Medico-legal liability of injuries arising from laryngoscopy.

OBJECTIVE: Dental and mucosal injuries from laryngoscopy in the peri-operative period are common medico-legal complaints. This study investigated lawsuits arising from laryngoscopy. METHODS: Westlaw, a legal database containing trial records from across the USA, was retrospectively reviewed. Plaintiff and/or defendant characteristics, claimed injuries, legal outcomes and awards were extracted. RESULTS: Of all laryngoscopy-related dental or mucosal injuries brought before a state or federal court, none (0 per cent) resulted in a defence verdict against the provider or monetary gain for the patient. Rulings in the patient's favour were observed only when laryngoscopy was found to be the proximate cause of multiple compounding complications that culminated in severe medical outcomes such as exsanguination, septic shock or cardiopulmonary arrest. CONCLUSION: Proper laryngoscopy technique and a robust informed-consent process that accurately sets patients' expectations reduces litigation risk. Future litigation pursuits should consider the low likelihood of malpractice allegation success at trial.

Ultrasound Therapy for the Skin.

Ultrasound energy is delivered to the dermal and subdermal tissue to induce thermal injury, leading to collagen remodeling and resulting in lifting and tightening of the skin. Ulthera and Sofwave are two Food and Drug Administration-approved systems that have demonstrated clinically significant results in providing eyebrow, submental, and neck lift and minimizing facial fine lines and wrinkles. Patient selection and management of expectations are important components to a successful treatment process. Both devices boast high patient satisfaction rates, minimal recovery time, and excellent safety profile. Ultrasound technology is an effective, nonsurgical option for facial rejuvenation.

Allegations of Failure to Obtain Informed Consent in Otolaryngology: Evidenced-Based Recommendations for Sinus Surgeons.

BACKGROUND: Informed consent requires preoperative discussion of surgical risks, complications, and alternative treatment options. Allegations of incomplete informed consent are common in the field of otolaryngology. OBJECTIVES: Analyze outcomes and case variables in cases of alleged informed consent failure involving otolaryngologists. METHODS: A legal research database containing state and federal case records from across the United States was retrospectively reviewed for malpractice claims involving informed consent and otolaryngology. RESULTS: Among the 128 informed consent cases identified, 72.6% resulted in favorable verdicts for otolaryngologists. Functional endoscopic sinus surgery (FESS) was the most common source of informed consent litigation in the field of otolaryngology, with an incidence four-fold higher than the next most litigated procedure of uvulopalatopharyngoplasty (21.9% vs 5.4%). The top four factors cited in FESS-related cases were CSF leak (10), inadequate discussion of alternative therapies (4), diplopia (3), and meningitis (3). Cases resulting in a transient injury were significantly less likely to result in a payment from a plaintiff verdict or settlement (9.1%) as compared to payment-rates among cases involving permanent complications (34.6%) (p = 0.005). CONCLUSIONS: Failure to obtain informed consent is an important factor in medical malpractice litigation. This report identifies specific, actionable recommendations aimed at protecting sinus surgeons from liability and ensuring that patients are better informed.

Varicella Zoster Virus Reactivation Involving the Vagus Nerve.

OBJECTIVES: To characterize the presentation, clinical course and functional outcomes of patients with varicella zoster virus (VZV) reactivation involving the vagus nerve. To highlight the role of otolaryngology in acute and long-term management of laryngopharyngeal VZV and its sequelae. METHODS: Retrospective review of 3 patients with laryngopharyngeal VZV, managed at a tertiary referral center. RESULTS: All cases presented with vesicular lesions involving mucosa of the laryngopharynx. Each experienced vocal fold hypomobility, among other otolaryngologic sequelae. All were treated with systemic antivirals and corticosteroids. Mucosal lesions resolved within 7 days of treatment initiation; functional deficits persisted for months to years. Dysphonia improved to a plateau at 3 months, while dysphagia took longer to resolve. One patient with disseminated disease experienced bilateral vocal fold paralysis requiring temporary tracheostomy. CONCLUSIONS: Vagal neuropathy secondary to VZV reactivation is a rare clinical entity with a variety of laryngeal manifestations. Early initiation of systemic therapy and serial endoscopic evaluations are critical components of acute management when laryngopharyngeal involvement is suspected. Otolaryngologists should plan for long-term phonatory and deglutitive therapy in these cases, as neurologic sequelae can persist for months to years following initial insult. LEVEL OF EVIDENCE: Level 4 (Case-series).

