Predictors for Difficult Laryngeal Exposure in Suspension Laryngoscopy: A Systematic Review and Meta-Analysis

Objectives/Hypothesis

Many researchers have investigated parameters that could independently predict difficult laryngeal exposure (DLE) in suspension laryngoscopy; however, inconsistent results and conclusions have been reported in previous studies. We conducted a meta-analysis of the existing literature to determine the parameters that are significant for a standardized preoperative DLE prediction system.

Methods

The literature was retrieved systematically from PubMed, Embase, Web of Science, China national knowledge infrastructure (CNKI), and Wangfang until October 2022. In eligible studies, data were extracted and analyzed using the R language, and effective measures were odds ratios with 95% confidence intervals (CIs) for dichotomous variables and mean differences (MD) with 95% CIs for continuous variables.

Results

The search yielded 1574 studies, of which eighteen involving 2263 patients were included. Pooled analysis demonstrated that patients with DLE during microsurgery are often men (OR =1.73, 95% CI = [1.16, 2.57]); older age (MD = 5.47 years, 95% CI = [2.44, 8.51]); high body mass index (BMI; MD = 1.19Kg/m2, 95% CI = [0.33, 2.05]); bullnecked (MD =2.50cm, 95% CI = [1.56, 3.44]); limited mouth opening (MD = -0.52cm, 95% CI = [-0.88, -0.15]); limited neck flexibility (MD = -10.05cm, 95% CI = [-14.10,-6.00]); specific anatomical characteristics; and modified Mallampati's index or test (OR = 3.37, 95% CI = [2.07, 5.48]).

Conclusion

Our study made a comprehensive and systematic analysis of The DLE relevant factors. Gender, age, body mass index(BMI), neck circumference (NC), modified Mallampati's index(MMI), inter-incisor gap(IIG), hyoid-mental distance (HMD), thyroid-mental distance (TMD), sterno-mental distance (SMD), and flexion-extension angle were eventually identified as highly correlated factors for DLE.

Rethinking Perioperative Antibiotic Prophylaxis for Low-Risk Head and Neck Procedures

OBJECTIVE

For true clean-contaminated head and neck procedures, the literature supports ≤24 hours of perioperative antibiotics. However, there are certain otolaryngology procedures with low surgical site infection (SSI) risk for which there is negligible benefit from antibiotic prophylaxis. The objective of this evaluation was to describe antibiotic use and adherence to evidence-based institutional guidelines in low-risk head and neck procedures.

METHODS

This was a single-center, retrospective cohort study of patients undergoing low-risk clean-contaminated head and neck procedures wherein antibiotic prophylaxis was not indicated, based on evidence-based institutional guidelines.

RESULTS

Among the 291 included patients, perioperative antibiotics were unnecessarily administered in 29% of patients. Among patients who received antibiotics, 76% received preoperative antibiotics and 41% received postoperative antibiotics, for a median duration of 7 days. There were no significant differences in SSIs, mortality, and length of stay for those receiving perioperative antibiotics versus those not receiving perioperative antibiotics.

CONCLUSION

These data highlight the need for antibiotic stewardship interventions and partnerships between antibiotic stewardship teams and surgical services.

Prospective Evaluation and Validation of the Laryngoscore and the mini-Laryngoscore

OBJECTIVE

The Laryngoscore was described in 2014 as a practical preoperative assessment tool to predict difficult laryngeal exposure (DLE) during transoral approaches to the larynx. In 2019 the authors proposed a version with a reduced number of variables, called the mini-Laryngoscore. We aim to critically appraise and externally validate these two tools and if needed and possible, to optimize these tools.

METHODS

103 consecutive patients who underwent a microlaryngoscopy between November 2017 and June 2020 at the Leuven University Hospitals were prospectively included and subjected to a presurgical evaluation of 15 parameters and a peroperative scoring of the anterior commissure visualization. Subsequent analysis focused on the concordance of our findings with those of Piazza et al., the discriminatory ability of the test, and the validity of the included items. We then evaluated a modified prediction tool.

