Woody hardness classification impact on salvage laryngectomy functional outcomes.

PURPOSE: Post-radiation therapy salvage surgeries are challenging for surgeons due to tissue fibrosis. The woody hardness classification is valuable in differentiating the degree of neck stiffness, but its clinical utility has not been evaluated. We applied it to patients undergoing salvage laryngectomy to study the impact of woody hardness on postoperative outcomes. MATERIALS AND METHODS: A retrospective observational study was performed on patients undergoing salvage laryngectomy between 2014 and 2019. Patients were assigned into the A (extremely woody hard), B (moderately woody hard), or C (mildly woody hard) woody hardness class. The primary outcome was pharyngoesophageal stricture development. Secondary outcomes included time to pharyngoesophageal stricture, pharyngocutaneous fistula development, time to pharyngocutaneous fistula, development of post-operative complications, and tracheoesophageal puncture complications. RESULTS: Fifty-one patients were included in the study: Class A 1 patient, Class B 30 patients, and Class C 20 patients. The single Class A patient was grouped with the Class B patients. The development of a pharyngoesophageal stricture shows consistent negative association with woody hardness despite most analyses not reaching statistical significance. These associations are robust to a number of confounding variables in multivariate logistic and time to event analyses. Furthermore, the time to event analysis controlling for squamous cell carcinoma diagnosis led to a statistically significant association between woody hardness (i.e., A/B higher risk) and time to stricture (HR=5, p=0.02). CONCLUSIONS: This study suggests that this classification may be useful in predicting pharyngoesophageal stricture formation in salvage laryngectomy patients and could be used to implement stricture preventive measures.

Trigeminal Nerve Blockade in the Pterygopalatine Fossa for the Management of Postoperative Pain in Three Adults Undergoing Tonsillectomy: A Proof-of-Concept Report.

SETTING: Post-tonsillectomy pain in adults can be severe and is often poorly controlled. Pain can lead to decreased oral intake, bleeding, longer hospital stays, emergency department visits, dehydration, and weight loss. Due to persistent pain despite scheduled medications, other methods for pain control are needed. Local/regional anesthetic options have been previously studied in this population. Unfortunately, neither the injection of local anesthetics into the tonsillar fossa nor the postoperative topical application of local anesthetics to the tonsillar bed has demonstrated efficacy in large systematic reviews. PATIENTS: Here we report on the post-tonsillectomy pain experience of three patients who were treated with perioperative nerve blocks placed in the pterygopalatine fossa. This represents an as-yet unexplored option for post-tonsillectomy pain control. INTERVENTION: After induction of general anesthesia, before surgical incision, a 25-gauge spinal needle was advanced into the pterygopalatine fossa using a suprazygomatic, ultrasound-guided approach. Ropivacaine and dexamethasone were deposited into the pterygopalatine fossa. RESULTS: All three patients experienced excellent pain control for the duration of their recovery and required ≤10 mg of oxycodone over the two weeks after surgery. CONCLUSIONS: Our case series of three patients provides proof of concept that use of nerve blocks in the pterygopalatine fossa can be useful for the control of post-tonsillectomy pain. Further study is needed to confirm these initial results.

Respiratory-Swallow Pattern Following Total Laryngectomy.

The goal of this study was to further characterize respiratory patterns in total laryngectomees with attention to respiratory-swallow pattern as it relates to presence/absence of tracheoesophageal puncture (TEP) and bolus consistency. It was hypothesized that participants with TEP would exhibit respiratory-swallow patterns that were significantly different than those without TEP and that bolus consistency (thin or solid) would modulate respiratory-swallow pattern. Data were collected from 12 adults (8 male), aged 46-67 years (mean 57) status post total laryngectomy (1-30 years; average 6 years). Those actively receiving chemoradiation, with history of esophageal cancer, with neurologic disease, with history of lung cancer, with known or suspected recurrence of head and neck cancer (HNC), or with severe cognitive deficits were excluded. Laryngectomy participants were asked to swallow three sips of water and three bites of graham cracker. Submental surface EMG activity was used to detect swallows and a custom stoma mask in line with a pneumotachograph measured airflow during the swallows. Non-parametric Mann-Whitney test for differences was used to detect significance for our dependent variables, TEP or bolus consistency and independent variables, respiratory-swallow pattern. Laryngectomee's showed preference for swallow during inspiration which is inconsistent with the expiratory pattern preference found in healthy adults with intact larynges by McFarland et al. (Respir Physiol Neurobiol 234:89-96, 2016) but consistent with the pattern preference for inspiration (or non-dominant respiratory-swallow phase pattern) found in the HNC population at-large by Brodsky et al. (J Appl Physiol 112(10):1698-1705, 2012). No significant difference was found in swallow pattern with regards to presence/absence of TEP or bolus consistency.

