children with obstructive sleep apnea Li-Ang Lee, Chung-Guei Huang

Objective: To elucidate the associations among the tonsil microbiome, serum level of interleukin 10 (IL-10), and clinical characteristics in healthy weight children with obstructive sleep apnea (OSA).

Method: This prospective cohort study recruited healthy weight children with OSA who underwent adenotonsillectomy between March 1, 2017 and January 31, 2019. The tonsil microbiome was examined using bacterial 16S rRNA gene-targeted high throughput amplicon sequencing and the morning serum level of IL-10 was measured by immunoassay.

Results: A total of 33 consecutive patients (11 girls and 22 boys) with a median age of 6.0 years, body mass index z-score of -1240.360 and apnea-hypopnea index (AHI) of 5.4 events/hour completed this study. At phylum level, the relative abundances of Actinobacteria(r=0.40, P=.02), Gemmatimonadetes(r=0.44, P=.01), BRC1 (r=0.38, P=.03), WS4 (r=0.43, P=.01),Halanaerobiaeota(r=0.43, P=.01), Kiritimatiellaeota(r=- 0.36, P = .04) and Modulibacteria (r=0.43, P=.01) were significantly related to the serum level of IL-10 (Spearman correlation test). The relative abundance of Gemmatimonadetes (r=-0.37, P=.04) significantly correlated with platelet-to- lymphocyte ratio (PLR) whereas the relative abundances of Bacteroidetes (r=0.44, P=.01) and Deferribacteres (r=0.41, P=.02) were significantly associated with AHI. The serum level of IL-10 was significantly associated with PLR (r=-0.40, P=.02), but IL-10 and PLR were not related to AHI.

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Conclusion: These results suggest that the tonsil microbiome involves systemic inflammation (PLR), anti- inflammation (IL-10) and OSA (AHI) in healthy weight children with OSA. These findings offer the possibility of the tonsil microbiome as a promising pharmaceutical target in childhood OSA, which warrants further investigations.

Transglottic Migration of a Nasal Trumpet: A Case Report and Literature Review Mark Russo, Amanda R Walsh, Karina Charipova, William Z. Gao

Objective: 1) To recognize the potential for medical devices such as nasopharyngeal airways (NPAs) to become iatrogenic airway foreign bodies. 2) To review instruments and technique critical to safe extraction of these foreign bodies in awake patients.

Method: We present a 53-year-old man with a history of NPA placement at an outside hospital that became embedded within the nasal cavity prior to transfer to our institution. Attempted nasogastric tube placement contributed to migration and displacement of the NPA from the nasal cavity into the glottis/trachea.

Results: Given the patent lumen of the NPA and presence of a flange preventing further distal migration, awake bedside extraction in the intensive care unit was deemed a safe treatment option. The foreign body was successfully removed using topical anesthesia and curved laryngeal forceps with visualization on flexible laryngoscopy. Literature review demonstrated that iatrogenic medical device foreign bodies such as NPAs are rare, but can lead to airway obstruction and mortality. Selection of appropriately sized NPAs, proper stabilization, and monitoring are important for prevention.

Conclusion: NPAs are effective, minimally invasive devices to manage upper airway obstruction. However, these devices can become dislodged, resulting in an obstructive airway foreign body. Preventative measures should be taken when using NPAs to avoid iatrogenic displacement. In select patients, awake foreign body removal can be safely accomplished with the use of key instrumentation.

Unique airway solution for awake laser excision of subglottic stenosis in a difficult airway Heather Koehn, James Daniero

Objective: Patients with significant subglottic stenosis (SGS), who are difficult to ventilate and difficult to intubate, would likely undergo awake tracheostomy. The authors present a unique case report of a difficult airway which was managed with a unique transnasal supraglottic ventilation strategy in order to avoid tracheostomy.

Method: Case Report

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Results: A 48 y.o. female with morbid obesity (BMI 59), severe OSA, restrictive lung disease in the setting of SGS with 50% obstruction and sarcoidosis, Tracheostomy was recommended, however she refused despite counseling regarding the risks including respiratory failure and death. Therefor she required an endoscopic procedure while managing her difficult airway. She was unable to be ventilated using an LMA or mask ventilation. A nasal trumpet was placed to assist with mask ventilation. In order to proceed with the necessary procedure, ventilation through the nasal trumpet (28F) was performed using an endotracheal tube connector (5.5), connected to the anesthesthetic circuit. Then through the contralateral naris, with a therapeutic bronchoscope utilizing a flexible fiber CO2 laser with topical anesthetic, dexmedetomidine and propofol for conscious sedation. Using the flexible fiber CO2 laser, radial incisions were made significantly increasing the patency of the airway. The patient’s stenosis was reduced from 50% to 20% and has remained stable for 6 months postoperatively.

Conclusion: Supraglottic ventilation with a nasal trumpet connected to an anesthesia circuit allowed a working channel bronchoscope in the contralateral side. This proved to be a successful anesthetic and operative technique in an awake patient requiring excision of subglottic stenosis.

Creative Approach to Esophageal Hex Nut Removal in Elderly Kyphotic Woman Joshua Senter, Kevin Stavrides, Thorsen Haugen

Objective: To present the unique management of a large esophageal foreign body in a kyphotic individual.

Method: Case report including radiographic imaging and intraoperative photographs.

Results: We present the case of a 72-year-old female with a past medical history of schizophrenia, kyphosis, and multiple foreign body ingestions who presents with progressive dysphagia and regurgitation of food. Computed tomography (CT) imaging and a chest x-ray (CXR) demonstrated two metallic foreign bodies in the mid-to- distal esophagus. The largest esophageal foreign body appeared consistent with a hex nut 2.7 cm in diameter on CXR. Gastroenterology successfully removed a rock during esophagogastroduodenoscopy, but Otolaryngology was consulted for rigid esophagoscopy to address the retained hex nut. None of the available instruments were sturdy enough to firmly grasp such a large object. Multiple passes of a balloon catheter with distal inflation were unsuccessful. Ultimately, the tip of a velvet suction was bent to a ninety-degree angle. After confirming no sharp edges had been created, the angled suction tip was used to hook the hex nut, resulting in successful extraction.

Conclusion: Foreign body removals can require creative solutions due to patient anatomy or specifications of the object. This case report describes a creative approach to removal of a sizeable foreign body. A thorough literature review was performed regarding esophageal foreign body management. Particular attention was paid to risks and management strategies in the kyphotic individual, but our review revealed a lack of evidence on the subject matter and the need for future studies.

