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OBJECTIVE: This study identifies how recurrent Zenker's diverticula are treated. METHODS: A retrospective chart review was performed from four tertiary referral academic voice and swallowing centers to identify individuals who underwent surgery for recurrent Zenker's diverticulum. Demographic data, surgical modalities for primary and revision surgery, symptoms pre and post revision and complications were recorded. RESULTS: 56 individuals met inclusion criteria. Primary surgery was open in 30.3% (n = 17) and endoscopic in 69.6% (n = 39). Revision surgery was performed via an open approach in 37.5% of cases (N = 21) and via an endoscopic approach in 62.5% of cases (N = 35). Revision surgical technique was based on pouch size, patient age and comorbidities, as well as patient and surgeon preference. There were no major complications and few minor complications. CONCLUSION: Zenker's diverticulum symptoms can recur regardless of primary treatment modality. Both endoscopic and open approaches can safely treat recurrent Zenker's diverticula.
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Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Divertículo de Zenker/cirurgia , Fatores Etários , Idoso , Comorbidade , Endoscopia Gastrointestinal/métodos , Endoscopia Gastrointestinal/estatística & dados numéricos , Feminino , Humanos , Masculino , Recidiva , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , SegurançaRESUMO
OBJECTIVES: Nasogastric tubes (NGT) are often placed after surgery for cricopharyngeal muscle pathology due to risk of infection and mediastinitis. The aim of this study was to examine if this practice is necessary. METHODS: A retrospective case series of subjects who underwent surgery for hypopharyngeal diverticula or cricopharyngeal bars from March 2011 to June 2018 was conducted. Demographic data, type of surgery, placement of feeding tube, initiation of oral feeding, and any complications were recorded. RESULTS: Sixty-four surgeries were performed for Zenker's diverticula (ZD; N = 52), Killian-Jamieson diverticula (N = 2), and cricopharyngeal bar (N = 10). Mean age and ZD pouch size were 74.0 ± 10.6 years and 3.1 ± 1.8 cm, respectively. Procedures included 48 carbon dioxide laser-assisted myotomies, 14 open diverticulectomies, and 2 endoscopic stapler-assisted diverticulotomies. Of the 64 patients, 19 (29.7%) received intraoperative NGTs while the remaining 45 (70.3%) did not receive NGTs. The former cohort had the NGTs removed on post-operative day (POD) 4.5 ± 2.5, and the non-NGT cohort started clear liquid diet (CLD) on POD 1.2 ± 0.7 days, where 38 patients (84.4%) started CLD on POD 1, and 5 patients (7.8%) were started on oral diet on POD 2-4. Over time, fewer NGTs were placed and oral diets were started sooner. There were 5 complications occurring in 3 patients from the NGT cohort (15.5%) and 2 from the non-NGT cohort (4.4%). CONCLUSIONS: Surgery for hypopharyngeal diverticula and CPB may not require routine perioperative NGT placement which can be associated with higher rates of complication. Patients can safely receive CLD on POD 1.
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Nutrição Enteral/métodos , Hipofaringe/cirurgia , Intubação Gastrointestinal , Cuidados Pós-Operatórios/métodos , Procedimentos Desnecessários , Divertículo de Zenker/cirurgia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Nutrição Enteral/efeitos adversos , Feminino , Humanos , Intubação Gastrointestinal/efeitos adversos , Masculino , Pessoa de Meia-Idade , Miotomia/métodos , Procedimentos Cirúrgicos Otorrinolaringológicos/métodos , Estudos Retrospectivos , Fatores de TempoRESUMO
PURPOSE: To assess fiberoptic endoscopic evaluation of swallowing (FEES) findings in individuals with cricopharyngeal bar (CPB) and Zenker's diverticulum (ZD). METHODS: In this retrospective chart review spanning from 2010-2018, individuals diagnosed with CPB or ZD and undergoing FEES were identified. Patient demographics, radiographic studies, and treatments were recorded, and findings were compared between CPB, ZD of < 3 cm, and ZD ≥ 3 cm. RESULTS: Sixty-one individuals consisting of 48 patients with ZD and 13 patients with CPB met inclusion criteria. Post-swallow hypopharyngeal reflux (PSHR) of undigested food bolus, present with or without Valsalva maneuver, was noted in 23%, 84%, and 75% of patients with CPB, ZD < 3 cm, and ZD ≥ 3 cm, respectively. The sensitivity and specificity of the finding for those with ZD were 81% and 83%, respectively. Of patients with ZD, reflux resolved in all but six individuals after surgery. Four of these patients underwent revision surgery with the reflux subsequently resolving, and two patients with persistent reflux were asymptomatic and did not desire further treatment. CONCLUSIONS: PSHR is a good tool to identify the presence of a ZD and is less helpful to identify a CPB. Elimination of PSHR is a good tool to determine treatment success in patients with ZD and CPB. LEVEL OF EVIDENCE: IV.