RESULTS

Of 103 patients, 18 (17.5%) had DLE. The Laryngoscore and mini-Laryngoscore predicted this with a "good" C-index of respectively 0.727 (95%CI: 0.608-0.846) and 0.714 (95%CI: 0.605-0.823). A newly created prediction tool including only three parameters (Interincisors gap, upper jaw dental status and previous treatments) showed a better discriminatory ability (C-index = 0.835, 95%CI: 0.726-0.944) than the original Laryngoscore, a finding that needs further external validation.

CONCLUSION

The original Laryngoscore and the mini-Laryngoscore displayed a good discriminative ability. Some parameters can be left out of the Laryngoscore without losing discrimination. An even better prediction model seems possible, using a weighted sum of selected predictor variables and by using the parameters in their continuous form.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1807-1812, 2024.

Return to Vocal Performance Following Microlaryngoscopy in Singers

INTRODUCTION

Although microlaryngoscopy has been recognized to be effective in addressing lesions in vocal performers, no detailed information regarding return to performance (RTP) following surgery exists. We describe our experience and offer proposals to establish standardized criteria for RTP among vocal performers.

METHODS

Records for adult vocalists who underwent microlaryngoscopy for benign vocal fold (VF) lesions and had a clearly documented RTP date between 2006 and 2022 were reviewed. Patient demographics, diagnoses, interventions, and postsurgical care before and after RTP were described. The need for medical and procedural interventions and rate of reinjury were used to determine the success of RTP.

RESULTS

Sixty-nine vocal performers (average age: 32.8 years, 41 [59.4%] female, 61 [88.4%] musical theater) underwent surgery for 37 (53.6%) pseudocysts, 25 (36.2%) polyps, 5 (7.2%) cysts, 1 (1.4%) varix, and 1 (1.4%) mucosal bridge. Fifty-seven (82.6%) underwent voice therapy. The average time to RTP was 65.0 ± 29.8 days. Prior to RTP, six (8.7%) experienced VF edema requiring oral steroids and one (1.4%) underwent a VF steroid injection. Within 6 months following RTP, eight (11.6%) received oral steroids for edema and three underwent procedural interventions (two steroid injections for edema/stiffness, one injection augmentation for paresis). One patient experienced pseudocyst recurrence.

CONCLUSIONS

Return to vocal performance at an average of 2 months following microlaryngoscopy for benign lesions appears overwhelmingly successful, with low rates of need for additional intervention. There is a need for validated instruments to better measure performance fitness to refine and possibly accelerate RTP.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:329-334, 2024.

Indirect laryngeal surgery of vocal fold polyps: a dying or evolving art?

Objective

Vocal fold polyps (VFPs) are the most common benign laryngeal lesions that require surgery and are routinely managed by microlaryngoscopy (MLS) under general anaesthesia. Prior to introduction of MLS, VFPs were removed using indirect laryngoscopic surgery (ILS) in local anaesthesia, a procedure that required substantial surgical skill to operate with an unmagnified mirror view of the larynx. With the adoption of wireless endoscopy equipment and personal computers, we tried to simplify this technique so that it can be easily performed in the office. This study aimed to assess the effectiveness of ILS by comparing voice outcomes with MLS.

Materials and methods

ILS and MLS were performed in six patients each. Treatment outcomes were measured using a voice self-assessment and objective acoustic analysis. The total cost of both procedures was calculated.

Results

Both techniques allowed successful removal of VFPs in all patients, without significant intergroup differences in voice outcomes. The cost of ILS was significantly lower.

Conclusions

Despite the pilot nature of the study and the small sample size, our data indicate the potential value of this technique which, considering its simplicity and economic value could be used as an alternative to MLS in carefully selected patients.

Developing an Objective Structured Assessment of Technical Skills (OSATS) for Microlaryngoscopy

BACKGROUND

Microlaryngoscopy is a basic technical skill in Oto-HNS. It is essential for residency programs to have a competency-based assessment tool to evaluate residents' performance of this procedure. An Objective Structured Assessment of Technical Skills (OSATS) is a procedure-specific assessment, which consists of the following: (a) Operation-Specific Checklist and (b) Global Rating Scale (GRS).

