Laryngeal Blastomycosis, an Unexpected Diagnosis: A Case Report

Isolated laryngeal blastomycosis is an extremely rare entity with few cases described in the medical literature. Nonspecific and chronic presenting symptoms such as dysphonia, dyspnea, dysphagia, and/or cough are described, with isolated reports requiring urgent management related to respiratory distress. We present a case report of a 63-year-old immunocompetent female diagnosed with isolated laryngeal blastomycosis, document the treatment regimen and subsequent clinical course. In view of the rarity of this diagnosis, isolated laryngeal blastomycosis has the potential for clinical and pathologic misdiagnosis. Without an accurate diagnosis, blastomycosis remains untreated and the risk for airway disease progression increases.

Telemedicine and the Interdisciplinary Clinic Model: During the COVID-19 Pandemic and Beyond

The emergence of the novel coronavirus disease 2019 (COVID-19) and the subsequent need for physical distancing have necessitated a swift change in health care delivery. Prior to the COVID-19 outbreak, many institutions utilized an interdisciplinary clinic model including both a laryngologist and a speech-language pathologist for the evaluation of patients with voice, swallowing, and upper airway disorders. To improve access, many providers are pursuing the use of interdisciplinary telemedicine to provide individualized patient-centered care while allowing for physical distancing. The purpose of this commentary is to review the current literature regarding telemedicine in laryngology and speech-language pathology as well as the current and future states of practice for interdisciplinary tele-evaluations.

Upper Esophageal Sphincter Dilation for Recalcitrant Dysphagia Secondary to Dermatomyositis

Dermatomyositis is a rare multisystem autoimmune disorder occasionally accompanied by dysphagia. It is typically treated with immune modulating agents; however, dysphagia is often unresponsive to these. Previous reports have demonstrated the utility of videoflouroscopy and manometry in understanding the etiologies of dysphagia to inform a procedural target, historically the cricopharyngeus muscle. We present a case of dermatomyositis and dysphagia resistant to medical management in a patient found by videoflouroscopy and manometry to have severe oropharyngeal dysphagia, esophageal dysmotility and a cricopharyngeal web. We demonstrate the utility and safety of upper esophageal sphincter dilation by transnasal esophagoscopy even in the setting of multifactorial dysphagia.

Smoking status and symptom burden in surgical head and neck cancer patients

OBJECTIVES/HYPOTHESIS

Head and neck squamous cell carcinoma (HNSCC) patients who smoke are at risk for poor treatment outcomes. This study evaluated symptom burden and clinical, sociodemographic, and psychosocial factors associated with smoking in surgical patients to identify potential targets for supportive care services.

STUDY DESIGN

Cross-sectional survey.

METHODS

Individuals with HNSCC of the oral cavity, larynx, or pharynx were recruited from two cancer centers and completed questionnaires assessing smoking status (never, former, current/recent), patient characteristics, and symptoms before surgery.

RESULTS

Of the 103 patients enrolled, 73% were male, 52% were stage IV, 41% reported current/recent smoking, and 37% reported former smoking. Current/recent smokers were less likely than former smokers to have adequate finances (53% vs. 89%, P = .001) and be married/partnered (55% vs. 79%, P = .03). Current/recent smokers were also more likely than both former and never smokers to be unemployed (49% vs. 40% and 13%, respectively, all P = .02) and lack health insurance (17% vs. 5% and 13%, respectively, all P ≤.04). Fatalistic beliefs (P = .03) and lower religiosity (P =.04) were more common in current/recent than never smokers. In models adjusted for sociodemographic/clinical factors, current/recent smokers reported more problems than former and never smokers with swallowing, speech, and cough (P ≤.04). Current/recent smokers also reported more problems than never smokers with social contact, feeling ill, and weight loss (P ≤ .02).

