Karuna Dewan

All Publications

• Patient Reported Outcomes and Objective Swallowing Assessments in a Multidisciplinary Dysphagia Clinic. The Laryngoscope Dewan, K., Clarke, J. O., Kamal, A. N., Nandwani, M., Starmer, H. M. 2020

  Abstract

  OBJECTIVES/HYPOTHESIS: Dysphagia encompasses a complex compilation of symptoms which often differ from findings of objective swallowing evaluations. The purpose of this investigation was to compare the results of subjective dysphagia measures to objective measures of swallowing in patients evaluated in a multidisciplinary dysphagia clinic.STUDY DESIGN: Prospective cohort study.METHODS: The study cohort included all patients evaluated in the multidisciplinary dysphagia clinic over 24months. Participants were evaluated by a multidisciplinary team including a laryngologist, gastroenterologist, and speech-language pathologist. Evaluation included a videofluoroscopic swallowing study (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES), and transnasal esophagoscopy (TNE). Data collected included diet (FOIS), Eating Assessment Tool (EAT-10) score, Reflux symptom index (RSI) score, and the findings of the VFSS exam.RESULTS: A total of 75 patients were included in the analysis. The average EAT-10 score was 16.3±2.1, RSI was 21.4±0.6, and FOIS score was 6.0±1.33. VFSS revealed impairments in the oral phase in 40% of the cohort, pharyngeal in 59%, and esophageal in 49%. Abnormalities were noted in one phase for 32%, in 2 phases in 32%, and three phases in 18%. Patients with abnormal pharyngeal findings on VFSS had significantly higher EAT-10 scores (P = .04). Patients with abnormal oral findings on VFSS were noted to have significantly lower FOIS scores (P = .03).CONCLUSIONS: Data presented here demonstrate a relationship between patient reported symptoms and objective VFSS findings in a cohort of patients referred for multidisciplinary swallowing assessment suggesting such surveys are helpful screening tools but inadequate to fully characterize swallowing impairment.LEVEL OF EVIDENCE: 3 Laryngoscope, 2020.

  View details for DOI 10.1002/lary.29194

  View details for PubMedID 33103765

• Dysphagia and Dysphonia, a Pairing of Symptoms Caused by an Unusual Pair of Diseases: Castleman's Disease and Myasthenia Gravis. The Annals of otology, rhinology, and laryngology Abdelmeguid, A., Rojansky, R., Berry, G. J., Dewan, K. 2020: 3489420949581

  Abstract

  OBJECTIVES: To describe a case of coincident Castleman's disease and myasthenia gravis that initially presented as rapidly progressive dysphagia and dysphonia and to review the unique pathophysiology of these two uncommon diagnoses.METHODS: Case report and literature review.RESULTS: Castleman's disease, angiofollicular or giant lymph node hyperplasia, is a rare benign lymphoid proliferation. Traditionally, the disease is classified based on histologic and clinical characteristics. Fewer than 10 cases with concurrent myasthenia gravis have been reported. Myasthenia gravis and thymic epithelial tumors are both associated with acetylcholine receptor antibody. While patients with isolated Castleman's disease are usually asymptomatic, those who have concurrent myasthenia gravis and undergo surgical treatment are at increased risk of postoperative myasthenic crisis. Both pre- and postoperative plasmapheresis are suggested to improve muscle strength and prevent severe postoperative complications.CONCLUSIONS: In the setting of multiple cranial neuropathies including velopalatal insufficiency and bilateral ptosis it is important to consider myasthenia gravis. Castleman's disease occurs rarely in conjunction with myasthenia gravis but may increase the risk of myasthenic crisis.

  View details for DOI 10.1177/0003489420949581

  View details for PubMedID 32812444

• Aspects of the assessment and management of pharyngoesophageal dysphagia. Annals of the New York Academy of Sciences Allen, J., Dewan, K., Herbert, H., Randall, D. R., Starmer, H., Stein, E. 2020

  Abstract

  Swallowing complaints are common and may have significant consequences for nutrition and pulmonary health. Etiology varies and different aspects of the deglutitive system may be affected. A thorough assessment from the oral cavity to the stomach will provide physiologic information that enables specific targeted management plans to be devised. Although the swallow trajectory bridges anatomic areas, there has previously been a tendency to compartmentalize assessment and treatment by arbitrary anatomic boundaries. It is now clear that this approach fails to appreciate the complexity of swallow mechanics and that systems (oral, pharyngeal, esophageal, and pulmonary) are intertwined and codependent. Swallowing specialists from different backgrounds and with complementary skill sets form a multidisciplinary team that can provide insight and address multiple areas of management. With the advent of new tools for instrumental evaluation, such as manometry, targeted rehabilitative strategies can be informed by physiology, increased in precision and breadth, and assessed quantitatively. Surgical approaches have evolved toward endoscopic techniques, and food technology is expanding options in dietary management. The multidisciplinary team is core to managing this varied and often neglected patient population. This review is for clinicians treating swallowing disorders and will explore the selected aspects of the assessment and management of pharyngoesophageal swallowing disorders.

