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Buras M, DeSisto N, Holdgraf R. Effect of COVID-19 on the incidence of postintubation laryngeal lesions. Proc AMIA Symp 2023; 36:453-457. [PMID: 37334095 PMCID: PMC10269381 DOI: 10.1080/08998280.2023.2204544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/01/2023] [Accepted: 04/04/2023] [Indexed: 06/20/2023] Open
Abstract
Background Critically ill patients intubated in the intensive care unit experience prolonged intubation leading to increased frequency of laryngeal injuries. This study aimed to demonstrate a suspected increase in vocal fold injury in patients who were intubated with COVID-19 as compared with patients intubated for other reasons. Methods A retrospective review of medical records was performed to identify patients examined using flexible endoscopic evaluation of swallowing exams. The study included 25 patients with COVID-19 and 27 without COVID-19 at Baylor Scott & White Medical Center in Temple, Texas. Various injuries were evaluated, ranging from granulation tissue to vocal cord paralysis. Severe lesions were those causing clinically significant airway obstruction or requiring operative intervention. The incidence of laryngeal injury in patients intubated for COVID-19 was then compared with that of patients intubated for other reasons. Results The increased presence of severe injury in COVID-positive patients appeared clinically significant but was not statistically significant (P = 0.06). Interestingly, patients who received pronation therapy had 4.6 times the odds of more severe injury compared with patients who did not (P = 0.009). Conclusion Lower thresholds for performing flexible laryngoscopy on postintubated patients who are proned may allow for earlier intervention and reduce morbidity in an already at-risk population.
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Affiliation(s)
- Madison Buras
- Department of Otolaryngology, Baylor Scott & White Medical Center – Temple, Temple, Texas
| | - Nicole DeSisto
- School of Medicine, Texas A&M Health Sciences Center, Dallas, Texas
| | - Randall Holdgraf
- Department of Otolaryngology, Baylor Scott & White Medical Center – Temple, Temple, Texas
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Shoffel-Havakuk H, Lahav Y, Shopen Y, Reuven Y, Bachar G, Hamzany Y. Dilation, Steroid Injection, and Cough Exercise for Correction of Posterior Glottic Stenosis. Laryngoscope 2023; 133:883-889. [PMID: 35815928 DOI: 10.1002/lary.30293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/14/2022] [Accepted: 06/14/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe the DISCO protocol (Dilation, Steroid injection, and post-operative Cough Exercise); a novel treatment for posterior glottic stenosis (PGS). Restoring glottic mobility in PGS is a major challenge. In orthopedic and plastic surgery, post-operative physical therapy is associated with improved motion range and flexibility; yet, this principle was never applied to laryngeal surgery. METHODS A retrospective cohort of PGS adult patients, treated by the DISCO protocol during 2018-2020. DISCO involves the following: scar release, glottic dilation, and steroid injection, followed by post-operative cough as glottic physical therapy. Maximal glottic opening angle (MGOA), relative glottic opening area (RGOA), and relative glottic insufficiency area (RGIA) were calculated before and post-operatively. RESULTS Seventeen patients were included; PGS etiology was post-intubation (n = 10), post-irradiation (n = 3), both (n = 1) and joint sclerosis (n = 3). Six patients also had additional airway disorders. Sixteen patients were tracheostomy-dependent. 2 (12%), 8 (47%) and 7 (41%) patients had type II, III and IV stenosis, respectively. Surgery included scar release, dilation and steroid injection alone in 7 patients; and additional unilateral sub-mucosal arytenoidectomy in 10. The mean follow-up was 17.5 months. There were no major complications. Successful outcomes (e.g., decannulation or permanent capping) were achieved in 14 (82%) patients with some restoration of joint movement. None had a persistent voice or swallowing complaints. Both MGOA and RGOA increased in all patients (p < 0.001). RGIA remained unchanged (p = 0.878). CONCLUSIONS The DISCO protocol is a novel, effective and safe approach for PGS correction that can be easily applied. It can restore vocal fold mobility and may expand the glottic airway without causing glottic insufficiency. LEVEL OF EVIDENCE 4 Laryngoscope, 133:883-889, 2023.
