Late Displacement of a Montgomery Thyroplasty Implant following Endotracheal Intubation

Objectives:

We document a late displacement of a thyroplasty implant following endotracheal intubation.

Methods:

A 66-year-old man was referred to our clinic with a chief complaint of breathy dysphonia immediately following an elective inguinal hernia repair under general endotracheal anesthesia. The patient's medical history was significant for a medialization laryngoplasty with a Montgomery implant 14 years earlier.

Results:

Examination and computed tomographic scanning of the neck confirmed displacement of the implant. The patient underwent revision medialization laryngoplasty with successful restoration of his voice quality.

Conclusions:

This case report illustrates a potential complication of endotracheal intubation in patients who have previously undergone vocal fold medialization procedures.

Pleomorphic rhabdomyosarcoma presenting as a hypopharyngeal mass

BACKGROUND

Rhabdomyosarcoma (RMS) is a rare malignancy derived from skeletal muscle with approximately 40% of cases involving the head and neck. The pleomorphic variant, however, most commonly occurs in the extremities and has never, to our knowledge, been described in the pharynx.

METHODS

A 46-year-old man with no significant medical history presented to the emergency department complaining of hemoptysis. A CT scan of the head and neck revealed a hypopharyngeal mass originally favored to be a benign process.

RESULTS

Operative endoscopy revealed a previously unseen mucosal ulceration, and subsequent biopsy resulted in the final diagnosis of pleomorphic RMS.

CONCLUSION

Although quite rare, RMS should be considered in the differential diagnosis of a hypopharyngeal mass.

Difficult Airway Simulation for Novice Physicians: A Randomized Trial Comparing Traditional and Video-Assisted Laryngoscopy

Objectives:

Detect a difference in intubation success and total intubation times between novice physicians using either a Macintosh laryngoscope or a video-assisted laryngoscope (Glidescope®) on a difficult airway manikin simulator.

Methods:

This prospective randomized trial was performed in June 2012. 40 first year residents with less than five total live intubations were recruited. Training was provided by both faculty otolaryngologists and anesthesiologists using both laryngoscope types on a manikin airway simulator in a standard intubation scenario. This was followed by randomization to use one of the aforementioned laryngoscopes in a difficult intubation scenario. The difficult airway simulation entailed oral cavity/oropharyngeal obstruction using tongue inflation, with rigid cervical spine immobilization preventing extension and elevation of the head and limiting oral cavity opening. Success was defined as a confirmed endotracheal intubation by the instructor in 120 seconds or less.

Results:

The Macintosh laryngoscope group (n=19) had an intubation success rate of 52.63% with a mean intubation time of 69.0 (95% CI: 52.7, 85.2) seconds. The video-assisted group (n=21) demonstrated a significantly higher success rate of 100% (p<0.0001) and a decreased mean intubation time of 23.1 (95% CI: 18.4, 27.8) seconds (p<0.0001).

Conclusions:

Novice physicians with little to no prior intubation experience showed significantly higher intubation success with lower intubation times using a video assisted laryngoscope in a difficult airway manikin simulator.

Validity and Reliability of the Glottal Function Index

OBJECTIVE

To evaluate a symptom-focused vocal impairment instrument for the evaluation of patients with voice disorders.

DESIGN

Prospective, nonrandomized study of patients with voice disorders undergoing treatment with validation of a new symptom index, the Glottal Function Index (GFI).

SETTING

Voice disorders clinic at an academic tertiary care hospital.

PATIENTS

Consecutive patients undergoing therapy for glottal insufficiency, adductor spasmodic dysphonia, nodules, and granuloma (40 patients in each group) and 40 control patients.

INTERVENTIONS

The Pearson correlation coefficient was used to evaluate GFI reproducibility and to compare it with the Voice Handicap Index (VHI). The paired-samples t test was used to compare pretherapy and posttherapy GFI values.

MAIN OUTCOME MEASURES

Correlation of GFI with VHI; comparison of the GFI in normals, and in pretherapy and posttherapy GFI and VHI scores.