  View details for DOI 10.1111/nyas.14456

  View details for PubMedID 32794195

• Cricopharyngeal Achalasia: Management and Associated Outcomes-A Scoping Review. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Dewan, K., Santa Maria, C., Noel, J. 2020: 194599820931470

  Abstract

  OBJECTIVE: There is little consensus regarding the efficacy and safety of treatment options for cricopharyngeal (CP) achalasia. The purpose of this scoping review is to assess the literature regarding the various treatments for this disease.DATA SOURCES: PubMed was searched for all articles addressing treatment of adult CP achalasia between January 1990 and June 2019.REVIEW METHODS: In total, 351 peer-reviewed results were reviewed by 3 otolaryngologists for inclusion. After review of titles, abstracts, and full texts, 60 articles were selected.RESULTS: Among included studies, 55% were retrospective and 45% were prospective. Forty-five percent of studies were case series. CP achalasia etiologies included idiopathic (28%), cerebrovascular accident (CVA) (28%), neurologic disease (17%), head and neck radiation treatment (11%), Zenker's diverticulum (10%), and myositis (5%). Most commonly employed treatments were botulinum toxin injection (40%), endoscopic CP myotomy (30%), dilation with either balloon or bougie (25%), and open CP myotomy (15%). A proportion of patients were treated with more than 1 approach. Most studies included both subjective and objective outcome measures. Complications were reported most often in patients with a history of head and neck radiation.CONCLUSIONS: Small sample sizes and heterogeneity of causes and treatments of CP achalasia, as well as short duration of follow-up, make it challenging to assess the superiority of one treatment over another. There is a need for a prospective study that more directly compares outcomes of administration of botulinum toxin, dilation, and CP myotomy in patients with CP achalasia of similar etiologies.

  View details for DOI 10.1177/0194599820931470

  View details for PubMedID 32571156

• Anterior cervical pain syndrome: Risk factors, variations in hyolaryngeal anatomy, and treatments Dewan, K., Yang, C., Penta, M. WILEY. 2020: 702–5

  View details for DOI 10.1002/lary.28018

  View details for Web of Science ID 000514225500027

• Chemotherapy and dysphagia: the good, the bad, the ugly. Current opinion in otolaryngology & head and neck surgery Dewan, K. 2020

  Abstract

  Dysphagia is a debilitating, depressing and potentially life-threatening complication in cancer patients that is likely underreported. The purpose of this review is to critically synthesize the current knowledge regarding the impact of chemotherapeutic regimens on swallowing function.Those patients with cancers involving the aerodigestive tract, head and neck cancer and oesophageal cancer are at highest risk of developing dysphagia. The most common dysphagia causing toxicity of chemotherapeutic agents is mucositis/stomatitis. The use of cisplatin is correlated with increased incidence of mucositis. Similarly, the addition of melphalan is also associated with worsening mucositis and dysphagia. In some cases of oesophageal cancer, thyroid cancer, metastatic lung or breast cancer the use of chemotherapy can improve swallow function as obstructive lesions are reduced.There is limited literature regarding the role of chemotherapy in the development or treatment of dysphagia. Most dysphagia that occurs during cancer treatment is attributable to radiation or the synergistic effect of radiation and chemotherapy. Patients with disordered swallowing prior to treatment have the greatest risk of developing posttreatment dysphagia. Studies are needed to determine whether acute inflammation associated with oropharyngeal mucositis predisposes for late dysphagia.

  View details for DOI 10.1097/MOO.0000000000000672

  View details for PubMedID 33027141

• Lessons learned from open laryngotracheal airway resection and primary anastomosis in high risk patients. PloS one Dewan, K., Berke, G. S., Chhetri, D. K. 2020; 15 (9): e0238426

  Abstract

  Laryngotracheal stenosis is one of the most difficult conditions treated by the Otolaryngologist. Open resection of stenosis with primary airway anastomosis is the definitive treatment for this condition. However, some patients are considered high risk candidates for open airway surgery and management and outcomes in this group have not been reported. The purpose of this investigation is to identify a series of high risk patients who underwent open laryngotracheal surgery and detail the lessons learned in regards to their post-operative course and outcomes.A retrospective cohort study of all patients that underwent airway resection and primary anastomosis over a fifteen-year period was performed. High-risk patients, those with medical comorbidities that impair wound healing, were identified. Post-operative course, management of complications, and ultimate airway outcomes were noted.Seven patients fitting the high-risk category were identified. Comorbidities were poorly controlled insulin dependent diabetes mellitus (N = 4), poorly controlled hypertension (N = 4), end stage renal disease requiring hemodialysis (N = 3), chronic obstructive pulmonary disease (N = 1), and history of radiation therapy (N = 1). Each patient suffered postoperative complications of varying degrees including postoperative infection (N = 1), formation of granulation tissue at the anastomotic site (N = 3), and postoperative hematoma (N = 1). Management included treatment of infection and complications. Anastomotic dehiscence was managed with tracheostomy and T-tubes.High-risk medical comorbidities may not be absolute contraindications for open laryngotracheal resection of airway stenosis. However, this experience emphasizes the importance of preoperative medical optimization and comprehensive postoperative care.

