Intractable Aspiration Treated With Laryngectomy After SLAD-R Surgery: A Case Report

A variety of surgical treatment options exist for adductor spasmodic dysphonia (ADSD) with selective adductor recurrent laryngeal nerve denervation and reinnervation (SLAD-R) being one of the more popular. We present a case of bilateral vocal fold paralysis (BVFP) for SLAD-R resulting in the need for total laryngectomy. We suggest BVFP is more common than reported and that we all must insure optimal long term follow up of our surgical patients. Laryngoscope, 2024.

Transnasal Humidified Rapid Insufflation Ventilatory Exchange in Endoscopic Esophageal Surgery

OBJECTIVES

Transnasal humidified rapid insufflation ventilatory exchange (THRIVE) describes apneic oxygenation using humidified high flow nasal-cannula oxygen. Although it has been described as a sole mode of oxygenation in endoscopic laryngotracheal surgery, its use in endoscopic esophageal surgery under general anesthesia with neuromuscular paralysis has not previously been described. The objective of this study is to assess the safety and efficacy of THRIVE in esophagology.

METHODS

We conducted a retrospective review of adult patients undergoing esophageal procedures under general anesthesia who were oxygenated using THRIVE at two academic institutions. Demographic, clinical, and anesthesiologic data were collected and analyzed.

RESULTS

14 cases performed from March 2021 to March 2022 met inclusion criteria. 13/14 (92.9%) of patients were able to maintain oxygenation throughout the entirety of their procedure. The mean apneic time was 17.9 minutes with a maximum of 32 minutes. One patient required "rescue" intubation due to failure to maintain oxygenation. Excluding the sole THRIVE failure, the median SpO2 at the conclusion of surgery was 99% (range 94-100%). A linear regression model yielded an increase in EtCO2 of 0.95 mmHg/min or 0.127 kPa/min. SpO2 was negatively associated with both tobacco pack-year smoking history (R2 = 0.343, P = .014) and BMI (R2 = 0.238, P = .038).

CONCLUSION

THRIVE is a feasible, safe, and efficacious means of apneic oxygenation for patients undergoing esophageal endoscopic surgery under general anesthesia with neuromuscular paralysis, which may be particularly beneficial in patients with airway stenosis, as post-intubation changes can have severe clinical implications for this patient population. Obese patients and tobacco smokers may be at increased risk of oxygen desaturation when using THRIVE.

Airway Management in Singers: A Cross-sectional Survey

OBJECTIVE

To review and establish current practices regarding airway management in vocal professionals undergoing surgery.

STUDY DESIGN

Cross-sectional survey SETTING: The setting included practitioners that treat vocal professionals across international sub-specialty societies.

SUBJECTS AND METHODS

A twenty-one-item survey was sent to practitioners that routinely treat vocal professionals including the American Broncho-Esophagological Association, European Laryngological Society, and 2017 Fall Voice Conference attendees. It included questions regarding the respondents' demographics, preferences for airway control in non-laryngeal and laryngeal surgery, and peri-operative management.

RESULTS

Total respondents (n = 163): 82.8% were Laryngologists, 4.3 % were General Otolaryngologists, 3.1% were Head & Neck Oncologists, and 6.8% were Speech-Language Pathologists. One hundred twenty-five of the participants (76.7%) classified their experience with vocal professionals as 'extensive' or 'often.' For non-laryngeal surgery, there was a tendency towards laryngeal mask airway (53.1%) over endotracheal intubation (46.9%). For professional singers, a smaller endotracheal tube was recommended. Size varied based on sex. For males, 88.5% recommended a tube ≤7.0 in non-singers; 98.2% recommended a tube ≤7.0 in singers. In females 76.1% recommended a tube ≤6.0 for non-singers; 94.6 % recommended a size ≤6.0 in a female singer. For laryngeal surgery, 14% of providers personally intubated patients over 90% of the time. Of the providers who work with trainees, 60.5% did not allow resident intubation.

CONCLUSION

Objective data regarding precautions in airway management of professional voice users is scarce. This is the largest survey to date on current practices. Survey results indicate that smaller ETTs are preferred for singers, and that more experienced practitioners are preferred for the intubation.

Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review

OBJECTIVE

To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD).

METHODS

Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report.

RESULTS

A total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval [CI]: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03).

CONCLUSION

KJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2110-2115, 2023.

Multi-institutional search for patient factors associated with adverse events following tracheotomy

BACKGROUND

Tracheotomy is a common procedure for otolaryngologists. The risk of complications is difficult to predict. This study aims to identify measurable preoperative indicators associated with adverse events following tracheotomy.

