Tracheoesophageal Fistula as a Complication of Prolonged Ventilation in COVID-19: Description of Reconstruction and Review of the Literature.

Infection with COVID-19 pneumonia may necessitate intubation and mechanical ventilation. Viral inflammation and pressure necrosis may lead to scarring, stenosis, and in severe cases, fistula formation. Nonmalignant tracheoesophageal fistulas (TEF) represent a surgical challenge and may necessitate locoregional tissue transfer and tracheal resection to prevent recurrence and maintain airway patency. We present a case of TEF in a 63-year-old female secondary to prolonged mechanical ventilation in the setting of COVID pneumonia, detailing the clinical findings and surgical repair. Primary closure of the esophageal defect with pectoralis major muscle flap onlay and tracheal resection, with median sternotomy for access, provided successful intervention, allowing for subsequent tracheostomy decannulation and return to a complete oral diet. This case offers further evidence of the increased risk of airway complications in COVID-19 infection and provides otolaryngologists with an example of a rare surgical approach useful in management.

Modalities of treatment for laryngotracheal stenosis: the EVMS experience.

OBJECTIVES/HYPOTHESIS: The aims of the study were to identify trends in surgical management of laryngotracheal stenosis (LTS) based on lesion location, as well as to recognize factors associated with recurrence and repeat surgical intervention. STUDY DESIGN: The study is a retrospective review of all adult patients cared for at a tertiary care laryngology practice with a diagnosis of laryngotracheal stenosis between October 2001 and July 2010, following Institutional Review Board approval. METHODS: This study collectively measured demographics, comorbidities, etiologies, sites of stenoses, treatment modalities, and recurrences. RESULTS: Incisions made with the carbon dioxide (CO2) laser were the most common modality of treatment; patients with multilevel tracheal stenosis were most likely to have undergone at least one operation in which the CO2 laser was used to make incisions (78.7%). Balloon dilation was most commonly employed in patients with multilevel tracheal stenosis (66.0%). Lowest rates of decannulation were identified in patients with a pure tracheal stenosis (23.1%). Patients presenting with multilevel tracheal stenosis underwent the most procedures (6.7). Supraglottic, glottic, and multilevel laryngeal stenosis recurred at the lowest rates. Patients suffering from diabetes mellitus recurred in an average period of 3.9 months, a shorter time frame than those without diabetes, who recurred every 10.5 months. CONCLUSIONS: Laser incision and/or balloon dilation are most effective in treatment of pure glottic, subglottic, and tracheal stenosis. Multilevel tracheal stenosis warrants closer follow-up, and is more likely to require multiple procedures. Worsening stenosis despite endoscopic management warrants an open procedure. Diabetes is associated with an earlier recurrence of stenosis.

Global health initiatives of US otolaryngology residency programs: 2011 global health initiatives survey results.

OBJECTIVES/HYPOTHESIS: The objectives of this work were to quantify the involvement of US otolaryngology residency programs in global health endeavors, identify goals and services provided, and determine the participation of residents and fellows. STUDY DESIGN: Cross-sectional survey of US otolaryngology faculty. METHODS: A 10-point online questionnaire was distributed to 103 US otolaryngology residency program directors; all faculty involved in global health volunteerism were invited to participate. RESULTS: Twenty-nine global health initiatives were represented. Most of the 24 residency programs involved (66%) had organized global health offices at their institutions; only 4% actually cooperated with these offices. Most often, only one attending (55%) was involved at each institution. Residents/fellows participated 65% of the time. Abroad, US otolaryngologists worked with freestanding hospitals or clinics (24%), American nongovernmental organizations (17%), academic centers (14%), and remote locations (14%). Most (96%) provided specialty surgical services, but some provided primary care (28%) and general surgical services (14%); 72% trained foreign surgeons. Most respondents (79%) reported that the clinical work done abroad was substantial enough for Accreditation Council for Graduate Medical Education (ACGME) standards. Only one fifth of respondents knew the name of the nearest otolaryngology training institution. Humanitarian aid was the most prevalent goal (100%), followed by resident/fellow exchange (45%) and faculty exchange (21%). CONCLUSIONS: At least a quarter of US otolaryngology residency programs engage in global health volunteerism. Most do not utilize institutional global health resources and are unaware of otolaryngology training programs abroad. There may be a role for global health education within the ACGME competency of systems-based practice.