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Affiliation(s)
- Hagit Shoffel-Havakuk
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yonatan Lahav
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Yoni Shopen
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yonatan Reuven
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gideon Bachar
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaniv Hamzany
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rohlfing ML, Kan K, Tierney WS, Plocienniczak MJ, Edwards HA, Tracy LF. Historical Review and Modern Case of Spontaneous Laryngeal Abscess. Ann Otol Rhinol Laryngol 2022:34894221115757. [PMID: 35923122 DOI: 10.1177/00034894221115757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Laryngeal abscesses are rare in the modern antibiotic era. Historically, they were associated with systemic infections including typhoid fever, measles, gonorrhea, syphilis, and tuberculosis. More recent authors have described cases resulting from iatrogenic injury and immunosuppression. This report presents a novel case of laryngeal abscess in the setting of uncontrolled diabetes and a detailed review of modern, reported cases of spontaneous laryngeal abscess. METHODS Report of a single case. Also, PubMed was queried for cases of laryngeal abscess since 1985. CASE REPORT A 58-year-old male with poorly controlled diabetes presented with odynophagia, dysphagia, and dyspnea. He had biphasic stridor, and flexible laryngoscopy showed reduced mobility of bilateral vocal folds and narrowed glottic airway. He was taken urgently for awake tracheostomy and microdirect laryngoscopy. Laryngoscopy demonstrated fullness and fluctuance of the right hemilarynx. The abscess cavity was entered endoscopically via paraglottic incision extending into the subglottis. The patient was treated with an 8-week course of ampicillin-sulbactam with resolution of infection. RESULTS Seven additional cases of spontaneous laryngeal abscesses published after 1985 were identified. In total, 6 of 8 had some form of immunodeficiency (75%). The most common presenting symptoms were dysphonia (8/8, 100%), odynophagia (5/8, 62.5%), and dyspnea/stridor (4/8, 50%). All cases were treated with surgical incision and drainage. CONCLUSIONS Laryngeal abscesses are rare in the era of modern antibiotics. This review confirms that the majority of recent episodes occurred in the setting of immunodeficiency and are caused by non-tubercular bacteria. These infections are commonly associated with impaired vocal fold mobility which may contribute to dyspnea, stridor, and airway compromise. Surgical intervention is necessary for treatment and culture-directed antimicrobial therapy. Poorly controlled diabetes is a newly described context for development of spontaneous laryngeal abscess.
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Affiliation(s)
- Matthew L Rohlfing
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Krystal Kan
- Department of Otolaryngology, University of Illinois Chicago, Chicago, IL, USA
| | - William S Tierney
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Heather A Edwards
- Department of Otolaryngology, Boston Medical Center, Boston, MA, USA
| | - Lauren F Tracy
- Department of Otolaryngology, Boston Medical Center, Boston, MA, USA
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Hollis AN, Ghodke A, Farquhar D, Buckmire RA, Shah RN. Postoperative Inhaled Steroids Following Glottic Airway Surgery Reduces Granulation Tissue Formation. Ann Otol Rhinol Laryngol 2021; 131:1267-1273. [PMID: 34965742 DOI: 10.1177/00034894211065805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Transoral laser surgery for glottic stenosis (transverse cordotomy and anteromedial arytenoidectomy (TCAMA)) is often complicated by granulation tissue (GT) formation. GT can cause dyspnea and may require surgical removal to alleviate airway obstruction. Inhaled corticosteroids (ICS) have been shown to reduce benign vocal fold granulomas, however its use to prevent GT formation has not been described. We aimed to analyze the effect of immediate postoperative ICS on GT formation in patients undergoing transoral laser surgery for glottic stenosis. METHODS A retrospective analysis of patients that had transoral laser surgery for glottic stenosis from 2000 to 2019 was conducted. Surgical instances were grouped into those that received postoperative ICS and those that did not. Demographics, diagnosis, comorbidities, intraoperative adjuvant therapy, and perioperative medications were collected. Differences in GT formation and need for surgical removal were compared between groups. A multivariate exact logistic regression model was performed. RESULTS Forty-four patients were included; 16 required 2 glottic airway surgeries (60 surgical instances). Of the 23 instances where patients received immediate postoperative ICS, 0 patients developed GT; and of the 37 instances that did not receive postoperative ICS, 15 (40.5%) developed GT (P < .0001). Eight (53.3%) of these cases returned to the OR for GT removal. ICS use was solely associated with the absence of GT formation (P = .042) in the multivariate analysis. CONCLUSIONS Immediate postoperative use of ICS seems to be a safe and effective method to prevent granulation tissue formation and subsequent surgery in patients following transoral laser airway surgery for glottic stenosis.