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Evaluation of Non-Technical Skills in a Complex Airway Simulation Brian Ward, Tanya Meyer, Miles Montegut, Kathryn Roth, Aaron Joffe, Maya Sardesai

Objective: Simulation-based training is integral in otolaryngology resident education around airway emergencies and is often focused on technical skill development. Non- technical skills have been shown to improve outcomes in emergency situations, and are therefore a target for resident education. Strategies for evaluating non-technical skill performance in order to identify opportunities for improvement are limited. In addition, standardized scoring by experts can be costly and time-consuming. This study aimed to determine the feasibility of using a validated scale to evaluate non-technical skills of residents at different levels of otolaryngological training in a complex simulation setting, and to determine whether scoring could be performed by novices in a comparable way to experts.

Methods: 18 residents participated in a high-fidelity complex airway emergency simulation. Each performance was videorecorded and the audio was transcribed and deidentified. Transcripts were scored by 8 evaluators with varying levels of expertise. NOTSS performance was compared between residents of different levels of training and scoring was compared between experts and novices.

Results: NOTSS scoring was feasible for each of the 18 trainees in each of the 4 NOTSS domains. Scores in each domain generally improved with trainee seniority, especially for situational awareness and decision- making with more modest changes in communication and leadership. Scoring by novices was comparable to that of experts.

Conclusions: Non-technical skills were effectively evaluated using the NOTSS in an emergency airway simulation by both expert and novice raters. This strategy may serve as a means to identify opportunities for non-technical skills development among Otolaryngology trainees.

Safety of Surgery for Zenker Diverticula from a National Insurance Database Michael Andrew Witt, Michael Bryan Mullen, Mark Fritz

Objective: To assess rates of postoperative complications after Endoscopic Zenker Diverticulotomy and Open Zenker Diverticulectomy, and to identify factors associated with adverse outcomes.

Method: We queried a national database of insurance claims for Current Procedural Terminology (CPT) codes representing Endoscopic Zenker Diverticulotomy and Open Zenker Diverticulectomy performed between 2011 and 2017. Patients age 18-100 continuously enrolled with their insurance provider were included. Demographic information, additional CPT codes, concomitant diagnoses, and anticoagulant medication data were collected for all patients included. 30-day postoperative mortality was assessed and ICD9/10 codes for complications including esophageal perforation, hemorrhage, pneumothorax, and sepsis were flagged.

Results: We identified 229 patients representing 237 unique encounters for endoscopic approach. Two patients, each with one encounter, were excluded from analysis due to diagnoses of laryngeal and hypopharyngeal cancer. Of the patients analyzed, 133 were male and 94 were female. The average age for unique patients was 68.61 years. Of these procedures, 5 resulted in esophageal perforation, and 4 resulted in pneumothorax among other complications. One patient in the open approach group of 14 patients developed SIRS. There were no mortalities within the 30-day postoperative period.

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Conclusion: Evidence from a national insurance claim database suggests Endoscopic Zenker Diverticulotomy carries a small but significant risk of serious complications. The most common complications identified were esophageal perforation and pneumothorax, which occurred in 2.2% and 1.8% of patients respectively. However, it is important to recognize that all data used was retrospective, and further investigation is warranted.

Utility of Video Recorded Flexible Nasolaryngoscopy for Neonatal Vocal Cord Assessment in a Prospective Cohort Stephen Chorney

Objective: Assessing vocal cord mobility by flexible nasopharyngolaryngoscopy (NPL) can be challenging in neonates due to endolaryngeal swelling, secretions, or movement. To date, prospective studies evaluating the incidence and diagnostic accuracy of vocal cord paralysis (VCP) after patent ductus arteriosus (PDA) repair are limited. We determined the incidence of VCP in a subset of patients and compared rates when the diagnosis was made at the bedside or with video recordings.

Method: Prospective cohort of preterm neonates undergoing bedside NPL within two weeks of extubation following PDA repair. Two pediatric otolaryngologists, blinded to the initial diagnosis, reviewed video recordings of the NPL.

Results: Eighty infants were enrolled and 37 with a recorded NPL were included in our cohort. Average age at birth was 25.2 weeks (SD: 1.2) and adjusted age at NPL was 37.0 weeks (SD: 4.5), which was 9.5 days (SD: 14.7) after extubation. There were 6 diagnosed with left VCP (16.2%) at bedside, and 9 diagnosed by video review (24.3%) (p=0.56). Videos confirmed all 6 VCP diagnosed initially, but also identified 3 additional cases. Though imperfect, reviewing NPL by video showed substantial reliability (kappa=0.75, p<0.005), with a 91.9% agreement.

Conclusion: The diagnosis of VCP in neonates can be challenging. Video recorded NPL most often confirms the bedside diagnosis, but may also identify discrepancies. Physicians should consider the limitations of diagnosis especially when infants persist with symptoms such as weak voice or signs of postoperative aspiration.

The evaluation and measurement of oropharyngeal swallowing motion using cine-magnetic resonance imaging Tohru Sogami

Objective: The aim of this study was to examine the feasibility of cine-MRI for a new evaluation method of oropharyngeal motions in normal swallowing and other maneuvers such as swallowing rehabilitations.

Method: Six healthy volunteers were scanned during swallowing with 3-tesla MRI. First, normal swallowing of fruits juice was observed. Then, the tongue-hold swallowing was performed as a rehabilitation technique. The MRI images were identified by T1- weighed cross sectional images, 25 frames per second. The number of aspiration incidents were counted.

Results: In the normal swallowing, cine-MRI can evaluate the movement of the tongue, palate, epiglottis, thyroid cartilage and pharyngeal wall. Fluid flow during swallowing can be identified with T1 high signaling. In the tongue-hold swallowing, the change of tongue position and posterior pharyngeal wall were found. There was no aspiration incident.

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Conclusion: Cine-MRI is a safe examination for the evaluation of oropharyngeal structure during swallowing. Because this method needs lying position, it is difficult to apply directly to patients. However, normal subjects can endure the aspiration risk. MRI has higher discriminability of soft tissue than video fluoroscopy, therefore, it can be a comparison technique of various rehabilitations. Also, multi-dimensional examination including the axial imaging will show us further findings which is not able be obtained by video fluoroscopy.