METHODS

The charts of adults undergoing tracheotomy for respiratory failure at one of four university-affiliated hospitals between 1/2012 and 8/2018 were reviewed. Complications were analyzed in the context of demographics, physiologic parameters, and comorbidities.

RESULTS

Among 507 tracheotomies performed, the most common complications included infection, bleeding, and cardiac arrest. Mortality was 39 % in patients with pulmonary hypertension, 42 % in those with ejection fraction ≤ 40 and 32 % in those with abnormal right ventricular function, double the rates in patients without each of these findings.

CONCLUSION

Many critically ill tracheotomy patients experience significant rates of adverse events. Risk factors for mortality include ejection fraction ≤ 40, pulmonary hypertension, and abnormal ventricular function. These should be considered for use in preoperative counseling.

LEVEL OF EVIDENCE: 4

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.

Low Pressure Low Frequency Jet Ventilation: Techniques, Safety and Complications

OBJECTIVE

Manual jet ventilation is a specialized oxygenation and ventilation technique that is not available in all facilities due to lack of technical familiarity and fear of complications. The objective is to review our center's 15 year experience with low pressure low frequency jet ventilation (LPLFJV).

METHODS

Retrospective review of procedures utilizing LPLFJV from 2005 to 2019 were performed collecting patient demographic, surgery type and complications. Fisher exact test, Chi square, and t-test were used to determine statistical significance.

RESULTS

Four hundred fifty-seven patients underwent a total of 891 microlaryngeal surgeries-279 cases for voice disorders, 179 for lesions, and 433 for airway stenosis. The peak jet pressure for all cases did not exceed 20 psi and average peak pressure for the last 100 procedures in this case series was 14.9 ± 4.6 psi. The average lowest oxygen saturation for all cases was 95% ± 0.6%. Brief intubation was required in 154 cases (17%). Surgical duration was significantly longer for cases requiring intubation P < .001. The need for intubation was not associated with smoking or cardiopulmonary disease, but was strongly associated with body mass index (BMI). Intubation rates were 7% for normal weight (BMI < 25, N = 216), 13% for overweight (BMI 25-30, N = 282), 24% for obese (BMI 30-40, N = 342), and 37% for morbidly obese (BMI > 40, N = 52) patients. Three patients developed respiratory distress in the recovery unit and 2 patients required intubation.

CONCLUSION

LPLFJV assisted by intermittent endotracheal intubation is an exceedingly safe and effective intraoperative oxygenation and ventilationmodality for a broad variety of laryngeal procedure.

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.

Virtual Dysphagia Evaluation: Practical Guidelines for Dysphagia Management in the Context of the COVID-19 Pandemic

With encouraging signs of pandemic containment nationwide, the promise of return to a full range of clinical practice is on the horizon. Clinicians are starting to prepare for a transition from limited evaluation of emergent and urgent complaints to resumption of elective surgical procedures and routine office visits within the next few weeks to months. Otolaryngology as a specialty faces unique challenges when it comes to the COVID-19 pandemic due to the fact that a comprehensive head and neck examination requires aerosol-generating endoscopic procedures. Since the COVID-19 pandemic is far from being over and the future may hold other highly communicable infectious threats that may require similar precautions, standard approaches to the clinical evaluation of common otolaryngology complaints will have to be modified. In this communication, we present practical recommendations for dysphagia evaluation with modifications to allow a safe and comprehensive assessment.

In-Office Evaluation and Management of Dysphagia

Dysphagia is a common complaint encountered in otolaryngology clinics. Approaching the patient with dysphagia starts with a comprehensive symptomatic analysis and thorough physical examination. The recent rapid revolution in office-based procedures has a great impact in the evaluation and management of dysphagia. Currently, diagnostic and therapeutic procedures can be performed safely and effectively in the office setting with the advantage of avoidance of sedation or general anesthesia.