CONCLUSIONS

HNSCC patients reporting current/recent smoking before surgery have high-risk clinical and sociodemographic features that may predispose them to poor postoperative outcomes. Unique symptoms in HNSCC smokers may be useful targets for patient-centered clinical monitoring and intervention.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:127-133, 2017.

Botulinum toxin treatment of false vocal folds in adductor spasmodic dysphonia: Functional outcomes

OBJECTIVES/HYPOTHESIS

Supraglottic injection of botulinum toxin (Botox) has been described as an effective treatment for adductor spasmodic dysphonia (ADSD). Anecdotal evidence suggests that the patients have little to no breathiness after injection, but no formal longitudinal studies have been carried out to date. The purpose of this study was to examine the voice outcomes in patients with ADSD after supraglottic Botox injection.

STUDY DESIGN

Retrospective case series.

METHODS

Patients with ADSD who were treated with supraglottic Botox injections completed a qualitative self-evaluation of voice function after injection using the percentage of normal function (PNF) scale, a validated, quantitative scale from 0% (no function) to 100% (normal function). Posttreatment voice improvement after injection was determined using a Voice Handicap Index-10 (VHI-10) questionnaire.

RESULTS

A total of 198 supraglottic injections were performed between July 2011 and October 2014. Twenty-five questionnaires were completed. Mean postinjection PNF was 95.0% ± 8.4% and was significantly increased from the preinjection mean PNF (62.5%) ± 22.6% (P < 0.001). The mean best VHI-10 for all injections was 7.23. In 19 of 25 patients (76%), there was no reduction in PNF in the early postinjection period. In the remaining six patients (24%), the decline in mean vocal function was 9.2%.

CONCLUSIONS

Supraglottic Botox injection is an effective treatment for ADSD. Postinjection voice is significantly improved, and the majority of patients do not experience breathy voice/decline in vocal function after injection.

The Validity of Self-reported Recent Smoking in Head and Neck Cancer Surgical Patients

OBJECTIVE

In cancer patients, cigarette smoking causes poorer response to treatment, treatment toxicity, increased risk of recurrence, higher surgical complication rates, and poorer overall survival. As such a significant determinant of patient prognosis, accurate classification of current smoking status is important. Self-reported smoking status may lead to misclassification if patients conceal their true status. The purpose of this study was to assess the validity of self-reported tobacco use during the previous 48 hours in head and neck cancer patients on the day of surgery.

STUDY DESIGN

Cross-sectional.

SETTING

Two academic medical centers in the southeastern United States.

SUBJECTS AND METHODS

On the day of surgery, 108 head and neck cancer patients completed a survey asking about tobacco use during the past 48 hours and had semi-quantitative levels of urinary cotinine measured to biochemically validate self-reported recent smoking.

RESULTS

Self-reported smoking yielded a sensitivity of 60.9% (95% CI, 45.4%-74.9%) and a specificity of 98.4% (95% CI, 91.3%-100.0%). The sensitivity increased to 76.1% (95% CI, 61.2%-87.4%) when allowing for the possibility that exposure to secondhand smoke or use of nicotine-containing products could have caused a positive cotinine test.

CONCLUSION

In this patient population, self-reported recent smoking yielded a high (39%) proportion of false-negatives, and even 24% remained false-negatives after allowing for other sources of nicotine exposure. This magnitude of underreporting combined with the importance of tobacco use to patient prognosis supports the need for routinely biochemically verifying recent tobacco use in self-reported nonsmokers within the clinical setting.

Tobacco use and surgical outcomes in patients with head and neck cancer

BACKGROUND

Tobacco use is a risk factor for head and neck cancer, but effects on postoperative outcomes are unclear.

METHODS

Patients with head and neck cancer (n = 89) were recruited before surgery. We assessed self-reported tobacco use status (never, former, or current) at study entry and recent tobacco exposure via urinary cotinine on surgery day. Outcomes included hospital length of stay (LOS) and complications.