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Transtornos de Deglutição , Divertículo de Zenker , Deglutição , Transtornos de Deglutição/diagnóstico , Transtornos de Deglutição/etiologia , Esofagoscopia , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Divertículo de Zenker/diagnóstico por imagem , Divertículo de Zenker/cirurgiaRESUMO
LEVEL OF EVIDENCE: Level 4 (Case Series). OBJECTIVE: Dysphagia is a debilitating condition that is associated with many etiologies. It can have a devastating effect on a patient's quality of life with long-term sequelae that make it a source of medical malpractice litigation. This study analyzed medical malpractice cases involving dysphagia and looked for factors determining legal liability. METHODS: The Westlaw Next legal database (Thomson Reuters, New York, NY) was searched for relevant malpractice cases and assessed for several factors including if the dysphagia was iatrogenic, the amount paid by the defendant, and the medical specialty of the defendants. RESULTS: A total of 45 cases of dysphagia were included. The majority of these cases were jury verdicts for the defendant (73.3%). Iatrogenic dysphagia was alleged in 55.5% of cases. Settlements and verdicts favoring the plaintiff resulted in awards ranging between $25,000 and $5,003,000 with a mean of $1,014,015. The most frequent physician specialists named were general surgeons (24.1), internists (11.1%), anesthesiologists (9.3%), gastroenterologists (7.4%), and otolaryngologists (5.6%). Iatrogenic dysphagia (OR 8.89 CI 1.02-77.32), medication-related iatrogenesis (OR 18.86 CI 1.82-195.41), and cases naming multiple specialties as a defendant (OR 5.90, CI 1.07-32.55) were factors associated with a verdict for the plaintiff or a settlement. CONCLUSION: Dysphagia is a condition with medicolegal consequences for many specialties. While the majority of these cases are decided in favor of the defendant the cost of a negative outcome is considerable. Iatrogenic dysphagia and naming more than one defendant specialty were associated with increased odds of a plaintiff verdict or settlement.
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Transtornos de Deglutição/etiologia , Responsabilidade Legal , Imperícia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Doença Iatrogênica , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , New York , Adulto JovemRESUMO
OBJECTIVES: To evaluate if nebulized 4% lidocaine alone provides adequate laryngopharyngeal anesthesia for office-based diagnostic transnasal tracheoscopy (TNT). METHODS: A retrospective chart review (January 2011 to June 2014) and a prospective case series (July 2014 to December 2014) of patients who underwent diagnostic TNT were performed at a university voice and swallowing center. TNT cases were categorized by method of topical laryngopharyngeal anesthesia: nebulized 4% lidocaine and 4% lidocaine drip (phase I) and nebulized 4% lidocaine only (phase II). RESULTS: TNT was performed a total of 59 times on 38 patients. Eleven (69%) of 16 phase I TNT procedures involved significant patient discomfort and severe cough following the lidocaine drip. Forty-two (98%) of 43 phase II TNT procedures were completed comfortably; 1 case required additional anesthesia by lidocaine drip. Retrospectively, 100% (n=8) of patients who underwent both phase I and phase II TNTs were noted to prefer anesthesia with nebulizer alone. In a prospective case series of 14 phase II TNT cases, 6 (86%) of 7 patients who previously underwent phase I TNT reported preference for anesthesia with nebulizer alone. CONCLUSIONS: Nebulized lidocaine appears to provide sufficient laryngopharyngeal anesthesia for diagnostic TNT. It is preferred by patients over laryngeal drip.