Intubation-Related Laryngeal Pathology Precluding Tracheostomy Decannulation: Incidence and Risk Factors for Development Kirsten Meenan

Objective: To identify the incidence and risk factors for intubation-related glottic or subglottic lesions that preclude decannulation in a large population of tracheotomized patients.

Method: A three-year retrospective review of tracheotomized patients in an acute rehab facility who underwent routine endoscopic evaluation of the airway as part of the facility’s decannulation protocol was performed. Patients with known upper airway pathology, laryngeal trauma, cricothyrotomy and prior head and neck radiation were excluded. The laryngeal pathology was classified, and demographics and clinical features were compared between those whose lesions precluded decannulation and all other patients.

Results: Three hundred and thirty-one patients met inclusion criteria. 101 patients (30.5%) had laryngotracheal lesions. 45 patients (13.6%) had intubation-related lesions of the glottis or subglottis that precluded decannulation prior to medical or surgical treatment. The lesions precluding decannulation included posterior glottic stenosis (33.3%), granulation tissue (24.4%), vocal fold immobility (17.8%), subglottic stenosis (15.6%), combination of granulation tissue and stenosis (6.7%), and glottic edema (2.2%). A BMI greater than 25kg/m2 was associated with laryngeal lesions precluding decannulation, X2 (1, N= 324) = 5.88, p = .015. There was no difference in age, sex, race, smoking history, diabetes mellitus, endotracheal tube size, number of days intubated, and number of intubations between groups.

Conclusion: BMI greater than 25kg/m2 was the only risk factor significantly associated with the development of laryngeal lesions preventing decannulation. Given that 13.6% of tracheotomized patients have laryngeal lesions precluding decannulation, an endoscopic airway evaluation is critical to prevent decannulation failure and future airway symptoms.

Diffuse idiopathic hyperostosis (DISH) with Cervical Osteophytes Causing Dyspnea-A single Institution Case Series James Metkus

Objective: Diffuse idiopathic hyperostosis (DISH) is characterized by calcifications affecting mainly the spinal anterior longitudinal ligament. This disease is mainly asymptomatic, but cervical osteophytes can sometimes cause dysphagia, hoarseness, and even dyspnea. The dyspnea derives from compression of the larynx leading to airway compromise. The objective of this case series was to present patients complaining of dyspnea due to cervical osteophytes at a single institution, their subsequent treatment, and review of the literature.

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Method: This is a case series review describing the presentation of the patients with cervical osteophytes causing dyspnea, treatment and outcomes. A review of the literature was also performed highlighting dyspnea induced by cervical osteophytes.

Results: Both patients had tracheostomy procedures done as a result of their osteophytes causing airway compression. One patient had been decannulated prior to presentation, but had bilateral vocal fold immobility. The other still had the tracheostomy at time he presented and had severe compression of the cricoid cartilage. Both patients underwent an anterior approach for their cervical osteophyte resections. In both cases the osteophytes were successfully resected. One patient was successfully decannulated, the other still has bilateral vocal fold mobility issues. Both patients still had dysphagia.

Conclusion: While traditionally DISH is felt to be asymptomatic, cervical osteophytes should be considered in the differential of dyspnea among older patients that present with dysphagia. If they are treated earlier for their dysphagia complaints this may not lead to airway compromise seen in both of our patients.

Anatomic Correlates with Subjective Swallowing Symptoms in Zenker’s Diverticulum Raphael Hanna

Objective: Considerable variability in swallowing disability occurs in patients with Zenker’s diverticulum (ZD). We sought to evaluate the impact of several anatomic structures involved in swallowing identifiable on radiographic studies and correlate them to the severity of swallowing impairment perceived by patients with ZD.

Method: Retrospective case series of patients undergoing fluoroscopic swallowing studies (VFSS) for Zenker’s diverticulum at a tertiary dysphagia centre. Anatomic parameters identified on VFSS of patients with ZD were correlated with subjective perception of swallowing using Eating Assessment Tool (EAT-10) scores. Upper esophageal sphincter (UES) diameter at the point of maximal distention, area of diverticulum on the lateral view, height of the diverticulum and the entrance angle of esophagus were measured.

Results: We identified 24 patients with ZD (61.1% male, mean age=72.2 years). Narrow UES diameter was significantly correlated with dysphagia severity (r=-0.5647, p=0.0283). Largest area of diverticulum (r=-0.1449, p=0.7234), diverticulum height (r=-0.1040, p=0.7234), and esophageal entrance angle (r=-0.1040, p=0.7234) were not correlated with EAT-10 scores.

Conclusion: UES sphincter diameter was predictive of severity of swallowing dysfunction in patients with ZD. Size of ZD and the angle of bolus entry in patients with ZD are not predictive of swallowing dysfunction. Understanding the predictors of swallowing dysfunction will assist in counselling patients on postoperative expectations.

Can the EDI Distinguish PVFMD From Airway Stenosis in Obese Patients?

Kevin Calamari

Objective: Expiratory disproportion index (EDI) is the ratio of forced expiratory volume in one second (FEV1) divided by peak expiratory flow rate (PEFR) multiplied by 100. An elevated EDI (>50) can differentiate airway stenosis from paradoxical vocal fold movement disorder (PVFMD), but this has not been verified when considering body habitus. We hypothesize that the predictive value of elevated EDI in differentiating stenosis from PVFMD will be lower in obese patients as compared to non- obese patients.

Method: Patients >18 years old with recorded PFT values, BMI, and airway imaging were reviewed retrospectively from 01/2011-10/2018. EDI was recorded for four cohorts: obese/PVFMD, obese/stenotic, non-

Conclusion: Prior literature has established that EDI can distinguish stenosis from PVFMD in the general population. However, our results show that the mean EDI values were not significantly different in the obese cohorts, and an elevated EDI was not as sensitive at identifying stenotic cases. This suggests that the EDI should be used with caution in obese patients and should not be relied upon to rule out stenosis. obese/PVFMD, and non- obese/stenotic, to determine the mean EDI and the sensitivity/specificity of an elevated EDI.

Results: Mean EDI values were 73.38+/-16.14 and 48.40+/-4.11 in the non-obese stenotic and PVFMD groups, respectively (p<0.05). They were 58.76+/-8.42 and 47.67+/-3.30 in the obese stenotic and PVFMD groups, respectively (p>0.05). At a threshold of >50, EDI had a sensitivity of 100% and specificity of 48.0% in differentiating between stenotic and PVFMD cases in the non-obese cohort and 51.9% and 63.6% in the obese cohort.