Airway management of a patient with linear immunoglobulin A bullous dermatosis: A case report.

BACKGROUND: There is limited literature on managing the airway of patients with linear immunoglobulin A (IgA) bullous dermatosis, a rare mucocutaneous disorder that leads to the development of friable bullae. Careful clinical decision making is necessary when there is a risk of bleeding into the airway, and a multidisciplinary team approach may lead to decreased patient morbidity during these high-risk scenarios, especially when confronted with an unusual cause for bleeding. CASE SUMMARY: A 45-year-old African American female presented to our ambulatory surgical center for right corneal transplantation due to corneal perforation after blunt trauma in the setting of cicatricial conjunctivitis and diffuse corneal neovascularization from linear IgA bullous dermatosis. The diagnosis of IgA dermatosis was recent, and the patient had been lost to follow-up. The severity of the disease and extent of airway involvement was unknown at the time of the surgery. Significant airway bleeding was noticed upon intubation and the otorhinolaryngology team had to be called to the operating room. The patient required transfer to the intensive care unit where a multidisciplinary team was involved in her case. The patient was extubated on postoperative day 4. CONCLUSION: A multidisciplinary approach to treating this disease is the best course of action before a surgical procedure. In our case, key communication between the surgery, anesthesia, and dermatology teams led to the quick and safe treatment of our patient's disease. Ambulatory surgery should not be considered for these cases unless they are in full remission and there is no mucous membrane involvement.

Longitudinal Examination of Swallowing Safety and Vocal Fold Mobility in Cardiac Surgical Patients.

BACKGROUND: Aspiration and vocal fold mobility impairment (VFMI) are frequently reported in adults after cardiac surgery (CS) and impede recovery. Preoperative and postoperative laryngoscopic evaluations have not been undertaken, masking the incidence and evolution of dysphagia and VFMI in CS patients. We therefore sought to determine frequency of unsafe swallowing and VFMI before and after CS. METHODS: Thirty-five adults undergoing elective CS enrolled. Participants underwent fiberoptic endoscopic evaluations of swallowing and VFMI before and after surgical procedure. Trained raters performed duplicate, blinded ratings with the validated Penetration-Aspiration Scale, and a laryngologist performed blinded ratings of VFMI. Descriptive, Wilcoxon signed rank, and McNemar tests were performed. RESULTS: Preoperative swallowing safety profiles were 60% safe, 34% penetration, and 6% aspiration. Postoperative swallowing safety profiles were 14% safe, 63% penetration, and 23% aspiration. Significant differences in preoperative to postoperative swallowing outcomes were noted for Penetration-Aspiration Scale scores (P < .0001), unsafe swallowing (40% vs 86%; χ2 = 12.8; P = .0003), and aspiration (6% vs 23%; χ2 =6; P = .01). No differences in VFMI were noted preoperatively to postoperatively (partial VFMI, 9% vs 23%; P > .05). CONCLUSIONS: A 4-fold increase in aspiration was observed in CS patients. No cases of vocal fold paralysis were observed across time points. These data highlight the utility of instrumental laryngoscopic evaluations during the acute postoperative phase.

Neopharyngeal Stricture following Laryngectomy.

Stricture formation is a serious complication following pharyngeal reconstruction. These strictures can be life-threatening and can severely impact quality of life. In this article, the existing literature on surgical risk factors linked to neopharyngeal stricture formation is reviewed. Intraoperative preventative measures reconstructive surgeons should consider are also discussed. Finally, this article will describe the evaluation and management of pharyngoesophageal strictures, including the challenges and options when dealing with refractory strictures.