Where am I? Transnasal esophagoscopy outside the normal esophagus

Medical malpractice is costly and disruptive, and it is important to prevent. We conducted a study with the objective to look at medical malpractice in robotic surgery overall, to evaluate reasons for litigation, and to comment on possible strategies to avoid litigation with transoral robotic surgery. We used the Westlaw computerized database to identify all state and federal verdict summaries in medical malpractice cases. We found 17 cases alleging malpractice that involved the use of robotic surgery. In all, the plaintiffs in 6 cases (35%) contended that an open rather than a robotic approach should have been used, 5 (29%) alleged negligent credentialing, 4 (24%) alleged training deficiencies, 2 (12%) alleged manufacturing problems, and 1 (6%) charged that robotic surgery should have been performed instead of open surgery (1 case involved two of these allegations). In 11 cases (65%), plaintiffs charged that robotic surgery contributed to an undesirable outcome, and in 6 cases (35%) they raised concerns about informed consent. In all, only 5 of the 17 lawsuits (29%) resulted in plaintiff verdicts or settlements; damages ranged from $95,000 to $7.5 million. We believe the courts should not play a major role in establishing safety guidelines for the introduction of new technology such as robotic surgery. Instead, training and credentialing guidelines should be established by appropriate national associations and societies to assist hospitals in doing so.

Effect of Chromoendoscopy Filters on Visualization of KTP Laser-Associated Tissue Changes: A Cadaveric Animal Model

Standard KTP laser (potassium titanyl phosphate) wavelength-specific protective eyewear often impairs visualization of tissue changes during laser treatment. This sometimes necessitates eyewear removal to evaluate tissue effects, which wastes time and poses safety concerns. The objective was to determine if "virtual" or "electronic" chromoendoscopy filters, as found on some endoscopy platforms, could alleviate the restricted visualization inherent to protective eyewear. A KTP laser was applied to porcine laryngeal tissue and recorded via video laryngoscopy with 1 optical (Olympus Narrow Band Imaging) and 8 digital (Pentax Medical I-scan) chromoendoscopy filters. Videos were viewed by 11 otolaryngologists wearing protective eyewear. Using a discrete visual analog scale, they rated each filter on its ability to improve visualization,. No filter impaired visualization; 5 of 9 improved visualization. Based on statistical significance, the number of positive responses, and the lack of negative responses, narrow band imaging and the I-scan tone enhancement filter for leukoplakia performed best. These filters could shorten procedure time and improve safety; therefore, further clinical evaluation is warranted.

Laser-assisted surgery of the upper aero-digestive tract: a clarification of nomenclature. A consensus statement of the European Laryngological Society

Acronyms and abbreviations are frequently used in otorhinolaryngology and other medical specialties. CO₂ laser-assisted transoral surgery of the pharynx, the larynx and the upper airway is a family of commonly performed surgical procedures termed transoral laser microsurgery (TLM). The abbreviation TLM can be confusing because of alternative modes of delivery. Classification and definition of the different types of procedures, performed transorally or transnasally, are proposed by the Working Committee for Nomenclature of the European Laryngological Society, emphasizing the type of laser used and the way this laser is transmitted. What is usually called TLM, would more clearly be defined as CO₂ laser transoral microsurgery or CO₂ TOLMS or CO₂ laser transoral surgery only (with a handpiece) would be defined as CO₂ TOLS. KTP transnasal flexible laser surgery would be KTP TNFLS. Transoral use of the flexible CO₂ wave-guide with a handpiece would be a CO₂ TOFLS. One can argue that these clarifications are not necessary and that the abbreviation TLM for transoral laser microsurgery is more than sufficient. But this is not the case. Laser surgery, office-based laser surgery and microsurgery are frequently and erroneously interchanged for one another. These classifications allow for a clear understanding of what was performed and what the results meant.

The feasibility of gamma radiation sterilization for decellularized tracheal grafts

OBJECTIVES/HYPOTHESIS

The most promising stem cell-derived tracheal transplantation approach is dependent upon the use of decellularized tracheal grafts. It has been assumed that a sterilization step, such as gamma radiation, would damage the delicate extracellular matrix of the graft, thus rendering it less viable for cellular repopulation, although this has not been thoroughly investigated.

STUDY DESIGN

Laboratory-based comparative analysis.

METHODS

Fifteen murine tracheas of strain C57/B-6 mice were obtained. Thirteen were subjected to a detergent-enzymatic decellularization process. Of these decellularized tracheas (DT), eight were irradiated, exposing five tracheas to a radiation level of 25 kGy (DT25) and three to 5 kGy (DT5). Two were left untreated. The two untreated tracheas, two DTs, and two DT25s were prepared and examined using both scanning and transmission electron microscopy. Bioburden calculations were obtained from three DTs, three DT25s, and three DT5s by homogenization, serial dilution, and streak plating.

RESULTS

Electron microscopy of untreated fresh tracheas and DTs showed a slight qualitative degradation of cartilage ultrastructure due to the decellularization process. In contrast, examination of DT25 shows significant degradation including poor overall preservation of cartilage architecture with disorganized collagen fibers. The nonirradiated DTs had a calculated bacterial bioburden of 7.8 × 10⁷ to 3.4 × 10⁸ colony-forming units per gram. Both the DT25 and DT5 specimens were found to have a bioburden of zero.