Actinomyces Laryngitis Presenting as Laryngeal Foreign Body with Acute Airway Obstruction Mark Gerber; Brian A Walker, Aditi Bhuskute

Objective: describe identification and management of actinomyces laryngitis presenting as foreign body with airway obstruction.

Method: case report and review of literature.

Results and Conclusion: Actinomycetes infection of the larynx is very rare with only one prior case report found in the English literature. We present a case of actinomycetes laryngitis in a 23 yo who presented in respiratory distress. The radiographic images suggested infraglottic/subglottic edema/narrowing but the endoscopic findings noted diffuse erythema, edema and a laryngeal foreign body ball valving and obstructing the posterior airway. Rigid endoscopy identified a white material wedged in the left ventricle extruding into and obstructing the airway. After removal in two pieces, it was identified as cartilaginous remnants. The surgical management, work up and medical therapy along with a review of literature will be presented.

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Evaluating the Readability of Online Patient Education Materials for Laryngopharyngeal Reflux Daniel Cates, Travis Denna

Objective: To assess the readability of online materials regarding laryngopharyngeal reflux.

Method: We conducted a Google search for “laryngopharyngeal reflux” and the top 50 relevant results were analyzed. Websites were classified into professional-oriented versus patient- oriented resources. Additionally, results were categorized by resource origin including academic medical center, private specialty group, health advice website, and professional medical resource. Each result was evaluated with the following readability tools: Flesch Reading Ease Score (FRES), Gunning Fog Index (GFI), Flesch-Kincaid Grade Level (FKGL), Coleman-Liau Index (CLI), Simple Measure of Gobbledygook (SMOG) index, Automated Readability Index (ARI), and Linsear Write Formula (LWF).

Results: Readability scores for online resources were FRES 49.1 ± 3.3, GFI 12.8 ± 0.9, FKGL 11.1 ± 0.9, CLI 11.6 ± 0.5, SMOG 9.6 ± 0.6, ARI 11.5 ± 1.1, and LWF 11.9 ± 1.4. Readability was significantly more difficult on FRES (P< .00) for professional- oriented vs patient-oriented resources and estimated reading grade levels were significantly higher on GFI (P< .00), FKGL (P<.00), CLI (P< .00), SMOG (P< .00), ARI (P< .00), and LWF (P< .00). Among patient-oriented resources, there was no difference in readability scores between academic medical center, private specialty group, and health advice websites (P> .05).

Conclusion: Online resources pertaining to laryngopharyngeal reflux are written above the recommended reading level for the average American. Professional-oriented websites are more difficult to read than those targeting patients. Readability of patient-oriented websites are similar regardless of resource origin.

Creation and Implementation of a Laryngology Symptom Diary for Trial Vocal Fold Injection Christopher Dwyer, Andree-Anne Leclerc, Vyvy N Young, Clark A Rosen

Objective: Patient recollection of the impact of trial vocal fold injection (VFI) is a crucial factor in determining future treatment. This study describes a new clinical tool, the Laryngology Symptom Diary (LSD), and assesses its clinical value in decision- making after trial VFI.

Method: The LSD allows patients to rate both standardized and customized laryngeal symptoms on a weekly basis. Patients undergoing trial VFI were instructed to complete the diary pre- injection and until their follow- up appointment. Upon follow-up, the patient and laryngologist completed surveys on their experience using the diary.

Results: 15 patients undergoing trial VFI were given the LSD. The diary was completed and returned by 73.3% (n=11) of patients. A median of 6 weeks was recorded (range 4-17 weeks). Of those completing the diary, 72.2% (n=8/11) found it useful in documenting the evolution of their symptoms. From a patient perspective, 45.5% (n=5/11) found the diary useful in determining additional treatment decisions, 36.4% (n=4/11) were neutral, and 18.2% (n=2) did not find the diary of particular help. The treating surgeon noted excellent concordance in diary entries and patient impression of symptoms (100%, n=11/11), and was able to use the diary in recommending subsequent treatment options in 91.1% (n=10/11) of patients.

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Conclusion: The utility of a trial VFI lies in assessing the response (negative, neutral or positive) of vocal fold augmentation on patients’ symptoms. The Laryngology Symptom Diary facilitates patients in tracking the evolution of their symptoms and guides the clinician in subsequent treatment planning.

Amiodarone Induced Vocal Tremor: A Case Study Semirra Bayan, Lindsay Rigelman, Diana Orbelo

Objective: Amiodarone is a drug frequently used to treat cardiac arrhythmia refractory to other medical therapies. With its narrow therapeutic range and prolonged loading phase, administration can be challenging with many known noxious side effects. A myriad of both central and peripheral neurotoxicity has been reported in the literature. Included in this have been a wide range of different types of tremor. Voice tremor, however, has not been reported. We present a patient with an amiodarone induced vocal tremor.

Method: A 69-year-old woman presented to our otolaryngology clinic with complaints of an involuntary expiratory noise and shortness of breath with lying flat and exertion. She was actively being treated for medically refractory atrial fibrillation with amiodarone. Laryngeal symptoms began one month after starting amiodarone. Flexible laryngeal exam demonstrated a tremulous movement of the thyroarytenoid muscles, most notable during exhalation, and a tremor with phonation. Patient also demonstrated mild head tremor.

Results: Evaluation with neurology confirmed amiodarone induced vocal tremor. In coordination with cardiology, amiodarone was discontinued. Patient had persistence of vocal tremor two months after discontinuing amiodarone. Botulinum toxin injections were initiated.

Conclusion: This is the first presentation of amiodarone induced vocal tremor. We discuss the importance of practitioner knowledge of medication induced laryngeal tremor.

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Hypersensitivity to Cymetra After Injection Laryngoplasty: A Case Report

Caitlin Bertelsen, William E Karle, Joshua S Schindler

Objective: Micronized Alloderm (Cymetra, Lifecell Corporation, Branchburg, NJ) is a temporary injectable filler commonly used in injection laryngoplasty (IL). Advantages include biocompatibility, ability to be prepared and injected in-office, and lack of donor site. Few associated complications have been reported. These include two cases of development of submucosal masses within the vocal fold and one case of intralaryngeal99 abscess formation. We describe the first reported case of hypersensitivity to Cymetra after IL. Method: Case report of a hypersensitivity reaction to Cymetra after IL.

