Established Adult Tracheostomy Tube Exchange: How Often is Enough?

Currently, there is no clinical consensus on how often adults with long-term tracheostomies should have their tubes exchanged. For high-functioning patients who are able to provide diligent tracheostomy care tubes can be exchanged every 6 months. Patients who have a difficult time with tracheostomy care should have them exchanged every 1-3 months.

Safety of Percutaneous Dilatational Tracheostomy in Critically Ill Adults With Obesity: A Retrospective Cohort Study.

OBJECTIVE: This study aimed to assess the safety and efficacy of endoscopic percutaneous dilatational tracheostomy (PDT) in obese and nonobese critically ill adults. METHODS: A retrospective study of all cases of PDT performed at two academic health centers between 2016 and 2023 was conducted. Primary outcomes included peri- and postoperative complications stratified by both timing and severity. body mass index (BMI) data were stratified according to the World Health Organization classification (class I obesity defined as BMI ≥ 30, class II obesity ≥35 and <40, class 3 obesity ≥40). RESULTS: Totally 336 patients underwent a PDT, 279 of whom had available BMI data: 193 (69.2%) patients had a normal BMI, 56 (20.1%) had class I obesity, 15 (5.4%) class II obesity, and 15 (5.4%) class III obesity. The overall complication rates for the class I, II, and III obesity were 8.9%, 13.3%, and 13.3%, respectively. All procedures were successfully completed at the bedside (no conversions to an open approach), and there was no procedure-related mortality. The only accidental decannulation event was in a patient with class III obesity. There was no difference in overall complication rates between patients without obesity and patients with obesity (7.3% vs. 10.5%, respectively, p = 0.370). CONCLUSION: This study significantly expands the current literature and represents one of the largest studies to date reporting on PDT in patients with obesity. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Geriatric Voice: Distinctive Clinical Profiles of Working Seniors in a Tertiary Laryngology Clinic.

OBJECTIVES: Voice disorders have been reported in up to 47% of the geriatric population. Few studies have assessed dysphonia in the elderly, with none examining vocal function in working seniors. This study aims to profile the clinical characteristics of individuals aged 65 years and older, comparing working and non-working seniors. STUDY DESIGN: Retrospective cohort study. METHODS: Medical charts were reviewed for patients aged 65 years and older referred to the McGill University Health Centre Laryngology Clinic (January 2018-March 2020). Variables studied included sociodemographics, comorbidities, voice complaints, lifestyle factors, diagnoses, voice acoustics [maximum phonation time (MPT), S/Z ratio, F0], GRBAS scale, Voice Handicap Index-10 (VHI-10), Reflux Symptom Index (RSI), and treatment modalities. RESULTS: A total of 267 patients were included, with a mean [standard deviation (SD)] age of 74.2 (6.6) years and 61% of female patients. Occupation information was available in 148 cases, of which 31.1% were still working and 12.8% were professional voice users. The predominant voice complaint was dysphonia/hoarseness (48.8%) and the most prevalent diagnosis was presbyphonia (31.8%). The mean (SD) VHI-10 and RSI scores were 19.8 (9.0) and 18.7 (9.4) points, respectively. Voice therapy was prescribed for 155 patients (58.7%): 124 attended at least one session with significant post-treatment improvements in the GRBAS and VHI-10 scores (P < 0.01). In the univariate analysis, working seniors had a significantly more prevalent singing habit (P = 0.04) and laryngopharyngeal reflux diagnosis (P = 0.01), displaying a significantly longer MPT (P < 0.001) and lower G-B-S scores (P < 0.05). After adjusting mean differences, only MPT and the G-S scores were significantly different between both groups. CONCLUSIONS: The predominant diagnosis in elders with voice complaints was presbyphonia. Voice therapy proved effective in improving the VHI-10 and GRBAS scores for geriatric patients. Almost one-third of seniors remained in the workforce, demonstrating superior vocal profiles, specifically in the MPT and the grade and strain of perceptual voice quality.

Surgical Treatment of Early Glottic Cancer.