OBJECTIVE

The objective of this study was to create an OSATS for adult microlaryngoscopy.

METHODS

This was a prospective study, with an initial qualitative phase for OSATS development (Phase I), and a clinical pilot phase (Phase II). In Phase I, interviews were conducted with three laryngologists to establish a stepwise description of adult microlaryngoscopy and review a previously validated GRS for relevance to microlaryngoscopy. Responses were used to create a framework for the OSATS. The OSATS was then presented to Oto-HNS residents and laryngologists in an alternating fashion, for review of clarity and relevance. A pilot study was then performed to evaluate the resident performance of adult microlaryngoscopy. Multiple regression analysis was carried out to investigate whether training level, case complexity, and previous OSATS exposure could predict participant scores.

RESULTS

Phase I of this study led to the creation of a 34-item OSATS. The pilot study (N = 28 procedures) revealed that training level was significantly correlated with increased OSATS scores. There was no statistically significant correlation between case complexity and resident scores. Assessors reported the perceived utility of the OSATS and intent for use in residency training.

CONCLUSION

Application of the proposed OSATS will allow for competency-based assessment of the resident performance of microlaryngoscopy.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2719-2724, 2023.

Paralysis Versus Non-Paralysis Anesthesia for Operative Laryngoscopy: A Randomized Controlled Trial

OBJECTIVE

To compare outcomes between two standard-of-care anesthesia regimens for operative laryngoscopy: general anesthesia with a neuromuscular blocking agent (NMBA) versus remifentanil and propofol (non-NMBA).

METHODS

This was a prospective, single-blinded, randomized controlled trial at a tertiary care center. Patients were randomized to either anesthesia using rocuronium (NMBA) or with remifentanil/propofol infusion alone (non-NMBA). Intraoperative impressions, anesthesia data, and post-operative patient surveys were collected.

RESULTS

Sixty-one patients who underwent suspension laryngoscopy from 2020 to 2022 were included (25 female, 36 male, ranging 20-81 years). Thirty patients were enrolled in the NMBA arm and 31 patients in the non-NMBA arm. Heart rate and mean arterial pressure were higher in the NMBA (p < 0.01). Patients in the non-NMBA group were more likely to require vasopressors (p = 0.04, RR = 3.08 [0.86-11.05]). Surgeons were more frequently satisfied with conditions in the NMBA group (86.7%) compared to the non-NMBA group (58.1%, p < 0.01). Procedures were more likely to be paused due to movement in the non-NMBA group (45.1%) compared to the NMBA group (16.6%, p < 0.03, RR = 2.26 [1.02-4.99]). Patients in the non-NMBA group were more likely to endorse myalgia the week after surgery (44%) compared to the NMBA group (8.3%, p < 0.01) and reported higher average pain levels on a 0-10 pain scale (3.7) compared to the paralysis group (2.0).

CONCLUSIONS

Anesthesia with rocuronium was associated with better intraoperative conditions and postoperative pain compared to anesthesia with remifentanil/propofol. Remifentanil/propofol were associated with lower blood pressure and suppression of laryngoscopy-associated tachycardia.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:2654-2664, 2023.

Needle in the Haystack: Wire Bristle Foreign Body Presenting Deep Within the Tongue Base

OBJECTIVES

To report a case of ingested wire bristle embedded within the extrinsic musculature of the tongue requiring a transcervical approach for removal and to provide a revised algorithm for the management of ingested wire bristles.

METHODS

The clinical record of 1 patient who ingested a grill brush wire bristle was reviewed. A literature review was also conducted to refine a treatment algorithm for managing ingested wire bristles.

RESULTS

We present a case of a 53-year-old male who accidentally ingested a grill brush wire bristle. After multiple unsuccessful endoscopic attempts at removal, the wire bristle migrated deep into the extrinsic musculature of the tongue, necessitating a transcervical approach for adequate visualization and retrieval.

CONCLUSIONS

This is the first case reported of a wire bristle migrating deep into the tongue musculature that was successfully removed via a transcervical approach. Our proposed algorithm provides a comprehensive approach to the management of ingested wire bristles, specifically in cases where endoscopic retrieval is not feasible.

