Hemodynamic Changes during Otolaryngological Office-Based Flexible Endoscopic Procedures

Objectives:

A preponderance of literature supports the safety of office-based flexible endoscopic procedures of the upper aerodigestive tract; however, until recently there were no data regarding hemodynamic stability during these procedures. A recent study showed intraprocedure changes in patients' hemodynamic parameters, raising the concern that perhaps patients should be monitored during these procedures. The aim of our study was to determine whether physiologically significant alterations in vital signs occur during office-based flexible endoscopic procedures.

Methods:

We performed a retrospective review of 100 consecutive patients who underwent office-based flexible endoscopic procedures of the upper aerodigestive tract from July 2010 to October 2011. Baseline values and the maximal changes in systolic blood pressure, diastolic blood pressure, heart rate, and oxygen saturation were recorded and compared.

Results:

One hundred consecutive patients were included in the study. Twenty-one patients (21%) had severe hypertension and 40 patients (40%) had tachycardia during the procedure. The mean change overall in systolic blood pressure was 26.2 mm Hg (p < 0.001), the mean change in diastolic blood pressure was 13.9 mm Hg (p < 0.001), the mean change in heart rate was 16.6 beats per minute (p < 0.001), and the mean change in oxygen saturation was 1.6% (p < 0.001). These changes were significant. On further breakdown into groups, patients over 50 years of age and patients who were undergoing esophageal or laser procedures had significant elevations in heart rate (p = 0.01 and p = 0.04, respectively). An elevation in diastolic blood pressure was also significant in patients who were undergoing esophageal or laser procedures (p = 0.04 for both).

Conclusions:

These data concur with those of the previous report that found potentially significant hemodynamic changes during office-based procedures. Although preliminary, our findings suggest that it may be wise to monitor vital signs in patients over 50 years of age and patients who are undergoing an esophageal or laser procedure who are at risk for complications that could arise from tachycardia and hypertension.

New technology applications: Knotless barbed suture for tracheal resection anastomosis

OBJECTIVES/HYPOTHESIS

Tracheal resection anastomoses are often under tension and can be technically challenging. New suture materials such as V-loc (barbed, knotless wound closure device) may offer advantages over conventional methods. The objective of this study is to determine if a running V-loc suture is of comparable tensile strength to conventional closure.

STUDY DESIGN

Laboratory based study of human cadaveric tissue.

METHODS

Fresh human cadaveric tracheas were dissected and incised into segments. Anastomosis of adjacent segments was then performed with either submucosal interrupted 3-0 Vicryl, or a running submucosal 3-0 V-loc suture. Anastomosed specimens were stretched to failure on an Instron force tension machine. Surgeon satisfaction was recorded by visual analog scale (VAS).

RESULTS

The tensile strength of 12 tracheal anastomoses was tested. Video documentation of V-loc suture technique and anastomosis failure was recorded. In both Vicryl (80%) and V-loc (100%) anastomoses, failure occurred at the membranous intercartilaginous region. In 20% of the Vicryl anastomoses, the suture was noted to break prior to tissue failure. Anastomoses with V-loc suture had equivalent failure force (mean, 59 N) compared to interrupted Vicryl (51 N), with P = .57. On VAS, surgeons were more satisfied with V-loc suture closure compared to interrupted Vicryl closure (paired t test, P = .003).

CONCLUSIONS

Tracheal anastomosis with running v-loc suture is a feasible alternative to conventional closure with interrupted Vicryl suture. V-loc suture provided a surgical advantage by improved ease of use.

Reducing Complications from Tracheotomy

Program Description: While tracheotomies are regularly performed by otolaryngologists nationwide and abroad, technique and perioperative management vary widely between surgeons. Recently, the Academy Airway and Swallowing Committee performed a multi-institutional study reviewing the technique, management, and outcomes from a large series of consecutive tracheotomies. We have used our study, as well as national and international databases to construct tracheotomy evidence-based guidelines for the otolaryngologist. We will discuss incorporation of tracheostomy care teams for the merging of quality care, medical economics, and patient safety. Guidelines will be presented in an interactive format (surveying the audience on their current practices) with the goal of optimizing intraoperative patient safety and minimizing early and late postoperative complications.

Educational Objectives: 1) Understand the management factors associated with tracheotomy complications. 2) Understand how tracheostomy care teams can optimize patient management. 3) Information will be presented in an interactive format with audience participation.

