Philip A. Weissbrod

Background: Throat and airway symptoms are common, but only a small proportion are reflux‐related. The term “laryngopharyngeal reflux” has variable definitions in the literature and has been used to describe symptomatic patients with or without objective reflux, often leading to prolonged/unnecessary treatment trials. Purpose: The San Diego consensus introduced the term laryngopharyngeal symptoms (LPS) to describe upper aerodigestive symptoms with potential relationship to reflux physiology, including cough, regurgitation, throat pain, throat clearing, excess phlegm, and hoarseness/voice change. This review describes presentation, health care burden and risk stratification of throat and airway symptoms in light of the San Diego consensus definitions and clinical approach. Laryngopharyngeal reflux disease (LPRD) requires objective evidence of pathologic reflux in addition to LPS. Importantly, LPS alone do not predict LPRD. While various validated patient‐reported outcome instruments are available, only some are LPS/LPRD‐specific, and all lack specificity for making a diagnosis of LPRD. These instruments may have value in tracking symptoms over time and post‐treatment. Concurrent typical reflux symptoms may prompt empiric anti‐reflux medication trials as initial therapy. Risk stratification scores have been developed for the purpose of directing upfront therapy for high‐risk patients and investigation for intermediate/low‐risk patients, but their clinical use needs further validation. Objective diagnosis of LPRD provides confidence in escalation of reflux interventions. Life‐threatening long‐term sequelae are infrequent in LPS/LPRD, although impact on quality of life and healthcare burden can be profound.

Objectives: A clinical swallow evaluation (CSE) is a subjective exam with limited diagnostic accuracy. We hypothesize that audiometric data collected superficially can enhance the detection of swallowing dysfunction. This study examines audiometric differences between normal and dysfunctional swallows on Flexible Endoscopic Evaluation of Swallowing (FEES) using a digital stethoscope. Methods: In this single‐center prospective study, adult patients undergoing FEES for dysphagia had a digital stethoscope placed on the left neck. Audiometric data were analyzed by consistency and compared to Penetration‐Aspiration Scale (PAS) and Yale Pharyngeal Residue Severity Rating Scale (YPS) scores. Results: Forty‐nine patients with a total of 617 individual swallow events were included. Twenty‐two patients (45%) had a PAS score of 1–2, 20 (41%) had a PAS score of 3–5, and 7 (14%) had a score of PAS 6–8. Multivariable analysis revealed significant differences in swallow duration ( F = 4.65; p = 0.01), peak amplitude ( F = 10.6; p < 0.0001), area under the curve ( F = 6.13; p = 0.002), and median frequency ( F = 8.52; p = 0.0002). Patients with PAS ≥ 3 had prolonged swallow (5.4 s versus 3.3 s, p < 0.0001), lower peak amplitudes (0.25 dB versus 0.32 dB; p < 0.001), and a lower median frequency (169.4 Hz versus 214.8 Hz; p < 0.0001) compared to those with PAS 1–2. Higher YPS scores (III–V) were associated with a longer swallow duration (5.5 s versus 3.5 s, p < 0.0001) and lower median frequency (158.1 Hz versus 221.1 Hz; p = 0.0005). Conclusion: Audiometric data reveals significant differences in swallow duration, amplitude, and frequency in patients with swallow dysfunction. These findings suggest that audiometric analysis may serve as a valuable adjunct to the standard CSE. Level of Evidence: 3.