CONCLUSIONS

Gamma radiation at 25 kGy degrades the architecture of decellularized tracheal grafts. These ultrastructural changes may prove detrimental to graft viability; however, bioburden calculations suggest that a 5 kGy radiation dose may be sufficient for sterilization.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:E258-E264, 2017.

The Accuracy of the Laryngopharyngeal Reflux Diagnosis

Objective

To determine the prevalence and also accuracy of the laryngopharyngeal reflux (LPR) referring diagnosis and to determine the most useful clinical tool in arriving at the final diagnosis in a tertiary laryngology practice.

Study Design

Case series with planned data collection.

Setting

Six tertiary academic laryngology practices.

Subjects and Methods

We collected referring diagnosis and demographic information, including age, sex, ethnicity, referring physician, and whether or not patients had prior flexible laryngoscopy for 1077 patients presenting with laryngologic complaints from January 2010 and June 2013. Final diagnosis after the referred laryngologist’s examination and the key diagnostic test used was then recorded.

Results

Of 1077 patients, 132 had a singular referring diagnosis of LPR. Only 47 of 132 patients (35.6%) had LPR confirmed on final primary diagnosis. Transnasal flexible laryngoscopy confirmed this in 27 of 47 (57.4%) patients. Eighty-five of 132 (64.4%) had a different final diagnosis than LPR. Sixty-five of 85 (76.5%) of these alternative pathologies were diagnosed with the aid of laryngeal stroboscopy.

Conclusions

LPR appears to be an overused diagnosis for laryngologic complaints. For patients who have already had transnasal flexible laryngoscopic exams prior to their referral, laryngeal stroboscopy is the key diagnostic tool in arriving at the correct diagnosis.

Diagnostic Laryngeal Electromyography: The Wake Forest Experience 1995–1999

BACKGROUND:

Laryngeal electromyography (LEMG) is a valuable diagnostic/prognostic test for patients with suspected laryngeal neuromuscular disorders.

OBJECTIVE:

To report our experience with diagnostic LEMG at the Center for voice Disorders of Wake Forest University and to evaluate the impact of LEMG on clinical management.

METHODS:

Retrospective chart review of 415 patients who underwent diagnostic LEMG over a 5-year period (1995–1999).

RESULTS:

Of 415 studies, 83% (346 of 415) were abnormal, indicating a neuropathic process. LEMG results altered the diagnostic evaluation (eg, the type of radiographic imaging) in 11% (46 of 415) of the patients. Unexpected LEMG findings (eg, contralateral neuropathy) were found in 26% (107 of 415) of the patients, and LEMG results differentiated vocal fold paralysis from fixation in 12% (49 of 415). Finally, LEMG results altered the clinical management (eg, changed the timing and/or type of surgical procedure) in 40% (166 of 415) of the patients.

CONCLUSIONS:

LEMG is a valuable diagnostic test that aids the clinician in the diagnosis and management of laryngeal neuromuscular disorders.

Pulsed Dye Laser Treatment of Laryngeal Granulomas

Laryngeal granulomas are effectively treated with antireflux therapy and speech therapy. Failure to respond leads to treatment with Botox or surgical excision. We report on the use of the pulsed dye laser for treating chronic granulomas that do not respond to standard therapy. We performed a retrospective review from September 2002 to September 2003. Patients identified with chronic granulomas that were not responding to standard therapy were treated in our office with the pulsed dye laser. Ten patients were identified; the mean age was 58 years. Two patients underwent more than one pulsed dye laser treatment. Five of the 10 had resolution of their lesions, and 3 had a partial response. Two were unchanged. The average follow-up was 6 months, and there were no complications. We conclude that in-office use of the pulsed dye laser is a relatively safe and effective method for treating laryngeal granulomas that do not respond to antireflux therapy and speech therapy.

Intraobserver and Interobserver Reliability in Laryngopharyngeal Sensory Discrimination Thresholds: A Pilot Study

Objectives:

Laryngopharyngeal sensory discrimination threshold (LPSDT) testing is a method used to detect sensory deficits in patients in whom swallowing disorders are suspected. LPSDTs have been used to stratify patient risk status with regard to aspiration and to guide dietary management. The aim of this pilot study was to evaluate the intraobserver and interobserver reliability of LPSDT testing among a group of examiners with differing levels of testing experience.