Successful Management of a Symptomatic Vallecular Cyst in an Adult: A Case Report

In adults, vallecular cysts are usually asymptomatic but can present with respiratory and gastrointestinal manifestations. A 45-year-old man presented with a four-month progressive history of dysphonia, dysphagia to solid, snoring, choking, apnea, and aspiration. On examination, the patient was vitally stable with no remarkable local and physical examination. Flexible nasoendoscopy, computer tomography, and subsequent micro-laryngoscopy revealed a non-pulsating, non-congested 3 x 2 cm cyst obscuring vocal cord visualization. The cyst was removed completely by cold and hot techniques and was sent for biopsy. This case report presents the successful management of a symptomatic vallecular cyst through electrocautery.

Vocal Fold Cyst Formation after Photoangiolytic KTP Laser Treatment of Early Glottic Cancer

OBJECTIVE

The incidence of post-operative glottic cyst (POGC) formation in patients treated with transoral laser microsurgery with potassium-titanyl-phosphate laser (TLM-KTP) photoablation of early glottic carcinoma (EGC) has not previously been described.

METHODS

A retrospective chart review was performed to identify all patients with early glottic cancer who underwent with single-modality TLM-KTP at our institution. Each patient received regular follow up with videostroboscopy for tumor surveillance. New glottic cysts seen on surveillance examinations were noted and their management was documented.

RESULTS

A total of 33 patients met inclusion criteria. Eight patients (24%) developed POGC's within the original geographic perimeter of the cancerous vocal fold(s): 6 in the infraglottic region and 2 near the vocal process, at an average of 8 months after their initial cancer surgery. Of these 8 POGC's, 7 were at the periphery of the original tumor distribution and 1 was in the center of it. No POGC's were associated with any change in voice. Four of the 8 POGC's were phonosurgically excised, all without evidence of malignancy on pathology. The remaining 4 were monitored: 2 were stable for an average of 49 months of follow up; the remaining 2 resolved spontaneously by 7 and 31 months after first identification.

CONCLUSIONS

POGC's are a frequent sequela of TLM-KTP for EGC. While these results suggest that they are unlikely to represent submucosal recurrences, surgeons should have a low threshold to biopsy if there is clinical concern for such and should counsel patients pre-operatively about the potential for their formation.

Channeled fiberoptic for vocal cord polyp excision under spontaneous respiration using intravenous anesthesia and hi-flow nasal oxygen (STRIVE-Hi) technique: A case report and review of the literature

Microlaryngoscopy for benign vocal cord lesion excision is a procedure with good outcomes and relatively few complications that is performed worldwide. The anterior one-third of the vocal cords is a relatively common site to find benign polyps, and the excision of cases with adequate laryngeal exposure is relatively easy. However, they can sometimes present a challenge when laryngeal exposure is suboptimal, which leads to trouble in accessing the site. The factors that can lead to difficulties in laryngeal exposure are numerous, such as restricted mouth opening, limited neck extension, large tongue size, and others. The preoperative prediction of difficult laryngeal exposure (DLE) can be obtained by different scoring and grading systems. We have used the Laryngoscore in this case. However, management options for such cases remain limited. Here, we present a case that was managed using channeled cup forceps under fiberoptic endoscopy with the STRIVE-Hi technique used to administer anesthesia.

Systematic review of laryngocele and pyolaryngocele management in the age of robotic surgery

OBJECTIVE

A laryngocele is a space that develops as a result of pathological dilatation of the laryngeal saccule. However, the reported management of laryngoceles varies. We conducted a systematic review of the literature regarding the surgical management of laryngoceles and pyolaryngoceles, to understand the evolving nature of treatment for this rare condition.

METHODS

We searched for publications in the PubMed, Cochrane Library, JBI Library of Systematic Reviews, and Ovid databases using the terms "laryngocele", "pyolaryngocele", and "laryngopyocele", and reviewed the identified articles.

