Laryngeal Inflammation: Diagnosis and Treatment Challenges

Program Description:

Using an interactive format, panelists will discuss epidemiology, symptomatology, and co-morbid conditions contributing to laryngopharyngeal inflammation; diagnosis/differential diagnosis; challenges in diagnosing causative factors; addressing diagnostic challenges to define a treatment plan; current evidence; treatment challenges and impact of co-morbid conditions; and future research and management implications. The panel will consider “real world” patient management algorithms. The audience will help answer the following questions: What are the typical ‘challenges’ in diagnosing laryngopharyngeal inflammation? What diagnostic testing options should be employed? Which after first treatment failure? What are the common treatment pathways? What differential data should be considered? What healthcare costs impact options? When is referral recommended?

Educational Objectives:

1) Describe current practice trends on the diagnosis and management of laryngopharyngeal inflammation. 2) Recognize the common challenges in diagnosing laryngeal inflammation to define appropriate treatment strategies. 3) Evaluate current evidence-based literature supporting current diagnosis and treatment paradigms.

Challenging Cough Cases: A New Frontier in Otolaryngology

Program Description:

Otolaryngologists are playing an increasingly important role in the evaluation and treatment of patients with chronic cough. This miniseminar will involve the use of challenging case presentations, panel discussion, and audience participation to emphasize evidence-based practice and the “state-of-the-art” for patients with chronic cough. Controversial areas will include the concept of prioritization and use of evidence-based protocols, the importance of early diagnosis in value-based healthcare, and basic science mechanisms for inter-relatedness of aerodigestive disease. Also, the costs of care, time to diagnosis and resolution, and underlying risks to the patient will be addressed.

Educational Objectives:

1) Use evidence-based treatment guidelines in the evaluation and treatment of chronic cough. 2) Recite the spectrum of common and uncommon causes with an appreciation of the basic science mechanisms. 3) Evaluate these complex patients, perform a procedure-oriented evaluation, and prescribe appropriate pharmacotherapy at their home institution.

Definition, prevalence and burden of oropharyngeal dysphagia: a serious problem among older adults worldwide and the impact on prognosis and hospital resources

Oropharyngeal dysphagia describes difficulty with eating and drinking. This benign statement does not reflect the personal, social, and economic costs of the condition. Dysphagia has an insidious nature in that it cannot be 'seen' like a hemiplegia or a broken limb. It is often a comorbid condition, most notably of stroke, and many other neurodegenerative disorders. Conservative estimates of annual hospital costs associated with dysphagia run to USD 547 million. Length of stay rises by 1.64 days. The true prevalence of dysphagia is difficult to determine as it has been reported as a function of care setting, disease state and country of investigation. However, extrapolating from the literature, prevalence rises with admission to hospital and affects 55% of those in aged care settings. Consequences of dysphagia include malnutrition, dehydration, aspiration pneumonia and potentially death. The mean cost for an aspiration pneumonia episode of care is USD 17,000, rising with the number of comorbid conditions. Whilst financial costs can be objectively counted, the despair, depression, and social isolation are more difficult to quantify. Both sufferers and their families bear the social and psychological burden of dysphagia. There may be a cost-effective role for screening and early identification of dysphagia, particularly in high-risk populations.

Oropharyngeal dysphagia pathophysiology, complications and science-based interventions

The etiology of oropharyngeal dysphagia can be broad, and includes aging with atrophy, debilitation, stroke, neurodegenerative and muscular diseases, tumor and postsurgical deformity, as well as effects due to medications and drying of the mucosal membranes. Pathophysiology depends on the multiple causative factors, including the cortex and neural connections to generate the swallow, as well as the oropharyngeal musculature. While chronic debilitation and age may result in nutritional deficiency and poor hydration, the other causes generally present with aspiration risk more acutely. Bacteriologically, aspiration pneumonia is usually polymicrobial with a predominance of Gram-negative enteric bacilli. However, there is emerging evidence to suggest that odontogenic sources may complicate the severity of bacterial load. The principles behind science-based interventions are primarily aspiration assessment with bedside evaluation, and ultimately modified barium swallow (videofluoroscopy) or functional endoscopic evaluation of swallowing (with or without sensory testing). Each has its advantages and logistical concerns. Intervention and rehabilitation is unique to the patient's needs, but may include reconditioning and therapy with a speech and language pathologist, and surgical options. The emerging roles of neuroplasticity and external neuromuscular stimulation are also discussed.