INTRODUCTION: The term laryngopharyngeal reflux (LPR) is frequently applied to aerodigestive symptoms despite lack of objective reflux evidence. The aim of this initiative was to develop a modern care paradigm for LPR supported by otolaryngology and gastroenterology disciplines. METHODS: A 28-member international interdisciplinary working group developed practical statements within the following domains: definition/terminology, initial diagnostic evaluation, reflux monitoring, therapeutic trials, behavioral factors and therapy, and risk stratification. Literature reviews guided statement development and were presented at virtual/in-person meetings. Each statement underwent 2 or more rounds of voting per the RAND Appropriateness Method; statements reaching appropriateness with ≥80% agreement are included as recommendations. RESULTS: The term laryngopharyngeal symptoms (LPS) applies to aerodigestive symptoms with potential to be induced by reflux and include cough, voice change, throat clearing, excess throat phlegm, and throat pain. Laryngopharyngeal reflux disease (LPRD) refers to patients with LPS and objective evidence of reflux. Importantly, the presence of LPS does not equate to LPRD. Laryngoscopy has value in assessing for nonreflux laryngopharyngeal processes, but laryngoscopic findings alone cannot diagnose LPRD. LPS patients should be categorized as with or without concurrent esophageal reflux symptoms. While lifestyle modification and empiric trials of acid suppression ± alginates are appropriate when esophageal reflux symptoms coexist, upper endoscopy and ambulatory reflux monitoring are required for LPRD diagnosis when symptoms persist, when LPS is isolated, or when management needs to be escalated to include invasive antireflux management. The two recommended ambulatory reflux monitoring modalities, 24-hour pH-impedance and 96-hour wireless pH monitoring, are not mutually exclusive with distinct roles for the evaluation of LPS. Laryngeal hyperresponsiveness and hypervigilance commonly contribute to both LPS and LPRD presentations and are responsive to laryngeal recalibration therapy and neuromodulators. DISCUSSION: The San Diego Consensus represents the formal modern-day interdisciplinary care paradigm to evaluate and manage LPS and LPRD.

Concentric tube robots (CTRs) are well-suited to address the unique challenges of minimally invasive surgical procedures due to their small size and ability to navigate highly constrained environments. However, uncertainties in the manufacturing process can lead to challenges in the transition from simulated designs to physical robots. In this work, we propose an end-to-end design workflow for CTRs that considers the oftenoverlooked impact of manufacturing uncertainty, focusing on two primary sources — tube curvature and diameter. This comprehensive approach incorporates a two-step design optimization and an uncertainty-based selection of manufacturing tolerances. Simulation results highlight the substantial influence of manufacturing uncertainties, particularly tube curvature, on the physical robot's performance. By integrating these uncertainties into the design process, we can effectively bridge the gap between simulation and real-world performance. Two hardware experiments validate the proposed CTR design workflow. The first experiment confirms that the performance of the physical robot lies within the simulated probability distribution from the optimization, while the second experiment demonstrates the feasibility of the overall system for use in micro-laryngeal surgical tasks. This work not only contributes to a more comprehensive understanding of CTR design by addressing manufacturing uncertainties, but also creates a new framework for robust design, as illustrated in the context of microlaryngeal surgery

Objective: To characterize presentation, disease course, and treatment of idiopathic subglottic stenosis (iSGS) in non‐Caucasian women and compare this cohort to the predominantly female, Caucasian patient cohorts identified in the literature.Study Design: Retrospective review. Results are compared to systematic review of demographics.Setting: Multiple California institutions from 2008 to 2021.Methods: Patients with intubation within 2 years of disease or who met exclusion criteria listed in prior publications were excluded. A systematic review of iSGS patient demographics was also completed for comparison.Results: Of 421 patients with iSGS, 58 self‐identified as non‐Caucasian women, with 50 ultimately included. Mean age of onset was 45.1 years old (95% confidence interval [CI], 41.5‐48.8), and mean age at diagnosis was 47.2 years (95% CI, 43.6‐50.7). Mean Charlson comorbidity index was 1.06 (n = 49, 95% CI, 0.69‐1.44). At diagnosis, Cotton‐Meyer severity scores (documented in n = 45) were Cotton‐Myer (CM) I (28.9%), CM II (40%), and CM III (31.1%). Mean age at first endoscopic surgery was 47.7 (95% CI, 44.2‐51.3) years. 64% experienced disease recurrence with a median of 11 months between their first and second surgery. Our systematic review identified 60 studies that reported demographic features in patients with iSGS. 95% of pooled patients were Caucasian, while other demographic features were similar to the current cohort.Conclusion: The non‐Caucasian population, almost 14% of this Californian cohort, does not differ from the majority Caucasian population detailed in contemporary literature. This cohort supports the presence of some racial and ethnic heterogeneity in this disease population.