Methods:

Twenty-seven healthy volunteers were enrolled in the study to elicit LPSDTs for intraobserver and interobserver reliability measurements. The examiners represented 3 levels of testing experience: An attending laryngologist, a laryngology fellow, and an otolaryngology resident. With the examiners blinded to test results, each subject was examined twice by one examiner and once by a different examiner in an alternating fashion.

Results:

Six subjects were unable to tolerate the examinations because of coughing and gagging. Spearman rank correlations revealed strong intraobserver reliability for the experienced endoscopists (ie, attending and fellow) but poor reliability for the novice endoscopist (ie, resident). Poor interobserver reliability regardless of endoscopy experience was found. Eighteen percent of the participants demonstrated LPSDTs of more than 4.0 mm Hg (above normal).

Conclusions:

1) Intraobserver reliability was good for experienced endoscopists. 2) Interobserver LPSDT agreement between endoscopists was poor. 3) Eighteen percent of the subjects demonstrated elevated LPSDT thresholds of more than 4 mm Hg.

Hands-on Training Methods for Vocal Fold Injection Education

Objectives:

Vocal fold injection (VFI) in the office setting and in the operating room is becoming increasingly popular. Most training programs fail to educate residents in performing these injections. In this report, we describe novel and effective teaching tools that provide real-life simulation of VFI for the education of residents and otolaryngologists in practice.

Methods:

Equipment was developed to allow the use of excised fresh cadaver larynges to simulate peroral VFI in a life-sized model of the human head and neck. A separate setup was also developed for use of a laryngoscope holder and cadaver larynges to simulate microlaryngoscopy VFI. Each of these VFI training setups allows the student to perform and practice VFI in a simulated setting with physical and anatomic constraints and laryngeal anatomy similar to those of real-life VFI. The use of fresh cadaver larynges allows the user to have a realistic feel of actual injection. A visual analog scale was used to measure the participants' comfort levels with the peroral and microlaryngoscopic injection techniques before and after the workshop.

Results:

Pre-workshop and post-workshop surveys were collected from 22 of the VFI course participants. The mean comfort levels for VFI prior to the workshop were 22 for peroral VFI and 69 for microlaryngoscopy VFI (0 = not comfortable at all and 100 = very comfortable). The post-workshop comfort levels were 52 for peroral VFI and 85 for microlaryngoscopy VFI. The differences in the pre- and post-workshop comfort level scores for each VFI technique were significant (microlaryngoscopy, p = .001; peroral, p <0001).

Conclusions:

The use of VFI simulations appears to improve surgeon comfort level with injection techniques. The described training simulations may be useful for allowing residents and practicing otolaryngologists to learn VFI before attempting these techniques on actual patients.

Cost Savings of Unsedated Office-Based Laser Surgery for Laryngeal Papillomas

Objectives:

Unsedated office-based laryngeal laser surgery (UOLS) is now an effective alternative to traditional operating room-based suspension microdirect laryngoscopy under general anesthesia. This procedure includes pulsed dye laser (PDL) treatment of recurrent respiratory papillomas, granulomas, leukoplakia, and polypoid degeneration. The objective of this study was to determine the magnitude of the cost savings derived by moving these types of procedures from the operating room to the office setting.

Methods:

Retrospective cost-identification analysis was performed by comparing the billing records of patients who underwent surgical laser treatment for recurrent respiratory papillomatosis in the operating room to the costs and charges for patients who underwent similar procedures with the in-office PDL.

Results:

In performing surgery with the PDL in the office, the average cost savings was more than $5,000 per case. Current reimbursement rates do not cover the cost of performing UOLS.

Conclusions:

The potential cost savings of UOLS are tremendous; however, at present significant financial disincentives prevent proliferation of this technology.

Patient Tolerance of In-Office Pulsed Dye Laser Treatments to the Upper Aerodigestive Tract

INTRODUCTION: Recent advances in technology have facilitated a movement toward unsedated in-office treatment of laryngeal, tracheal, and esophageal lesions. The objective of this study was to determine patient tolerance of inoffice pulsed-dye laser (PDL) treatment of upper aerodigestive tract pathoses via the transnasal esophagoscope.

METHODS: Three hundred twenty-eight unsedated in-office PDL cases were performed at a university-based tertiary referral center in 131 patients. These procedures were performed for various upper aerodigestive pathoses, including recurrent respiratory papillomatosis, chronic granulomas, and recurrent leukoplakia. Eighty-nine subjects completed a phone survey concerning their discomfort level after the PDL procedure. They were also asked specific questions about recovery time, pain medication, and preference of operating room versus inoffice procedures.