Intracranial sarcoid granuloma as an extension of severe sinonasal sarcoidosis.

Sarcoidosis is a chronic, multisystem, granulomatous disease of unknown etiology. It manifests with a wide range of symptoms and clinical findings, including some that occur in the head and neck. Sinonasal sarcoidosis, in particular, frequently demonstrates a rather recalcitrant course and a potential for severe complications if left untreated. We present the case of a 46-year-old woman with extensive sinonasal sarcoidosis that progressed to involve the skull base and olfactory tract and ultimately led to the formation of a granuloma within the frontal lobe that required craniotomy and excision. Although surgery is not considered the primary treatment modality for sarcoidosis, it may have a role in managing this highly variable disease in certain patients.

A multi-institutional analysis of tracheotomy complications.

OBJECTIVES/HYPOTHESIS: To define the prevalence of tracheotomy tube complications and evaluate risk factors (RFs) associated with their occurrence. STUDY DESIGN: Multi-institution historical cohort. METHODS: Data regarding tracheotomy tube complications from consecutive surgeries performed across eight participating institutions between January 1, 2008 and December 31, 2009 were retrospectively collected. Patient demographics, comorbidities, physician specialty, and surgical technique were recorded and statistically analyzed to identify the incidence of surgical complications following tracheotomy and associated RFs. RESULTS: The charts of 1,175 tracheotomy procedures were reviewed from eight academic institutions. Otolaryngologists performed 66.2% of the tracheotomies. Intraoperative, early (<1 week), and late complication rates were 1.4%, 5.6%, and 7.1%, respectively. Postoperative bleeding was identified as the most common early complication (2.6%), whereas airway stenosis was the most common late complication (1.7%). The use of outer flange security sutures to anchor the tracheostomy tube was negatively associated with the incidence of early complication (P<.0001). The use of large endotracheal tubes (size>7.5) and obesity were associated with the development of airway stenosis (P<.05).Twenty-two percent of patients undergoing tracheotomy died during hospitalization. CONCLUSIONS: Perioperative tracheotomy complications are rare; however, the rate of death for all causes is high (22%) in this population. Obesity and the use of endotracheal tubes over 7.5 in size are major risk factors for the development of airway stenosis. Although percutaneous tracheotomy resulted in a significantly higher rate of postoperative bleeding (6.6%) than the open method (1.9%) (P<.05), the use of outer flange tracheostomy tube sutures may reduce this complication.

Recurrent laryngeal nerve monitoring versus identification alone on post-thyroidectomy true vocal fold palsy: a meta-analysis.

