Comparative Treatment Outcomes for Idiopathic Subglottic Stenosis: 5-Year Update

The North American Airway Collaborative (NoAAC) previously published a 3-year multi-institutional prospective cohort study showing variation in treatment effectiveness between 3 primary surgical techniques for idiopathic subglottic stenosis (iSGS). In this report, we update these findings to include 5 years of data evaluating treatment effectiveness. Patients in the NoAAC cohort were re-enrolled for 2 additional years and followed using the prespecified published protocol. Consistent with prior data, prospective observation of 487 iSGS patients for 5 years showed treatment effectiveness differed by modality. Cricotracheal resection maintained the lowest rate of recurrent operation (5%), followed by endoscopic resection with adjuvant medical therapy (30%) and endoscopic dilation (50%). These data support the initial observations and continue to provide value to providers and patients navigating longitudinal decision-making. Level of evidence: 2-prospective cohort study.

Thrombocytopenia as a Prognostic Marker in Patients with Acute Encephalitis at a Tertiary Care Centre in Northern India

Encephalitis is challenging to manage given the diversity of clinical and epidemiologic features. Various predictors of outcome have been studied so far including thrombocytopenia, cerebral edema, hypoglycaemia, development of status epilepticus and need for endotracheal intubation. Thrombocytopenia represents one of the potentially modifiable risk factors for poor prognosis in encephalitis. A better understanding of the epidemiology of this devastating disease and identification of predictors of outcome and management of reversible factors will pave the way for better management of the disease.

MATERIAL

A total of 98 Hospitalised patients of Acute Encephalitis were enrolled in the study. Diagnoses were confirmed by CSF and Neuroimaging studies. Platelet count <150,000/cumm was considered as thrombocytopenia. Mild, moderate and severe thrombocytopenia was categorized at platelet count 100,000-150,000, 50,000-100,000 and <50,000/ cumm, respectively. Outcome at discharge was assessed using the Modified Ranking Score, categorized into 3 groups - good (0-2), fair (3-4), and poor (5-6). Chi-square, ANOVA and Independent samples 't'-tests were used to compare the data.

OBSERVATION

Mean age of patients was 34.06±18.76 (range 14-85) years. Majority of patients were males (54.1). Mean GCS at admission was 9.41±1.90. Acute viral encephalitis(unclassified) (n=33; 33.7%), Scrub typhus (n=24; 24.5%) and Japanese encephalitis virus (n=12; 12.2%) were the most common underlying etiologies. A total of 74 (75.5%) patients had thrombocytopenia. Mild, moderate and severe thrombocytopenia was seen in 34 (34.7%), 30 (30.6%) and 10 (10.2%) cases. Thrombocytopenia was significantly higher in Dengue and Scrub as compared to other etiologies. Thrombocytopenia and its severity showed a significant association with lower GCS and higher mRS scores indicating a poor outcome.

CONCLUSION

Thrombocytopenia is associated with a poor clinical status and adverse outcomes in patients with encephalitis of all causes.

Surface kinematic and depth-resolved analysis of human vocal folds in vivo during phonation using optical coherence tomography

SIGNIFICANCE

The human vocal fold (VF) oscillates in multiple vectors and consists of distinct layers with varying viscoelastic properties that contribute to the mucosal wave. Office-based and operative laryngeal endoscopy are limited to diagnostic evaluation of the VF epithelial surface only and are restricted to axial-plane characterization of the horizontal mucosal wave. As such, understanding of the biomechanics of human VF motion remains limited.

AIM

Optical coherence tomography (OCT) is a micrometer-resolution, high-speed endoscopic imaging modality which acquires cross-sectional images of tissue. Our study aimed to leverage OCT technology and develop quantitative methods for analyzing the anatomy and kinematics of in vivo VF motion in the coronal plane.

APPROACH

A custom handheld laryngeal stage was used to capture OCT images with 800 A-lines at 250 Hz. Automated image postprocessing and analytical methods were developed.

RESULTS

Novel kinematic analysis of in vivo, long-range OCT imaging of the vibrating VF in awake human subjects is reported. Cross-sectional, coronal-plane panoramic videos of the larynx during phonation are presented with three-dimensional videokymographic and space-time velocity analysis of VF motion.

CONCLUSIONS

Long-range OCT with automated computational methods allows for cross-sectional dynamic laryngeal imaging and has the potential to broaden our understanding of human VF biomechanics and sound production.

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis

OBJECTIVES

To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients.

METHODS

Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence.

RESULTS

The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression.

CONCLUSIONS

Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis

Question

What are the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS)?

Findings

In this cohort study of 810 patients with iSGS who underwent 1 of the 3 most common surgical treatments, 23% of patients underwent a recurrent surgical procedure during the 3-year study period, but recurrence differed by modality (cricotracheal resection, 1%; endoscopic resection with adjuvant medical therapy, 12%; and endoscopic dilation, 28%). Among successfully treated patients, those who underwent cricotracheal resection reported the highest quality of life but the greatest perioperative risk and worst long-term voice outcomes.

Meaning

These results show the feasibility of integrating an engaged rare disease community with a network of surgeons to facilitate rapid and nuanced treatment comparisons; findings may help inform treatment decision-making in iSGS.

Importance

Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research.

Objective

To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease.

Design, Setting, and Participants

In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook.

Main Outcomes and Measures

The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications.

Results

Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score–matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk.

Conclusions and Relevance

In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

Surgical management of recurrent Zenker's diverticulum: A multi-institutional cohort study

OBJECTIVE

This study identifies how recurrent Zenker's diverticula are treated.

METHODS

A retrospective chart review was performed from four tertiary referral academic voice and swallowing centers to identify individuals who underwent surgery for recurrent Zenker's diverticulum. Demographic data, surgical modalities for primary and revision surgery, symptoms pre and post revision and complications were recorded.

RESULTS

56 individuals met inclusion criteria. Primary surgery was open in 30.3% (n = 17) and endoscopic in 69.6% (n = 39). Revision surgery was performed via an open approach in 37.5% of cases (N = 21) and via an endoscopic approach in 62.5% of cases (N = 35). Revision surgical technique was based on pouch size, patient age and comorbidities, as well as patient and surgeon preference. There were no major complications and few minor complications.

CONCLUSION

Zenker's diverticulum symptoms can recur regardless of primary treatment modality. Both endoscopic and open approaches can safely treat recurrent Zenker's diverticula.

Early Adverse Events Following Transcervical Hypopharyngeal Diverticulum Surgery

Objective:

To describe rates of short-term morbidity following transcervical surgical treatment of hypopharyngeal diverticulum (HD) and analyze predictors of adverse events.

Methods:

The 2005 to 2017 National Surgical Quality Improvement Program database was queried to identify patients diagnosed with HD undergoing open transcervical diverticulectomy.