Extracts from The Cochrane Library

The “Cochrane Corner” is a quarterly section in the Journal that highlights systematic reviews relevant to otolaryngology– head and neck surgery, with invited commentary to aid clinical decision making. This installment features a Cochrane Review, “Topical Anaesthetic or Vasoconstrictor Preparations for Flexible Fibre-optic Nasal Pharyngoscopy and Laryngoscopy,” that finds no evidence of reduced pain or discomfort for topical treatment prior to endoscopy.

Tracheotomy timing and outcomes in the critically ill

OBJECTIVE

To examine the impact of early tracheotomy in nontrauma patients on duration of mechanical ventilation (MV), intensive care unit (ICU) stay, and overall hospital stay.

DESIGN

Case series with chart review.

SETTING

Tertiary care medical center.

METHODS

A retrospective study was performed for patients undergoing tracheotomy from 2005 to 2010. Demographics; survival; duration of endotracheal intubation, MV, ICU, and overall hospital stay; and incidence of ventilator-associated pneumonia (VAP) were assessed. Tracheotomy was considered early if it was performed by day 7 of MV and late thereafter. Nonparametric statistics were used to compare results from each group.

RESULTS

Of the 592 patients included in the analysis, 128 received tracheotomy early and 464 late. Differences between age, sex, and overall survival were not statistically significant. Duration of MV was 45% less (mean ± standard error: 21.47 ± 1.86 days vs 39.33 ± 1.33 days; P < .001), total ICU stay was shortened by 33% (17.52 ± 1.38 days vs 26.27 ± 0.73 days; P < .001), and length of overall hospital course was reduced by 34% (35.85 ± 2.57 days vs 54.28 ± 1.60 days; P < .001) in the early tracheotomy group. Three patients (2.3%) from the early tracheotomy group developed VAP as compared with 15 (3.2%) from the late group. Duration from tracheotomy to ICU transfer and 30% overall mortality did not differ significantly between groups.

CONCLUSION

Early tracheotomy in ICU patients is associated with earlier ICU discharge, shorter duration of mechanical ventilation, and decreased length of overall hospital stay without affecting mortality.

Challenging Cough Cases: A New Frontier in Otolaryngology

Program Description: Both acute and chronic cough are responsible for a significant portion of all ambulatory medical visits annually (about 3%), over-the-counter self-medication expenses in excess of $3.6 billion in the United States, and impaired quality of life. According to 2007 data, there were more than 27 million visits to all physicians for cough, but that same year otolaryngologists saw a total of only 17 million visits for all diagnoses. This suggests a large unmet need for otolaryngologists to participate in the care of these patients. The diagnosis of cough can be simple or profoundly challenging, and it may be a sentinel indicator of severe underlying disease. The list of diseases that may induce cough is growing, along with an appreciation of their interrelations. For example, the Unified Airway concept supports our long-held observation that the upper and lower airway diseases are closely related. There is also a spectrum of overlapping asthmatic, non-asthmatic, and suppurative pulmonary disease. Gastroesophageal reflux (both distal and proximal LaryngoPharyngeal Reflux), along with neurologic reflexes and aspiration are similarly important. And the complex interplay of neurologic reflexes for cough in the brainstem may result in paradoxical vocal fold motion and disordered breathing. Otolaryngologists are playing an increasingly important role in the multidisciplinary evaluation of these challenging patients, and mastering many procedures associated with cough patients. The spectrum of medical specialists also includes pulmonology and chest physicians, allergy and immunology, gastroenterology, neurology, cardiology, infectious disease, speech and swallowing pathologists, as well as psychiatry. This miniseminar will involve the use of case presentations, panel discussion and audience participation to emphasize evidence-based practice and “state-of-the-art.” Controversial areas will include the inter-relatedness of the disease, the role of speech therapy in disordered breathing, and the importance of early diagnosis in value-based healthcare.

Educational Objectives: 1) Learn the spectrum of common and uncommon causes of chronic cough. 2) Understand evidence-based treatment guidelines in the evaluation and treatment of these patients. 3) Be prepared to participate in interdisciplinary discussion of these patients at their home institution.