OBJECTIVES/HYPOTHESIS: To compare by meta-analysis the effect of recurrent laryngeal nerve (RLN) monitoring versus RLN identification alone on true vocal fold palsy rates after thyroidectomy. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A search of MEDLINE (1966-July 2008), EMBASE (1980-July 2008), Cochrane Central Register of Clinical Trials (CENTRAL), Cochrane Database of Systematic Reviews, clinicaltrials.gov, and The National Guideline Clearinghouse databases was performed. References from retrieved articles, presentation data, and correspondence with experts was also included. All authors used a detailed list of inclusion/exclusion criteria to determine articles eligible for final inclusion. Two authors independently extracted data including study criteria, methods of vocal fold function assessment, laryngeal nerve monitor type, and surgical procedure. Odds ratios (OR) were pooled using a random-effects model. Associations with patient and operative characteristics were tested in subgroups. RESULTS: One randomized clinical trial, seven comparative trials, and 34 case series evaluating 64,699 nerves-at-risk were included. The overall incidence of true vocal fold palsy (TVFP) was 3.52% for intraoperative nerve monitoring (IONM) versus 3.12% for nerve identification alone (ID) (OR 0.93; 95% confidence interval [CI], 0.76-1.12]. No statistically significant difference in transient TVFP (2.74% IONM vs. 2.49% ID [OR 1.07, 95% CI, 0.95-1.20]), persistent TVFP (0.75% IONM vs. 0.58% ID [OR 0.99, 95% CI, 0.79-1.23]), or unintentional RLN injury (0.12% IONM vs. 0.33% ID [OR 0.50, 95% CI, 0.15-1.75]) was found. CONCLUSIONS: This meta-analysis demonstrates no statistically significant difference in the rate of true vocal fold palsy after using intraoperative neuromonitoring versus recurrent laryngeal nerve identification alone during thyroidectomy.

Use of botulinum toxin type A for chronic cough: a neuropathic model.

OBJECTIVE: To review the experience and outcomes of a novel use of botulinum toxin type A (BtxA) in the treatment of chronic cough. DESIGN: Retrospective case series. SETTING: Academic referral center. PATIENTS: A total of 438 patients were diagnosed as having laryngeal spasm and chronic cough, and 6 were documented as having chronic cough treated with BtxA injections. Two patients were excluded from the study because of a history of tracheostomy or concurrent laryngeal and voice dysfunction. INTERVENTION: Electromyography-guided BtxA injections of the thyroarytenoid muscles. MAIN OUTCOME MEASURES: Patient demographics (age and sex), voice-related quality-of-life scores, postprocedure complications, number of BtxA units used, number and length of treatments, and voice outcomes are reviewed. RESULTS: Three of the 4 patients (75%) were women, and the mean patient age was 55.6 years (range, 38-64 years). All patients had significant relief of cough after BtxA injection, with complete resolution after a median of 7 injections (range, 4-16), using a mean dose of 4.0 U (range, 1.0-10.0 U) per treatment session for a mean duration of 25.7 months (range, 7.2-42.9 months). CONCLUSIONS: To our knowledge, this is the first reported series in the literature of the use of BtxA in the treatment of chronic cough in adults. In this small case series, we report a neuropathic model for chronic cough caused by neuroplastic changes and laryngeal hyperactivity as an explanation for the effectiveness of BtxA treatment. Further research and long-term follow-up are warranted, but BtxA is effective in directly decreasing laryngeal hypertonicity and possibly reducing neurogenic inflammation and neuropeptide-mediated cough. Botulinum toxin type A can be considered for the treatment of chronic cough refractory to other medical therapies.

Laryngeal mucous membrane pemphigoid: a systematic review and pooled-data analysis.

OBJECTIVES/HYPOTHESIS: To perform a systematic pooled-data analysis of literature data involving laryngeal mucous membrane pemphigoid (MMP). STUDY DESIGN: A systematic review and pooled-data analysis. METHODS: We conducted a systematic literature search of MEDLINE, EMBASE, Cochrane Central Register of Clinical Trials, Cochrane Database of Systematic Reviews, clinicaltrials.gov, and the National Guideline Clearinghouse databases without language restriction for studies including combinations of relevant terms. All authors independently screened the abstracts of the search results, identified articles eligible for review, and critically appraised the full-text studies. Pooled-data analyses and Kaplan-Meier survival analyses were conducted using SPSS version 16.0 software (SPSS Inc., Chicago, IL). RESULTS: Of the 2,524 citations reviewed, the included articles consisted of 63 case reports and 10 case series reporting on 141 patients with laryngeal MMP. No clinical trials or comparative trials were found. The overall calculated prevalence of laryngeal MMP was 12.2% (95% confidence interval [CI], 11.5-12.9%) of cases of MMP or one in 10 million persons in the general population. Mean age at laryngeal MMP onset was 59.7 years (95% CI, 57.9-61.1 years), and the supraglottis was the most commonly affected site (84.8%, 95% CI, 82.5-87.2%). Distribution among genders was equivalent (P = .655). The presence of antiepiligrin autoantibodies was associated with increased laryngeal involvement (Odds ratio 7.9, 95% CI, 3.9-16.0). The overall 5-year relative survival rate was 92.4% (standard error, 8.4) with a follow-up range of 1 to 221 months. Standard medical therapy alone occasionally improved the condition; however, relapses were frequent, and 10.5% eventually required tracheostomy. Laryngeal surgical interventions seemed to be effective in severe cases. CONCLUSIONS: Laryngeal MMP is a rare condition that can be life threatening without proper treatment and frequent follow-up.