Results:

A total of 597 patients with a mean age of 71.4 ± 12.3 years were included. Thirty-day adverse events were experienced by 63 (10.6%) subjects, including 6.5% unplanned reoperations, 4.2% surgical complications, 4.4% medical complications, 2.7% readmissions, and 0.7% deaths. Medical complications notably included pneumonia (2.0%), reintubation (1.2%), sepsis (1.2%), intubation >48 hours (0.5%), urinary tract infection (0.5%), or deep vein thrombosis (0.5%), while surgical complications included organ/space infection (2.0%) and superficial (1.3%) or deep (1.0%) surgical site infection. Gender, race, functional status, diabetes, dyspnea, hypertension, steroid use, and recent weight loss were not associated with adverse events. Length of operation and hospitalization were both higher among those with adverse events (127.4 ± 107.9 vs 95.7 ± 59.8 minutes, P = 0.027, and 7.4 ± 7.4 vs 2.8 ± 3.6 days, P < 0.001). On multivariable logistic regression, high American Society of Anesthesiologists (ASA) class (OR = 2.02, P = 0.017), smoking (OR = 2.10, P = 0.044), and operation time (OR = 1.01; P = 0.005) were independent predictors of adverse events. Obesity was not associated with length of stay, readmission/reoperation, or complications. However, increased age was associated with shorter operations ( P = 0.020), higher length of hospitalization ( P < 0.001), and higher mortality ( P = 0.027) and readmission rates ( P = 0.023).

Conclusion:

Understanding clinical factors associated with complications following open surgery for HD such as ASA score, smoking status, length of operation, and age can help optimize surgical outcomes for at-risk patients.

Utilization and Influence of Online Support Communities in Idiopathic Subglottic Stenosis Patients

OBJECTIVES

To determine the factors that shape utilization of social media-based online support communities (OSCs) and study the influence of these communities on medical decision-making in patients with Idiopathic Subglottic Stenosis (iSGS).

STUDY DESIGN

Survey study.

METHODS

A survey investigating OSC use was sent to the 1,056 members of the North American Airway Collaborative (NoAAC) iSGS¹⁰⁰⁰ cohort in January 2018. Responses were merged with the existing NoAAC data set containing extensive demographic data, disease-specific history, and responses to validated patient-reported outcome measures.

RESULTS

A total of 755 individuals with iSGS and mean age of 51.8 ± 11.6 years were included (99% female, 98% white, 63% college educated) and 58% were OSC users. Younger age, female gender, and college education were each associated with OSC use (P < .05). Users spent 2.5 ± 3.3 hours per week on the platforms. Time spent on OSC was not associated with total number of prior treatments. Higher disease anxiety (FoP-Q, R = 0.26, P < .001), lower social support (MOS, R = -0.12, P = .037), and lower level of shared-decision-making with the treating physician (SDM-Q9, R = -0.16, P = .007) were weakly associated with more hours spent engaging an OSC. OSC use influenced treatment and physician choice in 35% and 26% of users, respectively. Increased time spent on OSC use was associated with increased influence on patient medical decisions regarding treatment, surgery, and physician choice (P < .05).

CONCLUSION

OSC engagement is common in patients with iSGS. Disease anxiety, social support, and relationship with the physician may influence OSC utilization. More OSC engagement weakly associated with greater OSC influence on patient medical decision-making.

LEVEL OF EVIDENCE

NA. Laryngoscope, 131:1821-1827, 2021.

Is nasogastric tube feeding necessary after hypopharyngeal diverticulum surgery?

OBJECTIVES

Nasogastric tubes (NGT) are often placed after surgery for cricopharyngeal muscle pathology due to risk of infection and mediastinitis. The aim of this study was to examine if this practice is necessary.

METHODS

A retrospective case series of subjects who underwent surgery for hypopharyngeal diverticula or cricopharyngeal bars from March 2011 to June 2018 was conducted. Demographic data, type of surgery, placement of feeding tube, initiation of oral feeding, and any complications were recorded.

RESULTS

Sixty-four surgeries were performed for Zenker's diverticula (ZD; N = 52), Killian-Jamieson diverticula (N = 2), and cricopharyngeal bar (N = 10). Mean age and ZD pouch size were 74.0 ± 10.6 years and 3.1 ± 1.8 cm, respectively. Procedures included 48 carbon dioxide laser-assisted myotomies, 14 open diverticulectomies, and 2 endoscopic stapler-assisted diverticulotomies. Of the 64 patients, 19 (29.7%) received intraoperative NGTs while the remaining 45 (70.3%) did not receive NGTs. The former cohort had the NGTs removed on post-operative day (POD) 4.5 ± 2.5, and the non-NGT cohort started clear liquid diet (CLD) on POD 1.2 ± 0.7 days, where 38 patients (84.4%) started CLD on POD 1, and 5 patients (7.8%) were started on oral diet on POD 2-4. Over time, fewer NGTs were placed and oral diets were started sooner. There were 5 complications occurring in 3 patients from the NGT cohort (15.5%) and 2 from the non-NGT cohort (4.4%).

CONCLUSIONS

Surgery for hypopharyngeal diverticula and CPB may not require routine perioperative NGT placement which can be associated with higher rates of complication. Patients can safely receive CLD on POD 1.

Fiberoptic endoscopic evaluation of swallowing findings in individuals with Zenker's diverticulum and cricopharyngeal bar

PURPOSE

To assess fiberoptic endoscopic evaluation of swallowing (FEES) findings in individuals with cricopharyngeal bar (CPB) and Zenker's diverticulum (ZD).

METHODS

In this retrospective chart review spanning from 2010-2018, individuals diagnosed with CPB or ZD and undergoing FEES were identified. Patient demographics, radiographic studies, and treatments were recorded, and findings were compared between CPB, ZD of < 3 cm, and ZD ≥ 3 cm.

RESULTS

Sixty-one individuals consisting of 48 patients with ZD and 13 patients with CPB met inclusion criteria. Post-swallow hypopharyngeal reflux (PSHR) of undigested food bolus, present with or without Valsalva maneuver, was noted in 23%, 84%, and 75% of patients with CPB, ZD < 3 cm, and ZD ≥ 3 cm, respectively. The sensitivity and specificity of the finding for those with ZD were 81% and 83%, respectively. Of patients with ZD, reflux resolved in all but six individuals after surgery. Four of these patients underwent revision surgery with the reflux subsequently resolving, and two patients with persistent reflux were asymptomatic and did not desire further treatment.

CONCLUSIONS

PSHR is a good tool to identify the presence of a ZD and is less helpful to identify a CPB. Elimination of PSHR is a good tool to determine treatment success in patients with ZD and CPB.

LEVEL OF EVIDENCE

IV.

Safety of outpatient unilateral medialization laryngoplasty across two academic institutions

OBJECTIVES/HYPOTHESIS

Unilateral ML is a commonly performed surgery for dysphonia secondary to glottic insufficiency. The safety of this procedure performed in the outpatient setting has not been extensively examined. The purpose of the study was to assess the safety of outpatient unilateral ML in adults and determine the incidence and timing of postoperative complications across two tertiary-care academic medical centers.