Results: Cymetra was prepared according to manufacturer instructions and injected into the left true vocal fold (TVF) with a 23-gauge needle via the trans-thyroid cartilage route. One week later, the patient developed respiratory distress requiring intubation. Direct laryngoscopy demonstrated ecchymosis of the left hemilarynx

Office KTP Laser Revision Laryngoplasty: A Novel Treatment for Glottic Stenosis

Nwanmegha Young

Objective: Glottic stenosis is a narrowing of the airway at the level of the glottis and it is a devastating as well as a very difficult to manage disease. The etiologies of the stenosis include, scarring after intubation (posterior glottis stenosis), bilateral vocal paralysis or radiation. These patients have a comprised airway and many become tracheostomy dependent. Multiple procedures have been described to improve the airway status of patients with glottic stenosis. These include both endoscopic and open techniques however regardless to approach the outcomes have been mixed. Studies have shown a wide range of decannulation rates (25%-65%) from the different approaches. This case series demonstrates a new simple technique applied early in the postoperative period after CO2 laser cordotomies. Treating the surgical wound with the KTP laser fiber before it matures helps to maintain the patency of vocal cord cordotomies and improve decannulation rates.

Method: 10 patients (ages 34-79) with glottic stenosis caused by a variety of etiologies presented with trachesostomy dependency. All underwent microlaryngoscopy with CO2 laser cordotomies in the operating room, Afterwards (average 16.3 days post-operation) all underwent office KTP laser laryngoplasty with debridement of the surgical bed.

Results: All patients tolerated in office laser laryngoplasty. In addition all patients were decannulated.

Conclusion: During the proliferative phase of healing scar tissue begins to form as well as wound contraction occurs. Using the KTP laser fiber during this period to lyse and debride this newly forming tissue can lead to higher rates of decannulation for these patients.

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Tracheocarotid Fistula: A Case Report and Literature review James Forston

Objective: The tracheocarotid fistula is an unusual but devastating complication of tracheostomy. Review of literatures revealed only a couple of cases: one case of tracheocarotid fistula was associated with subglottic laryngeal cancer, another case was associated with cuffed endotracheal tubes. The incidence was approximated to be 0.7%1, and it is uniformly fatal if not recognized and surgically corrected urgently.The purpose of this paper is to describe a case of tracheocarotid fistula occurring in a post trauma patient presenting with hemoptysis and epistaxis.

Method: Retrospective chart review.

Results: The patient had undergone tracheostomy two weeks prior to the incidence. The patient was initially treated by neck exploration with digital compression, followed by angiography with stent placement. Our patient survived but experienced temporary left sided weakness that resolved over the next four weeks, and was transferred to a rehab facility where she continues to recuperate.

Conclusion: We were fortunate in controlling this devastating event because massive hemoptysis from a tracheocarotid fistula is almost always fatal.

Wire-Bristle Grill Brush Injuries in the U.S. and Canada Brad Eichar

Objective: To describe the epidemiology of wire-bristle injury in the United States and Canada.

Method: The National Electronic Injury Surveillance System (NEISS) was utilized to determine a national weighted estimate of emergency department visits for wire-bristle injury in the United States from 1999 to 2018. The electronic Canadian Hospitals Injury Reporting and Prevention Program (eCHIRPP) was used to provide injury statistic data of wire-bristle injury in Canada from 2011 to 2019. Demographics, location of injury, and outcomes were analyzed from both databases. A literature search was utilized as a source of supplementary data.

Results: During the 20-year study period (1999-2018) of NEISS data and 8-year period of eCHIRPP data (2011-2018), we identified a total of 55 patients treated in the emergency department for wire-bristle grill brush related injuries. The literature revealed 41 cases of wire-bristle injury. Cases found in the NEISS database (n=33) extrapolated to an estimated 1,375 (95% confidence interval, 1083-1666) emergency department visits in the U.S. with 45% of these occurring within the last 5 years (n=15). Among both databases, individuals under the age of 19 were most commonly injured (n=28, 51%), and sex distribution was similar (31 males,23 females). The most common site of injury was the oropharynx in the NEISS (n=15, 45%), eCHIRPP (n=15, 68%), and the literature (n=26, 63%). The majority of patients who presented to the ED, were treated and released (n=35, 63%).

Conclusion: Injury from wire-bristle grill brush has not decreased in recent years in North America despite efforts to raise public awareness.

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Retrograde Cricopharyngeus Dysfunction (R-CPD): Long-term symptom relief in a large population via botulinum toxin injection Rebecca Hoesli, Melissa Wingo, Robert Bastian

Objective: To report additional experience with the newly reported syndrome of R-CPD and to report the percentage of persons with this disorder who achieve durable relief of debilitating symptoms after injection of botulinum toxin (BT) into the upper esophageal sphincter.

Method: 225 consecutive, unselected patients were diagnosed with R-CPD as the cause of their inability to belch, chest and abdominal pressure and bloating, socially awkward gurgling noises, and excessive flatulence. All 225 were subsequently treated with botulinum toxin, and 155 have been followed for at least 6 months for response.

Results: 155 patients met the follow up inclusion criteria. Of these, 153 (99%) experienced notable relief of their symptoms after injection with botulinum toxin into the cricopharyngeus muscle. 119 (77%) maintained the ability to burp beyond the expected effect of botulinum toxin. Of those who did not maintain symptom relief after the first injection, all did so after subsequent treatment: nine after an additional injection, one after 2 subsequent injections, one after a 2nd injection and then subtotal myotomy, one after subtotal myotomy, and one patient after 3 injections and then subtotal myotomy. 23 patients have not yet pursued additional treatment after return of symptoms.

Conclusion: In a case series of 155 patients with retrograde cricopharyngeus dysfunction, 77% of patients experience lasting relief of their symptoms after a single injection of botulinum toxin into the cricopharyngeus muscle. The rest can be re- treated for “salvage” of the ability to belch in one of the ways mentioned above.

Dilatational percutaneous tracheostomy under laryngosuspension Ihab Atallah, Mathieu Moulin, Paul Castellanos

Objective: To describe the technique and outcomes of percutaneous tracheostomy under laryngosuspension.