The incidence of all head and neck malignancies is rising worldwide, with carcinoma of the larynx constituting approximately 1% of all cancers. Early glottic cancer responds quite favorably to surgical intervention due to its early presentation, coupled with the low rate of regional and distant metastases. This article focuses on various approaches to the surgical treatment of early glottic cancer. Details include the clinical and radiological evaluation of laryngeal cancer, the goals of treatment, current surgical options for early disease, approach to surgical resection margins and management of nodal disease, and complications associated with each treatment modality.

Laryngeal Amyloidosis: What is the Role of Imaging?

OBJECTIVE/HYPOTHESIS: To review the imaging findings of laryngeal amyloidosis and to identify radiological findings suggestive of this disease. STUDY DESIGN: Retrospective case series. METHODS: A retrospective chart review of patients with pathologically confirmed laryngeal amyloidosis was performed from 2009 to 2022. Clinical and demographic factors were collected. A fellowship-trained head and neck radiologist reviewed all computed tomography (CT) scans and magnetic resonance imaging (MRI) findings within this cohort. RESULTS: 12 patients were identified and a total of 36 imaging studies analyzed. Localized amyloidosis was found in the supraglottic region (n = 6), glottic region (n = 7), and subglottic region (n = 5); six patients had disease spanning two subsites. The most common finding on the CT scan was a homogeneous and well-defined submucosal soft tissue mass. Punctate calcifications were present in three cases. The presence of contrast enhancement was identified in the majority of patients who underwent MRI (4/5). MRI showed consistent signal intensity, hypointense, or isointense on both T1-weighted and T2-weighted images. Diffusion-weighted sequences were obtained in every patient and did not demonstrate diffusion restriction. CONCLUSION: This is the largest series searching for unifying imaging characteristics of laryngeal amyloidosis. This research suggests that characteristics from CT and MR provide both similar and unique features of laryngeal amyloidosis on imaging. Both modalities identify a submucosal mass. CT is the preferred modality to demonstrate punctate calcifications, while MRI identifies enhancement and altered signal characteristics. The main benefit of serial imaging is the correlation with patient symptoms, identification of the extent of disease, and assisting in delineating appropriate timing for surgery.

Polymeric Microspheres Containing Human Vocal Fold Fibroblasts for Vocal Fold Regeneration.

OBJECTIVE: Most acellular injectable biomaterials for vocal fold (VF) wound treatment have limited regenerative potential due to their fast enzymatic degradation and limited recruitment of native cells postinjection. The injection of cells as therapeutic treatment often results in apoptosis due to stresses within the needle and the immune response of the host. Degradable microspheres may improve treatment effectiveness by increasing cell residence time, shielding cells during injection, and offering early protection against the immune system response. The objective of the present study was to investigate the potential of human VF fibroblasts encapsulated in polymeric microspheres as an injectable therapeutic treatment in vitro. METHODS: Alginate, alginate-poly-L-lysine, and alginate-chitosan microspheres were fabricated using electrospraying and characterized in terms of biocompatibility, swelling, and mechanical properties as well as cytokine production. RESULTS: Alginate microspheres were found to have the most desirable properties for VF regeneration. They were resistant to mechanical challenges. They were found to have a stiffness similar to that reported for native VF-lamina propria. They were found to be biocompatible and increased the proliferation of fibroblasts. Human VF fibroblasts encapsulated in alginate microspheres induced the production of interleukin (IL)-8 and IL-4 at 24 hours. CONCLUSION: The alginate microspheres fabricated in this study were found to offer potential advantages, as cell delivery tool. This study highlights the importance of combining biomaterials and cells to expedite the wound-healing process through cytokine production. Future work is aimed to further analysis of the wound-healing properties the microspheres. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1828-1834, 2021.

Characterizing Vocal Fold Injury Recovery in a Rabbit Model With Three-Dimensional Virtual Histology.