The tough tracheoesophageal puncture.

EDUCATIONAL OBJECTIVE: At the conclusion of this presentation, the participants should be aware of the technique and success of in-office transnasal esophageal (TNE)-guided tracheoesophageal puncture (TEP) placement in patients who have failed prior attempts in the operating room or are not healthy enough to undergo general anesthesia. OBJECTIVES: The aim of this study was to demonstrate the technique of TEP, which can be completed safely in an office setting when patients are not able to undergo general anesthesia due to medical comorbities or have previously had an unsuccessful attempt at TEP placement in the operating room due to anatomical reasons. STUDY DESIGN: This study is a retrospective chart review from 2007 to 2011. METHODS: A total of 13 outpatient adults with a history of total laryngectomy presenting to the laryngology clinic for TEP after either failing prior placement in the operating room or not being able to undergo general anesthesia due to medical comorbities were identified. In-office TNE-guided TEP placement was performed on all 13 patients. RESULTS: All subjects underwent successful TNE-guided TEP placement in the office. Complications included 1 possible false passage and 1 case of cellulitis. CONCLUSIONS: Patients who could not undergo TEP placement in the operating room due to poor exposure or medical comorbities were able to successfully undergo the procedure in an office setting with good results.

Upper Esophageal Dysphagia.

Esophageal dysphagia presents acutely, most frequently as a food impaction, or in a progressive fashion. Anatomic changes are frequently responsible. Although the history may be suggestive, diagnosis is made from imaging or endoscopic studies. In asymptomatic cases, observation is most appropriate. Treatment is frequently accomplished endoscopically. Strictures, cricopharyngeal hyperfunction, and Zenker diverticulum are potential etiologic causes. For the purpose of this article focused on upper esophageal dysphagia, delineation between the upper and lower parts is the crossing of the aortic arch but also includes the most distal aspects of the hypopharynx including the inferior pharyngeal constrictors and upper esophageal sphincter.

Reflex vs. volitional cough differences amongst head and neck cancer survivors characterized by time since treatment and aspiration status.

BACKGROUND: The aim of this study was to investigate differences in reflexive and volitional cough airflows in advanced stage head and neck cancer survivors as it relates to aspiration status and time since treatment. The hypothesis is that those who aspirate several years after treatment completion would demonstrate reduced airflows for all cough parameters compared to those recently status post treatment completion given the known progressive deterioration associated with radiotherapy. METHODS: Demographic and airflow data during both reflexive and volitional cough tasks and aspiration status as determined during fiberoptic endoscopic evaluation of swallow function were collected from 33 Head and Neck Cancer (HNC) survivors. RESULTS: Omnibus MANOVA for dependent airflow variables and independent variables aspiration status, time since treatment and cough type (reflex or volitional) was significant (F(3,1) = 184, p < 0.000) indicating that peak expiratory flow rates (PEFR) were reduced under reflex (mean PEFR 1.88 SD 0.7) versus volitional (mean PEFR 2.3, SD 0.7) cough types; reduced for aspirators versus non-aspirators (F(2,1) = 4.1, p = 0.04) and reduced for those in the subacute versus chronic phase status post Intensity Modulated Radiotherapy (IMRT) (F(2,1) = 10.05, p = 0.002). CONCLUSION: Findings of reduced reflexive compared to volitional cough airflows in head and neck cancer survivors are consistent with those from both healthy and other diseased populations. Additional findings that aspirators demonstrate reduced cough airflows compared to non-aspirators supports the hypothesis. Surprisingly, those recently status post treatment completion show worse cough airflows compared to those remotely status post treatment completion.

Vocal Fold Mobility Impairment After Cardiovascular Surgery: Incidence, Risk Factors, and Sequela.