Method: A consecutive series of patients who underwent percutaneous tracheostomy under laryngosuspension were reviewed for outcomes. The procedure is performed under general anesthesia and laryngosuspension. An 8.5 oral endotracheal tube is inserted and the cuff is inflated in the supraglottis, allowing access to the whole trachea and subglottis. The tube is taped to the laryngoscope. A rigid endoscope is inserted in the endotracheal tube through a swivel connector connected to the tube and the ventilation circuit. Percutaneous tracheostomy kit is used to perform dilatational tracheostomy at the desired level of the trachea under direct visual endoscopic control.

Results: Fifty patients underwent percutaneous tracheostomy under laryngosuspension. Fourteen cases were performed in an emergency. In all other cases, tracheostomy was performed as a part of a scheduled procedure affecting the airway or in patients requiring prolonged ventilation. Seventy percent of patients were considered high risk by virtue of one or more of the following: morbid obesity, coagulopathy, prior neck surgery, prior neck radiotherapy, laryngotracheal stenosis, or high ventilator demands. No complications occurred.

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Conclusion: Percutaneous tracheostomy under laryngosuspension has the advantage of optimal control of the patient ventilation and hemostasis throughout the procedure. High quality endoscopic vision and easy access to the airway under laryngosuspension allow tracheostomy to be performed with maximum safety.

Effect of Tracheostomy Timing and Method on 30-Day and 90- Day Survival Christopher Park, Rohini Bahethi, Anthony Yang, Mingyang Gray, Kevin Wong, Alfred Iloreta, Mark Courey

Objectives: The ideal timing and method of tracheostomy varies between patients, and such variations may impact patient outcomes. We aim to examine the association between tracheostomy timing, placement method, and patient characteristics on 30-day survival following discharge.

Method: Kaplan-Meier curves were created for 30-day survival following discharge after tracheostomy, comparing early vs. late (>12 days after intubation) tracheostomy placement, percutaneous vs non-percutaneous method, intensive care unit (ICU) length of stay (LOS), age, gender, race, BMI, and Charlson Comorbidity Index (CCI). Log rank tests were conducted to determine statistical significance. Lastly, Cox proportional hazard models were used to determine multivariable effect of these factors.

Results: Of the 652 records reviewed, 503 had complete data. None of the independent factors were associated with survival on univariate log-rank analysis. However, Cox proportional hazard models showed that ICU LOS >30 days and percutaneous tracheostomy were associated with decreased survival (p=0.02 and 0.01,respectively), and that late tracheostomy was associated with increased survival following discharge (p=0.01).Age, gender, race, CCI, and BMI were not independently associated with survival following discharge.

Conclusion: Patients who receive a percutaneous tracheostomy and have a longer ICU LOS may be at increased risk of mortality in the immediate time period following discharge. Thus, these patients should be identified and stratified for potentially greater follow-up measures and post-discharge care.

Management Considerations for Magnetic Foreign Bodies in the Supraglottic Airway Kevin Kovatch, Shannon D Fayson, S Ahmed Ali, Michelle M Chen, Rosh K V Sethi

Objective: Airway foreign bodies in the pediatric population require thoughtful and time-sensitive management. This study aims to highlight management considerations in cases of magnetic foreign body retrieval.

Method: Case report and review of literature.

Results: We present the illustrative case of a 2-year-old female presenting in minimal respiratory distress following the ingestion of two spherical magnets. Neck X-ray suggested the magnets were paired in the supraglottic larynx (Figure 1). Flexible laryngoscopy was deferred in favor of operating room management with definitive control of the airway via intubation. On direct laryngoscopy, the magnets were confirmed to be in a tenuous position pinned together at the petiole of the epiglottis, suspended over the glottis (Figure 2). Magnetic properties of OR instruments were tested prior to the case. We discuss these findings, as well as airway management considerations including the decision to perform the procedure in the operating room and the decision to intubate prior to retrieval attempts.

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Conclusion: Magnetic foreign bodies present unique challenges, particularly when two or more are ingested simultaneously. Supraglottic foreign bodies require complex management where the risks and benefits of flexible laryngoscopy, bedside awake management, and general anesthesia must be weighed. An understanding the differential ferromagnetism of commonly used operating room instruments is critical to avoid inadvertent displacement of magnetic foreign bodies and achieve a successful outcome.

Retrospective Analysis of Laryngeal Manifestations of Granulomatosis with Polyangiitis Natasha Minaya, Phillip Changhun Song

Objective: To document the specific sites of involvement and correlate them with presenting symptoms and clinical features. Method: A retrospective chart review was performed including all patients with a diagnosis of granulomatosis with polyangiitis (GPA) with laryngeal manifestations.

Results: Forty-four patients (14 male, 30 female) were evaluated for laryngeal manifestations. The mean age at onset was 48 years. We identified 9 patients (21%) with glottic/infraglottic disease, 11 patients (25%) with subglottic disease and 8 patients (18%) with transglottic disease; the remaining 16 patients (36%) had a normal airway upon examination. Hoarseness was the primary symptom in patients with glottic/infraglottic disease. Subglottic disease presented with symptoms related to airway obstruction.

Conclusion: Granulomatosis with polyangiitis involves different subsites within the larynx. The specific site of involvement relates to the presenting symptoms. Glottic/infraglottic disease is related to hoarseness, whereas subglottic disease is related to airway symptoms.

Barriers to decannulation after double-stage laryngotracheal reconstruction Maria Koenigs, Diego Preciado

Introduction/Objective: Double stage laryngotracheal reconstruction (dsLTR) is a major reconstructive technique for children with complex subglottic stenosis. Despite utilizing excellent surgical technique, greater than 10% of children cannot be decannulated after dsLTR. Additionally, many children have a significant delay to time to decannulation after surgery. We aimed to identify any potential social or demographic barriers for decannulation in children undergoing dsLTR beyond the severity of disease itself.

Methods: We performed a retrospective chart review from internal database of 41 identified dsLTR patients from a stand- alone children’s hospital.

Results: Of the identified 41 children who underwent dsLTR, 34 (82%) were able to be decannulated. Age, gender, race, insurance status, medical comorbidity, and multi-level stenosis did not predict decannulation rate (P = 045, P= 0.22, P = 0.22, P= 0.65, P =0.40, and P = 1.0, Fisher). Similarly, insurance status and race did not influence length of hospital stay after procedure (P = 0.95, P = 0.98, Mann-Whitney U) or time to decannulation (P = 0.13, P = 0.56, Log-rank). The only factor that increased length of time to decannulation was the use of both posterior and anterior graft (P = 0.002, Log-rank) compared to a single graft, reflecting the severity of preoperative disease. p.p1

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Conclusion: In a cohort with a similar decannulation rate to previous cohorts we did not observe any major demographic or social barriers that increased risk for decannulation failure or that increased time to decannulation.