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Anestesia Local/métodos , Endoscopia/métodos , Lidocaína/administração & dosagem , Administração por Inalação , Adulto , Idoso , Anestésicos Locais/administração & dosagem , Humanos , Pessoa de Meia-Idade , Nebulizadores e Vaporizadores , Nariz , Estudos Prospectivos , Estudos RetrospectivosRESUMO
Objective: To characterize presentation, disease course, and treatment of idiopathic subglottic stenosis (iSGS) in non-Caucasian women and compare this cohort to the predominantly female, Caucasian patient cohorts identified in the literature. Study Design: Retrospective review. Results are compared to systematic review of demographics. Setting: Multiple California institutions from 2008 to 2021. Methods: Patients with intubation within 2 years of disease or who met exclusion criteria listed in prior publications were excluded. A systematic review of iSGS patient demographics was also completed for comparison. Results: Of 421 patients with iSGS, 58 self-identified as non-Caucasian women, with 50 ultimately included. Mean age of onset was 45.1 years old (95% confidence interval [CI], 41.5-48.8), and mean age at diagnosis was 47.2 years (95% CI, 43.6-50.7). Mean Charlson comorbidity index was 1.06 (n = 49, 95% CI, 0.69-1.44). At diagnosis, Cotton-Meyer severity scores (documented in n = 45) were Cotton-Myer (CM) I (28.9%), CM II (40%), and CM III (31.1%). Mean age at first endoscopic surgery was 47.7 (95% CI, 44.2-51.3) years. 64% experienced disease recurrence with a median of 11 months between their first and second surgery. Our systematic review identified 60 studies that reported demographic features in patients with iSGS. 95% of pooled patients were Caucasian, while other demographic features were similar to the current cohort. Conclusion: The non-Caucasian population, almost 14% of this Californian cohort, does not differ from the majority Caucasian population detailed in contemporary literature. This cohort supports the presence of some racial and ethnic heterogeneity in this disease population.
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OBJECTIVE: To describe rates of short-term morbidity following transcervical surgical treatment of hypopharyngeal diverticulum (HD) and analyze predictors of adverse events. METHODS: The 2005 to 2017 National Surgical Quality Improvement Program database was queried to identify patients diagnosed with HD undergoing open transcervical diverticulectomy. RESULTS: A total of 597 patients with a mean age of 71.4 ± 12.3 years were included. Thirty-day adverse events were experienced by 63 (10.6%) subjects, including 6.5% unplanned reoperations, 4.2% surgical complications, 4.4% medical complications, 2.7% readmissions, and 0.7% deaths. Medical complications notably included pneumonia (2.0%), reintubation (1.2%), sepsis (1.2%), intubation >48 hours (0.5%), urinary tract infection (0.5%), or deep vein thrombosis (0.5%), while surgical complications included organ/space infection (2.0%) and superficial (1.3%) or deep (1.0%) surgical site infection. Gender, race, functional status, diabetes, dyspnea, hypertension, steroid use, and recent weight loss were not associated with adverse events. Length of operation and hospitalization were both higher among those with adverse events (127.4 ± 107.9 vs 95.7 ± 59.8 minutes, P = 0.027, and 7.4 ± 7.4 vs 2.8 ± 3.6 days, P < 0.001). On multivariable logistic regression, high American Society of Anesthesiologists (ASA) class (OR = 2.02, P = 0.017), smoking (OR = 2.10, P = 0.044), and operation time (OR = 1.01; P = 0.005) were independent predictors of adverse events. Obesity was not associated with length of stay, readmission/reoperation, or complications. However, increased age was associated with shorter operations (P = 0.020), higher length of hospitalization (P < 0.001), and higher mortality (P = 0.027) and readmission rates (P = 0.023). CONCLUSION: Understanding clinical factors associated with complications following open surgery for HD such as ASA score, smoking status, length of operation, and age can help optimize surgical outcomes for at-risk patients.