BACKGROUND: We aimed to determine the incidence and contributing risk factors of vocal fold mobility impairment (VFMI) in postoperative cardiovascular patients and evaluate the impact of VFMI on health-related outcomes. METHODS: This single-site prospective study enrolled adults undergoing sternotomy or thoracotomy procedures who underwent a fiberoptic laryngoscopy examination within 72 hours of extubation. Potential demographic and surgical risk factors and health-related outcomes were collected. A blinded laryngologist assessed VFMI and mucosal injury. Descriptives, univariate and multivariable regression analyses with odds ratios (OR) were performed. RESULTS: Of 185 eligible examinations, VFMI was confirmed in 25% of patients (7 complete, 39 partial VFMI) with left-sided involvement in 83% of cases. Laryngeal mucosal injury included granuloma (38%), posterior cricoid hypertrophy (37%), edema (29%), bruising (23%), and hemorrhage (9%). Independent risk factors for complete VFMI were aortic arch procedure (odds ratio 6.1), body mass index less than 25 (OR: 7.2), and African-American or Hispanic race (OR: 6.0). Patients with two or more identified risk factors had a 33.0 increased odds of complete VFMI compared with patients not having two or more risk factors. Compared with patients having normal vocal fold motion, patients with complete VFMI had a 2.7 increased odds of pneumonia, 5.7 higher odds of reintubation, a 7.3 times higher odds of death, and increased length of hospital stay and cost of care (P < .05). CONCLUSIONS: Interdisciplinary postoperative care and laryngoscopy examination are recommended for high-risk patients to facilitate early detection and improve patient outcomes.

Human papilloma virus-associated metachronous squamous cell carcinoma of the larynx and uterine cervix: Case report and review of the literature.

60 year old woman with a history of laryngeal carcinoma-HPV 16 positive, presents seven years later with an abnormal Pap smear. Cervical biopsy showed squamous cell carcinoma. Clinical stage was IB1. Patient underwent open radical hysterectomy and lymphadenectomy. Based on pathologic findings no adjuvant therapy was recommended. Uterine cervix carcinoma was also positive for HPV-16. There are no guidelines for cervical cancer screening in patients with laryngeal cancer and vice versa. Our recommendation is that patient with HPV-positive laryngeal cancer should be encouraged HPV vaccine as current guidelines, but more frequent screening, as recommended for women with specific co-morbid conditions, needs to be investigated. Research is needed to assess the role of screening for laryngeal cancer in women with cervical cancer and the effect of HPV vaccine on laryngeal cancer prevention.

Impact of Tussigenic Stimuli on Perceived Upper Airway Sensation and Motor Cough Response Following Total Laryngectomy.

BACKGROUND: Total laryngectomy (TL) is standard intervention for carcinoma of the head and neck or, in cases of non-functional larynx, as a result of disease or radiation exposure. Laryngeal extirpation serves as a unique human model of both recurrent and superior laryngeal nerve section and offers insight into motor and sensory aspects of cough: both volitional and in response to tussigenic stimuli. While motor changes in cough function are expected among those status post-TL due to postoperative reconstruction of the upper airway, motor cough parameters have not been well described and sensory aspects of cough are unknown in this population, which provides insight into a vagal denervation model in humans. METHODS: Data were collected from three groups totaling 80 adults (39 male), including 25 healthy younger adults (HYA), 27 healthy older adults (HOA), and 28 adults post-TL. Cough was elicited both upon command and in response to nebulized capsaicin. Outcome measures included urge to cough and cough airflows. RESULTS: Kruskal-Wallis test showed that two of the three groups differed significantly by urge to cough χ2(2, N = 244) = 8.974, p = 0.011. Post hoc analysis showed that post-TL subjects had reduced perceived urge to cough at all concentrations of capsaicin (p < 0.05). Cough airflows were significantly reduced for post-TL subjects compared to healthy controls in all metrics except post-peak phase integral (PPPI) for which HOA and TLs were comparable under both volitional and capsaicin-induced conditions. CONCLUSIONS: These findings support the hypothesis that both cough airflow and sensations are significantly reduced in post-TL subjects when compared with HOA. Interestingly, HOA and post-TL subjects have comparably reduced UTC and cough airflows when compared to HYA. The only metric of cough airflow for which these groups differ is the PPPI, which may be a compensatory adaptation for reduced cough airflows and/or sensation.

Curative-intent radiotherapy for glottic carcinoma in situ.

