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Human Papillomavirus and the Epidemiology of Head and Neck Cancer

Key Points Human papillomavirus (HPV) is a sexually transmitted pathogen that is etiologically responsible for a growing subset of oropharyngeal squamous cell carcinomas (OPSCC). HPV-related OPSCC (HPV-OPSCC) patients more often present with small primary-site disease and lymph node involvement when compared to patients with HPV-unrelated OPSCC. They tend to have fewer comorbidities and are less likely to have a heavy smoking history. Patients with HPV-OPSCC have…

Biology of Head and Neck Cancers

Key Points Molecular mechanisms underlying head and neck squamous cell carcinomas (HNSCCs) are opportunities for targeted therapeutics. Tobacco and human papilloma virus (HPV), risk factors for HNSCCs, impart genomic patterns; for example, mutation rates are higher for tobacco-associated tumors compared to HPV-associated tumors. Genetic mutations can be broadly grouped in major pathways: cell cycle (TP53, CDKN2A, MYC), mitogenic (EGFR, RAS, PI3K), differentiation (NOTCH1), and apoptotic. Epigenetic…

Fundamentals of Molecular Biology and Gene Therapy

Key Points Gene-therapy strategies involve replacing defective genes with functional variants, enhancing the expression of certain key genes, or suppressing genes that contribute to disease. Methods of administering gene therapy include direct injection of DNA/RNA, use of specialized nonviral vectors such as nanoparticles, or administration of a viral vector. More than 600 clinical trials have demonstrated the effectiveness of gene therapy in the treatment of a…

Tracheobronchial Endoscopy

Key Points Flexible and rigid bronchoscopy are essential diagnostic and therapeutic tools for management of thoracic diseases. Diagnostic yields of navigation/guided bronchoscopy increase with (1) experience of the user, (2) the presence of a bronchus sign on CT imaging, and (3) use of fine needle aspiration biopsy. Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) has high sensitivity for both benign and malignant disease and has been shown…

Zenker Diverticulum

Key Points Zenker diverticulum is the most common type of hypopharyngeal diverticulum. The most common presenting symptoms are dysphagia for solid food and food regurgitation. Definitive management is surgical treatment, which should be provided electively for relief of symptoms and prevention of the complications of aspiration and malnutrition. Endoscopic treatment with staple diverticulostomy should be considered the initial treatment of choice for most patients with new…

Transnasal Esophagoscopy

Key Points Transnasal esophagoscopy has diagnostic efficacy comparable to that of conventional sedated endoscopy but can be performed in an office-based setting without sedation. Performing transnasal esophagoscopy in an office-based setting is more cost-effective, more convenient, and safer for patients than conventional sedated endoscopy. Procedures such as biopsy, balloon dilation, laser ablation, and many others can be adapted to the office-based setting utilizing transnasal esophagoscopy. Transnasal…

Diseases of the Esophagus

Key Points Primary symptoms of underlying esophageal disorders, most often due to mechanical or motility disturbance, include heartburn, dysphagia, odynophagia, and regurgitation. Indications for endoscopy are presence of weight loss, upper gastrointestinal bleeding, dysphagia, odynophagia, chest pain, poor response to therapy, and for evaluation for Barrett esophagus. Esophageal manometry measures coordination of intraluminal pressure activities of the three functional regions of the esophagus: the lower esophageal…

Surgical Management of Upper Airway Stenosis

Key Points Accurate preoperative assessment of laryngotracheal stenosis is critical to a successful repair; it includes the use of multiple staging systems to evaluate diameter and levels of airway stenosis. The primary goals of surgical intervention are to establish an adequate airway and enable eventual decannulation. Timing of surgical intervention is important; chronic airway stenosis may be electively repaired following proper preoperative evaluation of possible inflammatory…

Laryngeal and Esophageal Trauma

Key Points Laryngeal trauma is rare (1 : 137,000) but acutely life-threatening, and if not promptly recognized and treated, it can cause significant long-term morbidity. External laryngeal trauma is blunt or penetrating. Internal trauma is most commonly due to translaryngeal intubation but can also be secondary to caustic ingestion or inhalation burns. The first priority in managing laryngeal trauma is establishing a safe airway. Definitive treatment needs to…

Chronic Aspiration

Key Points Intractable aspiration results in chronic soilage of the lower respiratory tract and life-threatening pulmonary infections. In adult patients, cerebrovascular accident with subsequent lower cranial nerve palsies is the most common cause of intractable aspiration; other causes include neuromuscular disorders, tumors (brainstem or laryngeal), postoperative aspiration, postradiation swallowing dysfunction, and traumatic or anoxic brain injury. Common causes of intractable aspiration in pediatric patients include cerebral…