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Affiliation(s)
- Alison N Hollis
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Ameer Ghodke
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Douglas Farquhar
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Robert A Buckmire
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Rupali N Shah
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Chang CWD, McCoul ED, Briggs SE, Guardiani EA, Durand ML, Hadlock TA, Hillel AT, Kattar N, Openshaw PJM, Osazuwa-Peters N, Poetker DM, Shin JJ, Chandrasekhar SS, Bradford CR, Brenner MJ. Corticosteroid Use in Otolaryngology: Current Considerations During the COVID-19 Era. Otolaryngol Head Neck Surg 2021; 167:803-820. [PMID: 34874793 DOI: 10.1177/01945998211064275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19. DATA SOURCES PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases. REVIEW METHODS Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19-specific findings. CONCLUSIONS Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients. IMPLICATIONS FOR PRACTICE SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.
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Affiliation(s)
- C W David Chang
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri, Columbia, Missouri, USA
| | - Edward D McCoul
- Department of Otorhinolaryngology, Ochsner Clinic, New Orleans, Louisiana, USA
| | - Selena E Briggs
- Department of Otolaryngology-Head and Neck Surgery, Georgetown University, Washington, DC, USA
| | - Elizabeth A Guardiani
- Department of Otolaryngology-Head and Neck Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Marlene L Durand
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, and Infectious Disease Service, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
| | - Tessa A Hadlock
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nrusheel Kattar
- Department of Surgery, Louisiana State University, Shreveport, Louisiana, USA
| | | | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina, USA
| | - David M Poetker
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Carol R Bradford
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Félix L, Tavares TL, Almeida VPB, Tiago RSL. Incidence of Laryngotracheal Lesions After Orotracheal Intubation in Coronavirus Disease Patients. Laryngoscope 2021; 132:1075-1081. [PMID: 34516003 DOI: 10.1002/lary.29862] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/22/2021] [Accepted: 08/28/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the incidence of lesions and severe sequelae and the risk factors for the development of laryngotracheal lesions after orotracheal intubation (OTI) in coronavirus disease (COVID-19) patients. STUDY DESIGN Prospective cohort study. METHODS In this prospective cohort study, we evaluated patients diagnosed with COVID-19 who were consecutively admitted to a tertiary hospital and required OTI from March 1, 2020 to October 31, 2020. Patients discharged were called for outpatient follow-up and endoscopic examination. RESULTS A total of 1,357 patients diagnosed with COVID-19, as confirmed by nasal swab reverse transcription polymerase chain reaction, were admitted. OTI for mechanical ventilation was required in 421 patients (31%). Of the intubated patients, 172 (40.9%) were discharged and 249 (59.1%) died. Outpatient evaluation by videoendoscopy was performed in 95 patients (55.2%) approximately 100 days after extubation. Laryngotracheal lesions were observed in 38 patients (40%), with 17.9% diagnosed with laryngotracheal stenosis or unilateral immobility while 6.3% had severe stenosis (grades 3 and 4). The factors presenting statistical significance for the development of laryngotracheal lesions were the endotracheal tube (ETT) size; prone position over the OTI period; and the increased leukocyte count, d-dimer, prothrombin time (PT), and international normalized ratio (INR) on the day OTI was performed. CONCLUSIONS The incidence of laryngotracheal lesion in COVID-19 patients is 40%, with 6.3% of them presenting with severe stenosis. There was a greater risk for the development of laryngotracheal lesions in patients using a larger ETT, kept in a prone position, presenting a greater inflammatory reaction (increased leukocyte count), or developing coagulation disorders (increased d-dimer, PT, and INR). LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Letícia Félix