STUDY DESIGN

Retrospective chart review, METHODS: A review of patients undergoing unilateral ML at two tertiary-care academic centers from 2011 to 2017 was performed. Patients undergoing bilateral medialization laryngoplasty, revision surgery, or those undergoing additional laryngeal framework procedures including arytenoid adduction were excluded. Patient demographics, operative details, and perioperative and postoperative complications were recorded. Comparisons were made between those individuals who underwent inpatient versus outpatient ML.

RESULTS

One hundred three total procedures met inclusion criteria. Fifty-seven were performed as outpatient procedures, and 46 individuals were observed for at least 23 hours following surgery. Silastic or Gore-Tex implants were used in all but two surgeries. There were no postoperative complications in either setting, including hematoma, dyspnea, wound infections or seromas.

CONCLUSIONS

The incidence of adverse events during and immediately following unilateral ML is very low. Patients can be discharged safely the day of surgery without geographic restrictions.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1647-1649, 2019.

Are Perioperative Antibiotics Necessary During Direct Microlaryngoscopy?

OBJECTIVES/HYPOTHESIS

There are currently no established recommendations for the use of perioperative antibiotics (PAs) to prevent surgical site infections (SSIs) for direct microlaryngoscopy (DML). This study examined the incidence of SSI in patients undergoing DML with and without PAs.

STUDY DESIGN

Retrospective, multi-institutional chart review.

METHODS

A retrospective, multi-institutional chart review was performed at four tertiary referral academic medical centers. Patients undergoing DML from 2010 to 2017 were identified using Current Procedural Terminology codes. Medical records of patients undergoing DML with biopsy, microsurgery, laser ablation, or vocal fold injection who had adequate follow-up were reviewed. Procedures with significant cartilage destruction, concurrent open surgery, or esophageal surgery were excluded. Data recorded included age, gender, pacemaker history, American Society of Anesthesiologists class, wound class, indication for surgery, use of laser, complications, emergency room visits, hospitalizations, pain, fever, and postoperative steroid and antibiotic prescriptions. Presence or absence of SSIs was evaluated by a fellowship-trained laryngologist.

RESULTS

There were 834 patients who met inclusion criteria. Of those, 698 did not receive PAs and 136 received PAs. The median age of patients was 54 years of age in the PA group and 57.5 years of age in the non-PA group, and all cases were recorded as wound class II. Overall, 58% of surgeries involved use of carbon dioxide or potassium-titanyl-phosphate laser. Only one SSI was reported on follow-up in a patient who did receive PAs.

CONCLUSIONS

SSIs are exceedingly rare following DML. PA use is not indicated for routine DML.

LEVEL OF EVIDENCE

4 Laryngoscope, 128:2838-2843, 2018.

Free Flap Versus Pedicled Flap Reconstruction of Laryngopharyngeal Defects: A 10-Year National Surgical Quality Improvement Program Analysis

OBJECTIVES/HYPOTHESIS

Large defects after total laryngectomy (TL) and total laryngopharyngectomy (TLP) often benefit from free flap (FF) or pedicled flap (PF) reconstruction to maintain continuity of the aerodigestive tract, protect great vessels, or reinforce pharyngeal closure. Although both techniques are commonly used, no consensus exists as to which results in fewer complications. The goal of this study was to determine if 30-day morbidity/mortality outcomes differ between PF and FF reconstruction in patients undergoing TL/TLP.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients were analyzed who underwent TL/TLP with reconstruction using records from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2015).

RESULTS

A total of 347 patients were included; 204 received FF reconstruction, whereas 143 received PF reconstruction. FF reconstruction was more commonly used with TLP defects (P = .001). The total operative time in the FF (590 ± 140 minutes) was longer than the PF (441 ± 125 minutes) group (P < .0001). There was a higher rate of postoperative transfusions in those undergoing FF reconstruction (P = .022). There was no significant difference in complication rates among TLP patients. Among TL patients only, FF reconstruction had a higher association with wound infections than PFs (P = .040). On multivariate analysis, low hematocrit was associated with complications (P = .031). Age (P = .031) and congestive heart failure exacerbation (P < .001) were associated with increased hospital stay. Overall, there were no differences in readmissions, reoperations, or deaths between the groups.

CONCLUSIONS

Reported complication rates after TL/TLP remain high, despite widespread usage of vascularized flaps in reconstruction. This comparison reveals no significant difference in postoperative complications between patients who received PF and FF laryngopharyngeal reconstruction.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:105-112, 2019.

Selective recurrent laryngeal nerve stimulation using a penetrating electrode array in the feline model

OBJECTIVES/HYPOTHESIS

Laryngeal muscles (LMs) are controlled by the recurrent laryngeal nerve (RLN), injury of which can result in vocal fold (VF) paralysis (VFP). We aimed to introduce a bioelectric approach to selective stimulation of LMs and graded muscle contraction responses.

STUDY DESIGN

Acute experiments in cats.

METHODS

The study included six anesthetized cats. In four cats, a multichannel penetrating microelectrode array (MEA) was placed into an uninjured RLN. For RLN injury experiments, one cat received a standardized hemostat-crush injury, and one cat received a transection-reapproximation injury 4 months prior to testing. In each experiment, three LMs (thyroarytenoid, posterior cricoarytenoid, and cricothyroid muscles) were monitored with an electromyographic (EMG) nerve integrity monitoring system. Electrical current pulses were delivered to each stimulating channel individually. Elicited EMG voltage outputs were recorded for each muscle. Direct videolaryngoscopy was performed for visualization of VF movement.

RESULTS

Stimulation through individual channels led to selective activation of restricted nerve populations, resulting in selective contraction of individual LMs. Increasing current levels resulted in rising EMG voltage responses. Typically, activation of individual muscles was successfully achieved via single placement of the MEA by selection of appropriate stimulation channels. VF abduction was predominantly observed on videolaryngoscopy. Nerve histology confirmed injury in cases of RLN crush and transection experiments.

CONCLUSIONS

We demonstrated the ability of a penetrating MEA to selectively stimulate restricted fiber populations within the feline RLN and selectively elicit contractions of discrete LMs in both acute and injury-model experiments, suggesting a potential role for intraneural MEA implantation in VFP management.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:1606-1614, 2018.

Mutation Analysis in Chronic Myeloid Leukemia Patient in Chronic Phase on Imatinib Having Delayed Achievement of Milestones or Loss of Response

Tyrosine kinase inhibitors (TKI's) are currently the drug of choice for management of chronic myeloid leukemia. Imatinib is the most commonly used first line TKI in India. Mutations leading to resistance to imatinib are the most common cause for imatinib failure. We studied pattern of kinase domain mutations in 40 patients of CML who either lost their response or did not achieve it in defined timepoints. Loss of molecular response was the most common indication for asking mutation analysis. Sixteen patients were found to have detectable mutations. M351T was the most common tyrosine kinase mutation followed by Y253H and H396R. Two patients had 2 mutations simultaneously. M351T is the most common mutation in our patient population.