Laryngeal Reinnervation

Key Points Ideal rehabilitation of unilateral vocal fold paralysis would involve restoration of vocal fold movement, position, bulk, and tone. Complete recovery from unilateral paralysis can only happen now through the spontaneous and appropriate regeneration of the recurrent laryngeal nerve (RLN). Early clinical results show that selective reinnervation can provide vocal fold motion. Nonselective reinnervation results in a laryngeal synkinesis without coordinated movement of the vocal…

Arytenoid Adduction and Abduction

Key Points Arytenoid adduction mimics the action of the lateral cricoarytenoid muscle to internally rotate the arytenoid to close the glottis. Arytenoid adduction is indicated for the treatment of laryngeal incompetence in patients with unilateral laryngeal paralysis. Arytenoid adduction can be often performed in combination with a thyroplasty. Arytenoid abduction mimics the action of the posterior cricoarytenoid muscle; it externally rotates the arytenoid to pull the…

Medialization Thyroplasty

Key Points Both medialization thyroplasty and vocal fold injection can be used successfully to manage glottal insufficiency associated with unilateral vocal fold motion impairment, vocal fold bowing, and soft tissue deficits. The choice of procedure, medialization thyroplasty or vocal fold injection, and injectable material should account for anatomic considerations, severity and duration of symptoms, potential for recovery, and patient health and life expectancy. Videostroboscopy is useful…

Acute and Chronic Laryngopharyngitis

Key Points Understanding the differences between the immunologic response of the laryngopharynx to pathogenic versus environmental stimuli will likely be critical as we better our understanding of diseases such as allergy, reflux, and malignancy. The most common causes of acute laryngopharyngitis in the general population are infectious, as part of an upper respiratory infection, whereas the most common causes of chronic laryngopharyngitis in patients cared for…

Benign Vocal Fold Mucosal Disorders

Key Points The two most common risks for vocal fold mucosal vibratory injury are a high intrinsic tendency to use the voice (talkativeness, extroversion) and a high extrinsic opportunity or necessity to use the voice, driven by occupation, family needs, social activities, and avocations. Visible vocal fold lesions from overuse may not cause an audible change in the speaking voice. Visible vocal fold lesions that cause…

Laser Surgery: Basic Principles and Safety Considerations

Key Points Laser technology has allowed for enhanced surgical treatment for a wide variety of otolaryngology indications, including those in otology, laryngology, bronchoesophagology, and facial plastic surgery. Every surgeon should have basic knowledge of laser physics and laser-tissue interactions to choose the proper laser and laser settings to minimize unnecessary tissue injury. The choice of surgical laser depends on several factors: target tissue, available modes of…

The Professional Voice

Key Points Management of patients with voice disorders is most effectively performed by a multidisciplinary team that includes a laryngologist, a speech-language pathologist, and a vocal pedagogue. All patients with voice disorders receive the same level of care regardless of their level of voice use. Voice and speech are produced according to the source-filter theory of voice production. In this theory, the vocal folds provide a…

Neurologic Disorders of the Larynx

Key Points Neurologic disorders of the larynx may be focal diseases or local manifestations of systemic disorders. Characteristic deficiencies found on clinical examination may aid in ascertaining the site of a lesion. Hyperfunctional disorders include dystonia, myoclonus, essential tremor, stuttering, and muscle tension dysphonia. Hypofunctional disorders include focal disorders, such as vocal fold paresis and paralysis, and central causes such as Parkinson disease, multiple sclerosis, neuromuscular…

Neurologic Evaluation of the Larynx and Pharynx

Key Points Evaluation of the larynx and pharynx is a multidisciplinary endeavor that may involve otolaryngologists, neurologists, speech-language pathologists, and radiologists. Normal functions of the larynx include regulation of respiratory mechanics, airway protection during deglutition, and phonation. Normal function of the pharynx includes maintenance of patency for respiration and effective constriction for swallowing with prevention of reflux into the nose or mouth. Neurologic evaluation begins with…

Voice Evaluation and Therapy

Key Points The voice is multidimensional, so voice assessment should be multidimensional. Auditory, visual, and tactile perceptual examinations are key components of a voice evaluation. It is important to characterize the patient's perception of the problem and the impact of the voice disorder on the patient's life. Several published scales can be used to report various aspects of handicap or quality of life. Specific measurements can…