- Otorhinolaryngology Service, Department of Laryngology and Cervicofacial Surgery, São Paulo State Civil Servants Hospital - FMO/IAMSPE, São Paulo, Brazil
| | - Tracy L Tavares
- Otorhinolaryngology Service, Department of Laryngology and Cervicofacial Surgery, São Paulo State Civil Servants Hospital - FMO/IAMSPE, São Paulo, Brazil
| | - Vinicius P B Almeida
- Otorhinolaryngology Service, Department of Laryngology and Cervicofacial Surgery, São Paulo State Civil Servants Hospital - FMO/IAMSPE, São Paulo, Brazil
| | - Romualdo S L Tiago
- Otorhinolaryngology Service, Department of Laryngology and Cervicofacial Surgery, São Paulo State Civil Servants Hospital - FMO/IAMSPE, São Paulo, Brazil
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7
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Lina I, Tsai HW, Ding D, Davis R, Motz KM, Hillel AT. Characterization of Fibroblasts in Iatrogenic Laryngotracheal Stenosis and Type II Diabetes Mellitus. Laryngoscope 2021; 131:1570-1577. [PMID: 32857885 PMCID: PMC7914267 DOI: 10.1002/lary.29026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/29/2020] [Accepted: 07/27/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Iatrogenic laryngotracheal stenosis (iLTS) is the pathological narrowing of the glottis, subglottis, and/or trachea due to scar tissue. Patients with type 2 diabetes mellitus (T2DM) are over 8 times more likely to develop iLTS and represent 26% to 53% of all iLTS patients. In this investigation, we compared iLTS scar-derived fibroblasts in patients with and without T2DM. STUDY DESIGN Controlled ex vivo study. METHODS iLTS scar fibroblasts were isolated and cultured from subglottic scar biopsies in iLTS patients diagnosed with or without type 2 diabetes (non-T2DM). Fibroblast proliferation, fibrosis-related gene expression, and metabolic utilization of oxidative phosphorylation (OXPHOS) and glycolysis were assessed. Contractility was measured using a collagen-based assay. Metabolically targeted drugs (metformin, phenformin, amobarbital) were tested, and changes in fibrosis-related gene expression, collagen protein, and contractility were evaluated. RESULTS Compared to non-T2DM, T2DM iLTS scar fibroblasts had increased α-smooth muscle actin (αSMA) expression (8.2× increased, P = .020), increased contractility (mean 71.4 ± 4.3% vs. 51.7 ± 16% Δ area × 90 minute-1 , P = .016), and reduced proliferation (1.9× reduction at 5 days, P < .01). Collagen 1 (COL1) protein was significantly higher in the T2DM group (mean 2.06 ± 0.19 vs. 0.74 ±.44 COL1/total protein [pg/μg], P = .036). T2DM iLTS scar fibroblasts had increased measures of OXPHOS, including basal respiration (mean 86.7 vs. 31.5 pmol/minute/10 μg protein, P = .016) and adenosine triphosphate (ATP) generation (mean 97.5 vs. 25.7 pmol/minute/10 μg protein, P = .047) compared to non-T2DM fibroblasts. Amobarbital reduced cellular contractility; decreased collagen protein; and decreased expression of αSMA, COL1, and fibronectin. Metformin and phenformin did not significantly affect fibrosis-related gene expression. CONCLUSION T2DM iLTS scar fibroblasts demonstrate a myofibroblast phenotype and greater contractility compared to non-T2DM. Their bioenergetic preference for OXPHOS drives their increased contractility, which is selectively targeted by amobarbital. LEVEL OF EVIDENCE NA Laryngoscope, 131:1570-1577, 2021.