RESULTS: The average comfort score was 7.4 (10 being minimal discomfort). Eighty-four percent did not use any pain medication; 87% stated that, if possible, they would prefer to undergo unsedated inoffice procedures rather than surgeries under general anesthesia for further treatment of their upper aerodigestive tract pathosis.

CONCLUSIONS: Unsedated transnasal treatment of upper aerodigestive tract pathoses is readily accepted and well-tolerated by otolaryngology patients. Patients overwhelmingly prefer the inoffice PDL over surgeries under general anesthesia.

Revision Gore-Tex Medialization Laryngoplasty

OBJECTIVE: To evaluate the indications, results, and safety of revision Gore-Tex medialization laryngoplasty (GML).

METHODS: A retrospective chart review of 156 patients that underwent GML procedures between the years 1998–2002. Study population consisted of those patients who required revision surgery for any reason.

RESULTS: Sixteen patients required 22 revision procedures. Indications for revision were divided into 2 groups, complications and glottal closure problems. Complications included extruded or displaced implants (n = 4). The most common glottal closure problem was undercorrection (n = 9). Others included anterior overcorrection (n = 1) and persistent posterior glottal gap (n = 2). Revision procedures included GML (n = 9), injection augmentation (n = 9), endoscopic implant removal (n = 2), and arytenoid adduction (n = 2). In patients with glottal closure problems, the GCI improved in all 10 and the voice rating scale improved in 9.

CONCLUSION: Reasons for revision of GML are variable, the most common being undercorrection. A variety of safe, effective revision techniques are available with a high success rate.

Office-Based Laryngeal Laser Surgery: A Review of 443 Cases Using Three Wavelengths

BACKGROUND: Unsedated office-based laser surgery (UOLS) of the larynx and trachea has significantly improved the treatment options for patients with laryngotracheal pathology including recurrent respiratory papillomas, granulomas, leukoplakia, and polypoid degeneration. UOLS delivered by flexible endoscopes has dramatically impacted office-based surgery by reducing the time, costs, and morbidity of surgery.

OBJECTIVES: To review our experience with 443 laryngotracheal cases treated by UOLS.

METHODS: The laser logbooks at the Center for Voice and Swallowing Disorders were reviewed for UOLS, and the medical and laryngological histories were detailed, as were the treatment modalities, frequencies, and complications.

RESULTS: Of the 443 cases, 406 were performed with the pulsed-dye laser, 10 with the carbon-dioxide laser, and 27 with the thulium: yttrium-aluminum-garnet laser. There were no significant complications in this series. A review of indications and wavelength selection criteria is presented.

CONCLUSION: Unsedated, office-based, upper aerodigestive tract laser surgery appears to be a safe and effective treatment option for many patients with laryngotracheal pathology.

Mechanical Modeling of the Human Cricoid Cartilage Using Computer-Aided Design: Applications in Airway Balloon Dilation Research

OBJECTIVES

Balloon dilation is generally considered first-line treatment for airway stenosis. Some dilation systems utilize a compliant balloon that can conform around rigid structures. Others use a noncompliant balloon that does not conform, allowing for dilation of more rigid stenoses. We hypothesized that subglottic dilation with a noncompliant balloon increases the likelihood of fracture of the cricoid when compared to a compliant balloon.

METHODS

Three fresh human cricoid cartilages were placed in a universal testing system to determine the expansile force necessary for cricoid fracture. Using these data, a 3D printer was used to construct a synthetic cricoid model possessing near identical physical characteristics to the human cricoid. Simulated dilation was then performed on the model using a compliant and a noncompliant balloon.

RESULTS

Human cricoid fracture occurred at 97.25 N (SD = 8.34), and the synthetic cricoid model fractured at 100.10 N (SD = 7.32). Both balloons fractured the model in every replicate experiment. Mean balloon internal pressure at fracture was 7.67 ATM (SD = 1.21) for the compliant balloon and 11.34 ATM (SD = 1.29) for the noncompliant balloon.

CONCLUSIONS

These data show that fracture of the cricoid is a valid concern in balloon dilation procedures where the balloon spans the subglottis. Furthermore, the hypothesis was rejected in that the compliant balloon system was at least as likely to fracture the cricoid model as the noncompliant.

Tracheal Size Variability Is Associated With Sex

Purpose:

Whereas selection of endotracheal tube (ETT) size in pediatric patients benefits from predictive nomograms, adult ETT sizing is relatively arbitrary. We sought to determine associations between cervical tracheal cross-sectional area (CTCSA) and clinical variables.

