Socioeconomic Influence on Speech Rehabilitation After Total Laryngectomy.

OBJECTIVE: Speech rehabilitation following a total laryngectomy significantly impacts the quality of life. Indwelling prosthetic voice restoration provides optimal outcomes; however, the long-term maintenance of these devices carries considerable financial costs, which are not universally covered by insurance. This investigation aimed to analyze associations between socioeconomic factors and outcomes in postlaryngectomy speech rehabilitation. STUDY DESIGN: Retrospective cohort analysis. SETTING: Academic tertiary-care center from May 2014 to September 2021. METHODS: In patients undergoing total laryngectomy, the incidence of tracheoesophageal puncture with indwelling vocal prostheses (TEP-VP) placement within the first postoperative year was compared among household income, demographic factors, and disease characteristics. Functional and maintenance outcomes served as secondary endpoints. RESULTS: Seventy-seven patients were included. Forty-five (58%) underwent indwelling TEP-VP (41 primaries). Eighty-nine percent of patients with annual incomes greater than $50k underwent TEP-VP compared to only 35% with incomes less than $50k/year. TEP-VP was performed in 85% of patients with commercial insurance, 70% with Medicare, 42% with Medicaid, and 0% with no insurance. On multivariate analysis, annual household incomes greater than $50k were predicted for TEP-VP placement (odds ratio: 12.7 [2.45-65.8], p = .002). The utilization of postoperative speech therapy and functional communication outcomes were similar among socioeconomic groups. Twelve patients were unable to afford supplies within the first year, with differences noted among insurance (p = .015) and income status (p = .003). CONCLUSION: Disparities in vocal and speech rehabilitation following laryngectomy may disproportionally affect underserved patients.

Improving Outpatient Follow-Up Rates for New In-Hospital Consults.

OBJECTIVE(S): This investigation aimed to define the rate of outpatient follow-up after in-hospital consultation, identify factors associated with establishing care, and evaluate an alternative scheduling process to improve outpatient adherence. METHODS: Two-phase, prospective study at an academic, tertiary-care institution from March 2020 to August 2022. First, all patients not previously known to our practice encountered via inpatient consult who warranted outpatient follow-up were prospectively captured. Logistic regression analysis was used to identify demographic, disease, and practice factors predictive of follow-up. Second, a randomized control trial was performed to validate the effects of pre-assigning appointments prior to discharge. RESULTS: Six hundred subjects were included in the final study cohort; 500 in phase-one, and 100 randomized during phase-two. In the phase-one cohort, 54% (n = 272) were lost to follow-up. Multivariate analysis showed increased odds of outpatient follow-up when appointments were pre-assigned before discharge (odds ratio [OR]: 3.69 [95% confidence interval [CI]: 2.29-5.96], p < 0.001), the primary reason for hospitalization was ENT and consult-related (OR: 3.29 [1.92-5.64], p < 0.001), and the diagnosis was one of Oncology (OR: 1.93 [1.02-3.69], p = 0.045) or Pediatrics (OR: 3.36 [1.41-7.98], p = 0.006) subspecialties. During phase-two, subjects randomized for pre-assigned appointments had higher outpatient follow-up (82%) compared to the control group (20%) (p < 0.001). CONCLUSION: Hospital-based consultations represent an important referral pathway for new patients. Disease characteristics may identify patients less likely to follow-up upon discharge. Appointment scheduling protocols, including pre-assigning appointments, are modifiable targets for improving adherence to care. Laryngoscope, 133:2540-2545, 2023.

When "Stay" Sutures Stay.

Chronic airway foreign bodies represent a rare and challenging entity faced by otolaryngologists. Herein, we describe the case of an adult woman found to have a 17 cm-long internalized tracheostomy stay suture retained 2 years after decannulation. Thorough evaluation and contingency planning allowed for safe and successful removal of this novel airway foreign body. The selective use of stay sutures in adult tracheostomies and proper peri-operative care may have prevented its incidence.