Plummer-Vinson syndrome heralded by postcricoid carcinoma.

Plummer-Vinson syndrome is one of the names given to the constellation of dysphagia, iron-deficiency anemia, and esophageal webbing. Treatment consists of iron supplementation, possibly dilation, and surveillance. The syndrome is associated with an increased risk of postcricoid carcinoma, which usually presents at an advanced stage. We present a case of an early postcricoid carcinoma that led to the diagnosis of Plummer-Vinson syndrome and subsequent treatment of both conditions.

Treatment of severe obstructive sleep apnea syndrome with a chinstrap.

A chinstrap alone improved severe obstructive sleep apnea as well as or better than the use of CPAP.

Subglottic stenosis in Erdheim-Chester disease: a previously unrecognized site of involvement.

We describe a case of laryngeal stenosis secondary to an etiology not previously described. A patient with Erdheim-Chester disease presented with airway obstruction and was found to have subglottic stenosis. Biopsy results confirmed Erdheim-Chester nodules as the cause of the obstruction. This case illustrates the need for biopsy to rule out malignancy and less common etiologies of subglottic stenosis.

Stridor and dysphagia in diffuse idiopathic skeletal hyperostosis (DISH).

As otolaryngologists, we are the first consulted for stridor and dysphagia. One must consider both extrinsic and intrinsic etiologies in the differential diagnosis of these symptoms. We report a series of patients with diffuse idiopathic skeletal hyperostosis (DISH) who presented with stridor or dysphagia. We describe the initial presenting symptoms, physical examination/radiographic findings, and discuss the management options. Traditional teaching is that surgery is rarely indicated for DISH of the cervical spine. Recommendations regarding the role of surgery as well as a review of our surgical experience are discussed.

Post-tonsillectomy morbidity and quality of life in pediatric patients with obstructive tonsils and adenoid: microdebrider vs electrocautery.

OBJECTIVE: To prospectively compare outcomes in children over age 2 with obstructive adenotonsillar hypertrophy when tonsillectomy is performed utilizing an intracapsular microdebrider technique versus low-wattage electrocautery technique. STUDY DESIGN AND SETTING: Prospective, single-blind, randomized controlled trial at a tertiary care children's hospital. RESULTS: Among the 300 children, those treated with the microdebrider resumed normal activity faster, with a median recovery of 2.5 days, and stopped taking pain medication sooner, with the median time to the last dose of 4 days. The microdebrider group were 3 times more likely to no longer need pain medications at 3 days postoperatively and 2.5 times less likely to be still needing pain medication 7 days postoperatively. They were twice as likely to be at a normal activity level by 3 days postoperatively and were less likely to still not have attained normal activity and normal diet after 7 days. There was no difference between groups in median days to return to normal diet (3.0 to 3.5 days). At 1-month follow-up, children in the microdebrider group were 5 times more likely to have residual tonsil tissue. CONCLUSIONS: Intracapsular tonsillectomy in children with obstructive adenotonsillar hypertrophy results in improved peri-operative outcomes. Residual tonsil tissue is more common with use of the microdebrider; however, the incidence of future obstruction or infection is unknown. EBM RATING: A-1b.