  View details for DOI 10.1371/journal.pone.0238426

  View details for PubMedID 32956400

• Where Dysphagia Begins: Polypharmacy and Xerostomia. Federal practitioner : for the health care professionals of the VA, DoD, and PHS Marcott, S., Dewan, K., Kwan, M., Baik, F., Lee, Y. J., Sirjani, D. 2020; 37 (5): 234–41

  Abstract

  Xerostomia, the subjective sensation of dry mouth, contributes to dysarthria, dysphagia, and diminished quality of life. Polypharmacy is a known and modifiable risk factor for xerostomia. The objective of this study was to evaluate the prevalence of dry mouth, the relationship between dry mouth and other oral conditions, and the impact of polypharmacy on dry mouth.This study was a retrospective cross-sectional study of all patients seen in fiscal year (FY) 2015 (October 1, 2014 to September 30, 2015) at the VA Palo Alto Health Care System (VAPAHCS), a tertiary care US Department of Veterans Affairs (VA) hospital. Patients diagnosed with xerostomia were identified using ICD-9 codes (527.7, 527.8, R68.2) and Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT) codes (87715008, 78948009).Of all the patients seen at VAPAHCS during FY 2015, 138 had a diagnostic code for xerostomia; of those patients, 84 had at least 1 documented speech, dentition, or swallowing (SDS) problem, and 55 (39.9%) were taking ≥ 12 medications, more than twice as many patients as in any one of the other groups studied (0-2, 3-5, 6-8, and 9-11 medications taken). Although 4,971 total patients seen at VAPAHCS had documented SDS problems during FY 2015, of those patients only 77 (1.5%) had an additional recorded diagnosis of xerostomia.Heightened physician awareness regarding the signs and symptoms of and risk factors for xerostomia is needed to improve health care providers' ability to diagnose dry mouth. Polypharmacy also must be considered when developing new strategies for preventing and treating xerostomia.

  View details for PubMedID 32454578

  View details for PubMedCentralID PMC7241606

• The Safety and Efficacy of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Laryngologic Surgery. The Laryngoscope Nekhendzy, V., Saxena, A., Mittal, B., Sun, E., Sung, K., Dewan, K., Damrose, E. J. 2020

  Abstract

  Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is an intraoperative ventilatory technique that allows avoidance of tracheal intubation (TI) or jet ventilation (JV) in selected laryngologic surgical cases. Unimpeded access to all parts of the glottis may improve surgical precision, decrease operative time, and potentially improve patient outcomes. The objective of this prospective, randomized, patient-blinded, 2-arm parallel pilot trial was to investigate the safety and efficacy of THRIVE use for adult patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration.Twenty adult, American society of anesthesiology class 1-3 patients with body mass index (BMI) < 35 kg/m2 were randomly assigned to either an experimental THRIVE group or active comparator conventional ventilation group (TI or supraglottic high-frequency JV [SHFJV]). Primary outcomes included intraoperative oxygenation, anesthesia awakening/extubation time, time to laryngoscopic suspension, number of intraoperative suspension adjustments, and operative time. Secondary patient outcomes including postanesthesia and functional patient recovery were investigated.Compared to TI/SHFJV, THRIVE use was associated with significantly lower intraoperative oxygenation (SpO2 93.0 ± 5.6% vs. 98.7 ± 1.6%), shorter time to suspension (1.8 ± 1.1 minutes vs. 4.3 ± 2.1 minutes), fewer suspension adjustments (0.4 ± 0.5 vs. 1.7 ± 0.9), and lower postoperative pain scores on recovery room admission (1.3 ± 1.9 vs. 3.7 ± 2.9) and discharge (0.9 ± 1.3 vs. 2.7 ± 1.8). The study was underpowered to detect other possible outcome differences.We confirm the safe intraoperative oxygenation profile of THRIVE for selected patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration. THRIVE facilitated surgical exposure and improved early patient recovery, suggesting a potential economic benefit for outpatient laryngologic procedures. The results of this exploratory study provide a framework for designing future adequately powered THRIVE trials.ClinicalTrials.gov (NCT03091179).II Laryngoscope, 2020.

  View details for DOI 10.1002/lary.28562

  View details for PubMedID 32078170

• Building an integrated multidisciplinary swallowing disorder clinic: considerations, challenges, and opportunities. Annals of the New York Academy of Sciences Starmer, H. M., Dewan, K., Kamal, A., Khan, A., Maclean, J., Randall, D. R. 2020

  Abstract

  Dysphagia is a complex condition with numerous causes, symptoms, and treatments. As such, patients with dysphagia commonly require a multidisciplinary approach to their evaluation and treatment. Integrated multidisciplinary clinics provide an optimal format for a collaborative approach to patient care. In this manuscript, we will discuss considerations for teams looking to build a multidisciplinary dysphagia clinic, including what professionals are typically involved, what patients benefit most from this approach, what tests are most appropriate for which symptoms, financial issues, and traversing interpersonal challenges.