Rhytidectomy-Information Patients Seek and Where They Find Answers.

Patients considering rhytidectomy often search for information online prior to in-office consultation. This study identifies the most searched queries regarding rhytidectomy and evaluates sources to which patients are directed. The search engine optimization tool Ahrefs was utilized to extract Google metadata on searches performed in the United States. Frequently asked questions were categorized by topic; websites were categorized by type. Journal of the American Medical Association (JAMA) benchmark criteria enabled information quality assessment. A total of 565 questions for three search phrases were extracted (265 "facelift," 265 "face lift," and 35 "rhytidectomy"). The majority of monthly searches in the facelift and face lift groups pertained to procedural cost, which was significantly higher than in the rhytidectomy group (52.9% and 50.7 vs. 0.0%, ANOVA p <0.001). The mean JAMA score for private practice sources (1.2 ± 0.42) was significantly lower than that of academic pages of (2.3 ± 1.9, p = 0.026) and commercial sources (3.0 ± 0.82, p = 0.008). The most popular destinations for rhytidectomy were California and Mexico (630 and 440 searches/month). Online searches for facelifts often revolve around the topic of cost and frequently direct patients to websites that provide inadequate information on authorship, attribution, disclosure, and currency.

Physical Therapy for Muscle Tension Dysphonia with Cervicalgia.

OBJECTIVES: This study investigated the effectiveness of a specialized manual physical therapy (PT) program at improving voice among patients diagnosed with concomitant muscle tension dysphonia (MTD) and cervicalgia at a tertiary care voice center. MATERIALS AND METHODS: Cervicalgia was determined by palpation of the anterior neck. Both voice therapy (VT) and PT was recommended for all patients diagnosed with MTD and cervicalgia. PT included full-body manual physical therapy with myofascial release. Patients underwent: 1) VT alone, 2) concurrent PT and VT (PT with VT), 3) PT alone, 4) VT, but did not have PT ordered by treating clinician (VT without PT order) or 5) VT followed by PT (VT then PT). The pairwise difference in post-Voice Handicap Index-10 (VHI-10) controlling for baseline variables was calculated with a linear regression model. RESULTS: 178 patients met criteria. All groups showed improvement with treatment. The covariate-adjusted differences in mean post-VHI-10 improvement comparing the VT alone group as a reference were as follows: PT with VT 9.95 (95% confidence interval 7.70, 12.20); PT alone 8.31 (6.16, 10.45); VT without PT order 8.51 (5.55, 11.47); VT then PT 5.47 (2.51, 8.42). CONCLUSION: Among patients diagnosed with MTD with cervicalgia, treatment with a specialized PT program was associated with improvement in VHI-10 scores regardless of whether they had VT. While VT is the standard of care for MTD, PT may also offer benefit for MTD patients with cervicalgia.

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis.

OBJECTIVES: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. METHODS: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. RESULTS: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. CONCLUSIONS: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Early Intervention for the Treatment of Acute Laryngeal Injury After Intubation.