Methods:

One hundred thirty-two consecutive patients undergoing noncontrasted chest computed tomography (CT) at a single tertiary care institution from January 2010 to June 2011 were reviewed. Patients with improper CT technique, endotracheal intubation, and pulmonary/tracheal pathology were excluded. Tracheal luminal diameters in anteroposterior (D1) and transverse (D2) were measured 2 cm inferior to the cricoid and used to determine CTCSA = π*D1*D2*¼. The demographic variables of age, height, weight, and body mass index (BMI) were tested for association with CTCSA by Spearman correlation. Wilcoxon rank-sum test was used to compare CTCSA by race and sex. Multivariate linear regression was performed including all clinical variables.

Results:

There were 91 patients who met inclusion criteria. There was no correlation between age, weight, or BMI and CTCSA. There was a significant positive correlation between patient height and CTCSA ( P = .001, R = 0.35); however, this was confounded by sex. Female patients had significantly smaller CTCSA (mean = 241 mm2) compared to male patients (mean = 349 mm2, P < .001). Multivariate linear regression stratified by sex revealed that height is correlated with CTCSA only in males ( P = .028). Males also had more variability in CTCSA (SD 118.6) compared to females (SD 65.5).

Conclusion:

Our data suggest that selection of ETT size in male patients should include height as a predictive factor. For female patients, it may be appropriate to select a uniformly smaller diameter ETT size.

Biomechanical changes from long-term freezer storage and cellular reduction of tracheal scaffoldings

OBJECTIVES/HYPOTHESIS

To determine structural biomechanical changes in tracheal scaffolds resulting from cellular reduction and storage at -80(o) C.

STUDY DESIGN

Laboratory-based study.

METHODS

Forty-four rabbit tracheal segments were separated into four treatment groups: untreated (group A, control), cellular-reduced (group B), storage at -80(o) C followed by cellular reduction (group C), and cellular-reduced followed by storage at -80(o) C (group D). Tracheal segments were subjected to uniaxial tension (n = 21) or compression (n = 23) using a universal testing machine to determine sutured tensile yield load and radial compressive strengths at 50% lumen occlusion. Mean differences among groups for tension and compression were compared by analysis of variance with post-hoc Tukey-Kramer test.

RESULTS

The untreated trachea (group A) demonstrated mean yield strength of 5.93 (± 1.65) N and compressive strength of 2.10 (± 0.51) N. Following treatment/storage, the tensile yield strength was not impaired (group B = 6.79 [± 1.58] N, C = 6.21 [± 1.40] N, D = 6.26 [± 1.18]; P > 0.10 each). Following cellular reduction, there was a significant reduction in compressive strength (group B = 0.44 N [± 0.13], P < 0.0001), but no further reduction due to storage (group C = 0.39 N [± 0.10]; P = 0.97 compared to group B).

CONCLUSION

The data suggest cellular reduction leads to loss of compressive strength. Freezing at -80°C (either before, or subsequent to cellular reduction) may be a viable storage method for tracheal grafts.

Thyroid ala perichondrial flaps for subglottic reconstruction

OBJECTIVES/HYPOTHESIS

Techniques available for reconstruction of the cricotracheal region in adults are currently suboptimal. We sought to 1) understand the anatomic basis for the thyroid ala perichondrial flap, 2) describe the technique of harvesting and intraluminal placement, and 3) learn the limitations of defects for which it can be used.

STUDY DESIGN

Cadaveric anatomical study.

METHODS

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

A total of 10 flaps were performed (6 male and 4 female). The average length of thyroid perichondrial flaps obtained was 1.67 cm. All 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 2.4 cm below the vocal cords. Using both flaps enabled coverage of the entire anterior 180 degrees of the airway lumen in all specimens. There were no significant differences in male/female or right-sided/left-sided flaps.

CONCLUSIONS

The thyroid ala perichondrial flap is technically feasible and can provide coverage of anterior airway defects up to approximately 2.4 cm below the true vocal cords. This flap could enable transfer of vascularized tissue to aid in cricotracheal reconstruction.

Defining the biomechanical properties of the rabbit trachea

OBJECTIVES/HYPOTHESIS

Surgical advancements rely heavily on validated animal models. The New Zealand White (NZW) rabbit is a widely used model for airway research, including regenerative medicine applications. Currently, the biomechanical properties of the normal rabbit trachea are not known. Our objective was to define these properties to assist in the standardization and understanding of future airway research using this model.

STUDY DESIGN

Laboratory-based study.