Haemostatic Profile in Patients of Myeloproliferative Neoplasms-A Tertiary Care Centre Experience

INTRODUCTION

Patients of MPN commonly present with abnormalities in laboratory coagulation tests that are consistent with hypercoagulable state. Some individuals with MPN exhibit a pattern of exclusive bleeding or thrombotic events; many others have both bleeding and thrombosis during the course of the disease.

AIM

This study was undertaken to assess the haemostatic defects and platelet functions in patients of MPN.

MATERIALS AND METHODS

One year prospective study was conducted at a tertiary care centre in North India in Department of Pathology in collaboration with Department of Clinical Haematology. All recently diagnosed cases of MPN along with 30 age and sex matched controls were included. Patients on antiplatelet drugs, antimyeloproliferative treatment, vitamin K agonists or antagonists, OCPs, Platelet count <1,00,000/μl, high grade fever, liver disease, pregnancy were excluded from this study. All the patients underwent screening investigations like CBC, peripheral smear evaluation, BT, PT, aPTT, Protein C and S measurement (clot based assay) and aggregation studies with ADP (5μM) (Optical Aggregometry with AGGRO/LINK 8 software and CHRONOLOG 700 aggregometer).

RESULTS

In present study, 50 cases were included. There was an occult prothrombotic state, suggested by significantly (p<0.001) reduced levels of Protein C and Protein S, but no patient presented with frank thrombosis while 8 out of 50 patients had haemorrhagic manifestations ranging from subdural haematoma to pin point petechial haemorrhages. Patients of CML-CP, ET, PV, PMF, MPN-NOS showed significantly reduced maximal aggregation with ADP (5μM) when compared to control (p<0.001). MPV also showed a statistically significant increase in these patients.

CONCLUSION

Thrombohaemorrhagic complications significantly affect the morbidity and mortality of MPN patients. This can be assessed by the use of platelet aggregation studies, Protein C and S activities and other coagulation studies. Timely diagnosis of these prothrombotic/haemorrhagic states can decrease the morbidity in these patients.

Does resident involvement in thyroid surgery lead to increased postoperative complications?

OBJECTIVES/HYPOTHESIS

To evaluate the impact of resident involvement during thyroid surgery on 30-day postoperative complications.

STUDY DESIGN

Retrospective cohort study.

METHODS

All patients who underwent thyroid surgery in 2011 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patient demographics, perioperative details, resident involvement in surgery, and 30-day postoperative complications were extracted. Propensity score analysis was used to match resident and nonresident cases. Univariate and multivariate analysis were performed to determine the relationship between resident involvement in thyroid surgery and postoperative outcomes.

RESULTS

One thousand seven hundred forty-seven patients with and 1,747 patients without resident involvement were case-matched for patient demographics, perioperative variables, and surgical case type. There was no significant difference (P = .19) in 30-day postoperative complication rates of surgeries with and without resident involvement, which were 1.4% and 2%, respectively. Operative time was longer in surgeries with residents than those without residents (119 ± 67 minutes vs. 102 ± 55 minutes, P < .001). Cases with resident involvement had an unplanned reoperation rate of 0.9%, which was significantly lower than the 2.3% rate of surgeries without residents (P = .001). Multivariate analysis revealed no significant association between resident involvement and overall complications (odds ratio = 0.70; P = .18).

CONCLUSIONS

Resident participation in thyroid surgery was not associated with an increased 30-day postoperative complication rate. These findings demonstrate that patient safety is not adversely affected by resident participation in thyroid surgery.

LEVEL OF EVIDENCE

2C Laryngoscope, 127:1242-1246, 2017.

Are Online Zenker’s Diverticulum Materials Readable and Understandable?

Objective

Patients use a multitude of resources to learn about Zenker’s diverticulum (ZD). The objectives of this study were to assess the readability and understandability of online materials on ZD, evaluate them against the existing criteria, and investigate the relationship between readability and understandability.

Methods

The first 50 webpages from an online search for ZD were analyzed. Twenty-one webpages had materials intended for patients and were included in the study. The patient education materials (PEMs) were analyzed using 6 readability tools. Four individuals used the Patient Education Materials Evaluation Tool (PEMAT) to assess the understandability. Fleiss κ interrater reliability analysis determined consistency among the raters. Finally, Pearson correlation coefficient analyzed the relationship between readability and understandability.

Results

The reading grade level of the materials reviewed ranged from 10th to 16th grade while the understandability ranged from 31% to 74%. Correlation analysis demonstrated a strong negative correlation between readability and understandability ( r = −0.62, P < .05). Fleiss’ κ interrater reliability for the raters demonstrated substantial agreement between the 4 raters (κ = 0.64).

Conclusion

Online PEMs pertaining to ZD are written well above the recommended reading level. Materials written at a lower reading level are more understandable. A wide range of understandability exists among materials with identical reading grade levels.

Implications for Practice

Health care providers need to create new PEMs for ZD that are available online that are both readable and understandable. The PEMAT and readability formulas can provide a framework for authors to create these materials.

Laryngeal adenocarcinoma not otherwise specified: A population-based perspective

OBJECTIVES/HYPOTHESIS

Laryngeal adenocarcinoma not otherwise specified (LAdC NOS) is a category to which variants of minor salivary gland tumors of the larynx that do not fit other well-characterized histological subtypes are assigned. Its rare nature and inconsistency in available reports has hindered the investigation and further understanding of this malignancy. In this study, a national population-based resource was used to evaluate the epidemiology and survival of this rare entity.

STUDY DESIGN

Retrospective population-based analysis.

METHODS

The Surveillance, Epidemiology, and End Results database was searched for patients diagnosed with LAdC NOS between 1973 and 2012. Patient demographics, tumor location, TNM stage, grade, incidence, and survival trends were collected and analyzed.

RESULTS

One hundred eleven patients met criteria for diagnosis of LAdC NOS, of which the majority were male (80.2%), white (84.7%), with a mean age of 65 years. The supraglottis was the most common site at presentation (38.7%). The majority presented with grade II tumor (45.7%). TNM staging revealed T2 (36.8%), N0 (72.2%), and M0 (88.9%) to be the most common classification. The overall incidence between the years of 2000 and 2012 was 0.008/100,000 individuals. The overall 5-year disease-specific survival (DSS) was 60.1%, compared to 85.7% in patients treated with combination surgery and radiotherapy.

CONCLUSIONS

LAdC NOS is an uncommon malignancy. It most commonly affects men in their mid-60s, indiscriminate of race. Lesions most commonly present in the supraglottis and are more often low grade histologically. DSS is highest in patient treated with combination surgery and radiotherapy.

LEVEL OF EVIDENCE

4 Laryngoscope, 2016 127:424-429, 2017.

The Utility of Recurrent Laryngeal Nerve Monitoring During Open Pharyngeal Diverticula Procedures

OBJECTIVES

The recurrent laryngeal nerve is at risk of injury during open pharyngeal diverticula operations. The utility of recurrent laryngeal nerve (RLN) monitoring during these procedures was investigated.

METHODS

A retrospective chart review was performed of 8 open pharyngeal diverticulectomies completed between 2009 and 2014. Intraoperative RLN monitoring took place during all operations.

