Indications and Short-Term Outcomes for In-Office Therapeutic Superior Laryngeal Nerve Block.

OBJECTIVE: Superior laryngeal nerve (SLN) block consists of injection of steroid and anesthetic at the internal branch of the SLN entry site. Prior case series have demonstrated beneficial effects on neurogenic cough. SLN blocks have also recently shown benefit for paralaryngeal pain. We describe short-term outcomes for multiple symptoms of irritable larynx syndrome (ILS) including neurogenic cough, dysphonia related to laryngeal hypersensitivity, inducible laryngeal obstruction (ILO), paralaryngeal pain, and isolated globus. METHODS: Retrospective review from 2 institutions of patients undergoing a single SLN block for the indications listed. Variables include age, sex, indication(s), known vagus neuropathy, and patient-reported outcomes at short-term follow-up. RESULTS: A total of 209 patients were included (59 males, 150 females; age: 58 ± 13 years). Twenty-six patients (12%) had a history of a vagus nerve injury. Indications included neurogenic cough (n = 149), dysphonia related to laryngeal hypersensitivity (n = 66), paralaryngeal pain (n = 50), ILO (n = 23), and isolated globus (n = 3). Some patients had multiple indications. Significant improvements in patient-reported measures occurred after a single SLN block within 2 to 4 weeks for neurogenic cough (cough severity index; 25.2 ± 11.2 to 19.0 ± 12.8; P < .001), dysphonia (voice handicap index-10; 22.1 ± 12.2-18.0 ± 13.3; P = .005), and ILO (dyspnea index; 21.0 ± 14.9-14.7 ± 15.7; P = .017). Subjective pain improved in 23 of 39 patients with paralaryngeal pain. There was no observed improvement for isolated globus. Presence of known vagal neuropathy or therapy around the time of SLN block did not affect outcome. CONCLUSION: SLN block can be an effective component of treatment for a variety of ILS symptoms. Patients may experience some improvement after 1 injection. LAY SUMMARY: Symptoms of irritable larynx syndrome, such as neurogenic cough, paralaryngeal pain, inducible laryngeal obstruction, and dysphonia related to laryngeal hypersensitivity can be challenging to manage. In-office Superior Laryngeal Nerve blocks can serve as a quick, well tolerated, adjunctive treatment with positive short-term outcomes. LEVEL OF EVIDENCE: 4.

Tracheal pressure generated by high-flow nasal cannula in 3D-Printed pediatric airway models.

OBJECTIVE: Heated and humidified high flow nasal cannula (HFNC) is an increasingly used form of noninvasive respiratory support with the potential to generate significant tracheal pressure. The aim of this study was to quantify the pressure generated by HFNC within the trachea in anatomically correct, pediatric airway models. METHODS: 3D-printed upper airway models of a preterm neonate, term neonate, toddler, and small child were connected to a spontaneous breathing computerized lung model at age-appropriate ventilation settings. Two commercially available HFNC systems were applied to each airway model at increasing flows and the positive end-expiratory pressure (PEEP) was recorded at the level of the trachea. RESULTS: Increasing HFNC flow produced a quadratically curved increase in tracheal pressure in closed-mouth models. The maximum flow tested in each model generated a tracheal pressure of 7 cm H2O in the preterm neonate, 10 cm H2O in the term neonate, 9 cm H2O in the toddler, and 24 cm H2O in the small child. Tracheal pressure decreased by at least 50% in open-mouth models. CONCLUSIONS: HFNC was found to demonstrate a predictable flow-pressure relationship that achieved sufficient distending pressure to consider treatment of pediatric obstructive sleep apnea and tracheomalacia in the closed-mouth models tested.

The minimal clinically important difference of the dyspnea index in laryngotracheal stenosis.

OBJECTIVE: The Dyspnea Index (DI) is a validated patient-reported outcome (PRO) instrument that has been used in the management of laryngotracheal stenosis (LTS). The minimal clinically important difference (MCID) is an established concept to help determine the change in a PRO instrument that reflects meaningful change for the patient. It is not known what change in the DI is of clinical significance in airway surgery. This study aims to determine the MCID for the DI in patients undergoing surgical treatment for LTS. METHODS: This is a prospective cohort study in which 26 patients with LTS completed the DI (score range 0 to 40) before and 6 to 8 weeks postoperatively, in addition to a Global Ratings Change Questionnaire (GRCQ), scored from -7 to +7, at the postoperative interval. A hypothesis test was carried out to test the association between GRCQ and change in DI. The MCID for change in DI was determined using anchor-based analysis. RESULTS: Overall mean change in DI was -11, and mean change in GRCQ was +5. Change in DI scores were significantly different among the improvement and no improvement groups (P value <0.002). Area under the receiver operating curve was 0.92, demonstrating high discriminatory ability of the change in DI score. A change of -4 was determined to be the threshold that discriminated between significant improvement and no improvement. CONCLUSION: A decrease of 4 in the DI can be considered as the MCID for patients with LTS after surgical treatment. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:1775-1779, 2020.