The Otolaryngologist’s Role in Management of Aspiration: A Practical Review

Program Description: Aspiration pneumonia is a major problem in the geriatric population, in patients who are hospitalized long term, and for people with head and neck cancer. It is the second most common type of nosocomial infection, resulting in massive mortality and morbidity; in the elderly, the mortality rates range from 20% to 50%, with a rate as high as 80% in some studies. The health care costs associated with aspiration pneumonia are staggering. While aspiration pneumonia is often due to oropharyngeal or laryngeal disorders, the role of the otolaryngologist in diagnosing and managing aspiration can vary significantly; this purely clinical miniseminar will focus on how the general otolaryngologist can maximally contribute to the care of patients with aspiration. The panelists will discuss the following: 1) The practical value of multiple diagnostic modalities will be reviewed, including fiberoptic laryngoscopy, transnasal esophagoscopy (TNE), modified barium swallow and other radiological imaging, functional endoscopic evaluation of swallowing (FEES), sensory testing, pH and impedance probes, and high resolution manometry; 2) in-office evaluation for surgical decision making; 3) when to perform a tracheotomy or refer for a gastrostomy tube; 4) nonsurgical treatment including swallowing therapy, stents, salivary control, injection of botulism toxin, and electrical stimulation; 5) surgical treatment including laryngeal framework surgery, cricopharyngeal myotomy, laryngeal suspension, laryngeal closure procedures, and sensory reinnervation. Illustrative cases will also be presented to highlight common dilemmas and challenges.

Educational Objectives: 1) Describe how in-office evaluation and procedures are useful for decision making in medical and surgical treatment. 2) Understand the value of different diagnostic modalities. 3) Describe medical and surgical treatments for aspiration.

Thyroid Perichondrial Flaps for Sub-Glottic Reconstruction

Objective: Techniques available for reconstruction of the crico-tracheal region in adults are currently suboptimal. We sought to 1) Understand the anatomic basis for the thyroid perichondrial flap, 2) Describe the technique of harvesting and intraluminal placement, and 3) Learn the limitations of defects for which it can be used.

Method: In fresh cadaveric specimens, the perichondrium of the outer layer of the thyroid cartilage was elevated by tracing the superior, medial and lateral borders of each thyroid cartilage ala. The inferiorly based flap was then placed into the airway through the cricothyroid membrane. The extent of coverage was measured.

Results: Current results are limited to female cadaveric measurements only. The extent of thyroid perichondrial flaps were 1.7 and 1.8 cm on the right and left respectively. The flaps were able to completely cover the cricoid cartilage and extended to but did not cover the first tracheal ring. Once placed intraluminally the flaps extended 2.5 and 2.6 cm below the true vocal cords on the right and left respectively. Using both flaps enabled coverage of the entire anterior 180 degrees of the airway lumen.

Conclusion: The thyroid perichondrial flap is technically feasible and can provide coverage of anterior airway defects up to approximately 2.5 cm below the true vocal cords. This flap could enable transfer of vascularized tissue to aid in crico-tracheal reconstruction. Further work in male cadavers as well as animal studies are in progress.

Laryngopharyngeal Reflux (LPR)

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

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

Association of asthma with clinically aggressive recurrent respiratory papillomatosis

OBJECTIVE

To determine whether there is an association between the presence of asthma and a clinically aggressive disease course in patients with recurrent respiratory papillomatosis (RRP).

DESIGN

Retrospective multi-institutional cohort study (level III evidence).

SETTING

Two academic medical centers in the southeastern United States.

PATIENTS

Adult patients with RRP treated at the Georgia Health Sciences University or at the Emory University School of Medicine between January 1998 and December 2009. Excluded from the study were adult patients who had been diagnosed as having RRP when they were a child (<18 years).

MAIN OUTCOME MEASURES

The primary outcome measure was the presence of a clinically aggressive RRP disease course (defined as distal spread of disease, >4 procedures performed in 12 months, or progression to laryngeal squamous cell carcinoma). The secondary outcome measure was the frequency of required surgical interventions.

RESULTS

Identified were 90 patients with RRP (age range at first diagnosis, 19.1-86.4 years). Seventeen patients had aggressive disease, and 73 patients had nonaggressive disease. Seven patients had a history of asthma, 5 of whom were using daily inhaled corticosteroids. An association was noted between the presence of asthma and aggressive RRP, which was found in 57% (4 of 7) of patients with asthma vs 16% (13 of 83) of patients without asthma (P = .02). Patients with asthma using daily inhaled corticosteroids were especially likely to have aggressive RRP, which was found in 80% (4 of 5) of corticosteroid users vs 15% (13 of 85) of nonusers (P = .004).