RESULTS

Most participants reported current (32.6%) or former (52.8%) tobacco use; 43.2% were cotinine-positive on surgery day. Complications occurred in 41.6% and mean LOS was 4.0 and 8.8 days in patients who received low and high acuity procedures, respectively. Current and former smokers were over 6 times more likely to have complications than never smokers (p = .03). For high acuity procedures, LOS was increased in current (by 4.4 days) and former smokers (by 2.3 days; p = .02).

CONCLUSION

Tobacco use status is associated with postoperative complications and may distinguish at-risk patients.

Voice Outcomes After Endoscopic Treatment of Laryngotracheal Stenosis

Objective:

This study aimed to assess vocal disability in patients with laryngotracheal stenosis who are managed with endoscopic surgery, comparing patients with posterior glottic stenosis (PGS) to those with subglottic or tracheal stenosis (SGS/TS).

Methods:

Patients who underwent endoscopic treatment for laryngotracheal stenosis with voice outcomes data from 2005 to 2013 were studied. The mean Voice Handicap Index–10 (VHI-10) was compared over the study period. Of those with SGS/TS, the distance from the vocal folds to the proximal portion of the stenosis was obtained and compared to VHI-10.

Results:

Forty-four patients met inclusion criteria. The mean VHI-10 for all patients was 14.6. Fifty percent were dysphonic (VHI-10 > 11). The mean VHI-10 for PGS patients was 22.4, and for SGS/TS patients, 10.9 ( P = .004). Of those with PGS, 78.6% were dysphonic compared to only 36.7% of those with SGS/TS. Voice Handicap Index–10 improved from 14.1 for those with proximal stenosis to 4 for those with stenosis more than 2 cm distal to the vocal folds.

Conclusion:

Following endoscopic management of stenosis, those with PGS have poorer voice outcomes compared to those with SGS/TS. The majority of those with SGS/TS are not dysphonic. Vocal outcomes are greatest for those with stenosis beginning at least 2 cm distal to the vocal folds.

Disposition of elderly patients after head and neck reconstruction

IMPORTANCE

A patient's needs at discharge, particularly the need for nursing facility placement, may affect hospital length of stay and health care costs. The association between age and disposition after microvascular reconstruction of the head and neck has yet to be reported in the literature.

OBJECTIVE

To determine whether elderly patients are more likely to be discharged to a nursing or other care facility as opposed to returning home after microvascular reconstruction of the head and neck.

DESIGN, SETTING, AND PARTICIPANTS

From January 1, 2001, through December 31, 2010, patients undergoing microvascular reconstruction at an academic medical center were identified and their medical records systematically reviewed. During the study period, 457 patients were identified by Current Procedural Terminology codes for microvascular free tissue transfer for a head and neck defect regardless of cause. Seven patients were excluded for inadequate data on the postoperative disposition or American Society of Anesthesiologists (ASA) score. A total of 450 were included for analysis.

MAIN OUTCOMES AND MEASURES

Demographic and surgical data were collected, including the patient age, ASA score, and postoperative length of stay. These variables were then compared between groups of patients discharged to different posthospitalization care facilities.

RESULTS

The mean age of participants was 59.1 years. Most patients (n = 386 [85.8%]) were discharged home with or without home health services. The mean age of those discharged home was 57.5 years; discharge to home was the reference for comparison and odds ratio (OR) calculation. For those discharged to a skilled nursing facility, mean age was 67.1 years (OR, 1.055; P < .001). Mean age of those discharged to a long-term acute care facility was 71.5 years (OR, 1.092; P = .002). Length of stay also affected the disposition to a skilled nursing facility (OR, 1.098), as did the ASA score (OR, 2.988).

CONCLUSIONS AND RELEVANCE

Elderly patients are less likely to be discharged home after free flap reconstruction. Age, ASA score, and length of stay are independent factors for discharge to a nursing or other care facility.