RESULTS

Open pharyngectomy and myotomy was successfully performed in all cases. In two cases the RLN was encountered outside of its normal course. The identity of the nerve was confirmed with electrical stimulation and normal EMG response. Vocal fold motion was preserved in all cases.

CONCLUSIONS

Use of intraoperative nerve monitoring in pharyngeal diverticula procedures may be beneficial, especially during open operations for Killian-Jamieson diverticulum (KJD) and large Zenker diverticulum (ZD), where the RLN is typically encountered outside of its normal course.

A randomized study of very low-dose factor VIII prophylaxis in severe haemophilia - A success story from a resource limited country

INTRODUCTION

Current factor prophylaxis strategy practised in developed countries is not feasible in resource constraint developing countries like India.

AIM

The aim of this study was to investigate the efficacy and safety of very low-dose factor prophylaxis in India.

METHODS

Children of 1-10 years of age with severe haemophilia were randomized to Prophylaxis group and Episodic (On demand) group. Children in prophylaxis group received very low-dose factor VIII (FVIII) concentrate, i.e. 10 units kg(-1) body weights on 2 days a week. Episodic group received factor concentrate in standard recommended doses. The study period was 11.5 months.

RESULTS

In total 21 children were enrolled in this study, 11 assigned to prophylaxis and 10 to episodic group. Children on prophylaxis had 11 joint bleeds in comparison to 57 joint bleeds in episodic group. Mean number of haemarthrosis per patient per month were 0.08 (0.08 ± 0.13) in prophylaxis group compared to 0.48 (0.48 ± 0.34) in episodic group (P < 0.05). Total FVIII consumption was 87.51 and 56.32 units kg(-1) month(-1) in prophylaxis and episodic group respectively (P = ns). Overall median hospital emergency visits were 1 day in prophylaxis group and 9 days in episodic group (P ≤ 0.05). Median days of absenteeism from school were 25 days in episodic group and 3 days in prophylaxis group (P < 0.05). No significant complications were noted in prophylaxis group and compliance was 98%.

CONCLUSION

To conclude, low-dose FVIII prophylaxis is cost effective, efficacious and a safe method of preventing joint bleeds and consequent joint damages.

Readability and Understandability of Online Vocal Cord Paralysis Materials

Objective

Patients use several online resources to learn about vocal cord paralysis (VCP). The objective of this study was to assess the readability and understandability of online VCP patient education materials (PEMs), with readability assessments and the Patient Education Materials Evaluation Tool (PEMAT), respectively. The relationship between readability and understandability was then analyzed.

Study Design and Setting

Descriptive and correlational design.

Method

Online PEMs were identified by performing a Google search with the term “vocal cord paralysis.” After scientific webpages, news articles, and information for medical professionals were excluded, 29 articles from the first 50 search results were considered. Readability analysis was performed with 6 formulas. Four individuals with different educational backgrounds conducted understandability analysis with the PEMAT. Fleiss’s Kappa interrater reliability analysis determined consistency among raters. Correlation between readability and understandability was determined with Pearson’s correlation test.

Results

The reading level of the reviewed articles ranged from grades 9 to 17. Understandability ranged from 29% to 82%. Correlation analysis demonstrated a strong negative correlation between materials’ readability and understandability ( r = −0.462, P < .05).

Conclusion

Online PEMs pertaining to VCP are written above the recommended reading levels. Overall, materials written at lower grade levels are more understandable. However, articles of identical grade levels had varying levels of understandability. The PEMAT may provide a more critical evaluation of the quality of a PEM when compared with readability formulas. Both readability and understandability should be used to evaluate PEMs.

Evaluation of Heating and Shearing on the Viscoelastic Properties of Calcium Hydroxyapatite Used in Injection Laryngoplasty

OBJECTIVE

To compare the viscoelastic properties of calcium hydroxyapatite (CaHA) to carboxymethylcellulose (CMC) injectables used for injection laryngoplasty and determine if they are affected by heating and shearing.

STUDY DESIGN

Experimental.

SETTING

University laboratory.

SUBJECTS AND METHODS

Vocal fold injection laryngoplasty with CaHA is oftentimes challenging due to the amount of pressure necessary to push the injectate through a needle. Anecdotal techniques, such as heating the product, have been suggested to facilitate injection. The viscoelastic properties of CaHA and CMC were measured with a rheometer. The effects of heating and shearing on sample viscoelasticity were recorded.

RESULTS

CaHA was 9.5 times more viscous than CMC (43,100 vs 4540 Pa·s). Heating temporarily decreased the viscosity of CaHA by 32%. However, it also caused the viscosity to subsequently increase after time. Shearing of CaHA reduced its viscosity by 26%. Heating and shearing together temporarily reduced the viscosity of CaHA by 52%.

CONCLUSION

A combination of heating and shearing had a more profound effect than heating or shearing alone on the viscosity of CaHA, potentially making it easier to inject temporarily. Long-term and in vivo studies are required to further analyze the effect of heating and shearing on CaHA injectables.

A novel device for measurement of subglottic stenosis in 3 dimensions during suspension laryngoscopy

IMPORTANCE

A challenge in treating subglottic stenosis is assessment of airway caliber before and after management. At present, surgeons lack a simple, efficient, and precise method of measuring subglottic stenosis intraoperatively. We present a novel, easily reproducible tool for measurement of the diameter, location, and length of subglottic stenosis during suspension laryngoscopy.

METHODS AND OBSERVATIONS

A set of 5 Kirschner wires (30-cm length and 1.6-mm diameter) were bent 90° at both ends to produce a series of 10 short ends designed to measure airway diameter (0.3- to 2.1-cm length with 2-mm intervals). Short, bent ends of the measuring sticks were designed to measure airway diameter. Hash marks at 2-mm intervals were created along the long axis of the measuring sticks to measure subglottic stenosis length and location relative to the vocal cords. The measuring stick was tested in 10 adult patients undergoing suspension microlaryngoscopy for endoscopic treatment of subglottic stenosis between September 2012 and July 2013. The accuracy of the measuring stick was evaluated using an airway phantom. The measuring stick enabled easy and precise quantification of subglottic stenosis diameter (82.5% agreement with reference; interobserver agreement, r = 0.995; P < .001), length (72.5%; r = 0.995; P < .001) and location during suspension laryngoscopy.

CONCLUSIONS AND RELEVANCE

The measuring stick is inexpensive and simple to construct. It allows for safe, accurate, and practical measurement of subglottic stenosis diameter, length, and location during suspension laryngoscopy.

Is Nebulized Lidocaine Adequate Topical Anesthesia for Diagnostic Transnasal Tracheoscopy?

OBJECTIVES

To evaluate if nebulized 4% lidocaine alone provides adequate laryngopharyngeal anesthesia for office-based diagnostic transnasal tracheoscopy (TNT).

METHODS

A retrospective chart review (January 2011 to June 2014) and a prospective case series (July 2014 to December 2014) of patients who underwent diagnostic TNT were performed at a university voice and swallowing center. TNT cases were categorized by method of topical laryngopharyngeal anesthesia: nebulized 4% lidocaine and 4% lidocaine drip (phase I) and nebulized 4% lidocaine only (phase II).