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Miotomia , Procedimentos Cirúrgicos Otorrinolaringológicos , Complicações Pós-Operatórias , Divertículo de Zenker/cirurgia , Fatores Etários , Idoso , Esfíncter Esofágico Superior/cirurgia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Miotomia/efeitos adversos , Miotomia/métodos , Pescoço/cirurgia , Duração da Cirurgia , Procedimentos Cirúrgicos Otorrinolaringológicos/efeitos adversos , Procedimentos Cirúrgicos Otorrinolaringológicos/métodos , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Reoperação/métodos , Reoperação/estatística & dados numéricos , Fatores de Risco , Fumar/epidemiologia , Estados Unidos/epidemiologia , Divertículo de Zenker/mortalidadeRESUMO
OBJECTIVES: To determine the factors that shape utilization of social media-based online support communities (OSCs) and study the influence of these communities on medical decision-making in patients with Idiopathic Subglottic Stenosis (iSGS). STUDY DESIGN: Survey study. METHODS: A survey investigating OSC use was sent to the 1,056 members of the North American Airway Collaborative (NoAAC) iSGS1000 cohort in January 2018. Responses were merged with the existing NoAAC data set containing extensive demographic data, disease-specific history, and responses to validated patient-reported outcome measures. RESULTS: A total of 755 individuals with iSGS and mean age of 51.8 ± 11.6 years were included (99% female, 98% white, 63% college educated) and 58% were OSC users. Younger age, female gender, and college education were each associated with OSC use (P < .05). Users spent 2.5 ± 3.3 hours per week on the platforms. Time spent on OSC was not associated with total number of prior treatments. Higher disease anxiety (FoP-Q, R = 0.26, P < .001), lower social support (MOS, R = -0.12, P = .037), and lower level of shared-decision-making with the treating physician (SDM-Q9, R = -0.16, P = .007) were weakly associated with more hours spent engaging an OSC. OSC use influenced treatment and physician choice in 35% and 26% of users, respectively. Increased time spent on OSC use was associated with increased influence on patient medical decisions regarding treatment, surgery, and physician choice (P < .05). CONCLUSION: OSC engagement is common in patients with iSGS. Disease anxiety, social support, and relationship with the physician may influence OSC utilization. More OSC engagement weakly associated with greater OSC influence on patient medical decision-making. LEVEL OF EVIDENCE: NA. Laryngoscope, 131:1821-1827, 2021.
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Laringoestenose/psicologia , Participação do Paciente/psicologia , Apoio Social , Doenças da Língua/psicologia , Língua/patologia , Adulto , Constrição Patológica , Tomada de Decisões , Feminino , Humanos , Laringoestenose/patologia , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Doenças da Língua/patologiaRESUMO
SIGNIFICANCE: The human vocal fold (VF) oscillates in multiple vectors and consists of distinct layers with varying viscoelastic properties that contribute to the mucosal wave. Office-based and operative laryngeal endoscopy are limited to diagnostic evaluation of the VF epithelial surface only and are restricted to axial-plane characterization of the horizontal mucosal wave. As such, understanding of the biomechanics of human VF motion remains limited. AIM: Optical coherence tomography (OCT) is a micrometer-resolution, high-speed endoscopic imaging modality which acquires cross-sectional images of tissue. Our study aimed to leverage OCT technology and develop quantitative methods for analyzing the anatomy and kinematics of in vivo VF motion in the coronal plane. APPROACH: A custom handheld laryngeal stage was used to capture OCT images with 800 A-lines at 250 Hz. Automated image postprocessing and analytical methods were developed. RESULTS: Novel kinematic analysis of in vivo, long-range OCT imaging of the vibrating VF in awake human subjects is reported. Cross-sectional, coronal-plane panoramic videos of the larynx during phonation are presented with three-dimensional videokymographic and space-time velocity analysis of VF motion. CONCLUSIONS: Long-range OCT with automated computational methods allows for cross-sectional dynamic laryngeal imaging and has the potential to broaden our understanding of human VF biomechanics and sound production.
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Laringe , Tomografia de Coerência Óptica , Fenômenos Biomecânicos , Humanos , Fonação , Prega Vocal/diagnóstico por imagemRESUMO
Chronic laryngitis is an inflammatory process of at least 3 weeks duration and affects phonation, breathing, and swallowing. This article describes the infectious, inflammatory, and autoimmune causes of chronic laryngitis. Symptoms of chronic laryngitis are nonspecific and may range from mild to airway compromise requiring emergent tracheostomy.