RESULTS

After removal of repeated studies and filtering for relevance and studies written in English, a total of 227 studies were included in this review. No meta-analyses or randomized controlled trials have been published. The identified studies have been summarized in 14 reviews conducted since 1946. The meta-analysis determined that endoscopy was the preferred approach for internal laryngoceles, while combined laryngoceles benefited from both internal and external surgical approaches.

CONCLUSIONS

Laryngocele management has progressed since its initial description, from open surgery to an endoscopic approach, and more recently to a robotic-assisted surgical approach. The uptake of robotic surgery as a possible treatment modality over the last decade shows much promise for the treatment of these conditions.

Vocal nodules management

Vocal fold nodules present the voice clinic team with a number of clinical dilemmas which are not as simple as previously thought. The definition, aetiology, prevalence and diagnosis are all poorly understood. Furthermore, treatment evidence for both behavioural and surgical approaches is weak. This paper reviews the published evidence pertaining to all of these aspects. Specific areas of uncertainty that remain include poorly defined nomenclature, the natural history of paediatric vocal nodules, the establishment of criteria to measure successful treatment, optimal configuration of speech therapy regimens and the rationale for surgical intervention. The authors suggest the development of evidence-based guidelines for UK practice.

Predicting laryngeal exposure in microlaryngoscopy: External validation of the laryngoscore

OBJECTIVES

Optimal laryngeal exposure during transoral laryngeal surgery is fundamental. We aimed to evaluate the reliability of a recently proposed score (Laryngoscore) in predicting difficult laryngeal exposure (DLE) in an independent cohort of patients undergoing elective microlaryngoscopy. We also verified the relation between DLE, surgeon's expertise, and difficult intubation, and investigated possible areas for score improvement.

STUDY DESIGN

Prospective validation study.

METHODS

A total of 136 patients were preoperatively evaluated using the Laryngoscore. Patients were divided into three classes according to patient position, type of laryngoscope, and need for external counterpressure to expose the anterior commissure. Based on their mean scores, two groups were identified: good laryngeal exposure (GLE) and DLE. A receiver operating characteristic curve with the Youden index was used to calculate the optimal cutoff value. The χ² and Fisher exact test were used to correlate GLE and DLE to the surgeon's expertise and difficult intubation. The intraoperative anatomical parameters underlying DLE were also recorded.

RESULTS

The optimal cutoff value for differentiating GLE and DLE was 4, which identified 80.6% of DLE cases. No statistically significant difference in GLE and DLE distribution was found between surgeons (P = 0.43). The correlation between difficult intubation and DLE was statistically significant (P = 0.03). The intraoperative parameters determining DLE were epiglottis characteristics (floppy, tight, or short), bulky abdomen and chest, bulky tongue base, mobile teeth, and a narrow laryngeal aditus.

CONCLUSION

The Laryngoscore is reliable for detecting DLE preoperatively. The inclusion of additional parameters may allow a more complete assessment and maximize its diagnostic accuracy.

LEVEL OF EVIDENCE

2b Laryngoscope, 129:1438-1443, 2019.

Glottic exposure for transoral laser microsurgery: Proposal of a mini-version of the laryngoscore

OBJECTIVES

Good laryngeal exposure (GLE) is typically regarded as an essential prerequisite for transoral laser microsurgery (TLM). The Laryngoscore is a preoperative scoring system aimed at predicting glottic visualization through the laryngoscope using easy patient-derived parameters. However, the presence of subjective variables may hamper its reliability and reproducibility. The aim of the present study was to provide a validation of the Laryngoscore and to develop a revised mini-version of the same, called mini-Laryngoscore (mLS), which could allow even quicker, yet sufficiently accurate, preoperative prediction of GLE.

STUDY DESIGN

Prospective cohort study.

METHODS

We prospectively evaluated 310 consecutive patients submitted to TLM between 2014 and 2017, grading each patient according to the variables considered in the Laryngoscore.

RESULTS

Among the 11 variables of the previous Laryngoscore, three were confirmed as statistically significant at validation: interincisors gap, thyromental distance, and upper jaw dental status. We chose these three variables as part of the revised mLS (ranging from 0 to 4). In our cohort, 30% of the patients obtained a score of 0, 57% a score of 1, 11% a score of 2, and 2% a score of ≥3. GLE was achieved in 97%, 85%, 65%, and 20% of cases, respectively.