METHODS

Fresh tracheas from four adult NZW rabbits were dissected into 20 segments. To examine the biomechanical properties, segments were subjected to uniaxial tension (n = 9) and compression (n = 11) testing. Yield and maximum load (tension) and force at 50% displacement (compression) were recorded, and differences between segments were examined using analysis of covariance.

RESULTS

Normative data for native rabbit trachea show mean maximum load = 6.44 newtons (N), yield load = 5.93 N, and compressive strength = 2.10 N. In addition to establishing the baseline measurements, statistically significant differences in tensile measures based on location along the trachea and diameter were identified. Proximal segments had significantly higher maximum load (P = .0029) and yield load (P = .0062) than distal segments. Association between diameter and both maximum load (P = .0139) and yield load (P = .0082) was observed.

CONCLUSIONS

The adult NZW rabbit trachea is intrinsically less able to withstand tensile and compressive forces, compared to other airway models such as sheep or cadaveric human. Establishment of normative values will enable future research into changes in tracheal biomechanical properties during regenerative medicine manipulation and processing.

Laryngeal Inflammation: Diagnosis and Treatment Challenges

Program Description:

Using an interactive format, panelists will discuss epidemiology, symptomatology, and co-morbid conditions contributing to laryngopharyngeal inflammation; diagnosis/differential diagnosis; challenges in diagnosing causative factors; addressing diagnostic challenges to define a treatment plan; current evidence; treatment challenges and impact of co-morbid conditions; and future research and management implications. The panel will consider “real world” patient management algorithms. The audience will help answer the following questions: What are the typical ‘challenges’ in diagnosing laryngopharyngeal inflammation? What diagnostic testing options should be employed? Which after first treatment failure? What are the common treatment pathways? What differential data should be considered? What healthcare costs impact options? When is referral recommended?

Educational Objectives:

1) Describe current practice trends on the diagnosis and management of laryngopharyngeal inflammation. 2) Recognize the common challenges in diagnosing laryngeal inflammation to define appropriate treatment strategies. 3) Evaluate current evidence-based literature supporting current diagnosis and treatment paradigms.

Practical Approach to Swallowing Problems

Program Description:

This miniseminar will present a practical approach to the evaluation of swallowing problems, one of the most common problems seen in otolaryngology practices. A combination of didactic teaching and case presentations will be used to illustrate appropriate workup of swallowing problems, including history, examination, and diagnostic tests. The use of swallowing evaluations, such as fluoroscopy, endoscopy, and manometry, will be discussed. Non-surgical and surgical approaches to managing swallowing problems, along with risks and benefits, will be presented.

Educational Objectives:

1) Identify a practical algorithm for the evaluation of swallowing problems. 2) Discuss the benefits of diagnostic tests for swallowing problems, including fluoroscopy, endoscopy, and manometry. 3) Apply the appropriate approach to non-surgical and surgical therapeutics for swallowing problems.

Microdebrider Complications in Laryngologic and Tracheal Surgery

Objectives:

There is no formal body of literature focusing on complications in laryngologic and airway surgery performed with microdebriders. Attendees can expect to: 1) Describe potential complications that may occur with microdebrider use during laryngologic and airway surgery. 2) Recognize which clinical situations are better suited to the use of the microdebrider. 3) Implement changes in clinical practice to improve operative safety when using the microdebrider in laryngologic and airway surgery.

Methods:

A literature review of microdebrider complications in otolaryngologic surgery was performed. A series of exemplary and illustrative cases seen by various surgeons in selected high volume laryngologic centers was confidentially solicited and is described.

Results:

Significant microdebrider complications are described, including severe hemorrhage, extensive tissue loss, and airway perforation, as well as ways to prevent and treat these complications.

Conclusions:

A thorough understanding of the microdebrider and its potential complications will improve surgical outcomes. Implications for Practice: Awareness of the risks and knowing when to use the microdebrider will allow the surgeon to successfully use this device in a safe and efficient manner.

Transnasal esophagoscopy

Since the mid 1900s, esophagoscopy has been performed under sedation or general anesthesia. With transnasal esophagoscopy (TNE), there has been a return to awake, in-office esophagoscopy. Technologic advances have allowed the advent of a ultrathin, flexible esophagoscope that is introduced transnasally, allowing esophagoscopy to be performed in unsedated patients. TNE correlates with conventional esophagoscopy (sedated, flexible esophagoscopy) in diagnostic capacity. Over time, as the benefits of TNE have become elucidated, the procedure has gained wider acceptance and continues to have its role in patient care defined.