Importance: Patients with laryngeal injury after endotracheal intubation often present long after initial injury with mature fibrosis compromising cricoarytenoid joint mobility and glottic function. Objective: To compare functional outcomes between early and late intervention for intubation-related laryngeal injury. Design, Setting, and Participants: This retrospective cohort study involved 29 patients with laryngeal injury resulting from endotracheal intubation who were evaluated at a tertiary care center between May 1, 2014, and June 1, 2018. Ten patients with intubation injury to the posterior glottis who received early treatment were compared with 19 patients presenting with posterior glottic stenosis who received late treatment. Statistical analysis was performed from May 1 to July 1, 2019. Exposures: Early intervention, defined as a procedure performed 45 days or less after intubation, and late treatment, defined as an intervention performed greater than 45 days after intubation. Main Outcomes and Measures: Patient-specific and intervention-specific covariates were compared between the 2 groups, absolute differences with 95% CIs were calculated, and time to tracheostomy decannulation was compared using log-rank testing. Results: The 2 groups had similar demographic characteristics and a similar burden of comorbid disease. Ten patients who received early intervention (7 women [70%]; median age, 59.7 years [range, 31-72 years]; median, 34.7 days to presentation [IQR, 1.5-44.8 days]) were compared with 19 patients who received late intervention (11 women [58%]; median age, 53.8 years [range, 34-73 years]; median, 341.9 days to presentation [IQR, 132.7-376.3 days]). Nine of 10 patients (90%) who received early intervention and 11 of 19 patients (58%) who received late interventions were decannulated at last follow-up (absolute difference, 32%; 95% CI, -3% to 68%). Patients who received early treatment required fewer total interventions than patients with mature lesions (mean, 2.2 vs 11.5; absolute difference, 9.3; 95% CI, 6.4-12.1). In addition, none of the patients who received early treatment required an open procedure, whereas 17 patients (90%) with mature lesions required open procedures to pursue decannulation. Conclusions and Relevance: This study suggests that early intervention for patients with postintubation laryngeal injury was associated with a decreased duration of tracheostomy dependence, a higher rate of decannulation, and fewer surgical procedures compared with late intervention. Patients who underwent early intervention also avoided open reconstruction. These findings may bear relevance to the management of patients requiring extended durations of endotracheal intubation during recovery for critical illness related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

The Proximal Airway Is a Reservoir for Adaptive Immunologic Memory in Idiopathic Subglottic Stenosis.

OBJECTIVES/HYPOTHESIS: Characterization of the localized adaptive immune response in the airway scar of patients with idiopathic subglottic stenosis (iSGS). STUDY DESIGN: Basic Science. METHODS: Utilizing 36 patients with subglottic stenosis (25 idiopathic subglottic stenosis [iSGS], 10 iatrogenic post-intubation stenosis [iLTS], and one granulomatosis with polyangiitis [GPA]) we applied immunohistochemical and immunologic techniques coupled with RNA sequencing. RESULTS: iSGS, iLTS, and GPA demonstrate a significant immune infiltrate in the subglottic scar consisting of adaptive cell subsets (T cells along with dendritic cells). Interrogation of T cell subtypes showed significantly more CD69+ CD103+ CD8+ tissue resident memory T cells (TRM ) in the iSGS airway scar than iLTS specimens (iSGS vs. iLTS; 50% vs. 28%, P = .0065). Additionally, subglottic CD8+ clones possessed T-cell receptor (TCR) sequences with known antigen specificity for viral and intracellular pathogens. CONCLUSIONS: The human subglottis is significantly enriched for CD8+ tissue resident memory T cells in iSGS, which possess TCR sequences proven to recognize viral and intracellular pathogens. These results inform our understanding of iSGS, provide a direction for future discovery, and demonstrate immunologic function in the human proximal airway. Laryngoscope, 131:610-617, 2021.

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

Unilateral Vocal Fold Immobility After Prolonged Endotracheal Intubation.

Importance: Endotracheal intubation and mechanical ventilation are life-saving treatments for acute respiratory failure but are complicated by significant rates of dyspnea and dysphonia after extubation. Unilateral vocal fold immobility (UVFI) after extubation can alter respiration and phonation, but its incidence, risk factors, and pathophysiology remain unclear. Objectives: To determine the incidence of UVFI after prolonged (>12 hours) mechanical ventilation in a medical intensive care unit and investigate associated clinical risk factors for UVFI after prolonged mechanical ventilation. Design, Setting, and Participants: This subgroup analysis of a prospective cohort study was conducted in a single-center medical intensive care unit from August 17, 2017, through May 31, 2018, among 100 consecutive adult patients who were intubated for more than 12 hours. Patients were identified within 36 hours of extubation and recruited for study enrollment. Those with an established tracheostomy prior to mechanical ventilation, known laryngeal or tracheal pathologic characteristics, or a history of head and neck radiotherapy were excluded. Exposure: Invasive mechanical ventilation via an endotracheal tube. Main Outcomes and Measures: The incidence of UVFI as determined by flexible nasolaryngoscopy. Results: One hundred patients (62 men [62%]; median age, 58.5 years [range, 19.0-87.0 years]) underwent endoscopic evaluation after extubation. Seven patients had UVFI, of which 6 cases (86%) were left sided. Patients with hypotension while intubated (odds ratio [OR], 10.8; 95% CI, 1.6 to ∞), patients requiring vasopressors while intubated (OR, 16.7; 95% CI, 2.4 to ∞), and patients with a preadmission diagnosis of peripheral vascular disease (OR, 6.2; 95% CI, 1.2-31.9) or coronary artery disease (OR, 5.1; 95% CI, 1.0-25.5) were more likely to develop UVFI. Conclusions and Relevance: Unilateral vocal fold immobility occurred in 7 of 100 patients in the medical intensive care unit who were intubated for more than 12 hours. Unilateral vocal fold immobility was associated with inpatient hypotension and preadmission vascular disease, suggesting that ischemia of the recurrent laryngeal nerve may play a role in disease pathogenesis.