OBJECTIVES/HYPOTHESIS: In animal studies of vocal fold scarring and treatment, imaging-based evaluation is most often conducted by tissue slicing and histological staining. Given variation in anatomy, injury type, severity, and sacrifice timepoints, planar histological sections provide limited spatiotemporal details of tissue repair. Three-dimensional (3D) virtual histology may provide additional contextual spatial information, enhancing objective interpretation. The study's aim was to evaluate the suitability of magnetic resonance imaging (MRI), microscale computed tomography (CT), and nonlinear laser-scanning microscopy (NM) as virtual histology approaches for rabbit studies of vocal fold scarring. METHODS: A unilateral injury was created using microcup forceps in the left vocal fold of three New Zealand White rabbits. Animals were sacrificed at 3, 10, and 39 days postinjury. ex vivo imaging of excised larynges was performed with MRI, CT, and NM modalities. RESULTS: The MRI modality allowed visualization of injury location and morphological internal features with 100-µm spatial resolution. The CT modality provided a view of the injury defect surface with 12-µm spatial resolution. The NM modality with optical clearing resolved second-harmonic generation signal of collagen fibers and two-photon autofluorescence in vocal fold lamina propria, muscle, and surrounding cartilage structures at submicrometer spatial scales. CONCLUSIONS: Features of vocal fold injury and wound healing were observed with MRI, CT, and NM. The MRI and CT modalities provided contextual spatial information and dissection guidance, whereas NM resolved extracellular matrix structure. The results serve as a proof of concept to motivate incorporation of 3D virtual histology techniques in future vocal fold injury animal studies. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1578-1587, 2021.

Voice Disorders in the Elderly.

Presbyphonia is more common than appreciated by most physicians, and it is associated with undesirable vocal characteristics such as hoarseness, weakness, breathiness, instability, and tremulousness. Hearing impairment in the patient or his or her friends, family, and associates exacerbates the problem, resulting in depression and social withdrawal, further reducing quality of life. Moreover, voice weakness and instability are all too often misinterpreted as reflecting intellectual instability. Expert diagnosis, medical treatment, voice therapy and training, and occasionally surgery usually can maintain or restore vocal stability and "youth."

A rare but serious entity: nasogastric tube syndrome.

Since its first description by Hunter in 1790, the nasogastric tube has become a frequently used method of alleviating gastrointestinal symptoms. Because the morbidity associated with its use is low the risks of complications are often underestimated. We present a case of bilateral vocal cord paralysis and supraglottic edema following nasogastric tube insertion-also known as Nasogastric Tube Syndrome (NGTS). Although this complication is rare, it can be life threatening. We discuss this phenomenon in the context of a meta-analysis of reported cases, notably: presenting symptoms, time at development and resolution of symptoms in relation to nasogastric intubation and propose treatment options.

Laryngeal inflammation assessed using the reflux finding score in obstructive sleep apnea.

OBJECTIVES: To evaluate the relationships between laryngeal inflammation assessed using the Reflux Finding Score (RFS), laryngeal sensory function, and apnea severity in patients with obstructive sleep apnea (OSA). METHODS: Endoscopic sensory testing (EST) was performed with subsequent blinded scoring from video of RFS. An RFS>7 was indicative of increased inflammatory change. RESULTS: Of 34 patients evaluated, 29 had OSA (apnea-hypopnea index [AHI]>or=15 events/h) at polysomnography. Increased inflammation was present in 26/29 (90%), with changes suggestive of laryngopharyngeal reflux. There were significant correlations between: inflammation and OSA severity (eg, RFS vs AHI, r=0.57, P<0.001); inflammation and laryngeal sensory impairment (EST detection threshold and pressure required to elicit the laryngeal adductor reflex, LAR); and the degree of sensory impairment and OSA severity. CONCLUSIONS: Laryngeal inflammation is prevalent among OSA patients and correlates with laryngeal sensory dysfunction, attenuation of the LAR, and apnea severity. EBM RATING: C-4.

Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases.