Microdeletion of 17q22q23.2 encompassing TBX2 and TBX4 in a patient with congenital microcephaly, thyroid duct cyst, sensorineural hearing loss, and pulmonary hypertension.

Microdeletions of the long arm of chromosome 17 are being reported with increasing frequency. Deletions of 17q22q23.2 may represent a genetically recognizable phenotype although its spectrum of genomic abnormalities, clinical manifestations, and critical regions are not fully delineated. Isolated reports and small case series suggest that deletions of 17q22q23.2 result in haploinsufficiency of dosage sensitive genes NOG, TBX2, and TBX4, which may be responsible for many aspects of the phenotype. Shared clinical features in this group of patients include microcephaly, prenatal onset growth restriction, heart defects, tracheoesophageal fistula, and esophageal atresia (TEF/EA), skeletal anomalies, and moderate to severe global developmental delay. We describe a female patient who presented with severe congenital microcephaly, thyroglossal duct cyst, sensorineural hearing loss, mild tracheomalacia, abnormal auricles, pulmonary hypertension, developmental delay, and postnatal onset growth delay. She had no TEF/EA or heart defects. Using a high density oligonucleotide microarray, we identified a microdeletion at 17q22q23.2, resulting in the heterozygous loss of several genes, including TBX2 and TBX4 but not NOG. The breakpoints did not lie within known segmental duplications. This case helps to further delineate the critical region for TEF/EA, which is likely confined to the chromosomal region proximal to 17q23.1, and suggests that genes in 17q23.1q23.2 may be associated with thyroglossal duct cysts. The role of TBX2 and TBX4 in pulmonary hypertension warrants investigation.

Pediatric endoscopic airway management with posterior cricoid rib grafting.

OBJECTIVES/HYPOTHESIS: To confirm and extend reported successful treatment of posterior glottic stenosis in pediatric patients using endoscopic laser division of the posterior cricoid plate with augmentation using costal cartilage. STUDY DESIGN: A retrospective chart review and case series. METHODS: Medical records were examined to determine the surgical indications, outcomes, and postoperative complications of this procedure. RESULTS: Twelve patients underwent the procedure, six females and six males, with an average age of 7 years (range, 2-26 years). There were 8/12 (67%) patients successfully decannulated after being tracheostomy dependent. There were no consistent anatomic abnormalities or surgical findings predictive of failure to decannulate. Average hospital stay was 3.6 days (range, 2-9 days). There were no deaths or other major complications; one patient had extrusion. CONCLUSIONS: Endoscopic posterior cricoid grafting is a valuable surgical option for patients with posterior glottic stenosis. The procedure is associated with low morbidity and permits decannulation in the majority of patients.

Characterization of bacterial biofilms on tracheostomy tubes.

OBJECTIVES/HYPOTHESIS: To characterize the structure and microbial content of biofilms found on tracheostomy tubes. To determine the correlation between the patients' clinical condition and biofilm content. STUDY DESIGN: Prospective observational series. METHODS: Tracheostomy tubes were collected from patients in both the inpatient and outpatient setting at an urban academic medical center. Sections of the tracheostomy tubes were evaluated by confocal microscopy and bacteria from them plated and identified. The number of colony forming units (CFUs) and species present were determined and a univariate analysis performed to correlate them with various clinical factors. RESULTS: Bacteria were cultured from 19 of the 21 tracheostomy tubes collected. There were between 1 x 10(6) and 1 x 10(10) CFUs present in each of the 2 mm sections. Twelve different bacterial species and one fungus were isolated from culture and speciation. The number of bacteria isolated and the CFUs calculated varied in tubes obtained from the same patient at different times. CONCLUSIONS: Biofilms were present on tracheostomy tubes in greater than 90% of tracheostomy tubes collected as early as 7 days after insertion in both the inpatients and outpatients. Although a variety of bacteria were identified in the biofilm, they often appeared as discrete microcolonies that appeared to be monospecies biofilm on confocal microscopy. There was a statistically significant inverse correlation between the number of colony forming units found and frequency of inner cannula change.