  View details for DOI 10.1111/nyas.14435

  View details for PubMedID 32686095

• False Identity: Lymphoid Hyperplasia Imitating a Large Paraganglioma. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India Dewan, K., Shires, C. B. 2019; 71 (Suppl 1): 790–94

  Abstract

  The danger of the parapharyngeal space mass comes from the small space and vital neighboring structures. Its differential diagnosis is broad, however benign lymphoid hyperplasia in this region has not been previously reported. The clinical presentation, imaging, surgical findings and pathology slides were reviewed in an adult patient with a parapharyngeal space mass. The literature on somatostatin-positive parapharyngeal space lesions was reviewed. A 51-year old male with otalgia for 3months, hearing loss, and tinnitus underwent audiogram, revealing asymmetric hearing loss. Laryngoscopy demonstrated a paretic true vocal cord. Subsequent MRI demonstrated 4.5cm post-styloid parapharyngeal space mass displacing the carotid artery anterolaterally. Octreoscan scan showed significant uptake of the somatostatin analog. Angiogram showed prominent vascular blush. The mass was excised transcervically and histopathology demonstrated lymphoid hyperplasia. This case demonstrates that post-styloid parapharyngeal masses may be lateral retropharyngeal nodes. An octreotide-positive lymphoid hyperplasia has never been previously reported.

  View details for DOI 10.1007/s12070-018-1552-8

  View details for PubMedID 31742065

• Hematologic malignancies of the larynx: A single institution review. American journal of otolaryngology Dewan, K., Campbell, R., Damrose, E. J. 2019: 102285

  Abstract

  BACKGROUND: Primary hematologic malignancies of the larynx are rare diagnoses, accounting for less than 1% of all laryngeal tumors. They most commonly present as submucosal masses of the supraglottis, with symptoms including hoarseness, dysphagia, dyspnea and rarely cervical lymphadenopathy.PURPOSE: METHODS: Retrospective case series of patients in a tertiary academic laryngeal practice with hematologic malignancy of the larynx presenting over a 10 year period; charts were reviewed for diagnosis, symptoms, treatment, and outcomes.RESULTS: 12 patients were found to have primary presentation of a hematologic malignancy within the larynx between 2009 and 2019. A submucosal mass was the most common finding, and hoarseness was the most common symptom. Local control of disease was high. Airway obstruction was managed with tracheostomy. Several patients required tube feeding prior to disease control. Most patients underwent radiation therapy and chemotherapy, although surgery alone was effective in patients with isolated disease.CONCLUSIONS: Hematologic malignancies of the larynx are rare but treatable. Biopsy is the mainstay of diagnosis, and imaging may be helpful to exclude diseases with a similar physical presentation (i.e., laryngocele). Prognosis depends on diagnosis but is generally favorable.

  View details for DOI 10.1016/j.amjoto.2019.102285

  View details for PubMedID 31515071

• Endoscopic Management of Postradiation Dysphagia in Head and Neck Cancer Patients: A Systematic Review ANNALS OF OTOLOGY RHINOLOGY AND LARYNGOLOGY Abu-Ghanem, S., Sung, C., Junlapan, A., Kearney, A., DiRenzo, E., Dewan, K., Damrose, E. J. 2019; 128 (8): 767–73

  View details for DOI 10.1177/0003489419837565

  View details for Web of Science ID 000481481400013

• Anterior cervical pain syndrome: Risk factors, variations in hyolaryngeal anatomy, and treatments. The Laryngoscope Dewan, K., Yang, C., Penta, M. 2019

  Abstract

  OBJECTIVE: Anterior cervical pain syndromes (ACPS) are a poorly understood entity associated with lateral neck discomfort when talking, chewing, or yawning, and with occasional excruciating pain and dysphagia. This investigation aims to describe patients with ACPS presenting symptoms and treatments.STUDY DESIGN: Retrospective chart review of all patients with ACPS presenting to a tertiary care laryngology practice in 1 year.METHODS: All patients diagnosed with ACPS for 1 year were reviewed. Patient gender, age, body mass index (BMI), and pain triggers were documented. The hyolaryngeal complex was measured on computed tomography (CT) scans of the neck. Treatments were recorded.RESULTS: Nine patients were diagnosed with an ACPS in a 1-year period. Sixty-seven percent were female with an average age of 47.3 years ± 16.6. The average BMI of a patient with ACPS was 24.8 ± 3.69. The most common symptom was point tenderness at the lateral aspect of the hyoid or superior cornu of the thyroid cartilage (89%). Pain triggers included speaking (67%), head turn (56%), chewing (44%), yawning (56%), and swallowing (56%). On CT imaging, eight of nine patients had abnormalities of the hyoid bone or the superior cornu of the thyroid cartilage, correlating 100% with point tenderness location. Treatments include physical therapy (33%), steroid injection (44%), lidocaine injection (22%), and surgical intervention (56%).CONCLUSION: ACPS is a frustrating condition for patients and physicians. Evaluation of anterior cervical pain with point tenderness should include imaging measurement of the thyrohyoid complex. Effective treatments include local steroid injection and surgical resection of the abnormal structure.LEVEL OF EVIDENCE: 4 Laryngoscope, 2019.