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Affiliation(s)
- Ioan Lina
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - Hsiu-Wen Tsai
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - Dacheng Ding
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - Ruth Davis
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - Kevin M Motz
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A
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8
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Ghodke A, Tracy LF, Hollis A, Adams K, Shah RN, Buckmire RA. Combined Transverse Cordotomy- Anteromedial Arytenoidectomy for Isolated Glottic Stenosis. Laryngoscope 2021; 131:2305-2311. [PMID: 33577090 DOI: 10.1002/lary.29438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Glottic stenosis is a discrete cause of airway compromise. We aimed to determine the surgical outcomes of transverse cordotomy with anteromedial arytenoidectomy (TCAMA), performed in the setting of isolated glottic stenosis resulting from two discrete etiologies: bilateral vocal fold paralysis (BVFP) and posterior glottic stenosis (PGS). STUDY DESIGN Retrospective, analytic cohort study. METHODS Twenty-six patients with isolated glottic stenosis were treated with TCAMA between 2006 and 2019. A retrospective analysis determined decannulation rates and intervals, voice outcomes, swallowing outcomes, and reoperation rates postoperatively. Outcomes between the two etiologic cohorts were compared. RESULTS Of the 26 patients, 16/26 patients were diagnosed with PGS and 10/26 with BVFP. Eighteen patients required tracheotomies during their clinical course (11/16 PGS, and 7/10 BVFP), and 100% were ultimately decannulated. The PGS cohort required two-sided interventions more frequently than the BVFP cohort (45.5% vs. 0%, P = .066). Trach-dependent PGS patients required a longer time to achieve decannulation than BVFP patients by a factor of 2.38, although the difference was not statistically significant (102.3 days vs. 42.9 days, respectively, P = .113). Patients demonstrated a significant change in maximum phonation time but no statistically significant differences with preoperative versus postoperative voice outcomes like voice-related quality of life. All patients ultimately returned to their baseline swallow function postoperatively. CONCLUSION TCAMA is an effective treatment for surgical rehabilitation of glottic stenosis caused by both BVFP and PGS. Patient-reported outcomes of postoperative vocal function remain consistent following surgical intervention. Additional, prospective studies with greater power are warranted to validate the contrasting outcomes observed when applying this discrete surgical technique across two distinct diagnostic cohorts in this retrospective study. LEVEL OF EVIDENCE 4. Laryngoscope, 2021.
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Affiliation(s)
- Ameer Ghodke
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, U.S.A
| | - Lauren F Tracy
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, Boston, Massachusetts, U.S.A
| | - Alison Hollis
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, U.S.A
| | - Katherine Adams
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Rupali N Shah
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - Robert A Buckmire
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
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Abstract
OBJECTIVE Predictors of tracheostomy decannulation in patients with laryngotracheal stenosis are not fully known, making prognosis difficult. The aim was to identify predictors of tracheostomy decannulation in adult patients with acquired stenosis of the larynx and/or trachea who were tracheostomy dependent. STUDY DESIGN Case series. SETTING Academic teaching hospital. METHODS A total of 103 consecutive adult patients with laryngotracheal stenosis who were tracheostomy dependent and seen by the otolaryngology clinic from January 1, 2013, to August 2, 2018, were included. Exclusion criteria included age <18 years, history of laryngeal cancer or head and neck radiation, or history of laryngeal fracture. The primary outcome was the presence of tracheostomy at last follow-up. The patients' etiology of stenosis, comorbid conditions, and characteristics of the stenosis were analyzed to determine if there was a statistically significant relationship with decannulation. RESULTS A total of 103 patients were included: 67% of patients were women and the average age was 53.5 years. Sixty-four patients (62%) were successfully decannulated. In multivariate analysis, patients who were successfully decannulated presented to the otolaryngology clinic earlier after tracheostomy was performed, were more likely to have been intubated due to trauma, and were less likely to have gastroesophageal reflux disease. In patients with subglottic or tracheal stenosis, those with granulation tissue without firm scar were more likely to be decannulated, and those who underwent rigid dilation were less likely to be decannulated. CONCLUSION Early evaluation by an otolaryngologist may increase the likelihood of tracheostomy decannulation in patients with laryngotracheal stenosis. Patient comorbidities may assist in predicting which patients will be successfully decannulated.