Objective: To examine the impact of increased body mass index (BMI) on (1) tracheotomy timing and (2) short‐term surgical complications requiring a return to the operating room and 30‐day mortality utilizing data from the Multi‐Institutional Study on Tracheotomy (MIST).Methods: A retrospective analysis of patients from the MIST database who underwent surgical or percutaneous tracheotomy between 2013 and 2016 at eight institutions was completed. Unadjusted and adjusted logistic regression analyses were used to assess the impact of obesity on tracheotomy timing and complications.Results: Among the 3369 patients who underwent tracheotomy, 41.0% were obese and 21.6% were morbidly obese. BMI was associated with higher rates of prolonged intubation prior to tracheotomy accounting for comorbidities, indication for tracheotomy, institution, and type of tracheostomy (p = 0.001). Morbidly obese patients (BMI ≥35 kg/m²) experienced a longer duration of intubation compared with patients with a normal BMI (median days intubated [IQR 25%–75%]: 11.0 days [7–17 days] versus 9.0 days [5–14 days]; p < 0.001) but did not have statistically higher rates of return to the operating room within 30 days (p = 0.12) or mortality (p = 0.90) on multivariable analysis. This same finding of prolonged intubation was not seen in overweight, nonobese patients when compared with normal BMI patients (median days intubated [IQR 25%–75%]: 10.0 days [6–15 days] versus 10.0 days [6–15 days]; p = 0.36).Conclusion: BMI was associated with increased duration of intubation prior to tracheotomy. Although morbidly obese patients had a longer duration of intubation, there were no differences in return to the operating room or mortality within 30 days.Level of Evidence: 3 Laryngoscope, 134:4674–4681, 2024

INTRODUCTION: Laryngopharyngeal symptoms such as cough, throat clearing, voice change, paradoxic vocal fold movement, or laryngospasm are hyper-responsive behaviors resulting from local irritation (e.g., refluxate) and heightened sympathetic tone. Laryngeal recalibration therapy (LRT) guided by a speech-language pathologist (SLP) provides mechanical desensitization and cognitive recalibration to suppress hyper-responsive laryngeal patterns. The aim of this study was to assess symptom response to LRT among patients with chronic laryngopharyngeal symptoms undergoing evaluation of gastroesophageal reflux disease (GERD). METHODS: Adults with chronic laryngopharyngeal symptoms referred for evaluation of GERD to a single center were prospectively followed. Inclusion criteria included ≥2 SLP-directed LRT sessions. Data from endoscopy, ambulatory reflux monitoring, and patient-reported outcomes were collected when available. The primary outcome was symptom response. RESULTS: Sixty-five participants completed LRT: mean age 55.4 years (SD 17.2), 46 (71%) female, mean body mass index 25.6 kg/m² (6.8), and mean of 3.7 (1.9) LRT sessions. Overall, 55 participants (85%) met criteria for symptom response. Specifically, symptom response was similar between those with isolated laryngopharyngeal symptoms (13/15, 87%) and concomitant laryngopharyngeal/esophageal symptoms (42/50, 84%). Among participants who underwent reflux monitoring, symptom response was similar between those with proven, inconclusive for, and no GERD (18/21 [86%], 8/9 [89%], 10/13 [77%]). DISCUSSION: Eighty-five percent of patients with chronic laryngopharyngeal symptoms referred for GERD evaluation who underwent LRT-experienced laryngeal symptom response. Rates of symptom response were maintained across patients with or without proven GERD and patients with or without concomitant esophageal reflux symptoms. SLP-directed LRT is an effective approach to incorporate into multidisciplinary management of chronic laryngopharyngeal symptoms/laryngopharyngeal reflux disease.