  View details for PubMedID 31050806

• Endoscopic Management of Postradiation Dysphagia in Head and Neck Cancer Patients: A Systematic Review. The Annals of otology, rhinology, and laryngology Abu-Ghanem, S., Sung, C., Junlapan, A., Kearney, A., DiRenzo, E., Dewan, K., Damrose, E. J. 2019: 3489419837565

  Abstract

  OBJECTIVES:: To systematically review the success rate and safety profile of the available endoscopic surgical options for radiation-induced dysphagia in head and neck cancer patients following organ preservation treatment, including upper esophageal sphincter (UES) dilation, cricopharyngeus (CP) myotomy (CPM), and CP intramuscular botulinum toxin (Botox) injection.METHODS:: A search of MEDLINE, Scopus, Google Scholar, and Cochrane databases was done to identify articles published between January 1980 and December 2017. Pediatric series, foreign language articles, series with Zenker's diverticulum or following primary surgical treatment including laryngectomy, open UES/CP surgery, or samples with fewer than 5 patients were excluded.RESULTS:: An initial search identified 539 articles. All titles and abstracts were reviewed. One hundred and sixteen potentially relevant articles were inspected in more detail, and 14 retrospective studies met eligibility criteria. Dilation group included 10 studies on anterograde and/or retrograde dilation, with an overall 208 patients. Success rate ranged from 42% to 100%. The endoscopic CPM group included 3 studies with a total of 36 patients, and the success rate ranged from 27% to 90%. In the Botox group, 1 one study with 20 patients met our inclusion criteria, with an overall 65% success rate (13/20). Major complications were only reported in the dilation group, which included esophageal perforation and death.CONCLUSIONS:: The lack of consistency across trials indicates insufficient evidence for guiding clinical practice. This systematic review suggests the need for greater standardization of outcomes and instruments. Future prospective evaluation should use validated patient-rated and clinician-rated assessment tools to optimally measure postoperative swallowing outcomes of head and neck cancer dysphagic patients following organ preservation therapy.

  View details for PubMedID 30895823

• Utility of videolaryngoscopy for diagnostic and therapeutic interventions in head and neck surgery. American journal of otolaryngology Shenson, J. A., Marcott, S., Dewan, K., Lee, Y. J., Mariano, E. R., Sirjani, D. B. 2019: 102284

  Abstract

  Videolaryngoscopy is commonly used by anesthesiologists to manage difficult airways. Recently otolaryngologists have reported use in select procedures; to date there is limited evaluation in head and neck surgery.Patients who underwent direct laryngoscopy (DL) with use of GlideScope videolaryngoscopy (GVL) were retrospectively identified from a tertiary care Veterans Affairs hospital. GVL was used to assist or replace traditional laryngoscopes for diagnostic and therapeutic procedures.Nineteen patients (48-83 years old) underwent 21 procedures. Difficult endotracheal intubation was reported in 53% of patients. GVL replaced traditional DL in 76% of cases, assisted evaluation prior to traditional DL in 10%, and rescued failed traditional DL in 14%. No complications occurred. Three indications for GVL were identified.GVL was safe in our experience and provides unique benefits in selected scenarios in head and neck surgery. Otolaryngologists can consider videolaryngoscopy as a complement to traditional DL.

  View details for DOI 10.1016/j.amjoto.2019.102284

  View details for PubMedID 32505434

• An Unusual Cause of Epistaxis: Paranasal Sinus Myeloid Sarcoma CASE REPORTS IN HEMATOLOGY Dewan, K., Baird, J. H., Shires, C. B. 2019

  View details for DOI 10.1155/2019/1312630

  View details for Web of Science ID 000459659100001

• An Unusual Cause of Epistaxis: Paranasal Sinus Myeloid Sarcoma. Case reports in hematology Dewan, K., Baird, J. H., Shires, C. B. 2019; 2019: 1312630

  Abstract

  We report a case of a 65-year-old female who presented with right-sided headaches, blurring of vision in the right eye, cold-induced epistaxis, and facial numbness in the trigeminal nerve distribution. Laboratory studies revealed a significant number of myeloblasts on peripheral smear with granulated cytoplasm, irregular nuclei, and prominent vacuoles. Magnetic resonance imaging (MRI) of the brain demonstrated a T1-enhancing 1.5 cm right-sided dural-based lesion involving the medial sphenoid wing, cavernous sinus, infratemporal fossa, and sphenoid sinus region. An endoscopic biopsy of the lesion within the sphenoid sinus confirmed the diagnosis of myeloid sarcoma, with myeloblasts comprising 30% of cellularity by flow cytometry. A subsequent bone marrow biopsy revealed a hypercellular marrow with 23% blasts by flow cytometry that demonstrated a similar immunophenotypic pattern to those seen in the sinus mass. Fluorescence in situ hybridization (FISH) testing revealed the balanced translocation t(8;21)(q22;q22.1), consistent with a diagnosis of acute myeloid leukemia with RUNX1-RUNX1T1-balanced translocation by WHO 2016 criteria. Myeloid sarcoma represents a rare extramedullary presentation of acute myeloid leukemia (AML), either alone or in conjunction with blood or bone marrow involvement. This case emphasizes the need for a broad differential diagnosis and an aggressive work-up for any unusual paranasal sinus mass.