Novel management of a posterior cricoid fracture with resorbable plating system Heather Koehn, James Daniero

Objective: Management of an unstable cricoid fracture in the setting of total laryngeal reconstruction is a surgical challenge. Typically a posterior cricoid fracture would be treated with suture reduction or be left to heal by second intention. We propose a novel technique for cricoid fracture reduction in order to improve reduction and stabilization within the airway as well as position segments in the same plane to prevent framework stenosis.

Method: Case Report

Results: We present a case of a 37 y.o. male with blunt laryngeal trauma which included complete laryngofissure, arytenoid dislocation, right vocal fold avulsion, anterior midline cricoid fracture, posterior cricoid midline fracture, as well as anterior first and second tracheal ring fractures. As part of the laryngeal reconstruction, fixation of the cricoid was necessary for stabilization. Utilizing the existing mucosal laceration over the posterior cricoid fracture, subperichondrial flaps were elevated bilaterally. Next a Stryker Delta resorbable 6 hole ladder plate (0.5mm profile) with 5-0 PDS suture was used to fixate the plate to the luminal sides of the cartilage in relative reduction. The mucoperichondrial flaps were approximated with 5-0 chromic suture. The laryngeal reconstruction was closed over a Montgomery laryngeal stent for three weeks. One month after stent removal, the mucosa was healed over the luminal surface with no displacement or extrusion of the plate.

Conclusion: Use of a luminal surface resorbable plating system for the reduction and fixation of a posterior cricoid fracture in the setting of total laryngeal reconstruction proved to be a viable option.

Effect of Treatment with a Selective JAK2 Inhibitor, Fedratinib, on Vocal Fold Scar in Rats Shinji Kaba

Objective: Vocal fold scar remains a major therapeutic challenge. Recently, the involvement of the Janus kinase (JAK)-2 signaling pathway in fibrosis has been reported. JAK2 is a receptor-associated tyrosine kinase that activates signal transducer and activator of transcription 3 (STAT3), which induces the expression of profibrotic genes and promote fibroblast activation. However, the role of the JAK2 pathway in vocal fold fibrosis has not been well documented. The purpose of this study was to investigate the effect of selective JAK2 antagonist (fedratinib) on vocal fold scar formation in rats.

Method: Bilateral vocal fold stripping was performed on Sprague-Dawley rats. At 1, 3, 5, and 7 days after injury, fedratinib or saline was injected into the bilateral thyroarytenoid muscle. The animals were euthanized and their larynges were harvested at 2 months after injury for histological and immunohistochemical analysis of vocal fold lamina propria.

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Results: Histological and immunohistochemical analysis showed a significant reduction in collagen deposition in the vocal fold lamina propria with less tissue contraction in the fedratinib- treated group compared to the sham-treated group.

Conclusion: Our results suggested that selective inhibition of the JAK2 signaling pathway is a potential therapeutic approach for the prevention of vocal fold scarring.

An Unusual Laryngeal Mass in a Child Rachelle Wareham

Objective: Pediatric dysphonia is most commonly caused by vocal nodules. However, it should be kept in mind that this is not always the case, as the differential diagnosis includes multiple other benign lesions as well as more worrisome pathologies that can cause laryngeal obstruction.

Method: This is a case report of a healthy 10 year-old boy who presented with a 3-month history of progressive hoarseness with stridor. The pediatrician initially recommended a trial of allergy medication, but the parent sought evaluation directly in the pediatric ENT clinic.

Results: Transnasal flexible laryngoscopy showed an exophytic, obstructive glottic mass involving the anterior commissure that was initially suspected on the optics of a small pediatric scope to be recurrent respiratory papillomatosis (RRP). However, after operative suspension microlaryngoscopy with biopsy, RRP was ruled out, and pathology showed exuberant granulation tissue most suggestive of a contact ulcer or laryngeal polyp that underwent extreme traumatization. The differential diagnosis for this mass includes autoimmune, infectious, and phonotraumatic etiologies, with possible GERD exacerbation. At the current time, medical evaluation is in process, and repeat laryngoscopy will be done.

Conclusion: This case reiterates published guidelines recommending that children with dysphonia should be evaluated with laryngoscopy.

Does Collaboration with Interpreters Impact Voice Therapy Attendance? Kah Whye Ryan Lim, Lauren F Tracy

Objective: Despite voice therapy being effective treatment for many voice disorders, up to 65% of English- speaking patients do not complete prescribed therapy. Studies evaluating this disconnect have focused on ethnically homogenous, English- speaking patients. In non-English speaking populations, voice therapy requires collaboration with interpreters which may create additional barriers to therapy efficacy and patient participation. The aim of this study is to evaluate factors associated voice therapy attendance in non-English speakers in a diverse safety-net hospital.

Method: Retrospective review of all adult patients from a diverse, safety-net hospital referred to speech language pathology (SLP) treatment for voice disorders from December, 2017 - December, 2018 (n=439). Primary spoken language, use of interpreter (in-person or telephone) and patient demographics were identified from medical records. Univariate and multivariate analysis compared patient factors with voice therapy attendance vs. nonattendance.

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Results: Of 439 patients, 231 (52%) attended therapy, 121 (28%) did not schedule therapy, and 87 (20%) no- showed for scheduled therapy. Patients requiring interpretation (n=143, 33%) and publicly insured (n=324, 75%) were significantly less likely to attend therapy (p=0.05, p=0.04) in univariate comparison. Multivariate comparison revealed public insurance correlated with therapy nonattendance (p=0.04). Patient gender, age, race, and distance from hospital did not correlate with attendance.

Conclusion: Non-English speakers may be less likely to attend voice therapy than English speakers and the use of interpreters may present an additional barrier to participation in voice therapy. Additional investigation into optimizing voice therapy for non-English speakers and collaboration with interpreters is warranted to optimize outcomes and resource allocation.