CONCLUSION

Our validation confirmed the predictive ability of the Laryngoscore. Furthermore, although composed of only three clinical parameters, the mLS was still able to convey useful information regarding the possibility of obtaining GLE.

LEVEL OF EVIDENCE

2 Laryngoscope, 129:1617-1622, 2019.

CO2 Transoral Microsurgery for Supraglottic Squamous Cell Carcinoma

The present study analyzed the results of the endoscopic approach to T1, T2 and selected T3 supraglottic carcinoma with the aim of reviewing functional and oncologic outcomes after different types of endoscopic supraglottic laryngectomies. This is a retrospective clinical study of 42 consecutive patients (mean age of 61.8 years, 33 males, 9 females) treated by the senior author for supraglottic squamous cell carcinoma with a transoral CO₂ laser approach and reviewed from November 2010 to September 2017. Surgical procedures were classified according to the European Laryngological Society. In addition to the standardized transoral supraglottic laryngectomies, we introduced a modified type IVb by sparing the inferior third of the arytenoid if not directly involved in the tumor. Swallowing was evaluated with the Swallowing Performance Status Scale reported by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology. Survival probabilities were estimated using Kaplan-Meier curves. Two type I, 2 type IIa, 2 type IIb, 3 type IIIa, 12 type IIIb, 13 type IVa, 3 type modified IVb, and 5 type IVb supraglottic laryngectomies were performed. Twenty-one patients (50%) underwent primary neck dissection. The pathologic TNM classification according to the 8th edition of the American Joint Committee on Cancer system was as follows: 9 pT1cN0, 2 pT1N0, 1 pT1N1, 7 pT2cN0, 1 rypT2cN0, 9 pT2N0, 4 pT2N1, 2 ypT2N1, 2 pT3cN0, 2 rypT3cN0, 1 pT3N1, and 2 pT3N2b. Mean follow-up was 3.4 years (range of 9 months to 6 years). According to the Kaplan-Meier analysis, 5-year disease-specific survival, local-relapse-free survival, nodal-relapse-free survival, overall laryngeal preservation and overall survival of patients without previous head and neck radiotherapy/open surgery were 100%, 95.2%, 87.8%, 100%, and 64.6%, respectively. Patients who underwent type I, IIa, and IIb resections (n = 6) started oral feeding the day after surgery, patients who underwent type III-IVb modified resections (n = 31) started oral feeding 3-4 days after surgery, and patients who underwent standard type 4b resections (n = 5) started oral feeding 7 days after surgery. Three months after surgery, patients without a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed significantly better swallowing compared to patients who underwent standard type IVb resection: grade 4-6 impairment of swallowing in 8 and 66.7% of cases, respectively (p = 0.006072); patients with a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed not statistically significant better swallowing compared to patients who underwent standard type IVb resection: grade 4-6 impairment of swallowing at 3 months in 16.7% and 50% of cases, respectively (p = 0.23568). Transoral CO₂ laser supraglottic laryngectomy is an oncologic sound alternative to traditional open neck surgery and chemo-radiotherapy. Recovery of swallowing is significantly worsened after total resection of the arytenoid. Modified type IVb procedure leaving intact, when possible, the inferior third of the arytenoid and consequently the glottic competence, improves functional outcome.

Ectopic Thymic Cyst of the Subglottis: Considerations for Diagnosis and Management

OBJECTIVES

To share the diagnostic and management challenges created by an extremely rare airway lesion-the subglottic ectopic thymic cyst.

STUDY DESIGN

Case report and literature review.

METHODS

We review the presentation, management, and clinical course of an infant who presented with a subglottic mass that was histologically confirmed as a thymic cyst. A brief literature review supplements the case presentation Results: We present the third described case of an ectopic thymic cyst presenting as a subglottic mass. The differential diagnosis of subglottic masses in neonates consists primarily of subglottic hemangioma and mucous retention cysts. Otolaryngologists must be prepared for unexpected findings when dealing with critical airways. We compare the presentation and management of our patient with the 2 previously described cases. We propose an embryologic theory for the origin of these rare lesions.

