Visual acuity outcome in patients with subretinal hemorrhage - office procedure vs. surgical treatment

PURPOSE

To evaluate the effects of intravitreal injection of tissue plasminogen activator (tPA) and gas vs. pars plana vitrectomy (PPV) surgery as first-line treatment for subretinal hemorrhage.

METHODS

Retrospective study of 107 adults treated for subretinal hemorrhage at a tertiary hospital during 2008-2019; 51 received injection of tPA and gas and 56 underwent PPV.

RESULTS

No between-group differences were found in age and sex, medical history, use of anticoagulants or antiplatelets, history of ocular surgeries, and previous use of intravitreal anti-VEGF. Overall follow-up time was longer in the PPV group (median 4.9 vs 3.28 years, p = 0.005). The hemorrhage was displaced in a similar percentage of patients in the tPA-and-gas group (n = 40, 78.4%) and the PPV group (n = 45, 80.4%) (p = 0.816). Approximately 80% of patients in the tPA-and-gas group were able to forgo PPV surgery. Visual acuity (in LogMAR) was similar in the two groups prior to the diagnosis of subretinal hemorrhage but better in the tPA-and-gas group at the end of follow-up (p < 0.001).

CONCLUSION

Injection of gas and tPA can be done immediately following diagnosis of subretinal hemorrhage as an office procedure. Visual acuity outcome is good, with a high rate of blood displacement. About 20% of patients might require additional PPV as secondary intervention.

Longitudinal Voice Outcomes Following Serial Potassium Titanyl Phosphate Laser Procedures for Recurrent Respiratory Papillomatosis

OBJECTIVE

Repeated surgical interventions are usually required to control recurrent respiratory papillomatosis (RRP), but at considerable risk of worsened postoperative voice quality. Potassium titanyl phosphate (KTP) laser has been reported to effectively manage RRP; however, voice quality after repeated procedures has not been investigated.

METHODS

This study recruited 16 patients with RRP treated using KTP laser between 2013 and 2019. KTP laser procedures were performed under general anesthesia via direct suspension laryngoscope or under local anesthesia via flexible endoscope, depending on the need for pathological proof, patient tolerance, and lesion size and location. Disease control was investigated by videolaryngostroboscopy. Voice outcome was evaluated using a 10-item voice handicap index (VHI-10), acoustic and perceptual analyzes.

RESULTS

We reviewed the medical records of 11 male and 5 female patients with RRP (age range: 23-73 years). Five patients received KTP laser once, six patients received it 2 to 5 times, and five patients received 6 to 15 procedures. Median VHI-10 decreased from 28.3 to 12.0 points after the initial procedure and were maintained at 10.1 to 11.0 points following subsequent procedures (P < .01, generalized estimating equation). Acoustic and perceptual analysis of voice quality also revealed significant improvements (P < .01), which remained stable even after 6 to 10 KTP laser procedures. Minor adverse events included slight fibrotic change of vocal folds and glottic web, but these did not significantly alter postoperative voice quality.

CONCLUSION

This longitudinal follow-up study revealed that serial KTP laser procedures can effectively control RRP while preserving phonatory function and maintaining adequate voice quality.

LEVEL OF EVIDENCE

4.

Pain perception with cervical tenaculum placement during intrauterine device insertion: a randomised controlled trial

INTRODUCTION

'Slow' and 'cough' techniques for tenaculum placement are commonly used. This trial sought to determine if one method of placement resulted in less pain for patients.

METHODS

This study was a randomised controlled trial of patients presenting for intrauterine device placement. Sixty-six participants were randomised to tenaculum placement via the 'slow' method (closure of tenaculum over a 5-s period) versus the 'cough' method (closure of tenaculum at the time of patient's cough). The primary outcome was pain at time of tenaculum placement measured on a 100 mm visual analogue scale. The study was powered to detect a 16 mm difference in pain. Secondary outcomes included pain with insertion and provider satisfaction with tenaculum grasp. Pain scores were analysed with Wilcoxon rank-sum test.

RESULTS

Sixty-six women were enrolled, 33 randomised to each group. Demographics were similar in each group. The primary outcome of pain with tenaculum placement showed a median pain score of 44 (IQR=21, 63) with slow placement and 32 (IQR=19, 54) with cough placement. There was no significant difference in pain scores between methods of tenaculum placement (p=0.16). There was no significant difference in overall pain scores (p=0.12). Provider satisfaction was not associated with one method of placement (p=1). Pre-procedure anxiety was significantly associated with pain at the time of tenaculum placement (p=0.01).

CONCLUSIONS

Neither the slow method nor cough method is superior for pain reduction or provider satisfaction. Pain with tenaculum use is significantly associated with anxiety.

CLINICAL TRIAL REGISTRATION

NCT02969421.

Adverse Reaction to Restylane: A Review of 63 Cases of Injection Laryngoplasty

The aim of this study is to review the prevalence of adverse reactions to cross-linked hyaluronic acid (HA) following injection laryngoplasty and discuss possible mechanisms. A retrospective chart review of patients who underwent injection laryngoplasty using HA was conducted. Demographic data included age, gender, etiology, site of injection, and amount injected. Adverse reaction was diagnosed by the presence of inflammatory reaction at the injection site. A total of 63 patients were included, divided into 41 males and 22 females with a mean age of 51.76 years. The most common etiology was vocal cord paralysis (n = 53), followed by postcordectomy, puberphonia, and vocal fold atrophy and bowing. The average amount injected was 0.56 (0.22) mL. Three cases out of 63 patients developed an adverse reaction and presented with airway symptoms, namely, progressive shortness of breath and globus 2 to 3 days postinjection. Adverse reactions following HA injection laryngoplasty may occur with life-threatening symptoms.