RESULTS

TNT was performed a total of 59 times on 38 patients. Eleven (69%) of 16 phase I TNT procedures involved significant patient discomfort and severe cough following the lidocaine drip. Forty-two (98%) of 43 phase II TNT procedures were completed comfortably; 1 case required additional anesthesia by lidocaine drip. Retrospectively, 100% (n=8) of patients who underwent both phase I and phase II TNTs were noted to prefer anesthesia with nebulizer alone. In a prospective case series of 14 phase II TNT cases, 6 (86%) of 7 patients who previously underwent phase I TNT reported preference for anesthesia with nebulizer alone.

CONCLUSIONS

Nebulized lidocaine appears to provide sufficient laryngopharyngeal anesthesia for diagnostic TNT. It is preferred by patients over laryngeal drip.

A case of pediatric acute lymphoblastic leukemia with invasive candidiasis: short review

Mortality rate associated with invasive fungal infections is very high. Early suspicion for fungal infections is important during intensive chemotherapy for acute leukemia. Empirical treatment with antifungals amphotericin B or caspofungin should be started if patient is not responding to broad spectrum antibiotics and if expected duration of neutropenia is prolonged. We are reporting a 3 years old girl child with diagnosis of pre-B acute lymphoblastic leukemia who developed invasive candidiasis with typical clinical and radiological findings during induction chemotherapy. Candida non-albicans was isolated and she was treated with amphotericin B followed by caspofungin. Patient deteriorated after initial response and succumbed to death. Species identification and sensitivity pattern of fungus can help in selecting appropriate antifungal drug.

Ten Steps to Develop Patient Education Videos for Individuals of All Health Literacy Levels

Objectives:

(1) Create a protocol for developing educational videos for patients of all health literacy levels. (2) Describe National Institutes of Health (NIH) guidelines, evidence-based principles of instructional design, and industry best practices related to creating educational videos for patients.

Methods:

Utilizing (1) NIH guidelines for patient education materials, (2) evidence-based principles of instructional design, and (3) industry best practices, a 10-step protocol was developed for creating video-based patient education materials. As a proof-of-concept, these 10 steps were used to create a short video to help patients understand flexible laryngostroboscopy.

Results:

Using NIH guidelines, a script was created with text designed for the sixth-grade reading level using the SMOG Readability Formula. Evidence-based principles of instructional design that were incorporated into the video included: the Personalization Principle, Multimedia Principle, Coherence Principle, Contiguity Principle, and Practice Principle. A video was recorded with a high definition camera, and audio narration was recorded separately. A short video describing laryngeal anatomy and showing actual footage laryngostoboscopy was edited on Camtasia Studio 8.0 and produced for optimized viewing on the iPad. The video was pilot tested on patients prior to undergoing flexible laryngostroboscopy at an outpatient otolaryngology–head and neck surgery clinic.

Conclusions:

There is currently no protocol for creating educational videos for patients with limited health literacy. This 10-step protocol was created to help those creating educational videos incorporate NIH guidelines, evidence-based principles of instructional design, and industry best practices into their projects.

Internet Usage and eHealth Literacy of Patients in an Otolaryngology–Head and Neck Surgery Clinic

Objectives:

(1) Investigate whether otolaryngology–head and neck surgery (OHNS) outpatients consult health-related online resources and establish baseline levels of perceived eHealth literacy. (2) Determine which resources patients use to investigate their disease and research treating physicians. (3) Explore relationships between perceived eHealth literacy, demographic data, and internet usage.

Methods:

A questionnaire was administered to 79 patients in a tertiary care OHNS outpatient setting between December 2013 and February 2014. The questionnaire recorded (1) demographic data, (2) health-related Internet use, and (3) eHealth Literacy Scale (eHEALS), a tool used to measure perceived eHealth literacy.

Results:

Seventy-five of 79 patients completed the questionnaire. Seventy-six percent (n = 57) of patients had consulted online resources regarding their disease. The most commonly used resources were prompted by search engine results such as Google (88%, n = 51) and health websites such as WebMD (71%, n = 41). Only 14% of this group used the American Academy of Otolaryngology—Head and Neck website. Fifty percent (n = 38) of patients consulted online resources regarding their otolaryngologist prior to their visit. The mean eHEALS score was 3.65/5.0 (95% confidence interval [CI], 3.46-3.84). For patients who search for health-related information online, the odds of using dedicated health websites were 90.8% lower for patients with an eHEALS score below the mean versus above the mean ( P = .017; 95% CI, 35%-98.7%).

Conclusions:

The majority of patients in this study consulted online resources to learn about their disease and physician. In this cohort, the perceived eHealth literacy influenced the type of website consulted. Patients with lower perceived eHealth literacy were less likely to consult dedicated health websites.

Barriers to Adoption of Office-Based Laryngeal Surgery

Objectives:

Office-based laryngeal surgery (OBLS) has been shown to be safe and efficacious for many common laryngeal disorders. Despite this, OBLS is not widely adopted by otolaryngologists. This study investigated what barriers exist to OBLS through a survey of practicing otolaryngologists.

Methods:

A questionnaire was sent to the membership of the Academy of Otolaryngology—Head and Neck Surgery in winter 2013.

Results:

A total of 173 otolaryngologists completed the survey. The availability of lasers for OBLS was cited as a major obstacle by 119 out of 173 (75%) of respondents. Reimbursement of disposables and lack of CPT codes for OBLS were the second and third major obstacles noted, respectively (85/173 [53%] and 68/173 [43%]). Reliability of results in the office was less commonly cited as a major obstacle by 24 out of 173 (15%) of respondents.

Conclusions:

Organizational and financial considerations continue to be barriers for adoption of OBLS.

Contemporary Management of Unilateral Vocal Fold Paralysis

Program Description:

This course will provide a comprehensive review of unilateral vocal fold paralysis (UVFP) management. The causes and workup of UVFP will be discussed. Special attention will be paid to office evaluation including utility of stroboscopy and laryngeal electromyography. Intervention including operating room–and office-based injection laryngoplasty will be described. The benefits of thyroplasty, arytenoid adduction, arytenopexy, and reinnervation will be debated. Case presentations will be used to highlight teaching points. Ample time will be allotted for audience participation and questions.

Educational Objectives:

(1) Describe how to perform a vocal fold injection. (2) Compare different methods to treat unilateral vocal fold paralysis.

Office-based injection laryngoplasty for the management of unilateral vocal fold paralysis

OBJECTIVE

Office-based injection laryngoplasty (OBIL) is a common method of addressing glottal insufficiency. This retrospective chart review identifies the demongraphics, laterality, technique, success rate, injectates, and complications of OBIL performed over a 3-year period at a single institution.

STUDY DESIGN

Retrospective chart review.

METHODS

All OBILs performed for the management of UVFP by the senior author over 3 years (2007-2009) were identified from billing records. The age, gender, laterality, underlying disease process, augmentation material, route of injection, and complications were recorded.