CONCLUSIONS

An ectopic thymic cyst is a rare and unexpected cause of neonatal stridor. Management of pediatric airway lesions must allow for unexpected findings at the time of diagnostic and therapeutic endoscopy. The appropriate management of subglottic thymic cysts is poorly defined, but close surveillance for recurrence is mandatory.

Laryngeal exposure and margin status in glottic cancer treated by transoral laser microsurgery

OBJECTIVE

Laryngeal exposure is one of the most limiting factors in transoral laser microsurgery (TLM) for glottic cancer. We evaluated the correlation between the degree of laryngeal exposure, as assessed by an easy previously described scoring tool (Laryngoscore), and histopathologic surgical margin status after TLM.

STUDY DESIGN

Prospective evaluation of 147 patients affected by Tis-T2 glottic cancer treated by TLM with curative intent between January 2012 and April 2016.

METHODS

All patients were preoperatively assessed and classified as having good (group A including Laryngoscore class 0-I) or suboptimal laryngeal exposure (group B including class II-III). Margins were classified as negative (more than 1 mm margin between healthy tissue and tumor) or positive (one/multiple superficial or deep margins involved by invasive or in situ carcinoma). Patients with multiple superficial or deep margin positivity were scheduled for TLM re-excision, open partial laryngectomy, or postoperative radiotherapy.

RESULTS

Twenty-one type I, 54 type II, 19 type III, 7 type IV, 41 type V, and 5 type VI cordectomies (according to the European Laryngological Society classification) were performed with an en-bloc or multi-bloc technique according to the size, site, and exposure of the lesion. Group A included 109 (74%) and group B included 38 (26%) patients. Positive surgical margins were overall observed in 39 (26.5%) cases: 21 (19.2%) in group A versus 18 (47.4%) in group B (P = 0.001).

CONCLUSION

Laryngeal exposure is one of the most important factors influencing TLM resection of glottic cancer within safe surgical margins. The importance of its adequate preoperative assessment cannot be overemphasized.

LEVEL OF EVIDENCE

2b. Laryngoscope, 128:1146-1151, 2018.

Caustic ingestions mimicking anaphylaxis: case studies and literature review

Anaphylaxis presents in children with rapid involvement of typically 2 or more organ systems including cutaneous, gastrointestinal, and respiratory. Caustic ingestions (CI) may also present with acute involvement of cutaneous, gastrointestinal, and respiratory systems. We present 2 cases of "missed diagnosis" that illustrate how CI presenting with respiratory symptoms can be mistaken for anaphylaxis owing to these similarities. Both of these patients had delay in appropriate care for CI as a result. These cases demonstrate the importance of considering CI in children who have gastrointestinal symptoms, respiratory distress, and oropharyngeal edema.

Preoperative clinical predictors of difficult laryngeal exposure for microlaryngoscopy: the Laryngoscore

OBJECTIVES/HYPOTHESIS

To identify a clinical predictor score for difficult laryngeal exposure (DLE) during operative microlaryngoscopy.

STUDY DESIGN

Prospective cohort study in two academic institutions.

METHODS

We evaluated 319 patients before microlaryngoscopy for benign and malignant glottic diseases by a standardized preoperative assessment protocol (Laryngoscore) that included 11 parameters: interincisors gap (IIG), thyro-mental distance, upper jaw dental status, trismus, mandibular prognathism, macroglossia, micrognathia, degree of neck flexion-extension, history of previous open-neck and/or radiotherapy, Mallampati's modified score, and body mass index (BMI). Each parameter was assessed to obtain a total score. Patients were divided into five classes according to the anterior commissure (AC) visualization: class 0, complete AC visualization with large-bore laryngoscopes in the Boyce-Jackson position; class I, as class 0 with external laryngeal counterpressure; class II, as class I in the flexion-flexion position; class III, as class II using small-bore laryngoscopes; and class IV, impossible AC visualization.