The Incidence of Laryngotracheal Stenosis in Neonates With a History of Ventilator-Associated Pneumonia.

OBJECTIVES/HYPOTHESIS: Neonatal patients requiring prolonged intubation are susceptible to both infection and laryngotracheal stenosis (LTS). This study investigated the effect of ventilator-associated pneumonia (VAP) on the development of LTS in neonates. STUDY DESIGN: Retrospective case-control study. METHODS: The incidence of LTS in neonates with VAP was compared with the incidence of LTS in matched intubated controls without VAP. Patients were treated at a tertiary-care medical center from 2004 to 2014. Eligible patient records were assessed for the development of LTS. Demographics, medical comorbidities, infection characteristics, and treatment variables were compared using unpaired t test or χ2 test. Statistical significance was set a priori at P < .05. RESULTS: When comparing the VAP patients with matched non-VAP controls, we found no significant differences in the incidence of LTS (VAP vs. non-VAP, 8.3% vs. 6.7%; P = .73). In subgroup analysis of the VAP cohort, LTS and non-LTS patients demonstrated similar VAP organisms on broncho-alveolar lavage (Klebsiella pneumoniae, Pseudomonas aeroginosa, Escherichia coli, methicillin-resistant Staphylococcus aureus, Streptococcus pneumoniae, and Enterobacter). Additionally, within the VAP cohort, LTS and non-LTS patients showed similar gestational age (LTS vs. non-LTS, 31.3 days vs. 28.1 days; P = .22), birth weight (LTS vs. non-LTS, 1.6 kg vs. 1.2 kg; P = .33), and similar intubation duration (LTS vs. non-LTS, 37.8 days vs. 27.5 days; P = .52). CONCLUSIONS: In this neonatal cohort, VAP was not associated with an increased incidence of LTS. Given severity of the burden of LTS on the healthcare system, multi-institutional longitudinal investigation into contributing risk factors for neonatal LTS is warranted. LEVEL OF EVIDENCE: NA Laryngoscope, 130:2252-2255, 2020.

Incidence and Outcomes of Acute Laryngeal Injury After Prolonged Mechanical Ventilation.

OBJECTIVES: Upper airway injury is a recognized complication of prolonged endotracheal intubation, yet little attention has been paid to the consequences of laryngeal injury and functional impact. The purpose of our study was to prospectively define the incidence of acute laryngeal injury and investigate the impact of injury on breathing and voice outcomes. DESIGN: Prospective cohort study. SETTING: Tertiary referral critical care center. PATIENTS: Consecutive adult patients intubated greater than 12 hours in the medical ICU from August 2017 to May 2018 who underwent laryngoscopy within 36 hours of extubation. INTERVENTIONS: Laryngoscopy following endotracheal intubation. MEASUREMENTS AND MAIN RESULTS: One hundred consecutive patients (62% male; median age, 58.5 yr) underwent endoscopic examination after extubation. Acute laryngeal injury (i.e., mucosal ulceration or granulation tissue in the larynx) was present in 57 patients (57%). Patients with laryngeal injury had significantly worse patient-reported breathing (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 1.05; interquartile range, 0.48-2.10) and vocal symptoms (Voice Handicap Index-10: median, 2; interquartile range, 0-6) compared with patients without injury (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 0.20; interquartile range, 0-0.80; p < 0.001; and Voice Handicap Index-10: median, 0; interquartile range, 0-1; p = 0.005). Multivariable logistic regression independently associated diabetes, body habitus, and endotracheal tube size greater than 7.0 with the development of laryngeal injury. CONCLUSIONS: Acute laryngeal injury occurs in more than half of patients who receive mechanical ventilation and is associated with significantly worse breathing and voicing 10 weeks after extubation. An endotracheal tube greater than size 7.0, diabetes, and larger body habitus may predispose to injury. Our results suggest that acute laryngeal injury impacts functional recovery from critical illness.