Laryngopharyngeal Reflux (LPR)

Program Description: Objective: Develop a working algorithm that effectively eliminates dangerous conditions while efficiently provides reasonable alternatives to address LPR symptoms. Methods: use an audience response system in combination with a structured set of questions directed to the audience. End result: a real world proposed treatment algorithm. White paper. Possible basis for outcomes assessment study. The overall goal of this session is to define current practice trends on the management of laryngopharyngeal reflux (LPR) based on actual audience participation/input, and the consideration of appropriate management for a typical patient. Using an interactive panel format, the moderator will prompt panelists to present a quick review of epidemiology, symptomatology, and co-morbid conditions impacting laryngopharyngeal reflux (LPR); diagnosis/differential diagnosis; current evidence on diagnostic and therapeutic management; and future research and management implications. After laying out background, the moderator/panel will consider real world patient management algorithms.

Educational Objectives: 1) Who is the typical patient presenting with laryngopharyngeal reflux (LPR) in an otolaryngology practice? 2) What diagnostic testing options are or should be employed? What are the common treatment pathways? 3) What differential data should be considered? What health care costs impact diagnosis/treatment? When is referral recommended?

Western Blot Confirmation of the H+/K+-ATPase Proton Pump in the Human Larynx and Submandibular Gland

Objective. The authors have previously demonstrated the H+/K+-ATPase (proton pump) in human larynx and lung glands via immunohistochemistry (IHC). The present hypothesis is that the proton pump is expressed in other seromucinous glands of the digestive tract that can be confirmed by IHC and Western blot analysis.

Study Design. Prospective controlled tissue analysis study.

Setting. Academic medical institution.

Methods. Ten anonymous fresh-frozen donor specimens were obtained, comprising 3 submandibular glands, 4 larynges, and 3 normal stomach specimens for control. Submandibular gland sections were immunostained with 2 monoclonal antibodies selectively reactive with α or β subunits of the H+/K+-ATPase. Western blot analysis was performed on all specimens.

Results. Consistent IHC staining was observed in the submandibular gland specimens for both α and β subunits. Western blot analysis revealed very strong expression for the stomach at 100 kDa, corresponding to the α protein, and weak but notable banding for all larynx and submandibular gland specimens. Similar findings were noted for the 60- to 80-kDa glycosylated β subunit protein, as well as the 52-kDa β subunit precursor for all specimens.

Conclusion. The H+/K+-ATPase (proton) pump is present in the human larynx and submandibular gland although in much lower concentrations than in the stomach. Proton pump involvement in human aerodigestive seromucinous glands may have a role in protecting mucosa from acid environments (local or systemic), explain heightened laryngeal sensitivity in those patients with laryngopharyngeal reflux, and be a site of action for proton pump inhibitor pharmacotherapy.

Dysphagia evaluation and care in the hospital setting: the need for protocolization

Dysphagia accounts for a small portion of hospital admissions but is associated with severe complications. This has been shown to result in longer hospital length of stay and increased risk of mortality with certain other diagnoses. Although there has been much research on causes and interventions for dysphagia, there has been variable impact in actual hospital practice. Also, nonuniform approaches to evaluating patients, such as screening high-risk populations, makes it difficult to measure outcomes of care. This commentary advises a more systematic approach that includes standardized protocols, risk stratification, and screening high-risk patients; makes the case for broadening the classification of dysphagia; and suggests a growing role for adjunctive enteral nutrition in patients with some compromise to swallowing.

The Challenge of Protocols for Reflux Disease

Objectives. Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are very common and controversial diseases. The authors have previously reviewed clinical practice guidelines (CPGs) on reflux disease, and these major consensus statements differ on what constitutes ideal management. The aim is to critically review existing protocols for reflux based on CPG recommendations and to present a refined protocol that may be further used to develop a critical pathway for reflux in ambulatory medical practice.

Study Design. Literature review with discussion.

Methods. A PubMed search was used to identify current clinical protocols or algorithms for reflux disease, and the principal elements of each were compared.

Results. Of the 828 articles identified in the search, 11 met the search criteria. Together with 4 articles previously identified, 15 were analyzed. All protocols discuss the important role of empiric therapy, although with differences in use. Only 5 protocols (33%) were based on systematic review such as CPGs. Eight protocols (53%) used alarm symptoms to prompt a workup. For these patients, upper endoscopy was by far the most common diagnostic method. The use of other modalities varies significantly between protocols. The authors propose a standard protocol based on patient risk factors that employs CPG recommendations and may be used for critical pathway outcomes measures.