Novel use of ultrasonic aspirator system for cricoid chondroma resection Neel K Bhatt, William Gao, Lindsay Reder, Karla O’Dell

Objective: Advancements in endoscopic approaches to the larynx have minimized the need for open, transcervical surgery. The ultrasonic aspirator system (Sonopet®) is routinely used for resecting calcified and rigid structures, since it selectively debrides solid tissue (e.g. bone, cartilage) while sparing mucosa. We present two cases of successful resection of cricoid chondroma using the Sonopet via a transoral suspension microlaryngoscopy approach.

Methods: Two patients that underwent transoral resection of cricoid chondroma using the Sonopet were retrospectively reviewed. Indications for surgery, patient factors, and operative technique were analyzed. Pre and post-procedure voice and swallowing indices were compared.

Results: Patients presented with submucosal laryngeal lesions suspected to be cricoid chondromas preoperatively, and a suspension microlaryngoscopy surgical approach was utilized. The overlying mucosa was incised and elevated. An extended length Sonopet was introduced through the laryngoscope to debride the neoplasm. The entirety of the visible mass was resected, and no cases required conversion to an open approach. Pathologic diagnosis was confirmed in both cases. The overlying mucosa was preserved, and the incision was reapproximated using a transoral suturing technique. There were no adverse events, and patients resumed an oral diet postoperatively.

Conclusions: The Sonopet appears to be a safe and useful tool for transoral resection of rigid and calcified masses of the larynx, including cricoid chondroma. For these cases, Sonopet may minimize the need for an open, transcervical approach.

Association Between Quality of Life Questionnaires In Patients With and Without Globus Vyvy Young, Sarah L Schneider, Christopher D Dwyer, Kristiana M Jordan, Clark A Rosen

Objective: Outcomes in laryngology focus primarily on patient reported outcome measures (PROMs). The increasing number of questionnaires may lead to survey fatigue. We sought to determine the relationship between the newest questionnaire, Laryngopharyngeal Universal Measure of Perceived Sensation (LUMP), and other laryngology PROMs.

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Method: Patients undergoing laryngology multidisciplinary evaluation prospectively completed these laryngology questionnaires: VHI-10, RSI, DI, CSI, EAT-10, SVHI-10, and LUMP. Patients with and without globus were compared. For part 1, summative score comparisons were performed. For part 2, individual itemresponses were evaluated.

Results: 124 patients (64 female) were assessed. Average age was 57.3+17.3 years. Thirty-eight patients self- reported globus. For patients with vs without globus, average VHI-10 was 17.95+12.5 vs 12.0+10.5 (p=0.007). Average RSI was 21.58+11.1 vs 11.6+8.4 (p=0.000). Average DI was 11.87+10.9 vs 6.8+10.7 (p=0.018). Average CSI was 11.74+12.2 vs 4.5+7.8 (p=0.001). Average EAT-10 was 15.0+11.9 vs 5.6+8.5 (p=0.000). Average SVHI-10 was 24.28+14.0 vs 15.1+15.3 (p=0.005). Average LUMP was 13.9+7.4 vs 4.6+4.9 (p=0.000). Multivariate ANOVA analyses demonstrated multiple significant associations between specific individual items among all laryngology PROMs. Interestingly DI and CSI had the highest number of significantly correlated individual items with LUMP.

Conclusion: Patients with self-reported globus had statistically significantly higher scores across all PROMs, and multiple individual items across all PROMs showed strong associations on multivariate analyses. These item analysis results bring into question the need for multiple surveys for laryngologic symptoms and should be used to pare down the overall number of questionnaires to decrease survey respondent fatigue.

Predictors of Outcomes Following Outpatient Unilateral Medialization Laryngoplasty Christopher Park, Anthony Yang, Alfred Iloreta

Objective: Previous literature has demonstrated the safety of outpatient unilateral medialization laryngoplasty (ML). The study aims to determine predictors of outcomes following outpatient unilateral ML.

Method: Patients undergoing unilateral ML between 2008 and 2016 in an outpatient setting were identified using ICD-9/10 diagnosis codes for unilateral vocal cord paralysis (478.31,478.32, J38.01) and CPT codes for ML (31588). Patient and provider characteristics were obtained. Multivariable regression was used to assess predictors of hospital admissions within 30 days of discharge and excessive hospitalization charges (>75th percentile).

Results: A total of 700 patients were identified as undergoing unilateral ML. The 30-day hospital admission rate was 2.1%. Baseline patient characteristics, including age, sex, Charlson comorbidity index, race and income did not significantly differ between patients who were hospitalization within 30 days and those who were not. Multivariable logistic regression demonstrated that the sole predictor of 30 days admission was race; specifically, black patients were more likely to be admitted (OR: 7.3, 95% CI: 1.4-36.8, p=0.0158). For hospitalization charges, patients’ incomes in the bottom two quartiles were protective of excessive hospitalization charges (p<0.05).

Conclusion: Short term hospitalization is rare following outpatient ML, suggesting that otolaryngologists are selecting suitable patients for outpatient treatment. However, disparities continue to exist, namely with regards to race.

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Incidence of Tracheoesophageal Puncture and Prosthesis Placement in the Medicare Population From 2012 to 2017 Brooke Su-Velez, Pranati PIllutla, Dinesh Chhetri

Objective: Tracheoesophageal puncture with prosthesis placement (TEP) provides restoration of voice function after total laryngectomy. Studies have reported widely variable rates of TEP after laryngectomy, and there is concern that low rates of TEP can result in suboptimal function. This study examines national trends in TEP placement in the Medicare fee-for-service patient population.

Method: Using the Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use Files containing Medicare part B fee-for-service claims data from 2012 through 2017, we identified the number of beneficiaries undergoing Healthcare Common Procedure Coding System (HCPCS) codes for total laryngectomy as well as TEP each year. TEP placement was divided by inpatient facility versus office or outpatient setting.

Results: There were 1,438 laryngectomies (including with neck dissection and reconstruction) performed in 2012 in this Medicare population, compared to 1,229 in 2017, with a mean of 1,301 each year. On average about 841 TEPs were performed per year, representing 64.8% of laryngectomies. Therefore, 35.3% of patients undergoing laryngectomy do not receive corresponding TEP placement annually. 813 TEPs were performed each year in an inpatient facility (including ambulatory surgery centers), and a mean of 28 TEPs were performed in the office setting per year.

Conclusion: Based on annual Medicare fee-for-service claims, over one-third of patients undergoing total laryngectomy do not undergo TEP placement. This represents an opportunity for improved restoration of voice function via TEP in this population.

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