RESULTS

Class 0-I-II (good/acceptable laryngeal exposure) presented a median score < 6. This value was chosen as cutoff for distinguishing favorable versus difficult/impossible laryngeal exposures. When the Laryngoscore was < 6, good laryngeal exposure was observed in 94% of patients, whereas when ≥ 6, DLE was encountered in 40%. When considering a Laryngoscore of ≥ 9, 67% of patients had a DLE. At univariate analysis, IIG, upper jaw dental status, macroglossia, micrognathia, degree of neck flexion-extension, and BMI statistically impacted on DLE (P < 0.05).

CONCLUSIONS

The Laryngoscore is a good predictor of DLE and assists in selecting the ideal candidates for operative microlaryngoscopy.

LEVEL OF EVIDENCE

2b.

Prevalence and risk factors for musculoskeletal problems associated with microlaryngeal surgery: a national survey

OBJECTIVES/HYPOTHESIS

Microlaryngeal surgery (MLS) presents ergonomic challenges to surgeons and potential risks for developing musculoskeletal symptoms (MSSx). This study describes prevalence and risk factors of MLS-associated MSSx.

STUDY DESIGN

Cross-sectional survey.

METHODS

A questionnaire was administered to members of the American Academy of Otolaryngology-Head and Neck Surgery. Outcome measures related to surgeon demographics, training, MLS experience, operating room setup, experience of MSSx in relation to MLS, treatment sought, and practice changes due to MSSx.

RESULTS

Response rate was 9.2% (n = 476); 83% reported musculoskeletal symptoms during MLS, and 21% reported rest breaks during MLS. Taking breaks was independently associated with back support lack (odds ratio [OR] = 2.08) and surgery lasting >30 minutes (OR = 1.68). Areas most commonly affected were neck, upper back, shoulder, and lower back. Ten percent reported treatment for MLS-related MSSx. Some respondents reported major practice changes due to MSSx, including fewer cases, ceasing to perform MLS, applying for disability, and early retirement.

CONCLUSIONS

Musculoskeletal symptoms are common (83%) among surgeons performing microlaryngeal surgery. Findings suggest multiple factors may contribute to development of MSSx in otolaryngologists. Risk factors for MSSx and taking breaks during surgery include average case operating time >30 minutes and absence of back support. Previous studies have identified neck flexion and lack of arm support as associated with risk of musculoskeletal injury. This study demonstrates that MSSx related to surgery do occur in otolaryngologists, and that poor surgical ergonomics may play a role. Surgeons should consider proper support and positioning during MLS to protect their health.

Surgical procedures for voice restoration

Surgical procedures for voice restoration serve to improve oral communication by better vocal function. They comprise of phonomicrosurgery, with direct and indirect access to the larynx; laryngoplasty; laryngeal injections; and surgical laryngeal reinnervation. The basis for modern surgical techniques for voice disorders is the knowledge about the ultrastructure of the vocal folds and the increasing experience of surgeons in voice surgery, while facing high social and professional demands on the voice. Vocal activity limitation and participation restriction has become more important in the artistic and social areas. A number of surgical methods that have been developed worldwide for this reason, are presented in this article. Functional oriented surgery has to meet high standards. The diagnostics of vocal function has to be multi-dimensional in order to determine the indication and the appropriate surgical intervention.

A Clinico-pathological study of Reinke'S oedema

An analysis of 92 eases of Reinke's oedema was done in this study. It wen most often seen in middle-aged persons. A Male predilection (57%) was found. In 68 (74%) cases, the lesions were unilateral and in 24 (26%) teses, the lesions were bilateral. Smoking (83%), vocal alms or misuse (80%) and chromnic respiratory tract infection (43%) were the main aetiological factors. No significant relationship of reinke's oedema with hypotkyroidsm was found. There were no dysplastic changes in the epithelium The treatment of reinke's oedema is a combination of surgery and vocal rehabilitation. Conventional microlaryngeal surgery is ideal for the treatment of Reinke's oedema. Acquired laryngeal web involving the anterior part of the vocal cords may develop if stripping of the both vocal cords is performed carelessly. Operating measures do not prevent recurrences of Reinke's oedema. Voice therapy and cessation of smoking in the postoperative period play important roles in the long term treatment results of Reinke's oedema.