Advanced age adversely affects chronic rhinosinusitis surgical outcomes.

BACKGROUND: Patient-specific and disease-specific factors shape the course of chronic rhinosinusitis (CRS) and its response to treatment, with optimal management involving interventions tailored to these factors. Recent evidence suggests CRS inflammatory signatures depend on age. The objective of this study was to determine whether age also influences quality-of-life (QOL) and postoperative outcomes. METHODS: Retrospective analysis of prospectively collected QOL data from 403 adults with medically refractory CRS who underwent functional endoscopic sinus surgery (FESS) at a tertiary care medical center between 2014 and 2018 was undertaken. Total and subdomain scores from the 22-item Sino-Nasal Outcome Test (SNOT-22) and the Short Form 8 Health Survey (SF-8) measure of general health completed at preoperative and postoperative visits were reviewed. RESULTS: Patients were divided into young (18 to 39 years, n = 100), middle-aged (40 to 59 years, n = 172), and elderly (≥60 years, n = 131) groups. Baseline total SNOT-22 scores differed between groups (p = 0.01), with middle-aged patients having the highest symptom burden and elderly patients having the lowest. Similar patterns were observed for SNOT-22 subdomains. Elderly patients reported smaller improvements and were less likely to achieve a minimally important clinical difference. CRS patients had worse SF-8 scores compared to the general population, and elderly patients were the least likely to match population norms following surgery. Age was an independent predictor of QOL outcomes after FESS. CONCLUSION: Age may play a significant role in CRS pathophysiology, symptom burden, and surgical outcomes. Elderly patients report smaller improvements in disease-specific and general health QOL after surgery. CRS management in the elderly population should incorporate age-dependent differences in symptom burden and expectations into treatment algorithms.

Incidence of Laryngotracheal Stenosis after Thermal Inhalation Airway Injury.

Inhalation injury is independently associated with burn mortality, yet little information is available on the incidence, risk factors, or functional outcomes of thermal injury to the airway. In patients with thermal inhalation injury, we sought to define the incidence of laryngotracheal stenosis (LTS), delineate risk factors associated with LTS development, and assess long-term tracheostomy dependence as a proxy for laryngeal function. Retrospective cohort study of adult patients treated for thermal inhalation injury at a single institution burn critical care unit from 2012 to 2017. Eligible patients' records were assessed for LTS (laryngeal, subglottic, or tracheal stenosis). Patient characteristics, burn injury characteristics, and treatment-specific covariates were assessed. Descriptive statistics, Mann-Whitney U-tests, odds ratio, and chi-square tests compared LTS versus non-LTS groups. Of 129 patients with thermal inhalation injury during the study period, 8 (6.2%) developed LTS. When compared with the non-LTS group, patients with LTS had greater mean TBSA (mean 30.3, Interquartile Range 7-57.5 vs 10.5, Interquartile Range 0-15.12, P = .01), higher grade of inhalation injury (mean 2.63 vs 1.80, P = .05), longer duration of intubation (12.63 vs 5.44; P < .001), and greater inflammatory response (mean white blood cell count on presentation 25.8 vs 14.9, P = .02, mean hyperglycemia on presentation 176.4 vs 136.9, P = .01). LTS patients had a significantly higher rate of tracheostomy dependence at last follow-up (50 vs 1.7%, P < .001). Six percent of patients with thermal inhalation injury develop LTS. LTS was associated with more severe thermal airway injury, longer duration of intubation, and more severe initial host inflammation. Patients with inhalation injury and LTS are at high risk for tracheostomy dependence. In burn patients with thermal inhalation injury, laryngeal evaluation and directed therapy should be incorporated early into multispecialty pathways of care.