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Laringite/diagnóstico , Laringite/etiologia , Laringite/terapia , Doenças Autoimunes/complicações , Infecções Bacterianas/complicações , Doença Crônica , Diagnóstico Diferencial , Disfonia/diagnóstico , Sensação de Globus/etiologia , Humanos , Inflamação/complicações , Neoplasias Laríngeas/patologia , Laringoscopia , Micoses/complicaçõesRESUMO
OBJECTIVES/HYPOTHESIS: Unilateral ML is a commonly performed surgery for dysphonia secondary to glottic insufficiency. The safety of this procedure performed in the outpatient setting has not been extensively examined. The purpose of the study was to assess the safety of outpatient unilateral ML in adults and determine the incidence and timing of postoperative complications across two tertiary-care academic medical centers. STUDY DESIGN: Retrospective chart review, METHODS: A review of patients undergoing unilateral ML at two tertiary-care academic centers from 2011 to 2017 was performed. Patients undergoing bilateral medialization laryngoplasty, revision surgery, or those undergoing additional laryngeal framework procedures including arytenoid adduction were excluded. Patient demographics, operative details, and perioperative and postoperative complications were recorded. Comparisons were made between those individuals who underwent inpatient versus outpatient ML. RESULTS: One hundred three total procedures met inclusion criteria. Fifty-seven were performed as outpatient procedures, and 46 individuals were observed for at least 23 hours following surgery. Silastic or Gore-Tex implants were used in all but two surgeries. There were no postoperative complications in either setting, including hematoma, dyspnea, wound infections or seromas. CONCLUSIONS: The incidence of adverse events during and immediately following unilateral ML is very low. Patients can be discharged safely the day of surgery without geographic restrictions. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1647-1649, 2019.
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Procedimentos Cirúrgicos Ambulatórios/métodos , Disfonia/cirurgia , Glote/cirurgia , Laringoplastia/métodos , Segurança do Paciente , Centros Médicos Acadêmicos , Dimetilpolisiloxanos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Politetrafluoretileno , Complicações Pós-Operatórias/epidemiologia , Próteses e Implantes , Reoperação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES/HYPOTHESIS: Large defects after total laryngectomy (TL) and total laryngopharyngectomy (TLP) often benefit from free flap (FF) or pedicled flap (PF) reconstruction to maintain continuity of the aerodigestive tract, protect great vessels, or reinforce pharyngeal closure. Although both techniques are commonly used, no consensus exists as to which results in fewer complications. The goal of this study was to determine if 30-day morbidity/mortality outcomes differ between PF and FF reconstruction in patients undergoing TL/TLP. STUDY DESIGN: Retrospective cohort study. METHODS: Patients were analyzed who underwent TL/TLP with reconstruction using records from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2015). RESULTS: A total of 347 patients were included; 204 received FF reconstruction, whereas 143 received PF reconstruction. FF reconstruction was more commonly used with TLP defects (P = .001). The total operative time in the FF (590 ± 140 minutes) was longer than the PF (441 ± 125 minutes) group (P < .0001). There was a higher rate of postoperative transfusions in those undergoing FF reconstruction (P = .022). There was no significant difference in complication rates among TLP patients. Among TL patients only, FF reconstruction had a higher association with wound infections than PFs (P = .040). On multivariate analysis, low hematocrit was associated with complications (P = .031). Age (P = .031) and congestive heart failure exacerbation (P < .001) were associated with increased hospital stay. Overall, there were no differences in readmissions, reoperations, or deaths between the groups. CONCLUSIONS: Reported complication rates after TL/TLP remain high, despite widespread usage of vascularized flaps in reconstruction. This comparison reveals no significant difference in postoperative complications between patients who received PF and FF laryngopharyngeal reconstruction. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:105-112, 2019.