RESULTS

The mean +/- SD normative GFI score was 0.87 +/- 1.32. The correlation coefficient for GFI between independent pretherapy measurements was 0.56 (P<.001). The correlation coefficient between total GFI and total VHI scores was 0.61 (P<.001). The mean posttherapy GFI scores improved among all groups as follows: glottal insufficiency: presenting GFI score, 12.7 +/- 4.1; posttherapy GFI score, 6.8 +/- 5.4; nodules: presenting GFI score, 12.9 +/- 4.2; posttherapy GFI score, 8.9 +/- 4.6; adductor spasmodic dysphonia: presenting GFI score, 13.2 +/- 4.1; posttherapy GFI score, 8.9 +/- 4.9; and granuloma: presenting GFI score, 7.8 +/- 4.6; posttherapy GFI score, 3.8 +/- 2.1. Relative to controls, the GFI score at presentation was significantly elevated and demonstrated significant reduction following treatment across each of these entities (P<.05).

CONCLUSIONS

The GFI is a reliable, reproducible, 4-item, self-administered symptom index with excellent criterion-based and construct validity. Its advantages over existing indexes include brevity and ease of administration. The GFI is a useful adjunct in the evaluation and treatment of patients with glottal dysfunction.

Transnasal esophagoscopy: revisited (over 700 consecutive cases)

BACKGROUND

High-resolution transnasal esophagoscopy (TNE) allows comprehensive, in-office examination of the esophagus without sedation.

OBJECTIVE

To compare the authors' present experience using TNE with our initial, previously reported experience.

METHODOLOGY

Retrospective review of 611 consecutive patients undergoing TNE was compared with 100 consecutive patients previously reported.

RESULTS

The most frequent indications for TNE were screening examination of the esophagus in reflux, globus, or dysphagia patients (n = 490), biopsy of a lesion in the laryngopharynx, trachea, or esophagus (n = 42), screening examination of the esophagus in head and neck cancer patients (n = 45), and evaluation for an esophageal foreign body (n = 12). Seventeen procedures were aborted secondary to a tight nasal vault. Significant findings were found in 50% (294/592). The most frequent findings were esophagitis (n = 98), hiatal hernia (n = 47), and Barrett's esophagus (n = 27). These results are similar to those previously reported.

CONCLUSIONS

TNE is safe, well tolerated by patients, and is easy to learn with a short learning curve. TNE may replace radiographic imaging of the esophagus in otolaryngology patients with reflux, globus, and dysphagia.

Prolonged postoperative disorientation after methylene blue infusion during parathyroidectomy

Methylene blue 7.5 mg/kg is frequently given at our institution during parathyroidectomy. The dye preferentially stains the parathyroids so as to provide better surgical visualization. Other than causing a pseudocyanosis, the technique is generally considered to be rather innocuous. We report a case of a patient who, after this procedure, had a postoperative course that was unusual because of slowly resolving altered mental status.

The role of transnasal esophagoscopy in head and neck oncology

OBJECTIVES/HYPOTHESIS

To review the current role of transnasal esophagoscopy (TNE) in all aspects of head and neck cancer patient treatment.

STUDY DESIGN

A retrospective database and chart review.

METHODS

A retrospective review of head and neck cancer patients undergoing TNE for a variety of diagnostic and therapeutic indications.

RESULTS

In a series of 17 patients with presumed head and neck malignancies, TNE provided 100% accuracy in biopsy results and staging of the tumor when compared with standard panendoscopy. The utility of TNE in other areas of head and neck cancer management, such as stricture dilation and secondary tracheoesophageal puncture, is demonstrated. This preliminary report strongly suggests that TNE may play a vital role in the management of head and neck oncology patients.

CONCLUSIONS

Transnasal esophagoscopy gives the surgeon the ability to perform a remarkable variety of procedures in the outpatient setting without sedation. It may obviate the need for routine panendoscopy in head and neck cancer patients.

Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux

OBJECTIVE

To report the prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux.

STUDY DESIGN

Prospective study of 58 consecutive patients with documented laryngopharyngeal reflux, all of whom underwent transnasal esophagoscopy as part of their reflux evaluations.

METHODS

All patients with a diagnosis of laryngopharyngeal reflux confirmed by abnormal pharyngeal pH monitoring over a 5-month period were included, and all subjects completed a self-administered reflux symptom index and underwent transnasal esophagoscopy with directed biopsy.