BACKGROUND: The aim of the study was to update our experience treating patients with glottic carcinoma in situ (CIS) with curative radiotherapy (RT). METHODS: Fifty patients received continuous-course RT using once-daily fractionation. Twenty-eight (56%) had recurrent or persistent CIS after resection. Median total dose was 63.0 Gy; median dose per fraction was 2.25 Gy. Median follow-up was 9.6 years for all patients and 8.4 years for survivors. RESULTS: After RT, 5 patients (10%) recurred locally; salvage surgery was performed in 4 (1 refused). Five-year outcomes were as follows: local control, 91%; ultimate local control (including patients successfully salvaged after local recurrence), 100%; ultimate local control with larynx preservation, 93%; local-regional control, 91%; ultimate local-regional control, 100%; distant metastases-free survival, 100%; cause-specific survival, 100%; and overall survival, 81%. No patient experienced a severe complication. CONCLUSION: RT is an excellent treatment for patients with CIS recurrent after transoral excision and those with previously untreated CIS who are unsuitable for partial laryngectomy.

The pain of nasal tampon removal after nasal surgery: a randomized control trial.

OBJECTIVE: The purpose of this study was to compare the pain and discomfort associated with the removal of two commercially available nasal tampons after nasal surgery. STUDY DESIGN: Prospective, paired, randomized clinical trial. SUBJECTS: Consecutive, consenting, adult patients undergoing nasal surgery. INTERVENTIONS: The nose was packed with a Rapid Rhino tampon (Applied Therapeutics, Tampa, FL) on one side and a Rhino Rocket tampon (Shippert Medical Technologies Corporation, Centennial, CO) on the other. OUTCOMES: The pain of packing removal was assessed with a validated 100-mm visual analog scale. Patient satisfaction was measured on a Likert scale from 1 to 5. RESULTS: In all 13 patients, the pain of removal was greater with the Rhino Rocket Tampon (82.7 +/- 20.9 mm) than with the Rapid Rhino tampon (12.0 +/- 11.9 mm); the mean difference was 70.7 mm (95% confidence interval [CI], 47.1-78.2 mm; P < 0.0001). Patient satisfaction was significantly higher with the Rapid Rhino nasal tampon (4.6 +/- 1.1 vs 1.5 +/- 0.7; mean difference 3.1 [95% CI, 2.6-3.6]; P < 0.001). CONCLUSIONS: Removal of the Rapid Rhino nasal tampon was significantly less painful and was associated with higher patient satisfaction than the removal of the Rhino Rocket nasal tampon.

Normal values for pharyngeal pH monitoring.

OBJECTIVES: We performed a prospective study of asymptomatic adult volunteers to establish normative values of pharyngeal pH using a novel pH probe. METHODS: The Dx-pH probe is a novel pH device capable of measuring liquid and aerosolized acid levels. Twenty asymptomatic patients (Reflux Symptom Index less than 10 and Reflux Finding Score less than 6) underwent simultaneous investigation with this probe placed in the oropharynx and a dual antimony probe placed in the hypopharynx and esophagus. The reflux parameters measured from the oropharyngeal probe included the percentage of time and the number of events in which the pH was less than 5.5,5.0,4.5, and 4.0. RESULTS: The upper limits of normal (95th percentile) for the number of events below pH of 5.5, 5.0, 4.5, and 4.0 per 24-hour period were 16.6, 10.7, 7.4, and 0.2, respectively. The upper limits of normal (95th percentile) for an acid exposure time below pH of 5.5, 5.0, 4.5, and 4.0 per 24-hour period were 820 seconds, 385 seconds, 75 seconds, and 3 seconds, respectively. CONCLUSIONS: Normative pharyngeal pH values are presented. Further studies are required to determine clinical relevance.

Endoscopic Dilation of Refractory Postlaryngectomy Strictures: A Case Series and Literature Review.