  View details for PubMedID 30891319

  View details for PubMedCentralID PMC6390259

• Validation of ultrasound as a diagnostic tool to assess vocal cord motion in an animal feasibility study GLAND SURGERY Dewan, K., Sebelik, M. E., Boughter, J. D., Shires, C. B. 2018; 7 (5): 433–39

  View details for DOI 10.21037/gs.2018.07.09

  View details for Web of Science ID 000447693100004

• A Clinical Trial of Proton Pump Inhibitors to Treat Children with Chronic Otitis Media with Effusion. The journal of international advanced otology Dewan, K., Lieu, J. 2018; 14 (2): 245–49

  Abstract

  OBJECTIVE: Gastroesophageal reflux (GER) is considered a cause of otitis media with effusion (OME). This study aimed to investigate whether OME can be effectively treated with a proton pump inhibitor (PPI), therefore implicating GER as a causative factor of OME.MATERIALS AND METHODS: A PPI or placebo was randomly administered to enrolled subjects for 4-8 weeks. To monitor effusion status, subjects underwent monthly pneumatic otoscopy and acoustic reflectometry. At enrollment and at completion of treatment, subjects underwent an audiogram and tympanogram for assessing changes in hearing due to altered fluid levels in the middle ear. After the treatment period, tympanostomy tube placement was recommended for subjects with unresolved effusion.RESULTS: This study enrolled 16 patients with an average age of 5.17 years. Between the treatment and placebo groups, there was no significant difference in the need for tympanostomy tubes. At completion of this study, patients receiving Lansoprazole demonstrated a significant improvement in pure tone average (p<0.01) and speech recognition thresholds (p=0.04). Four patients (25%) from the cohort dropped out of the study. Eight patients (50%) from the cohort required tympanostomy tube placement.CONCLUSION: Owing to difficulties with recruitment and small sample size, this study was unable to demonstrate the use of PPI in treating OME. A larger study is needed for further evaluation of this process.

  View details for PubMedID 30256198

• Assessment and Retrieval of Aspirated Tracheoesophageal Prosthesis in the Ambulatory Setting CASE REPORTS IN OTOLARYNGOLOGY Dewan, K., Erman, A., Long, J. L., Chhetri, D. K. 2018: 9369602

  Abstract

  Tracheoesophageal prosthesis (TEP) is the most common voice restoration method following total laryngectomy. Prosthesis extrusion and aspiration occurs in 3.9% to 6.7% and causes dyspnea. Emergency centers are unfamiliar with management of the aspirated TEP. Prior studies report removal of aspirated TEP prostheses under general anesthesia. Laryngectomees commonly have poor pulmonary function, posing increased risks for complications of general anesthesia. We present a straightforward approach to three cases of aspirated TEP prosthesis removed in the ambulatory setting. In each case, aspirated TEP was diagnosed with flexible bronchoscopy under local anesthesia at the time of consultation, and all prostheses were retrieved atraumatically using a biopsy grasper forceps inserted via the side channel of the bronchoscope. The aspirated TEP prosthesis can be safely and efficiently removed via bedside bronchoscopy.

  View details for DOI 10.1155/2018/9369602

  View details for Web of Science ID 000445570900001

  View details for PubMedID 30302298

  View details for PubMedCentralID PMC6158927

• Neuromuscular compensation mechanisms in vocal fold paralysis and paresis. Laryngoscope Dewan, K., Vahabzadeh-Hagh, A., Soofer, D., Chhetri, D. K. 2017

  Abstract

  Vocal fold paresis and paralysis are common conditions. Treatment options include augmentation laryngoplasty and voice therapy. The optimal management for this condition is unclear. The objective of this study was to assess possible neuromuscular compensation mechanisms that could potentially be used in the treatment of vocal fold paresis and paralysis.In vivo canine model.In an in vivo canine model, we examined three conditions: 1) unilateral right recurrent laryngeal nerve (RLN) paresis and paralysis, 2) unilateral superior laryngeal nerve (SLN) paralysis, and 3) unilateral vagal nerve paresis and paralysis. Phonatory acoustics and aerodynamics were measured in each of these conditions. Effective compensation was defined as improved acoustic and aerodynamic profile.The most effective compensation for all conditions was increasing RLN activation and decreasing glottal gap. Increasing RLN activation increased the percentage of possible phonatory conditions that achieved phonation onset. SLN activation generally led to decreased number of total phonation onset conditions within each category. Differential effects of SLN (cricothyroid [CT] muscle) activation were seen. Ipsilateral SLN activation could compensate for RLN paralysis; normal CT compensated well in unilateral SLN paralysis; and in vagal paresis/paralysis, contralateral SLN and RLN displayed antagonistic relationships.Methods to improve glottal closure should be the primary treatment for large glottal gaps. Neuromuscular compensation is possible for paresis. This study provides insights into possible compensatory mechanisms in vocal fold paresis and paralysis.NA Laryngoscope, 127:1633-1638, 2017.