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Retalhos de Tecido Biológico , Laringectomia/métodos , Faringectomia/métodos , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipofaringe/cirurgia , Laringectomia/mortalidade , Laringectomia/normas , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Faringectomia/mortalidade , Faringectomia/normas , Complicações Pós-Operatórias/mortalidade , Período Pós-Operatório , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade , Procedimentos de Cirurgia Plástica/mortalidade , Procedimentos de Cirurgia Plástica/normas , Reoperação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES/HYPOTHESIS: There are currently no established recommendations for the use of perioperative antibiotics (PAs) to prevent surgical site infections (SSIs) for direct microlaryngoscopy (DML). This study examined the incidence of SSI in patients undergoing DML with and without PAs. STUDY DESIGN: Retrospective, multi-institutional chart review. METHODS: A retrospective, multi-institutional chart review was performed at four tertiary referral academic medical centers. Patients undergoing DML from 2010 to 2017 were identified using Current Procedural Terminology codes. Medical records of patients undergoing DML with biopsy, microsurgery, laser ablation, or vocal fold injection who had adequate follow-up were reviewed. Procedures with significant cartilage destruction, concurrent open surgery, or esophageal surgery were excluded. Data recorded included age, gender, pacemaker history, American Society of Anesthesiologists class, wound class, indication for surgery, use of laser, complications, emergency room visits, hospitalizations, pain, fever, and postoperative steroid and antibiotic prescriptions. Presence or absence of SSIs was evaluated by a fellowship-trained laryngologist. RESULTS: There were 834 patients who met inclusion criteria. Of those, 698 did not receive PAs and 136 received PAs. The median age of patients was 54 years of age in the PA group and 57.5 years of age in the non-PA group, and all cases were recorded as wound class II. Overall, 58% of surgeries involved use of carbon dioxide or potassium-titanyl-phosphate laser. Only one SSI was reported on follow-up in a patient who did receive PAs. CONCLUSIONS: SSIs are exceedingly rare following DML. PA use is not indicated for routine DML. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2838-2843, 2018.
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Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Laringoscopia/métodos , Microcirurgia/métodos , Assistência Perioperatória/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Seguimentos , Humanos , Incidência , Doenças da Laringe/cirurgia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia , Adulto JovemRESUMO
OBJECTIVES/HYPOTHESIS: Laryngeal muscles (LMs) are controlled by the recurrent laryngeal nerve (RLN), injury of which can result in vocal fold (VF) paralysis (VFP). We aimed to introduce a bioelectric approach to selective stimulation of LMs and graded muscle contraction responses. STUDY DESIGN: Acute experiments in cats. METHODS: The study included six anesthetized cats. In four cats, a multichannel penetrating microelectrode array (MEA) was placed into an uninjured RLN. For RLN injury experiments, one cat received a standardized hemostat-crush injury, and one cat received a transection-reapproximation injury 4 months prior to testing. In each experiment, three LMs (thyroarytenoid, posterior cricoarytenoid, and cricothyroid muscles) were monitored with an electromyographic (EMG) nerve integrity monitoring system. Electrical current pulses were delivered to each stimulating channel individually. Elicited EMG voltage outputs were recorded for each muscle. Direct videolaryngoscopy was performed for visualization of VF movement. RESULTS: Stimulation through individual channels led to selective activation of restricted nerve populations, resulting in selective contraction of individual LMs. Increasing current levels resulted in rising EMG voltage responses. Typically, activation of individual muscles was successfully achieved via single placement of the MEA by selection of appropriate stimulation channels. VF abduction was predominantly observed on videolaryngoscopy. Nerve histology confirmed injury in cases of RLN crush and transection experiments. CONCLUSIONS: We demonstrated the ability of a penetrating MEA to selectively stimulate restricted fiber populations within the feline RLN and selectively elicit contractions of discrete LMs in both acute and injury-model experiments, suggesting a potential role for intraneural MEA implantation in VFP management. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1606-1614, 2018.