RESULTS

Eighty-two OBILs were attempted on 57 patients. The most common route of access was transoral (85.6%). All OBILs were able to be completed. Injectates used were hyaluronic acid derivatives (57.3%), calcium hydroxyapatite (16%), and Cymmetra (16.5%). Three complications (3.7%) occurred. Thirty percent of patients ultimately elected for thyroplasty or ansa reinnervation, 22% found their condition to self-resolve, 14% died, and 25% were lost to follow-up.

CONCLUSIONS

Using a variety of approaches, OBIL is possible in almost all patients. The single surgeon transoral route using a rigid angled telescope and curved injection needle was the most commonly used approach. Multiple injectates can be used and have good safety records. The final disposition of patients may be variable and warrants further investigation.

Swallowing Disorders in the Ambulatory Medical Setting

Objectives

The aims of this cross-sectional study were to explore the nationwide number and demographics of patient visits due to dysphagia and to investigate potential differences in their management between otolaryngologists and other physicians in the outpatient setting.

Study Design

Cross-sectional.

Setting

National Ambulatory Medical Care Survey.

Subjects and Methods

The data sets from 2007 to 2010 were queried to extract all cases with dysphagia as a reason for visit. Data regarding demographics, imaging studies, nonmedication therapies, diagnoses, medications, and patient disposition were compared between otolaryngologists, primary care physicians, and other specialists.

Results

Annually, 1,875,187 (95% confidence interval [CI], 1,443,876-2,307,204) outpatient visits were due to dysphagia, comprising 0.19% of all visits (95% CI, 0.14%-0.23%) and 1.55% (95% CI, 1.10%-2.0%) of the visits to otolaryngologists. The visits were mostly distributed between primary care physicians and other specialists, while 16.4% (95% CI, 11.3%-21.6%) visited an otolaryngology office. Otolaryngologists, primary care physicians, and other specialists ordered imaging studies in 22.8%, 10.2%, and 24.0% ( P = .02); performed aerodigestive-specific procedures in 20.8%, 4.0%, and 36.2% ( P < .0001); and referred the patient to another physician in 5.8%, 14.8%, and 2.8% ( P = .003) of the visits, respectively.

Conclusions

Almost 0.2% of office visits to physicians have a complaint of dysphagia. Otolaryngologists are involved in the care of a minority of these visits. The differences in the management of dysphagic patients may be due to different etiologies of the disease.

Association of dietary factors and other coronary risk factors with social class in women in five Indian cities

The association between social classes, food intake and coronary risk factors was determined. Cross-sectional surveys were conducted in 6-12 urban streets in each of five cities, each one from five different regions of India using similar methods of dietary intakes and criteria of diagnosis. We randomly selected 3257 women aged 25-64 years inclusive, from Moradabad (n = 902), Trivandrum (n = 760), Calcutta (n = 410), Nagpur (n = 405) and Bombay (n = 780). All subjects, after pooling of data, were divided into social class 1 (n = 985), class 2 (n = 790), class 3 (n = 774), class 4 (n = 602) and class 5 (n = 206) based on various attributes of socioeconomic status. Social class 1 was the highest and 5 was the lowest social class. Social classes 1-3 had greater intake of pro-atherogenic foods; total visible fat, milk and milk products, meat and eggs, as well as sugar and confectionery, compared to social classes 4 and 5. The consumption of wheat, rice, millets, fruits, vegetables and legume/total visible fat ratio were inversely associated with social class. Mean body mass index (BMI), obesity, overweight, central obesity and sedentary lifestyle were also significantly more common among subjects from higher social classes. Spearman's rank correlation showed that bodyweight, BMI, wheat, rice, millets, total visible fat, milk and milk products, meat, eggs, sugar and jaggery intakes were significantly correlated with social class. Social class 5 subjects had a lower intake of all foods and a lower BMI, suggestive of a higher rate of undernutrition among them. The findings indicate that the consumption of pro-atherogenic foods and other coronary risk factors are more common in higher social classes compared to lower social classes.

The changing landscape of total laryngectomy surgery

OBJECTIVE

To determine if the number of total laryngectomies (TL) performed in California has changed over a 15-year period from 1996 to 2010. We also sought to investigate if the location of surgery, length of stay, use of rotational/free flaps, cost, and complications changed over this period.

STUDY DESIGN

Cross-sectional.

SETTING

California Hospital Inpatient Discharge Data sets.

SUBJECTS AND METHODS

All patient records enlisting International Classification of Diseases, Ninth Revision, Clinical Modification procedural codes for total/radical laryngectomy were extracted from 1996 to 2010 data sets. Patients' demographics were evaluated. Hospitals were coded as university medical centers (UMCs) vs others. Population-adjusted surgery rates, percentage of surgeries with rotational/free flap and/or percutaneous endoscopic gastrostomy (PEG), length of stay, total charges, and disposition status were then analyzed and compared between UMCs and non-UMCs.

RESULTS

A total of 4145 TLs were performed in California during 1996 to 2010. The overall number of surgeries declined from 1.3 to 0.6 per 100,000 California residents (P < .001). The number of surgeries performed in non-UMCs dropped by 70% during this period (P < .001). The median length of stay increased from 10 to 12 days, and the median total charges increased from $45,000 to $192,000 over the 15-year period. The use of rotational/free flaps more than doubled, and the use of PEG tubes increased 7-fold.

CONCLUSION

The total number of TLs in California has declined and surgeries are currently being performed equally at UMCs and non-UMCs. The use of rotational/free flaps, costs, hospital stay length, and complications have increased over the past 15 years.

Microbiological sampling of the forgotten components of a flexible fiberoptic laryngoscope: what lessons can we learn?

The effectiveness of a Cidex-based decontamination protocol was analyzed for its effectiveness in cleaning various components of a flexible fiberoptic laryngoscope (FFL), including the handle, eyepiece, and detachable light cable. A random microbiological sampling and aerobic bacterial culture analysis of 6 FFL eyepieces, 6 FFL driver handles, and 5 light cables prior to patient use was performed. Of 17 samples collected, 7 (41%) were contaminated with bacterial organisms. Organisms recovered represented both environmental organisms from skin and oral flora origin. This study demonstrates that potential contaminants may be present on FFL eyepieces and light cables, which are commonly overlooked in the cleaning protocols of a standard otolaryngology clinic.

Evaluating the Effects of a 532-nm Fiber-Based KTP Laser on Transoral Laser Surgery Supplies

Objective

The KTP laser has become commonplace in transoral head and neck surgery. The interactions of this laser with commonly used supplies in transoral surgery have not been formally examined. This study evaluates the effects of the KTP laser on surgical supplies.

Study Design

Experimental study.

Setting

The study was conducted in an empty operating room at a university-affiliated medical center.

Methods

An Aura XP 532-nm KTP laser with a 600-nm fiber was used in pulsed and continuous modes. The beam was focused at the shaft and balloon of 3 “laser-safe” endotracheal tubes (ETTs), a polyvinyl chloride (PVC) ETT, and a Codman surgical patty. Time to penetrate was recorded.