  View details for DOI 10.1002/lary.26409

  View details for PubMedID 28059441

• Bilateral Vocal Fold Medialization: A Treatment for Abductor Spasmodic Dysphonia. Journal of voice : official journal of the Voice Foundation Dewan, K., Berke, G. S. 2017

  Abstract

  Abductor spasmodic dysphonia, a difficult-to-treat laryngologic condition, is characterized by spasms causing the vocal folds to remain abducted despite efforts to adduct them during phonation. Traditional treatment for abductor spasmodic dysphonia-botulinum toxin injection into the posterior cricoarytenoid muscle-can be both technically challenging and uncomfortable. Due to the difficulty of needle placement, it is often unsuccessful. The purpose of this investigation is to present a previously undescribed treatment for abductor spasmodic dysphonia-bilateral vocal fold medialization.A retrospective case review of all cases of abductor spasmodic dysphonia treated in a tertiary care laryngology practice with bilateral vocal fold medialization over a 10-year period was performed. The Voice Handicap Index and the Voice-Related Quality of Life surveys were utilized to assess patient satisfaction with voice outcome.Six patients with abductor spasmodic dysphonia treated with bilateral vocal fold medialization were identified. Disease severity ranged from mild to severe. All six patients reported statistically significant improvement in nearly all Voice Handicap Index and Voice-Related Quality of Life parameters. They reported fewer voice breaks and greater ease of communication. Results were noted immediately and symptoms continue to be well controlled for many years following medialization.Bilateral vocal fold medialization is a safe and effective treatment for abductor spasmodic dysphonia. It is performed under local anesthesia and provides phonation improvement in the short and long term.

  View details for DOI 10.1016/j.jvoice.2017.09.027

  View details for PubMedID 29132808

• Pulsed dye laser treatment of primary cryptococcal laryngitis: A novel approach to an uncommon disease AMERICAN JOURNAL OF OTOLARYNGOLOGY Ihenachor, E. J., Dewan, K., Chhetri, D. 2016; 37 (6): 572-574

  Abstract

  An 82-year-old supplemental oxygen dependent woman with severe COPD presented with an eight month history of worsening hoarseness and stridor. Office laryngoscopy revealed laryngeal edema and ulcerative masses throughout the larynx. In-office biopsies were positive for Cryptococcus neoformans. This report details a novel approach to the treatment of cryptococcal laryngitis, a combination of in-office pulsed-dye laser (PDL) ablation and medical therapy. Despite treatment with oral fluconazole, the recommended treatment for cryptococcal laryngitis the patient continued to be symptomatic with dysphonia and throat discomfort. Repeated laryngeal exam demonstrated persistent cryptococcal nodules. The patient was subsequently effectively treated with an in-office PDL laser. This case demonstrates the efficacy of in-office laser treatment for residual laryngeal Cryptococcus. For patients like this one, who have failed medical therapy and are unfit for general anesthetic, the in-office laser provides an excellent alternative treatment approach.

  View details for DOI 10.1016/j.amjoto.2016.08.007

  View details for Web of Science ID 000387736600019

  View details for PubMedID 27654751

• Incidence and implication of vocal fold paresis following neonatal cardiac surgery LARYNGOSCOPE Dewan, K., Cephus, C., Owczarzak, V., Ocampo, E. 2012; 122 (12): 2781-2785

  Abstract

  To study the incidence and implications of vocal fold paresis (VFP) following congenital neonatal cardiac surgery.Retrospective chart review.All neonates who underwent median sternotomy for cardiac surgery from May 2007 to May 2008 were evaluated. Flexible laryngoscopy was performed to evaluate vocal fold function after extubation. Swallow evaluation and a modified barium swallow study were performed prior to initiating oral feeding if the initial screening was abnormal.A total of 101 neonates underwent cardiac surgery during the study period. Ninety-four patients underwent a median sternotomy, and 76 of these were included in the study. Fifteen (19.7%) had vocal fold paresis (VFP) postoperatively. Almost 27% of the patients with aortic arch surgery had VFP while only 4.1% of the patients with nonaortic arch surgery developed VFP (P=0.02) Those patients who underwent aortic arch surgery weighed significantly less (P<0.01). All the patients with VFP had significant morbidity related to swallowing and nutrition (P=0.01) and required longer postsurgical hospitalization (P=0.02).The reported incidence of VFP following cardiac surgery via median sternotomy ranges between 1.7% and 67% depending on the type of surgery and the weight of the infant at the time of surgery. In our cohort, 19.7% had VFP. Surgery requiring aortic arch manipulation had a higher incidence of complications and required longer hospitalizations. These results may be used to improve informed consent and to manage postoperative expectations by identifying patients who are at higher risk for complications.