RESULTS

Of the 58 study patients with pH-documented laryngopharyngeal reflux, the mean age was 49 years (+/- 13 y), and 53% (31 of 58) were women. Of the study group, 40% (23 of 58) had heartburn and 48% (28 of 58) had abnormal esophageal reflux (by pH monitoring criteria); by transnasal esophagoscopy with biopsy, 12% (7 of 58) had esophagitis and another 7% (4 of 58) had Barrett's metaplasia. Thus, 60% of the study cohort had heartburn, and 81% (47 of 58) had normal esophageal epithelium (i.e., esophagitis or Barrett's metaplasia).

CONCLUSIONS

In the present series of patients with documented laryngopharyngeal reflux the prevalence of esophagitis and Barrett's metaplasia was only 19%. These data confirm the clinical impression that the patterns, mechanisms, and manifestations of laryngopharyngeal reflux differ from those of classic gastroesophageal reflux disease. Unlike gastroesophageal reflux disease, patients with laryngopharyngeal reflux uncommonly have esophagitis. Thus, although esophagoscopy may be an excellent method for screening the esophagus, it is not the method of choice for diagnosing laryngopharyngeal reflux.

Clinical manifestations of laryngopharyngeal reflux

Laryngopharyngeal reflux (LPR) is ubiquitous and associated with many head and neck symptoms and diagnoses. In some cases, the symptom is the diagnosis--for example, LPR can cause sore throat, chronic cough, globus pharyngeus, and laryngospasm. Alternately, LPR can be associated with specific histopathologic lesions--for example, vocal process granulomas. LPR can be the sole cause or an etiologic cofactor in the development of many disorders of the aerodigestive tract.

Pediatric laryngopharyngeal reflux

Laryngopharyngeal reflux (LPR) is common in children. It often affects the airway, and it has been associated with life-threatening disease. The diagnosis and treatment of LPR in children is somewhat different from that in adults.

Effects of activated macrophages and fibroblast growth factor on random skin flap survival in swine

OBJECTIVE

To examine the effect of application of activated autologous macrophages and basic fibroblast growth factor (FGF) on random skin flap survival in swine.

DESIGN

A randomized nonblinded controlled trial. According to a standard design, six dorsally based, random-pattern skin flaps were raised in each of 12 Yorkshire pigs.

METHODS

Twenty-five milliliters of blood is harvested from each animal 20 to 24 hours prior to flap creation. Monocytes are isolated, placed in culture medium, and then activated by the addition of platelet-derived growth factor (PDGF) and tissue growth factor beta (TGF-alpha). Following an 18-hour incubation period, the monocytes are decanted and quantified, and their viability confirmed. These cells are then infused into the wound bed of the treatment flaps immediately following flap creation, and FGF is added prior to flap closure. The position of treatment and control flaps is systematically varied with regard to anterior-to-posterior and side-to-side flap positions within each animal. The area of superficial flap necrosis is evaluated on postoperative day 7, digitally scanned, and analyzed using graphics software. Control flaps are elevated similarly, but receive no placebo treatment.

RESULTS

Two-way analysis of variance (ANOVA) demonstrated nonsignificant differences between pig side and anterior, middle, and posterior flap positions within treatment and control flap groups. Using side and position pooled data, a one-way ANOVA showed no statistically significant differences between treatment and control flaps.

CONCLUSIONS

The cellular and biochemical events following creation of a surgical wound are complex and incompletely understood. Our attempt to augment the natural role of the macrophage in wound healing by employing cytokines to activate these cells and to accelerate their arrival by implanting them into the wound bed failed to enhance flap survival. Further study is warranted to ascertain the details of wound healing, particularly with respect to cytokine concentrations and the timing of their roles, if we are to find a clinically applicable means of enhancing flap survival.

Acute coalescent mastoiditis in an infant: an emerging trend?

There is some evidence to suggest that the incidence and complications of ACM may be increasing. However, in the current era of widespread access to health care and broad-spectrum antibiotics, an intratemporal or intracranial complication from acute otitis media may not initially be suspected. The reported case is significant in that the patient was very young, had no underlying disease or immunocompromise, and did not have a known antecedent acute otitis media. With the emergence of resistant streptococcal species and prolonged survival in immunocompromised patients, the relative incidence of complications caused by acute otitis media will probably continue to rise, making it imperative that we raise our index of suspicion for previously rare infectious complications of relatively common diseases.