Results

The KTP laser beam was unable to penetrate any of the laser-resistant ETTs. It did react with the black number markings on the PVC ETT by producing sparks but was unable to penetrate the shaft of the ETT. The KTP laser was nonreactive with all ETT cuffs except in 1 of 3 trials with the outer balloon cuff of a Rusch Lasertubus ETT when the laser was used in a continuous mode. The KTP laser caused the production of a flame upon contact with the blue radiopaque strip of the surgical patty, even when the patty was wet.

Conclusion

This study demonstrates that a number of safe ETT options may be used during transoral laser microsurgery with a KTP laser. In addition, Codman surgical patties are shown to be a significant fire risk in KTP laser surgery.

Practical Management of Complications in Otolaryngology

Program Description:

Otolaryngologists perform a variety of surgeries, many of which inherently have a small margin for error. While most surgeries are uneventful, complications present special challenges and may create anxiety among surgeons. This miniseminar will employ a multidisciplinary approach to create a paradigm for management of the unwanted surgical complication. A case-based approach will be used to highlight common complications. Methods for prevention will be reviewed and keys for management of the unwanted complication will be presented. Cases from each otolaryngology subspecialty will be presented with opportunity for audience interaction and questions.

Educational Objectives:

1) Recognize common complications within otolaryngology-head and neck surgery. 2) Evaluate measures that can be taken preoperatively and intraoperatively to prevent complications. 3) Describe methods to manage common complications.

Safety Concerns of the CO2 Laser in Traditional and Hand-Held Modes in Transoral Laser Microsurgery

Objectives:

Comparisons between line-of-sight and fiber-optic carbon dioxide (CO2) lasers have not been previously reported in regards to interactions with commonly used products in transoral laser microsurgery. In this study we sought to address this gap.

Methods:

The beams of a traditional and an Omniguide fiber-based laser were focused on commonly used materials in transoral laser microsurgery. Three laser resistant endotracheal tubes (ETTs), a standard polyvinylcholoride (PVC) ETT, and cottonoids were evaluated. The time to penetrate through the material was recorded.

Results:

Neither laser beam completely penetrated any of the laser resistant ETTs within 90s of contact. However, both instantaneously perforated the absorbent coating of the laser resistant tubes, immediately exposing the underlying metal tape. The traditional laser perforated the PVC endotracheal tube at 0s, and the Omniguide laser did so within 3s. The Rusch Lasertubus ETT balloon cuff was the most resistant material to both lasers. Both laser beams perforated dry cottonoids instantaneously but were unable to penetrate excessively saturated cottonoids.

Conclusions:

In general the time to penetrate materials was longer for a traditional CO2 laser when used at the same power. The absorbent outer coating of all ETTs was easily penetrated with the laser, revealing highly reflective metallic tape. While supersaturated cottonoids were resistant to both lasers, dry pledgets could be penetrated. Of all ETTs tested, the Rusch Lasertubus ETT appears to be the most resistant to both lasers.

Trends of Total Laryngectomy: Analysis of California Patient Discharge Data 1996-2010

Objectives:

Determine if the number of total laryngectomies (TL) performed in California has changed over the last fifteen years. We also sought to investigate if the location of surgery, length of stay, and use of rotational/free flaps changed over this time period.

Methods:

All patient records enlisting ICD-9-CM procedural codes for laryngectomy were extracted from the California Patient Discharge Data sets of 1996-2010. Patients’ demographics were evaluated. Teaching otolaryngology hospitals were coded as academic. Population-adjusted surgery rates, percentage of surgeries with rotational/free flap and/or percutaneous endoscopic gastrostomy (PEG), length of stay, total charges, and disposition status were then analyzed and compared between academic and non-academic centers.

Results:

A total of 4,145 TLs were performed from 1996-2010. The overall number of surgeries declined from 1.3 surgeries per 100,000 California residents to 0.6 per 100,000 California residents. The number of surgeries performed in non-academic medical centers dropped by 70% during this time period ( P < .01). The median length of stay increased from 10 to 12 days, and the median total charges increased from $45000 to $192000 ( P < .01). The use of rotational/free flaps more than doubled, and the use of PEG tubes increased seven folds ( P < .01).

Conclusions:

The total number of patients undergoing TL in California has declined, and the surgery is increasingly being performed at academic medical centers. The use of rotational and free flaps has increased over the last 15 years.

Injection Laryngoplasty: Contemporary Indications/Techniques

Program Description:

This miniseminar will provide a contemporary review of injection laryngoplasty (IL). Common and overlooked causes of glottal insufficiency will be reviewed. Methods of evaluating patients and the timing of IL relative to patient presentation will be addressed. Technical discussions of how to perform IL in the operating room and in the office will take place. A thorough review of in-office IL will highlight indications and techniques for injection as well as discuss costs, billing, and other practical aspects required for establishing and maintaining an office-based practice. Case-based scenarios will be used to demonstrate pearls and pitfalls in performance of IL.

Educational Objectives:

1) Recognize laryngeal conditions that will benefit from vocal fold injection. 2) Gain familiarity with indications and approaches for in-office vocal fold injection. 3) Apply techniques to improve outcomes of vocal fold injections.

Microbiological Sampling of Common Otolaryngological Office Equipment: What Lessons Can We Learn?

Objectives:

Analyze whether standard decontamination protocols were effective in cleaning integral components of common otolaryngological office equipment, including flexible fiberoptic laryngoscopes, detachable light cables, and otoscope handles.

Methods:

A random microbiological sampling of 6 flexible fiberoptic laryngoscopes including the eye piece and the driver handle, 3 light cables, and 5 otoscope handles was performed. All equipment was sampled in the middle of a busy office session. Samples were then subjected to standard aerobic growth culture analysis.

Results:

From a total of 20 samples collected, 7 (35%) demonstrated contamination with bacterial organisms. 4 of the 20 sample sites (20%) exhibited human contamination, 2 of which were from light cables, 1 from a laryngoscope eye piece, and 1 from an otoscope handle.

Conclusions:

This microbiological evaluation of common office instruments demonstrates that there are numerous potential contaminates which may be present in the office setting. These include flexible laryngoscope eyepieces, light cables, and otoscopes, which are commonly overlooked in the cleaning protocols of a standard otolaryngology clinic.

Rational Use of Recombinant Factor VIIa in Clinical Practice

In the United States, the FDA-approved indications for recombinant factor VIIa is for bypassing inhibitors to factors VIII and IX in patients with hemophilia A and B respectively and for treatment of congenital factor VII deficiency. In European countries, rFVIIa is licensed for the above indications as well as for Glanzmann's thrombasthenia. In absence of high-quality data favoring off-label use of this agent and laboratory test to predict response to this agent, and in view of high cost of rFVIIa, off-label use of recombinant factor VIIa should be restricted to only when hemorrhage has not responded to transfusion or other conventional therapy. It appears, two such conditions where recombinant factor VIIa may be beneficial are traumatic and postpartum hemorrhages.