  View details for DOI 10.1002/lary.23575

  View details for Web of Science ID 000312540000029

  View details for PubMedID 22952115

• Radiology Quiz Case 2 Nontraumatic atlantoaxial subluxation (also known as Grisel syndrome) ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Dewan, K., Giannoni, C. 2012; 138 (2): 199-201

  View details for Web of Science ID 000300525900016

  View details for PubMedID 22351870

• Light-Induced Changes of the Circadian Clock of Humans: Increasing Duration is More Effective than Increasing Light Intensity SLEEP Dewan, K., Benloucif, S., Reid, K., Wolfe, L. F., Zee, P. C. 2011; 34 (5): 593-599

  Abstract

  To evaluate the effect of increasing the intensity and/or duration of exposure on light-induced changes in the timing of the circadian clock of humans.Multifactorial randomized controlled trial, between and within subject designGeneral Clinical Research Center (GCRC) of an academic medical center56 healthy young subjects (20-40 years of age)Research subjects were admitted for 2 independent stays of 4 nights/3 days for treatment with bright or dim-light (randomized order) at a time known to induce phase delays in circadian timing. The intensity and duration of the bright light were determined by random assignment to one of 9 treatment conditions (duration of 1, 2, or 3 hours at 2000, 4000, or 8000 lux).Treatment-induced changes in the dim light melatonin onset (DLMO) and dim light melatonin offset (DLMOff) were measured from blood samples collected every 20-30 min throughout baseline and post-treatment nights. Comparison by multi-factor analysis of variance (ANOVA) of light-induced changes in the time of the circadian melatonin rhythm for the 9 conditions revealed that changing the duration of the light exposure from 1 to 3 h increased the magnitude of light-induced delays. In contrast, increasing from moderate (2,000 lux) to high (8,000 lux) intensity light did not alter the magnitude of phase delays of the circadian melatonin rhythm.Results from the present study suggest that for phototherapy of circadian rhythm sleep disorders in humans, a longer period of moderate intensity light may be more effective than a shorter exposure period of high intensity light.

  View details for Web of Science ID 000291145800009

  View details for PubMedID 21532952

  View details for PubMedCentralID PMC3079938

• Assessment of self-selection bias in a pediatric unilateral hearing loss study OTOLARYNGOLOGY-HEAD AND NECK SURGERY Lieu, J. E., Dewan, K. 2010; 142 (3): 427-433

  Abstract

  To examine the differences between participants and nonparticipants in a study of children with unilateral hearing loss that might contribute to selection bias.Case-control study.Academic pediatric otolaryngology practice.Comparison of clinical and sociodemographic characteristics between the 81 participants and 78 nonparticipants with unilateral hearing loss in a case-control study.Compared with nonparticipants, the study participants were younger but were diagnosed at an older age. Participants were more likely to have been diagnosed through a primary care screen and have normal ear anatomy, and less likely to have an attributed etiology for their unilateral hearing loss or tried assistive hearing devices. No other significant demographic, socioeconomic, or clinical differences were identified.Self-selection bias may jeopardize both internal and external validity of study results and should be evaluated whenever possible. Methods to minimize self-selection bias should be considered and implemented during the planning stages of clinical studies.

  View details for DOI 10.1016/j.otohns.2009.11.035

  View details for Web of Science ID 000276574600024

  View details for PubMedID 20172393

  View details for PubMedCentralID PMC2975441

• Enlarged vestibular aqueduct in pediatric sensorineural hearing loss OTOLARYNGOLOGY-HEAD AND NECK SURGERY Dewan, K., Wippold, F. J., Lieu, J. E. 2009; 140 (4): 552-558

  Abstract

  Comparison of the Cincinnati criteria (midpoint >0.9 mm or operculum >1.9 mm) to the Valvassori criterion (midpoint > or =1.5 mm) for enlarged vestibular aqueduct (EVA) in pediatric cochlear implant patients.Cohort study.One hundred thirty pediatric cochlear implant recipients.We reviewed temporal bone CT scans to measure the vestibular aqueduct midpoint and opercular width.The Cincinnati criteria identified 44 percent of patients with EVA versus 16 percent with the Valvassori criterion (P < 0.01). Of those with EVA, 45 percent were unilateral and 55 percent were bilateral using Cincinnati criteria; 64 percent were unilateral and 36 percent bilateral using Valvassori criterion (P < 0.01). The Cincinnati criteria diagnosed 70 ears with EVA classified as normal using the Valvassori criterion (P < 0.01); 59 lacked another medical explanation for their hearing loss.The Cincinnati criteria identified a large percentage of pediatric cochlear implant patients with EVA who might otherwise have no known etiology for their deafness.

  View details for DOI 10.1016/j.otohns.2008.12.035

  View details for Web of Science ID 000264622700019

  View details for PubMedID 19328346

  View details for PubMedCentralID PMC2846828