Cotinine Level in Head and Neck Cancer Patients: An Objective Measure of Tobacco Use

Objectives:

1) Compare the prevalence of tobacco use in preoperative head and neck cancer patients as assessed by urinary cotinine and self-report. 2) Consider the importance of accurate measurement of tobacco use in pre-operative head and neck cancer surgical patients and potential implications for clinical interventions.

Methods:

Patients with squamous cell carcinoma of the upper aerodigestive tract undergoing a major head and neck surgical procedure were recruited from two academic medical centers from May 2011 to November 2012. We assessed preoperative tobacco exposure by self-report and urinary cotinine using a semiquantitative test strip.

Results:

We recruited 112 patients (mean age 59); 72.3% male, 82.1% white, 76.5% stages III-IV. The prevalence of tobacco use in the 48 hours prior to surgery was higher when assessed by urinary cotinine (41.1%) when compared to self-report (25.9%) (McNemar’s exact test, P < 0.0001). Sensitivity of self-reported tobacco use was 60.9% and specificity was 98.5%. Of those who denied tobacco use prior to surgery (N = 83), 18 (21.7%) had a positive urinary cotinine and 14 (16.9%) reported second-hand smoke exposure. There were no significant associations between second-hand exposure, gender, cancer stage, or prior treatment and positive cotinine.

Conclusions:

Accurate measurement of tobacco use is critical to care provision and intervention development for head and neck cancer patients. Self-report may fail to identify a significant number of tobacco users. Future analysis in this study will examine relationships among self-reported tobacco use, cotinine level, and postoperative outcomes including length of stay and wound infection.

Total serum immunoglobulin E as a marker for missed antigens on in vitro allergy screening

BACKGROUND

The diagnosis of inhalant allergies involves a medical history, physical exam, and allergen sensitivity testing; allergen sensitivity can be assessed by a specific immunoglobulin E (IgE) screen for inhalant allergens. Some patients with clinical suspicion for inhalant allergies have a negative specific IgE screen, but high total IgE. We theorize that elevated total IgE may indicate a false-negative screen caused by "missed allergens" not initially identified.

METHODS

Study patients with a negative allergy screen and elevated IgE (>116 kU/L) were identified (n = 26). Control patients (n = 26) were defined as having a negative screen and an IgE <2.95 kU/L. Both groups were tested with an expanded specific IgE panel and completed a questionnaire about other causes of elevated IgE.

RESULTS

The expanded panel was positive for inhalant allergens in 4 study patients (15%) and 0 control patients (p = 0.037). Within the study patients, 50% had asthma and 76.9% had chronic sinusitis. Only 2 control patients had asthma (11.5%), p = 0.003; 4 (19.2%) reported chronic sinusitis, p < 0.0001. Food allergen sensitivity was identified in 5 study patients and 1 control, p = 0.083.

CONCLUSION

This pilot study evaluated patients clinically suspected of allergy with a negative inhalant IgE screen. Those with a high total IgE were more likely to have a missed inhalant allergen on expanded testing, as well as asthma and chronic sinusitis, compared to those with a low total IgE. Further investigation of "missed antigen" and the role of chronic respiratory inflammatory disease in patients with elevated total IgE is warranted.

Validating Tobacco Use with Cotinine in Cancer Patients

Objective: Tobacco use may be a risk factor for poor outcomes following surgery for head and neck cancer patients. We sought to determine the prevalence of tobacco exposure prior to head and neck surgery using both patient report and urinary cotinine.

Method: Patients with squamous cell carcinoma of the upper aerodigestive tract undergoing a major head and neck procedure were recruited from 2 academic medical centers from 2011 to date. We assessed preoperative tobacco use by self-report and by cotinine level, a nicotine metabolite, in urine using a semiquantitative test strip.