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Terapia por Estimulação Elétrica , Estimulação Elétrica/instrumentação , Músculos Laríngeos/fisiologia , Contração Muscular/fisiologia , Nervo Laríngeo Recorrente/fisiologia , Paralisia das Pregas Vocais/terapia , Animais , Gatos , Modelos Animais de Doenças , Eletrodos Implantados , Eletromiografia , Fibras Nervosas/fisiologia , Nervo Laríngeo Recorrente/anatomia & histologia , Nervo Laríngeo Recorrente/patologia , Traumatismos do Nervo Laríngeo Recorrente/complicações , Traumatismos do Nervo Laríngeo Recorrente/patologia , Traumatismos do Nervo Laríngeo Recorrente/fisiopatologia , Paralisia das Pregas Vocais/etiologiaRESUMO
OBJECTIVES/HYPOTHESIS: To evaluate the impact of resident involvement during thyroid surgery on 30-day postoperative complications. STUDY DESIGN: Retrospective cohort study. METHODS: All patients who underwent thyroid surgery in 2011 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patient demographics, perioperative details, resident involvement in surgery, and 30-day postoperative complications were extracted. Propensity score analysis was used to match resident and nonresident cases. Univariate and multivariate analysis were performed to determine the relationship between resident involvement in thyroid surgery and postoperative outcomes. RESULTS: One thousand seven hundred forty-seven patients with and 1,747 patients without resident involvement were case-matched for patient demographics, perioperative variables, and surgical case type. There was no significant difference (P = .19) in 30-day postoperative complication rates of surgeries with and without resident involvement, which were 1.4% and 2%, respectively. Operative time was longer in surgeries with residents than those without residents (119 ± 67 minutes vs. 102 ± 55 minutes, P < .001). Cases with resident involvement had an unplanned reoperation rate of 0.9%, which was significantly lower than the 2.3% rate of surgeries without residents (P = .001). Multivariate analysis revealed no significant association between resident involvement and overall complications (odds ratio = 0.70; P = .18). CONCLUSIONS: Resident participation in thyroid surgery was not associated with an increased 30-day postoperative complication rate. These findings demonstrate that patient safety is not adversely affected by resident participation in thyroid surgery. LEVEL OF EVIDENCE: 2C Laryngoscope, 127:1242-1246, 2017.
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Competência Clínica , Internato e Residência , Segurança do Paciente , Complicações Pós-Operatórias/epidemiologia , Doenças da Glândula Tireoide/cirurgia , Feminino , Humanos , Masculino , Duração da Cirurgia , Pontuação de Propensão , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES/HYPOTHESIS: Laryngeal adenocarcinoma not otherwise specified (LAdC NOS) is a category to which variants of minor salivary gland tumors of the larynx that do not fit other well-characterized histological subtypes are assigned. Its rare nature and inconsistency in available reports has hindered the investigation and further understanding of this malignancy. In this study, a national population-based resource was used to evaluate the epidemiology and survival of this rare entity. STUDY DESIGN: Retrospective population-based analysis. METHODS: The Surveillance, Epidemiology, and End Results database was searched for patients diagnosed with LAdC NOS between 1973 and 2012. Patient demographics, tumor location, TNM stage, grade, incidence, and survival trends were collected and analyzed. RESULTS: One hundred eleven patients met criteria for diagnosis of LAdC NOS, of which the majority were male (80.2%), white (84.7%), with a mean age of 65 years. The supraglottis was the most common site at presentation (38.7%). The majority presented with grade II tumor (45.7%). TNM staging revealed T2 (36.8%), N0 (72.2%), and M0 (88.9%) to be the most common classification. The overall incidence between the years of 2000 and 2012 was 0.008/100,000 individuals. The overall 5-year disease-specific survival (DSS) was 60.1%, compared to 85.7% in patients treated with combination surgery and radiotherapy. CONCLUSIONS: LAdC NOS is an uncommon malignancy. It most commonly affects men in their mid-60s, indiscriminate of race. Lesions most commonly present in the supraglottis and are more often low grade histologically. DSS is highest in patient treated with combination surgery and radiotherapy. LEVEL OF EVIDENCE: 4 Laryngoscope, 2016 127:424-429, 2017.