Early medical therapy for acute laryngeal injury (ALgI) following endotracheal intubation: a protocol for a prospective single-centre randomised controlled trial.

INTRODUCTION: Respiratory failure requiring endotracheal intubation accounts for a significant proportion of intensive care unit (ICU) admissions. Little attention has been paid to the laryngeal consequences of endotracheal intubation. Acute laryngeal injury (ALgI) after intubation occurs at the mucosal interface of the endotracheal tube and posterior larynx and although not immediately manifest at extubation, can progress to mature fibrosis, restricted glottic mobility and clinically significant ventilatory impairment. A recent prospective observational study has shown that >50% of patients intubated >24 hours in an ICU develop ALgI. Strikingly, patients with AlgI manifest significantly worse subjective breathing at 12 weeks. Current ALgI treatments are largely surgical yet offer a marginal improvement in symptoms. In this study, we will examine the ability of a postextubation medical regime (azithromycin and inhaled budesonide) to improve breathing 12 weeks after ALgI. METHODS AND ANALYSIS: A prospective, single-centre, double-blinded, randomised, control trial will be conducted at Vanderbilt Medical Center. Participants will be recruited from adult patients in ICUs. Participants will undergo a bedside flexible nasolaryngoscopy for the identification of ALgI within 72 hours postextubation. In addition, participants will be asked to complete peak expiratory flow measurements immediately postintubation. Patients found to have ALgI will be randomised to the placebo control or medical therapy group (azithromycin 250 mg and budesonide 0.5 mg for 14 days). Repeat peak expiratory flow, examination of the larynx and patient-reported Clinical COPD (chronic obstructive pulmonary disease) Questionnaire, Voice Handicap Index and 12-Item Short Form Health Survey questionnaires will be conducted at 12 weeks postextubation. Consented patients will also have patient-specific, disease-specific and procedure-specific covariates abstracted from their medical record. ETHICS AND DISSEMINATION: The Institutional Review Board (IRB) Committee of the Vanderbilt University Medical Center has approved this protocol (IRB #171066). The findings of the trial will be disseminated through peer-reviewed journals, national and international conferences. TRIAL REGISTRATION NUMBER: NCT03250975.

Chronic rhino-sinusitis treatment in children with cystic fibrosis: A cross-sectional survey of pediatric pulmonologists and otolaryngologists.

OBJECTIVES: Children with cystic fibrosis (CF) have a high incidence of chronic rhinosinusitis (CRS); however, no clinical care guidelines currently exist for the management of CRS in these patients. As a result, there is variation in the treatment of CRS in children, especially when it comes to the frequency of surgery for nasal polyposis. METHODS: A 28-question survey was sent to pediatric otolaryngologists (POs) and pulmonologists (PPs) who care for pediatric CF patients. Questions assessed the level of agreement that practitioners had with various approaches to CRS care in pediatric CF patients. RESULTS: Responses from 114 POs and 50 PPs were included in our final analysis. Each group demonstrated significantly different approaches to the medical and surgical management of CRS in pediatric CF patients. POs prefer multi-modal approach while PPs prefer single-modal approaches. With respect to medical management, PPs incline towards IV antibiotics while POs tend toward oral steroids. CONCLUSION: POs and PPs strongly agree that CRS has an impact on overall disease state and quality of life of pediatric CF patients. However, POs and PPs significantly differ in their approach to treating CRS, demonstrating a potential need for clinical care guidelines for the management these common sequelae of CF.

Hearing Outcomes Following Type 3 Tympanoplasty With Stapes Columella Grafting in Canal Wall Down Mastoidectomy.