Results: We have recruited 49 patients to date (mean age, 60 years), 71.4% male, 85.7% non-Hispanic white, 60.0% stages III-IV. In the 48 hours before surgery, 11 patients (22.5%) reported tobacco use; 18 (36.7%) were identified by intraoperative urine cotinine. In sum, 57.1% of women and 28.6% of men tested positive for cotinine ( P = .06). Of those who denied tobacco use, 7 out of 38 (18.4%) were positive for cotinine (>2); sensitivity for self-report was 61.1%. Secondhand exposure was reported by 6 of 38 (15.8%) nonusers, 2 being cotinine positive. There was no association between secondhand exposure and positive cotinine (Fisher’s Exact, P = .30).

Conclusion: Tobacco is a major risk factor for head and neck cancer. The use of a urine cotinine screening test demonstrated that self-report may fail to identify a significant number of tobacco users. Implementation of cotinine screening could facilitate precise understanding of tobacco use patterns and opportunities for intervention.

Diagnostic radiation and the risk of multiple myeloma (United States)

OBJECTIVE

To evaluate the relationship between cumulative lifetime exposure to diagnostic radiation and the risk of multiple myeloma using data from a large, multi-center, population-based case-control study.

METHODS

Study subjects included a total of 540 cases with newly diagnosed multiple myeloma and 1998 frequency-matched population controls living in three areas of the United States (Georgia, Michigan, New Jersey). Information on exposure to diagnostic X-rays was obtained by personal interview.

RESULTS

No association was found between case-control status and the total number of reported diagnostic X-rays of any type (odds ratio (OR) for 20 or more compared to less than 5 X-rays = 0.9, 95% confidence interval (95% CI) = 0.7-1.2). There was no evidence of an excess risk of multiple myeloma among individuals who reported exposure to 10 or more diagnostic X-rays that impart a relatively high radiation dose to the bone marrow, as compared to individuals reporting no such exposures (OR 0.7, 95% CI 0.4-1.3).

CONCLUSIONS

These data suggest that exposure to diagnostic X-rays has a negligible impact, if any, on risk of developing multiple myeloma.

Genetic and developmental analysis of abdominal pigmentation differences across species in the Drosophila dunni subgroup

Abdominal pigmentation pattern varies dramatically among the species of the Drosophila dunni subgroup across the islands of the Caribbean. Previously, we developed a quantitative measure of abdominal pigmentation to assess phenotypic variation within and between species of this group. In this paper, we use this quantitative measure in an interspecific genetic analysis to decipher the underlying genetic basis of pigmentation differences between one of the lightest and the darkest species in the group. Our analysis shows that pigmentation expression in different areas of the abdomen is under separate genetic control. For these different abdominal regions, we detected a wide range of genetic effects, including X-linked, autosomal additive, near single-gene dominant, and sex-specific effects. Combining these genetic results with our earlier phenotypic and phylogenetic analyses, we present a simple conceptual model to explain how change in the control of expression of pigmentation has evolved throughout the D. dunni subgroup.

Evolution of abdominal pigmentation differences across species in the Drosophila dunni subgroup

The Drosophila dunni subgroup displays a nearly perfect latitudinal cline in abdominal pigmentation that likely resulted from selective forces acting in the habitat of each species during speciation. Here we characterize the nature of this clinal variation by developing a quantitative measure to assess variation in abdominal pigmentation within and between the D. dunni subgroup species. Using discriminant analysis, we confirm the existence of a cline and find that our quantitative measure of pigmentation distinguishes each of the species with singular efficacy. We then combine our quantitative phenotypic analysis of pigmentation with the phylogeny of the D. dunni subgroup species and map the species relationships into the three-dimensional morphological space defined by our pigmentation measures. In this manner, we can visualize how the species have traversed the morphological pigmentation space during the course of speciation. Our analysis reveals that natural selection has caused overall intensity of pigmentation among the northernmost species of the cline to converge. Along with this convergence in phenotype has been a relaxation in expression of sexual dimorphism in these species, indicating a possible shift in the relative intensity of natural and sexual selection. Our analysis indicates an accelerated rate of change in pigmentation for the darkest species in addition to this species evolving a novel abdominal pigmentation trait.