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Affiliation(s)
- Grace E Snow
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Taylor B Teplitzky
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Guardiani
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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10
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Qazi S, Mau T, Tibbetts KM. Impact of Patient Factors and Management Strategies on Outcomes After Transverse Posterior Cordotomy. Laryngoscope 2020; 131:1066-1070. [PMID: 32678917 DOI: 10.1002/lary.28931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/16/2020] [Accepted: 06/18/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Carbon dioxide laser transverse posterior cordotomy (TPC) aims to improve airway aperture in patients with glottic obstruction. Postoperative complications may worsen airway compromise and necessitate additional interventions. We sought to identify factors impacting outcomes after TPC. STUDY DESIGN Retrospective chart review. METHODS Medical records of patients who underwent TPC for glottic airway obstruction at a tertiary-care medical center between 2008 and 2018 were reviewed. Demographics, comorbidities, and intra- and postoperative management strategies were analyzed. RESULTS Twenty patients who underwent TPC for glottic airway obstruction met inclusion criteria. The mean age was 57 years, and 13 patients were female. Mean follow-up time was 442 days. Seven patients had posterior glottic stenosis, and 13 had bilateral vocal fold paralysis. Twelve patients developed postoperative complications including granuloma formation (four patients), hospital readmission for dyspnea due to glottic edema (five patients), need for revision surgery (nine patients), or failure to decannulate tracheotomy (five patients). Eight patients had an uncomplicated recovery with improved dyspnea, with two patients with tracheotomies decannulated. Patients with a history of smoking tobacco were more likely to experience complications (P = .035). There were no significant differences in outcomes with respect to history of head and neck radiation or gastroesophageal reflux disease. Steroid injection at the surgical site and postoperative medications did not significantly impact outcomes. With respect to granuloma formation, none of the variables analyzed reached significance. CONCLUSIONS History of tobacco use increases complication rates after TPC. Other patient comorbidities and intra- and postoperative management strategies do not impact outcomes. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1066-1070, 2021.
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Affiliation(s)
- Shafeen Qazi
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Ted Mau
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Kathleen M Tibbetts
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
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11
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Abstract
Posterior glottic stenosis (PGS) is a process that results in partial or total fixation of the vocal folds. Type I PGS (PGS-1) is an uncommon clinical entity that results from an interarytenoid adhesion/scar band that is separate from the posterior interarytenoid mucosa. We present a case series of patients with PGS-1 treated at our institution to contribute to the understanding of this complex clinical entity.
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Affiliation(s)
- Nima Vahidi
- Department of Otolaryngology-Head and Neck Surgery, 72054Virginia Commonwealth University, Richmond, VA, USA
| | - Lexie Wang
- Department of Otolaryngology-Head and Neck Surgery, 72054Virginia Commonwealth University, Richmond, VA, USA
| | - Jaime Moore
- Department of Otolaryngology-Head and Neck Surgery, 72054Virginia Commonwealth University, Richmond, VA, USA
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12
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Rios G, Morrison RJ, Song Y, Fernando SJ, Wootten C, Gelbard A, Luo H. Computational Fluid Dynamics Analysis of Surgical Approaches to Bilateral Vocal Fold Immobility. Laryngoscope 2019; 130:E57-E64. [PMID: 30883777 DOI: 10.1002/lary.27925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/04/2019] [Accepted: 02/20/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Bilateral vocal fold immobility (BVFI) is a rare and life-threatening condition in which both vocal folds are fixed, resulting in airway obstruction associated with life-threatening respiratory compromise. Treatment of BVFI is largely surgical and remains an unsatisfactory compromise between voice, breathing, and swallowing. No comparisons between currently employed techniques currently exist. We sought to employ computational fluid dynamics (CFD) modeling to delineate the optimal surgical approach for BVFI. METHODS Utilizing clinical computed tomography of BVFI subjects, coupled with image analytics employing CFD models and subject pulmonary function data, we compared the airflow features in the baseline pathologic states and changes seen between endoscopic cordotomy, endoscopic suture lateralization, and posterior cricoid expansion. RESULTS CFD modeling demonstrated that the greatest airflow velocity occurs through the posterior glottis on inspiration and anterior glottis on expiration in both the normal condition and in BVFI. Glottic airflow velocity and resistance were significantly higher in the BVFI condition compared to normal. Geometric indices (cross-sectional area of airway) were lower in posterior cricoid expansion surgery when compared to alternate surgical approaches. CFD measures (airflow velocity and resistance) improved with all surgical approaches but were superior with posterior cricoid expansion. CONCLUSION CFD modeling can provide discrete, quantitative assessment of the airflow through the laryngeal inlet, and offers insights into the pathophysiology and changes that occur after surgery for BVFI. LEVEL OF EVIDENCE NA. Laryngoscope, 130:E57-E64, 2020.