Conclusion. There are major differences between existing protocols for reflux disease in the literature, reflecting many clinical controversies. Outcomes of different protocols have not been extensively studied. The authors propose a new protocol that is a synthesis of those reviewed and based on risk stratification.

Odor identification ability and self-reported upper respiratory symptoms in workers at the post-9/11 World Trade Center site

Following the World Trade Center (WTC) collapse on September 11, 2001, more than 40,000 people were exposed to a complex mixture of inhalable nanoparticles and toxic chemicals. While many developed chronic respiratory symptoms, to what degree olfaction was compromised is unclear. A previous WTC Medical Monitoring and Treatment Program study found that olfactory and nasal trigeminal thresholds were altered by the toxic exposure, but not scores on a 20-odor smell identification test.

OBJECTIVES

To employ a well-validated 40-item smell identification test to definitively establish whether the ability to identify odors is compromised in a cohort of WTC-exposed individuals and, if so, whether the degree of compromise is associated with self-reported severity of rhinitic symptoms.

METHODS

The University of Pennsylvania Smell Identification Test (UPSIT) was administered to 99 WTC-exposed persons and 99 matched normal controls. The Sino-Nasal Outcomes Test (SNOT-20) was administered to the 99 WTC-exposed persons and compared to the UPSIT scores.

RESULTS

The mean (SD) UPSIT scores were lower in the WTC-exposed group than in age-, sex-, and smoking history-matched controls [respective scores: 30.05 (5.08) vs 35.94 (3.76); p = 0.003], an effect present in a subgroup of 19 subjects additionally matched on occupation (p < 0.001). Fifteen percent of the exposed subjects had severe microsmia, but only 3% anosmia. SNOT-20 scores were unrelated to UPSIT scores (r = 0.20; p = 0.11).

CONCLUSION

Exposure to WTC air pollution was associated with a decrement in the ability to identify odors, implying that such exposure had a greater influence on smell function than previously realized.

Cough

Both acute and chronic cough are responsible for a significant portion of all ambulatory medical visits annually, over-the-counter self-medication expenses in excess of $3.6 billion in the United States, and impaired quality of life. Yet otolaryngologists only see a small portion of these patients. The diagnosis of cough can be simple or profoundly challenging, and it may be a sentinel indicator of severe underlying disease. The list of diseases that may induce cough is growing, along with an appreciation of their interrelations. These include upper and lower airway diseases, related through the unified airway concept. Gastroesophageal reflux, aspiration, neurologic reflexes, tumor, and systemic diseases are also important. Otolaryngologists are playing an increasingly valuable role in the multidisciplinary approach to these challenging cough patients and master many procedures associated with their evaluation and treatment. There are also leadership opportunities in building coordinated teams to further patient care.

The H+/K+-ATPase (proton) pump is expressed in human laryngeal submucosal glands

OBJECTIVES/HYPOTHESIS

Diagnosis and treatment of gastroesophageal and laryngopharyngeal reflux disease has significantly increased over recent years. The larynx is highly sensitive to the effects of LPRD and is similarly responsive to proton pump inhibitor pharmacotherapy. The hypothesis of the study was that proton pump activity exists in the human larynx and plays a functional role in normal and/or pathological laryngeal tissue.

STUDY DESIGN

Pathological investigation.

METHODS

Two fresh human cadaveric larynges (one male and one female larynx) were obtained as part of an exempt protocol from the Human Subjects Committee and were formalin fixed and paraffin embedded. Banked human stomach tissue was also obtained for use as comparative positive and negative control specimens. Sections were immunostained with monoclonal antibodies reactive with both alpha and beta subunits of the H+/K+-ATPase (proton) pump. Specimens were reviewed for staining pattern and intensity.

RESULTS

Stomach parietal cells (known to produce gastric acid) exhibited strongly positive staining for both the alpha and beta subunits of the proton pump. There was no staining in stomach cells that were not morphologically consistent with the parietal cell. In the human larynx there were strong focal and identical staining patterns in the serous cells and ducts of the minor seromucinous glands by both alpha and beta monoclonals to the proton pump. There was variable staining in the laryngeal epithelium that was thought to be consistent with artifact staining resulting from tissue processing.

CONCLUSION

The H+/K+-ATPase (proton) pump is present in serous cells and ducts of submucosal glands in the human larynx. Proton pump inhibitor pharmacotherapy may have a site of action in seromucinous glands of the human larynx, with possible relevance for patients treated for chronic laryngitis with or without laryngopharyngeal reflux disease.