BACKGROUND: Endoscopic dilation of postlaryngectomy strictures (PLS) is safe and effective; however, PLS are often refractory and require serial dilations. Long-term outcomes of dilation in patients with refractory PLS are not well reported. MATERIALS AND METHODS: Seven patients with dysphagia and refractory PLS underwent serial endoscopic dilation therapy during a 4.5-year period. Dilation characteristics, technical success, clinical success, and diet advancement (as assessed by Diet/GT scale) were measured. Results. All strictures were complex, and there were no reported complications. The median number of dilations per patient was 12 (range 7 to 48). The average interval in between dilations was six weeks. Technical success was achieved in 6/7 patients, and clinical success was achieved in 2/7 patients. 6/7 patients had advancements in Diet/GT scores. CONCLUSIONS: Dilation of refractory PLS is safe and effective and frequently requires the use of a retrograde approach, fluoroscopic guidance, and/or lumen patency strings. Serial dilations are required to maintain luminal patency, relieve dysphagia, and advance oral diet. The definition of clinical success of dilation in these patients should avoid the use of a specific time interval between dilations to characterize success.

Patient compliance with proton pump inhibitor therapy in an otolaryngology practice.

OBJECTIVES: Proton pump inhibitors (PPIs) are used for the treatment of numerous otolaryngological disorders. It has been demonstrated that administration of the medication 15 to 45 minutes before a meal optimizes acid suppression. The rate of compliance with optimal PPI dosage patterns in an otolaryngology practice is not known. We sought to determine the rate of PPI compliance in patients seen in an otolaryngology practice. METHODS: We conducted an interview at a tertiary voice and swallowing center of 200 consecutive patients who were taking PPIs. RESULTS: Overall, 54% of patients took their PPI in an optimal manner. The rate of compliance was significantly higher for patients who had their PPI prescribed by an otolaryngologist (62%) than for patients whose PPI was prescribed by a non-otolaryngologist (40%). CONCLUSIONS: Nearly half of all patients seen at a voice and swallowing center were not compliant with optimal PPI usage. This percentage is similar to that found for other long-term medications. Patient education can lead to higher rates of compliance, improved acid control, and possibly improved treatment outcomes.

Inflammatory myofibroblastic tumor of the epiglottis excised with a carbon dioxide laser: Case report and literature review.

Inflammatory myofibroblastic tumor (IMT) is a benign neoplasm of intermediate biologic potential. It rarely occurs in the larynx, and it has not been previously reported in the epiglottis. We treated a 66-year-old woman who presented with progressive dysphonia and a mass on her suprahyoid epiglottis. The tumor was completely excised with a CO2 laser; no adjuvant therapy was administered. Histopathology revealed that the mass was an IMT. No evidence of recurrence was noted after 6 months of follow-up. We present what we believe is the first case of an epiglottic IMT to be reported in the literature, and we propose CO2 laser excision without adjuvant therapy as an acceptable treatment.

Incidence of vocal cord paralysis with and without recurrent laryngeal nerve monitoring during thyroidectomy.

OBJECTIVE: To compare the incidence of postoperative vocal cord paresis or paralysis in a cohort of patients who underwent thyroidectomy with and without continuous recurrent laryngeal nerve (RLN) monitoring by a single senior surgeon. We hypothesize that continuous RLN monitoring reduces the rate of nerve injury during thyroidectomy DESIGN: Retrospective medical chart review. SETTING: Academic tertiary care medical center. PATIENTS: A total of 684 patients (1043 nerves at risk) who underwent thyroid surgery under general anesthesia. MAIN OUTCOME MEASURE: Incidence of vocal cord paresis or paralysis in patients who underwent thyroid surgery with continuous RLN monitoring vs those undergoing surgery without continuous RLN monitoring. RESULTS: The incidence of unexpected unilateral vocal cord paresis based on RLNs at risk was 2.09% (n = 14) in the monitored group and 2.96% (n = 11) in the unmonitored group. This difference was not statistically significant. The incidence of unexpected complete unilateral vocal cord paralysis was 1.6% in each group. Two of the 5 paralyses in the unmonitored group and 7 of the 11 paralyses in the monitored group had complete resolution. CONCLUSIONS: Monitoring of the RLN does not appear to reduce the incidence of postoperative temporary or permanent complete vocal cord paralysis. There appeared to be a slightly lower rate of postoperative paresis with RLN monitoring, but this difference was not statistically significant.