Injection of basic fibroblast growth factor for unilateral vocal cord paralysis. Acta Otolaryngol 2017;137:962-967. [PMID: 28434284 DOI: 10.1080/00016489.2017.1314550]

OBJECTIVE

Unilateral vocal cord paralysis (UVCP) not only induces severe dysphonia, but aspiration as well. Although laryngeal framework surgery is usually performed to treat this condition, the procedure is not tolerated by some patients. In the previous study, basic fibroblast growth factor (bFGF) injections for vocal cord scarring and sulcus have been reported to provide favorable outcomes while being minimally invasive. In this study, the authors retrospectively investigated phonological outcomes after bFGF injection in patients with UVCP.

METHODS

This study was registered in University hospital Medical Information Network - Clinical Trials Registry (UMIN000019347). Nineteen patients with unilateral cord paralysis were treated with bFGF injection. The treatment regimen involved a single injection of 50 μg of bFGF into the muscle layer. More than six months after the injection, aerodynamic and acoustic outcomes were examined.

RESULTS

The voice handicap index, maximum phonation time, mean airflow rate, and pitch range improved significantly after injection of bFGF. No sex-related differences were observed in any phonological parameter.

CONCLUSION

bFGF injection, an easy method and suitable as an office procedure, significantly improved the hoarseness caused by UVCP. It is expected to be widely adopted and effective adjunctive drugs, and procedures are anticipated to be developed.

Serial office-based steroid injections for treatment of idiopathic subglottic stenosis

OBJECTIVES/HYPOTHESIS

Current treatment options for idiopathic subglottic stenosis include endoscopic interventions, resection, and tracheotomy. Recently, serial office-based steroid injections were proposed as an alternative that may stabilize or induce regression of airway stenosis without the need for repeated operations. Procedure completion rate, pain, complications, effect on stenosis, time since the last operation, and limitations have not been described.

STUDY DESIGN

Retrospective case series.

METHODS

Retrospective series of 19 patients undergoing serial office-based steroid injection for idiopathic subglottic stenosis. Outcome measures included completion rate, procedure-related pain scores, complications, percentage of airway stenosis, and time since the last operative intervention.

RESULTS

Procedure completion rate was 98.8%. Average pain score during the procedure was 2.3 ± 1.7 on a 10-point scale. There were no immediate complications. One patient underwent awake tracheotomy 8 days after her second injection and was later decannulated. Average stenosis decreased from 35% ± 15% to 25% ± 15% (n = 16; P = .086) over the first of three injections and 40% ± 15% to 25% ± 10% to 20% ± 10% (n = 8; P = .002) for those patients completing two sets of three injections. Fourteen of 17 patients undergoing at least three injections have not returned to the operating room since the first injection.

CONCLUSIONS

Office-based steroid injection represents a promising new treatment pathway for a disease that requires long-term management, offering a purely pharmacologic approach to a disorder that has traditionally been approached from a mechanical perspective. It is safe, well tolerated, and effective. Furthermore, it may help patients and physicians avoid repeated trips to the operating room and the associated risks.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2475-2481, 2017.

Comparison of tolerance and cost-effectiveness of two nasal anesthesia techniques for transnasal flexible laryngoscopy

OBJECTIVE

(1) Compare tolerance of aerosolized spray versus syringe administration of topical anesthesia for transnasal flexible laryngoscopy (TFL), (2) analyze cost-effectiveness of both techniques.

STUDY DESIGN

Prospective, blinded, randomized trial.

SETTING

Tertiary academic laryngology practice.

METHODS

One hundred and eight patients underwent TFL over 3 months. Patients were randomized to receive equivalent dose 1:1 neosynephrine/4% plain lidocaine mixture via aerosolized spray ("spray") or application with 1-cc syringe ("syringe"). Patients and physicians independently rated comfort of TFL on 5-point scale (1 = not at all comfortable to 5 = very comfortable). Data were collected on patient and endoscopist experience with TFL and reasons for poor tolerance of laryngoscopy. Cost analyses of disposable spray tips and syringes were calculated.

RESULTS

Both patients and physicians reported very high tolerance of TFL. Patient tolerance appears to be similar between spray- versus syringe-administered anesthesia, although study limitations preclude definitive analysis. Poor tolerance of laryngoscopy was reported in 6.5% with comparable distribution between anesthetic delivery methods. There was no impact of patient prior experience with TFL, and there was no difference between anesthetic methods for TFL performed by resident, fellow, or attending. The difference between costs of the disposable spray tip versus syringe was $1.32 per unit.

CONCLUSIONS

Use of a 1-cc syringe is an effective method to provide topical nasal anesthesia for TFL and saves $1.32 per unit compared to disposable spray tips. In our practice, transition to syringe-administered nasal anesthesia is projected to save $1300 per 1000 patients, or an anticipated $1000 per year per physician, with excellent patient tolerance of TFL.

Spinal manipulation for low-back pain: an office procedure

In properly selected patients, spinal manipulation is an alternative to the standard conservative approach to low-back pain. In this paper, an approach to the patient with low-back pain emphasizes the importance of a thorough history, physical examination, and diagnosis prior to manipulation. In addition to listing indications and contraindications, the authors discuss the process of selecting patients for manipulation according to pain and range of motion. Two manipulative techniques which can be easily learned and performed in the office by the family physician are described.