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Affiliation(s)
- Gabriel Rios
- Department of Mechanical Engineering, School of Engineering, Vanderbilt University, Nashville, Tennessee
| | - Robert J Morrison
- Department of Otolaryngology, School of Medicine, Vanderbilt University, Nashville, Tennessee.,Department of Otolaryngology-Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Yi Song
- Department of Mechanical Engineering, School of Engineering, Vanderbilt University, Nashville, Tennessee
| | - Shanik J Fernando
- Department of Otolaryngology, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Christopher Wootten
- Department of Otolaryngology, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Alexander Gelbard
- Department of Otolaryngology, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Haoxiang Luo
- Department of Mechanical Engineering, School of Engineering, Vanderbilt University, Nashville, Tennessee
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13
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Katsantonis NG, Kabagambe EK, Wootten CT, Ely EW, Francis DO, Gelbard A. Height is an independent risk factor for postintubation laryngeal injury. Laryngoscope 2018; 128:2811-2814. [PMID: 30325034 DOI: 10.1002/lary.27237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 03/20/2018] [Accepted: 03/22/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Intubation is an essential component of intensive care, yet it does have potential complications. Posterior glottic stenosis (PGS) is among the most severe sequela. Risk factors are poorly understood. One hypothesis is that large endotracheal tubes (ETTs) in smaller airways may increase risk. Because tracheal diameter is proportional to height, we designed a case-control study to evaluate the association between intensive care unit (ICU)-patient height (proxy for tracheal diameter) and their risk of postintubation PGS. STUDY DESIGN Retrospective case-control study METHODS: Among patients who underwent intubation in an ICU at a single tertiary care medical center between 2001 and 2015, a convenience sample of all patients with confirmed PGS (cases) were enrolled. Cases were matched 1:1 by age, sex, and race with intubated non-PGS controls chosen from the same population of ventilated patients. Data on height, weight, comorbidities, size of ETT, and duration of intubation were abstracted from the medical record. Multivariate models were used to test the association between patient height and risk of PGS development. RESULTS In all, 106 PGS cases (mean age 48.9 years, 50.7% female, 79.2% Caucasian) were identified; 77 met inclusion criteria. Compared to matched controls, cases were significantly shorter (mean 166 cm vs. 173 cm, P = .001). Height and PGS showed an inverse relationship in multivariate models. Specifically, odds of PGS decreased 9% (95% confidence interval: 0.01%-16%) for each centimeter increase in height. CONCLUSIONS Shorter height is independently associated with increased odds of having PGS. Further work should consider whether height should be incorporated into ETT selection algorithms. LEVEL OF EVIDENCE 3b Laryngoscope, 128:2811-2814, 2018.