OBJECTIVES/HYPOTHESIS: An evaluation of 500 adult, intubated, intensive care unit patients undergoing endoscopic percutaneous tracheotomy using the multiple and single dilator techniques was conducted to assess the feasibility and safety of the procedure as it compares with surgical tracheotomy. Endoscopy was used in all cases and evaluated as an added safety measure in reducing complications. STUDY DESIGN: A prospective evaluation of endoscopic percutaneous dilatational tracheotomy in 500 consecutive adult, intubated intensive care unit patients. METHODS: Between 1990 and 2003, endoscopically guided percutaneous dilatational tracheotomy (PDT) was performed in 500 consecutive adult, intubated patients in the intensive care units (ICU) of three tertiary care adult hospitals. The first 191 patients underwent PDT using the Ciaglia Percutaneous Tracheostomy Introducer Kit (Cook Critical Care Inc., Bloomington, Indiana) and in the remaining 309 patients the Ciaglia Blue Rhino Single Dilator Kit (Cook Critical Care Inc., Bloomington, Indiana) was used. The procedure was contraindicated in the following situations: 1) children, 2) unprotected airway, 3) emergencies, 4) presence of a midline neck mass, 5) inability to palpate the cricoid cartilage, and 6) uncorrectable coagulopathy. The following parameters were recorded preoperatively: age, sex, diagnosis, American Society of Anesthesia (ASA) class, body mass index (BMI), and number of days intubated. Recorded hematologic parameters included hemoglobin (Hgb), platelets, prothrombin time (PT), partial thromboplastin time (PTT), and the international normalized ratio (INR) since it became available in 1998. All patients were ventilated on 100% oxygen and vital signs were continuously monitored. Tracheotomy was carried out under continuous endoscopic guidance using a series of graduated dilators in the first 191 cases, and a single, tapered dilator in the remaining 309 patients. The preoperative data on each patient, along with the type of dilator used, the size of the tube, the intraoperative and postoperative complications, and blood loss information were recorded prospectively and maintained in a computer spreadsheet. Univariate analyses were used in each group separately for each type of dilator to assess the risks of a complication within subgroups defined by each parameter/characteristic, and the statistical significance assessed with a chi test, or Fisher exact test. RESULTS: The total complication rate was 9.2% (13.6% in the multiple dilator group, and 6.5% in the single dilator group), with more than half of these considered minor. Overall, the two most common complications were oxygen desaturation in 14 cases and bleeding in 12 cases. The absence of serious complications such as pneumothorax and pneumomediastinum are attributable to the use of bronchoscopy. There was no significant association between the rate of complications and age, gender, ASA, weeks intubated, tracheostomy tube size, Hgb levels, platelets, PT, PTT, or INR. There was a statistically significant relationship between experience and the likelihood of complications in the multiple dilator group (P < .0001), with a higher rate of complications in the first 30 patients (40%) compared with 8.7% in the remaining 161 patients. This relationship did not exist for the first 30 patients in the single dilator group. Patients with a BMI of 30 or higher experienced a significantly greater (P < .05) number of complications (15%), compared with an 8% complication rate in patients with a BMI of less than 30. This risk was even more significant for patients with a BMI of 30 or greater who were also in ASA class 4 (11/56 or 20%) (P < .02). CONCLUSIONS: Endoscopic PDT is associated with a low complication rate and is at least as safe as surgical tracheotomy in the ICU setting. Bronchoscopy significantly decreases the incidence of complications and should be used routinely. While embraced by critical care physicians, endoscopic PDT has been infrequently performed by otolaryngologists. As the airway experts, otolaryngologists are in the best position to learn and teach the procedure as it should be done.

Use of fluorescent light in detecting malignant and premalignant lesions in the oral cavity: a prospective, single-blind study.

OBJECTIVE: To determine the usefulness of the VELscope in detecting malignant and premalignant oral cavity lesions. STUDY DESIGN: Prospective clinical study. SETTING: Head and neck oncology clinic at an academic tertiary care centre. SUBJECTS AND METHODS: Eighty-five patients with a history of smoking, alcohol use, and/or head and neck cancer were recruited into the study. The VELscope was used to examine patients' oral cavities after a clinical examination. Biopsies were then taken from suspicious areas. RESULTS: Of the 85 patients included in the study, 33 underwent biopsies prompted by a clinical examination, the VELscope, or both. Biopsy results that showed invasive malignancy or dysplasias were considered positive. Five positive biopsies for premalignant lesions were detected only by the VELscope and were not visible on clinical examination. On the other hand, only one positive biopsy for a premalignant lesion was detected by the clinical examination only and not seen on the VELscope. Seven positive biopsies were detected by both methods. This indicates that the diagnostic yield from a regular examination was 47% (95% CI 23-72) and that the diagnostic yield from the addition of the VELscope was an additional 31% (95% CI 11-59). Sensitivity and specificity for the VELscope were 92% and 77%, respectively. CONCLUSION: The Velscope may add sensitivity to the clinical examination and be a useful adjunct in high-risk patients.