OBJECTIVES: To analyze hearing outcomes following Type 3 tympanoplasty with stapes columella grafting after canal wall down mastoidectomy and determine disease recurrence rates in patients undergoing this procedure. METHODS: This retrospective cohort analysis examines patients undergoing Type 3 tympanoplasty with stapes columella grafting following canal wall down mastoidectomy for cholesteatoma at a tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if they were found to have undergone the aforementioned procedure. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 6 months and 1 year postoperatively. RESULTS: Nineteen patients met criteria for this study. Erosion of the otic capsule, posterior fossa plate, or tegmen was noted in 37% of cases, highlighting disease severity. Eighteen (95%) had undergone prior otologic surgery. Mean time to short-term follow-up was 6 ± 3 months. The average short-term ABG was 26 ± 11 dB HL; 26% achieved an ABG <20 dB, and 58% achieved an ABG <30 dB. Fifteen had follow-up at least 1 year postoperatively (mean = 33 ± 16 months). At longer-term follow-up, mean ABG was 25 ± 10 dB HL; 33% achieved an ABG <20 dB, while 66% achieved an ABG <30 dB. Hearing remained stable over time (P = .52). At date of last clinical follow-up, only 1 (5%) patient had undergone revision for recurrent disease. CONCLUSION: In some patients undergoing canal wall down mastoidectomy for advanced or recurrent cholesteatoma, Type 3 tympanoplasty with stapes columella grafting yields marginal hearing benefit. This type of reconstruction is a viable option in this challenging patient cohort, particularly as it is associated with low rates of revision surgery.

Long-Term Hearing Outcomes following Total Ossicular Reconstruction with Titanium Prostheses.

OBJECTIVE: (1) Characterize a large cohort of patients undergoing total ossicular chain reconstruction with titanium prosthesis. (2) Analyze long-term hearing outcomes of the same cohort. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care center. SUBJECT AND METHODS: This study reviews patients who underwent total ossicular chain reconstruction (OCR) with titanium prostheses (TORPs) at a single tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if length of follow-up was 2 years or more. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 2 years. RESULTS: In total, 153 patients were identified who met inclusion criteria. The mean age of included patients was 40 years (range, 6-89 years). Sixty patients (39%) had a history of OCR, and 120 patients (78%) had a diagnosis of cholesteatoma at the time of OCR. Preoperatively, the mean ABG was 36 ± 12, whereas the mean ABG at 2-year follow-up improved to 26 ± 13. This was statistically significant (P < .0001) using a Wilcoxon matched-pairs signed rank test. Twelve patients (8%) required revision OCR. Two revisions were performed due to prosthesis extrusion (<1%). CONCLUSION: Titanium prostheses lead to significant improvement in hearing over long periods. The results are sustained as far out as 5 years following surgery. In addition, rates of revision surgery with titanium TORPs are low. Based on this series, there are no readily identifiable predictors for outcomes following total OCR.

Early Surgical Management of Thermal Airway Injury: A Case Series.

Inhalation injury is an independent risk factor in burn mortality, imparting a 20% increased risk of death. Yet there is little information on the natural history, functional outcome, or pathophysiology of thermal injury to the laryngotracheal complex, limiting treatment progress. This paper demonstrates a case series (n = 3) of significant thermal airway injuries. In all cases, the initial injury was far exceeded by the subsequent immune response and aggressive fibroinflammatory healing. Serial examination demonstrated progressive epithelial injury, mucosal inflammation, airway remodeling, and luminal compromise. Histologic findings in the first case demonstrate an early IL-17A response in the human airway following thermal injury. This is the first report implicating IL-17A in the airway mucosal immune response to thermal injury. Their second and third patients received Azithromycin targeting IL-17A and showed clinical responses. The third patient also presented with exposed tracheal cartilage and underwent mucosal reconstitution via split-thickness skin graft over an endoluminal stent in conjunction with tracheostomy. This was associated with rapid abatement of mucosal inflammation, resolution of granulation tissue, and return of laryngeal function. Patients who present with thermal inhalation injury should receive a thorough multidisciplinary airway evaluation, including early otolaryngologic evaluation. New early endoscopic approaches (scar lysis and mucosal reconstitution with autologous grafting over an endoluminal stent), when combined with targeted medical therapy aimed at components of mucosal airway inflammation (local corticosteroids and systemic Azithromycin targeting IL-17A), may have potential to limit chronic cicatricial complications.