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Affiliation(s)
| | - Edmond K Kabagambe
- Department of Otolaryngology Head and Neck Surgery, Nashville, Tennessee.,Division of Epidemiology, Department of Medicine, Nashville, Tennessee
| | | | - E Wesley Ely
- Veteran's Affairs Geriatric Research Education Clinical Center for Tennessee Valley, Nashville, Tennessee.,Division of Pulmonary and Critical Care, Department of Medicine , Vanderbilt University Medical Center, Nashville, Tennessee
| | - David O Francis
- Division of Otolaryngology, Department of Surgery , University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Alexander Gelbard
- Department of Otolaryngology Head and Neck Surgery, Nashville, Tennessee
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14
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Gadkaree SK, Gelbard A, Best SR, Akst LM, Brodsky M, Hillel AT. Outcomes in Bilateral Vocal Fold Immobility: A Retrospective Cohort Analysis. Otolaryngol Head Neck Surg 2018; 159:1020-1027. [PMID: 30223764 PMCID: PMC6422766 DOI: 10.1177/0194599818800462] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To test the hypothesis that the etiologies of bilateral vocal fold mobility impairment (BLVFI), bilateral vocal fold paralysis (BVFP), and posterior glottis stenosis (PGS) have distinct clinical outcomes. To identify patient-specific and procedural factors that influence tracheostomy-free survival. STUDY DESIGN Retrospective cohort study. SETTING Johns Hopkins Medical Center from 2004 to 2015. SUBJECTS AND METHODS Case series with chart review of 68 patients with PGS and 17 patients with BVFP. Multiple logistic regression analysis determined factors associated with airway prosthesis dependence at last follow-up and the procedural burden (defined as number of operative procedures per year). RESULTS PGS comprised the majority of BLVFI (76%). PGS injury arose primarily after endotracheal intubation (91%), while BVFP most commonly was due to iatrogenic surgical injury to bilateral recurrent laryngeal nerves (88%, P < .001). Overall in BLVFI, 66% were tracheostomy free at last follow-up (62% in PGS, 82% in BVFP). Of those who underwent an operative intervention to be decannulated, 88% were decannulated (90% PGS, 80% BVFP). Patients with PGS required higher procedural burden to achieve decannulation compared with the BVFP cohort (3.1 ± 5.2 vs 0.71 ± 1.4, P = .002). In multivariate analysis of PGS, smoking was a risk factor for tracheostomy dependence (P = .026). CONCLUSIONS BLVFI is primarily an iatrogenic complication. There are high rates of tracheostomy dependence in BLVFI, with procedural intervention needed for decannulation. Compared with BVFP, patients with PGS had a higher procedural burden overall and to achieve decannulation. Patients with PGS should be counseled that smoking, a modifiable risk factor, may increase the risk of tracheostomy dependence.
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Affiliation(s)
- Shekhar K. Gadkaree
- Department of Otolaryngology–Head & Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Baltimore, Maryland, USA
| | - Alexander Gelbard
- Department of Otolaryngology–Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Simon R. Best
- Department of Otolaryngology–Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lee M. Akst
- Department of Otolaryngology–Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Martin Brodsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander T. Hillel
- Department of Otolaryngology–Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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15
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Zhou AH, Patel VR, Hsueh WD, Paskhover B, Kaye R. Endoscopic Posterior Cricoid Split With Graft in an Adult With Posterior Cricoid Fracture. Laryngoscope 2018; 128:2864-2866. [PMID: 30208200 DOI: 10.1002/lary.27412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 05/22/2018] [Accepted: 06/05/2018] [Indexed: 11/10/2022]
Abstract
A 45-year-old man presented with bilateral vocal fold immobility (BVFI) following a remote history of assault. He was found to have a comminuted, telescoped, and ossified posterior cricoid fracture on imaging. Electromyography revealed normal cricothyroid and thyroarytenoid muscle function, but moderate chronic denervation of bilateral posterior cricoarytenoid muscles. The patient underwent endoscopic posterior cricoid split with rib graft (EPCS/RG), and he regained moderate vocal abduction and full vocal adduction, resolution of dysphonia, and was decannulated. This report describes the only case of an adult with BVFI due to a posterior cricoid fracture that was successfully treated with EPCS/RG. Laryngoscope, 128:2864-2866, 2018.
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Affiliation(s)
- Albert H Zhou
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Varesh R Patel
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Wayne D Hsueh
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Boris Paskhover
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Rachel Kaye
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
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