Importance: Tracheotomies are frequently performed by nonotolaryngology services. The factors that determine which specialty performs the procedure are not defined in the literature but may be influenced by tracheotomy approach (open vs percutaneous) and other clinicodemographic factors.Objective: To evaluate demographic and clinical characteristics associated with tracheotomies performed by otolaryngologists compared with other specialists and to differentiate those factors from factors associated with use of open vs percutaneous tracheotomy.Design, Setting, and Participants: This multicenter, retrospective cohort study included patients aged 18 years or older who underwent a tracheotomy for cardiopulmonary failure at 1 of 8 US academic institutions between January 1, 2013, and December 31, 2016. Data were analyzed from September 2022 to July 2023.Exposure: Tracheotomy.Main Outcomes and Measures: The primary outcome was factors associated with an otolaryngologist performing tracheotomy. The secondary outcome was factors associated with use of the open tracheotomy technique.Results: A total of 2929 patients (mean [SD] age, 57.2 [17.2] years; 1751 [59.8%] male) who received a tracheotomy for cardiopulmonary failure (652 [22.3%] performed by otolaryngologists and 2277 [77.7%] by another service) were analyzed. Although 1664 of all tracheotomies (56.8%) were performed by an open approach, only 602 open tracheotomies (36.2%) were performed by otolaryngologists. Most tracheotomies performed by otolaryngologists (602 of 652 [92.3%]) used the open technique. Multivariable regression analysis revealed that self-reported Black race (odds ratio [OR], 1.89; 95% CI, 1.52-2.35), history of neck surgery (OR, 2.71; 95% CI, 2.06-3.57), antiplatelet and/or anticoagulation therapy (OR, 1.74; 95% CI, 1.29-2.36), and morbid obesity (OR, 1.54; 95% CI, 1.24-1.92) were associated with greater odds of an otolaryngologist performing tracheotomy. In contrast, history of neck surgery (OR, 1.36; 95% CI, 0.96-1.92), antiplatelet and/or anticoagulation therapy (OR, 0.80; 95% CI, 0.56-1.14), and morbid obesity (OR, 0.94; 95% CI, 0.74-1.19) were not associated with undergoing open tracheotomy when performed by any service, and Black race (OR, 0.56; 95% CI, 0.44-0.71) was associated with lesser odds of an open approach being used. Age-adjusted Charlson Comorbidity Index score greater than 4 was associated with greater odds of both an otolaryngologist performing tracheotomy (OR, 1.26; 95% CI, 1.03-1.53) and use of the open tracheotomy technique (OR, 1.48, 95% CI, 1.21-1.82).Conclusions and Relevance: In this study, otolaryngologists were significantly more likely than other specialists to perform a tracheotomy for patients with history of neck surgery, morbid obesity, and ongoing anticoagulation therapy. These findings suggest that patients undergoing tracheotomy performed by an otolaryngologist are more likely to present with complex and challenging clinical characteristics.

Complete subglottic stenosis is often managed with surgical resection. However, involvement of the high subglottis can limit candidacy for open resection, and there are few treatment options for these patients. We refined an endoscopic approach that evolved into a tracheal rendezvous technique with T-tube placement as an alternative to open surgical resection. Here, we present our series, technique, and outcomes. A retrospective review was performed to identify patients who underwent endoscopic management of complete high subglottic stenosis at the University of California San Diego. The surgical technique was initially a two-step staged procedure and was subsequently revised to a single-stage procedure with stenosis ablation, dilation, and insertion of a T-tube, which was completed in one day. Patients were seen at regular follow-up intervals for reassessment. Five patients were identified with complete stenosis not amenable to surgical resection. The average age of the cohort was 44.8 years. The etiology of stenosis in all patients was related to prolonged intubation and tracheostomy, and the average length of stenosis was 19.6 mm. Stenosis resection was accomplished via laser ablation and balloon dilation, and the average T-tube length was 50.3 mm. All patients were discharged on postoperative day one. Two patients developed airway crusting within the T-tube and required emergency department visits. Decannulation was attempted in three patients, although failed in two. Tracheal rendezvous is a safe and effective procedure for patients with grade IV subglottic stenosis. This provides a feasible endoscopic alternative to patients who are not candidates for open surgical resection, ye are motivated to have phonatory capacity.

Objective: Swallowing is a complex neuromuscular task. There is limited spatiotemporal data on normative surface electromyographic signal during swallow, particularly across standard textures. We hypothesize the pattern of electromyographic signal of the anterior neck varies cranio‐caudally, that laterality can be evaluated, and categorization of bolus texture can be differentiated by high‐density surface electromyography (HDsEMG) through signal analysis.Methods: An HDsEMG grid of 20 electrodes captured electromyographic activity in eight healthy adult subjects across 240 total swallows. Participants swallowed five standard textures: saliva, thin liquid, puree, mixed consistency, and dry solid. Data were bandpass filtered, underwent functional alignment of signal, and then placed into binary classifier receiver operating characteristic (ROC) curves. Muscular activity was visualized by creating two‐dimensional EMG heat maps.Results: Signal analysis results demonstrated a positive correlation between signal amplitude and bolus texture. Greater differences of amplitude in the cranial most region of the array when compared to the caudal most region were noted in all subjects. Lateral comparison of the array revealed symmetric power levels across all subjects and textures. ROC curves demonstrated the ability to correctly classify textures within subjects in 6 of 10 texture comparisons.Conclusion: This pilot study suggests that utilizing HDsEMG during deglutition can noninvasively differentiate swallows of varying texture noninvasively. This may prove useful in future diagnostic and behavioral swallow applications.Level of Evidence: 4 Laryngoscope, 133:2695–2703, 2023