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.

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.

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.

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.

Laryngeal actinomycosis in an immunocompromised patient.

Actinomycosis of the larynx represents an unusual presentation for a common bacterium comprising the oral and oropharyngeal florae. There are few cases reported in the literature of laryngeal actinomycosis occurring primarily in the immunocompromised population. Here, we present a case in a 74-year-old man that occurred in the setting of neutropenia as a result of chemotherapy. Once the diagnosis was made with biopsy of the larynx, the infection was resolved after a prolonged course of penicillin-based therapy.

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.

Tracheocele: an unusual cause of dysphonia.

EDUCATIONAL OBJECTIVES: Describe the clinical presentation and management of tracheoceles. STUDY DESIGN: Retrospective case review and review of the medical literature. RESULTS: A 56 year old female patient presented with progressive dysphonia and history of benign thyroid nodules. Flexible laryngoscopy revealed a severely paretic right true vocal cord. Computed tomography revealed a right sided air filled sac in the tracheoesophageal groove suspicious for causing compression of the right recurrent laryngeal nerve. The patient underwent an elective right hemithyroidectomy and resection of the air filled sac. Post operative pathology of the air filled sax was consistent with a tracheocele. A laryngoscopy performed 6 months postoperatively demonstrated recovery of right cord function. CONCLUSIONS: Tracheoceles are an uncommon entity first described in 1846 by Rokitansky (1) with only a paucity of case reports in the literature describing the surgical management and treatment of this disease. Herein, we report a patient who presented with dysphonia from a tracheocele in the right tracheoesophageal groove who subsequently underwent surgical resection ultimately improving vocal cord function.

Nasopharyngeal amyloidosis: a case report.

Nasopharygeal amyloidosis is a rare entity described in the otolaryngology literature. It is usually isolated and does not represent a manifestation of systemic disease. Herein we discuss the first reported case of incidentally discovered nasopharyngeal amyloidosis leading to the diagnosis of systemic disease. A patient presented to the otolaryngology clinic with complaints of otalgia and eustachian tube dysfunction. He was noted to have a unilateral middle ear effusion and subsequent nasolaryngoscopy demonstrated a right nasopharyngeal mass at the eustachian tube orifice--this was biopsied and shown to be nasopharyngeal amyloidosis. Amyloidis is a condition which entails the abnormal deposition of proteins in tissue (local) and organs (systemic) throughout the body secondary to an alteration in the secondary structure of the protein into an insoluble form, termed amyloid. Amyloidosis in the head and neck most often presents in the larynx (60%), followed by the trachea (9%), orbit (4%), and nasopharynx (3%). The vast majority of these lesions represent isolated amyloidosis, which is not associated with a shortened lifespan or the sequelae associated with systemic disease. Treatment of local disease is typically excision followed by routine surveillance for recurrence. Treatment of systemic disease is complex, and should be managed by a Hematologist/Oncologist. Amyloidosis can be associated with malignancy, thus proper workup is important even when isolated lesions are discovered.

Revision laryngeal surgery for the suboptimal injection of calcium hydroxylapatite.

OBJECTIVE: The objective of this study was to describe the management of suboptimal injection of calcium hydroxylapatite during augmentation laryngoplasty. STUDY DESIGN: A retrospective review was conducted at four Voice and Swallowing centers to identify patients who had a suboptimal injection of calcium hydroxylapatite during augmentation laryngoplasty. RESULTS: Five patients (ages 19-75) were identified with an impaired voice secondary to a superficial injection of calcium hydroxylapatite or over-medialization of the true vocal fold. All patients underwent revision surgery with all experiencing subjective and objective improvement. CONCLUSION: Microflap excision can lead to successful return of vibratory function after a suboptimal injection of calcium hydroxylapatite. Complete control of the initial injection is paramount to avoiding this complication.

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.