Assuntos
Adenocarcinoma/diagnóstico , Neoplasias Laríngeas/diagnóstico , Neoplasias das Glândulas Salivares/diagnóstico , Glândulas Salivares Menores , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Intervalo Livre de Doença , Feminino , Humanos , Neoplasias Laríngeas/mortalidade , Neoplasias Laríngeas/patologia , Neoplasias Laríngeas/terapia , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Estudos Retrospectivos , Programa de SEER , Neoplasias das Glândulas Salivares/mortalidade , Neoplasias das Glândulas Salivares/patologia , Neoplasias das Glândulas Salivares/terapia , Fatores Sexuais , Análise de SobrevidaRESUMO
OBJECTIVES: The recurrent laryngeal nerve is at risk of injury during open pharyngeal diverticula operations. The utility of recurrent laryngeal nerve (RLN) monitoring during these procedures was investigated. METHODS: A retrospective chart review was performed of 8 open pharyngeal diverticulectomies completed between 2009 and 2014. Intraoperative RLN monitoring took place during all operations. RESULTS: Open pharyngectomy and myotomy was successfully performed in all cases. In two cases the RLN was encountered outside of its normal course. The identity of the nerve was confirmed with electrical stimulation and normal EMG response. Vocal fold motion was preserved in all cases. CONCLUSIONS: Use of intraoperative nerve monitoring in pharyngeal diverticula procedures may be beneficial, especially during open operations for Killian-Jamieson diverticulum (KJD) and large Zenker diverticulum (ZD), where the RLN is typically encountered outside of its normal course.
Assuntos
Eletromiografia/métodos , Monitorização Intraoperatória/métodos , Músculos Faríngeos/cirurgia , Traumatismos do Nervo Laríngeo Recorrente/prevenção & controle , Nervo Laríngeo Recorrente , Paralisia das Pregas Vocais/prevenção & controle , Divertículo de Zenker/cirurgia , Idoso , Idoso de 80 Anos ou mais , Estimulação Elétrica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Faringectomia , Estudos RetrospectivosRESUMO
OBJECTIVE: To compare the viscoelastic properties of calcium hydroxyapatite (CaHA) to carboxymethylcellulose (CMC) injectables used for injection laryngoplasty and determine if they are affected by heating and shearing. STUDY DESIGN: Experimental. SETTING: University laboratory. SUBJECTS AND METHODS: Vocal fold injection laryngoplasty with CaHA is oftentimes challenging due to the amount of pressure necessary to push the injectate through a needle. Anecdotal techniques, such as heating the product, have been suggested to facilitate injection. The viscoelastic properties of CaHA and CMC were measured with a rheometer. The effects of heating and shearing on sample viscoelasticity were recorded. RESULTS: CaHA was 9.5 times more viscous than CMC (43,100 vs 4540 Pa·s). Heating temporarily decreased the viscosity of CaHA by 32%. However, it also caused the viscosity to subsequently increase after time. Shearing of CaHA reduced its viscosity by 26%. Heating and shearing together temporarily reduced the viscosity of CaHA by 52%. CONCLUSION: A combination of heating and shearing had a more profound effect than heating or shearing alone on the viscosity of CaHA, potentially making it easier to inject temporarily. Long-term and in vivo studies are required to further analyze the effect of heating and shearing on CaHA injectables.
Assuntos
Carboximetilcelulose Sódica/química , Durapatita/química , Laringoplastia/métodos , Carboximetilcelulose Sódica/uso terapêutico , Durapatita/uso terapêutico , Elasticidade , Calefação , Humanos , Reologia , ViscosidadeRESUMO
OBJECTIVE: Patients use a multitude of resources to learn about Zenker's diverticulum (ZD). The objectives of this study were to assess the readability and understandability of online materials on ZD, evaluate them against the existing criteria, and investigate the relationship between readability and understandability. METHODS: The first 50 webpages from an online search for ZD were analyzed. Twenty-one webpages had materials intended for patients and were included in the study. The patient education materials (PEMs) were analyzed using 6 readability tools. Four individuals used the Patient Education Materials Evaluation Tool (PEMAT) to assess the understandability. Fleiss κ interrater reliability analysis determined consistency among the raters. Finally, Pearson correlation coefficient analyzed the relationship between readability and understandability. RESULTS: The reading grade level of the materials reviewed ranged from 10th to 16th grade while the understandability ranged from 31% to 74%. Correlation analysis demonstrated a strong negative correlation between readability and understandability (r = -0.62, P < .05). Fleiss' κ interrater reliability for the raters demonstrated substantial agreement between the 4 raters (κ = 0.64). CONCLUSION: Online PEMs pertaining to ZD are written well above the recommended reading level. Materials written at a lower reading level are more understandable. A wide range of understandability exists among materials with identical reading grade levels. IMPLICATIONS FOR PRACTICE: Health care providers need to create new PEMs for ZD that are available online that are both readable and understandable. The PEMAT and readability formulas can provide a framework for authors to create these materials.