CONCLUSIONS

Patients with asthma, particularly those using daily inhaled corticosteroids, may have a more clinically aggressive RRP course. The cause of this association is unclear, and clinical recommendations should not yet be made based on these data.

Hemicricoidectomy as the primary diagnosis and treatment for cricoid chondrosarcomas

OBJECTIVES/HYPOTHESIS

The objective was to present a new approach for the diagnosis and treatment of chondrosarcoma involving the cricoid cartilage. The technique involved an extramucosal resection of the ipsilateral half of the involved cricoid cartilage, providing enough tissue to be sent for pathological study, and resulted in good laryngeal function without jeopardizing patients' long-term survival.

STUDY DESIGN

Retrospective study.

METHODS

A retrospective study of eight patients who underwent hemicricoidectomy for cricoid chondrosarcoma was performed at the Center for Voice Disorders, Wake Forest University (Winston-Salem, NC). One patient was a woman and seven were men. The mean age at diagnosis was 64 years (age range, 53-72 y).

RESULTS

All patients had a low-grade tumor. Primary treatment included hemicricoidectomy in all cases. In six (75%) of the patients, tracheotomy was required at the initial surgery. The mean time for decannulation was 3.2 months (range, 5 d-1 y). In four cases a second procedure was required because of recurrence. The second procedure included two total laryngectomies and two endoscopic carbon dioxide laser excisions. The mean follow-up time was 3 years (range, 2 mo-10 y). At the time of writing, six patients were alive without recurrence, one patient was alive with disease; and one patient had died of unrelated causes.

CONCLUSION

The authors recommended unilateral hemicricoidectomy as the diagnosis and treatment of choice. This procedure allows sufficient tissue for histological study and provides good long-term breathing and phonatory function without compromising long-term survival. This procedure is appropriate for patients with 1) mobility of one vocal fold, 2) dysphonia or aphonia, and 3) an adequate subglottic airway.

Effects of Gold laser on the avian chorioallantoic membrane

OBJECTIVES

Office-based lasers have revolutionized the treatment of laryngeal disease. The 980-nm Gold laser is a device that may offer some practical advantages over other office lasers. The chick chorioallantoic membrane has been proposed as a model for predicting the effects of photoangiolytic lasers on vocal fold microvasculature. We sought to evaluate the effects of the Gold laser in this model.

METHODS

Vascular reactions in first-order vessels were determined for the Gold laser with both 0 degree straight and 30 degrees angled laser fibers. Vessels were treated at 15 W and a 500-ms pulse interval, with a 1-mm working distance. Pulse widths of 300 ms and 500 ms were evaluated. All vessels were treated until selective coagulation or vessel rupture.

RESULTS

We performed 60 trials on 30 embryos. The mean energy delivered was 33.7 J for the straight fiber and 51.2 J for the angled fiber. The laser achieved selective vessel coagulation without rupture in 100% (30 of 30) of straight fiber trials and in 100% (30 of 30) of angled fiber trials. In 6.7% (2 of 30) of straight fiber and 10% (3 of 30) of angled fiber trials, it caused minor injury to the surrounding albumin as indicated by white coagulum outside the vessel.

CONCLUSIONS

The Gold laser effectively coagulates small vessels without rupture at a working distance of 1 mm and settings of 15 W, 500-ms pulse interval, and 300- to 500-ms pulse width.

Normal values for pharyngeal pH monitoring

OBJECTIVES

We performed a prospective study of asymptomatic adult volunteers to establish normative values of pharyngeal pH using a novel pH probe.

METHODS

The Dx-pH probe is a novel pH device capable of measuring liquid and aerosolized acid levels. Twenty asymptomatic patients (Reflux Symptom Index less than 10 and Reflux Finding Score less than 6) underwent simultaneous investigation with this probe placed in the oropharynx and a dual antimony probe placed in the hypopharynx and esophagus. The reflux parameters measured from the oropharyngeal probe included the percentage of time and the number of events in which the pH was less than 5.5,5.0,4.5, and 4.0.

RESULTS

The upper limits of normal (95th percentile) for the number of events below pH of 5.5, 5.0, 4.5, and 4.0 per 24-hour period were 16.6, 10.7, 7.4, and 0.2, respectively. The upper limits of normal (95th percentile) for an acid exposure time below pH of 5.5, 5.0, 4.5, and 4.0 per 24-hour period were 820 seconds, 385 seconds, 75 seconds, and 3 seconds, respectively.

CONCLUSIONS

Normative pharyngeal pH values are presented. Further studies are required to determine clinical relevance.