The role of elective neck dissection in high-grade parotid malignancy: A hospital-based cohort study.

OBJECTIVES/HYPOTHESIS: The role of elective neck dissection (END) in patients with clinically N0 (cN0), high-grade parotid carcinoma is unclear. The objective of this study was to assess the association between END and survival in patients with cN0, high-grade parotid carcinoma. STUDY DESIGN: Retrospective, multicenter cohort study. METHODS: A review of hospital-based cases from the National Cancer Data Base was performed. Participants included patients diagnosed with cN0, high-grade parotid cancer between January 1, 2004 and December 31, 2013. The primary exposure was receipt of neck dissection. Secondary exposures included receipt of adjuvant radiation and/or chemotherapy. Univariate and multivariate survival analyses were performed. Unadjusted and adjusted survival estimates were determined. RESULTS: Overall, 1,547 patients were included, with a median follow-up time of 48 months. END did not have a statistically significant effect on 3-year survival (3-year: 69.9%, 95% confidence interval [CI]: 67.2 to 72.6). Survival at 3-years among those not receiving END was 66.1% (95% CI: 62.7 to 69.5). Parotidectomy and adjuvant radiotherapy had the strongest effect on mortality. There was no difference in 3-year survival among patients who underwent parotidectomy and adjuvant radiation stratified by receipt of END nor did END have a statistically significant effect on survival in mucoepidermoid carcinoma, adenocarcinoma, high-risk histology, high T stage, or academic center treatment subgroups. CONCLUSIONS: END did not have a statistically significant effect on survival among cN0 patients with high-grade parotid cancer when taking into account receipt of adjuvant therapy and confounding. The role of END on survival and locoregional control remains to be further elucidated in prospective studies. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1487-1495, 2020.

Supporting Spartina: Interdisciplinary perspective shows Spartina as a distinct solid genus.

In 2014, a DNA-based phylogenetic study confirming the paraphyly of the grass subtribe Sporobolinae proposed the creation of a large monophyletic genus Sporobolus, including (among others) species previously included in the genera Spartina, Calamovilfa, and Sporobolus. Spartina species have contributed substantially (and continue contributing) to our knowledge in multiple disciplines, including ecology, evolutionary biology, molecular biology, biogeography, experimental ecology, biological invasions, environmental management, restoration ecology, history, economics, and sociology. There is no rationale so compelling to subsume the name Spartina as a subgenus that could rival the striking, global iconic history and use of the name Spartina for over 200 yr. We do not agree with the subjective arguments underlying the proposal to change Spartina to Sporobolus. We understand the importance of both the objective phylogenetic insights and of the subjective formalized nomenclature and hope that by opening this debate we will encourage positive feedback that will strengthen taxonomic decisions with an interdisciplinary perspective. We consider that the strongly distinct, monophyletic clade Spartina should simply and efficiently be treated as the genus Spartina.

Effect of High-Flow Nasal Cannula on Expiratory Pressure and Ventilation in Infant, Pediatric, and Adult Models.

BACKGROUND: Heated and humidified high-flow nasal cannula (HFNC) is a widely used form of respiratory support; however, data regarding optimal flows for a given patient size or disease state are lacking. A comprehensive study of the physiologic effects of HFNC is needed to better understand the mechanisms of action. The objective of the current study was to quantify the effect of HFNC settings in age-specific, anatomically correct nasal airways and spontaneously breathing lung models. We hypothesized that there is an effect of flow on pressure and ventilation. METHODS: Three-dimensionally printed upper airway models of a preterm neonate, term neonate, toddler, small child, and adult were affixed to the ASL 5000 test lung to simulate spontaneous breathing with age-appropriate normal ventilation parameters. CO2 was introduced to simulate profound hypercapneic respiratory failure with an end-tidal partial pressure of carbon dioxide (PETCO2 ) of 90 ± 1 mm Hg. Two commercially available HFNC systems were applied to the airway models, and PEEP, inspired CO2, and exhaled CO2 (PETCO2 ) were recorded for 6 min across a range of flow. RESULTS: Increasing HFNC flow provided a non-linear increase in PEEP in closed-mouth models, with maximum tested flows generating 6 cm H2O in the preterm neonate to 20 cm H2O in the small child. Importantly, PEEP decreased by approximately 50% in open-mouth models. Increasing HFNC flow improved expiratory CO2 elimination to a certain point, above which continued increases in flow had minimal additional effect. This change point ranged from 4 L/min in the preterm neonate to 10 L/min in the small child. CONCLUSIONS: These findings may help clinicians understand the effects of HFNC at different settings and may inform management guidelines for patients with respiratory failure.