Closure of Tracheocutaneous Fistulae in Patients With Challenged Wound Healing.

OBJECTIVE: To describe and evaluate the surgical outcomes of multilayered closure of persistent tracheocutaneous fistulae (TCF) in patients with challenged wound healing. METHODS: A retrospective chart review of all patients who underwent closure of TCF by the senior author between October 2011 and December 2021 was performed. Age, body mass index (BMI), time between decannulation and TCF repair, medical comorbidities, procedure duration, length of hospitalization, and postoperative complications were recorded. The primary outcomes were closure of the fistula, postoperative subcutaneous emphysema, pneumomediastinum, pneumothorax, wound infection, or breakdown. Outcomes of patients with and without challenged wound healing were compared. RESULTS: Thirty-five patients who underwent TCF repair during the study period were identified. The mean age and BMI were 62.9 years and 28.43 respectively. Twenty-six (74%) patients met criteria for challenged wound healing at the time of the TCF repair. There was 1 (3.84%) minor complication in the challenged wound healing group and none (0%) in the control group (P = 1.00). No patients experienced wound breakdown or air leak noted on exam or chest radiography. CONCLUSION: Multilayered closure of persistent tracheocutaneous fistulae is a simple technique which is safe and effective even in patients with challenged wound healing.

Reversible Bevacizumab Induced Vocal Fold Necrosis.

BACKGROUND: As the use of anti-angiogenic treatments is gaining scope in the treatment of various malignancies, there are increasing reports of laryngeal side effects. We report two cases of laryngeal necrosis and dysphonia. METHODS: Two patients with gynecological malignancies presented with severe dysphonia 11-24 months after initiation of bevacizumab therapy. Videostroboscopic examination of the larynx revealed bilateral ulcerations and eschar of the superior surface with absent mucosal waves. RESULTS: Patients were treated with discontinuation of the bevacizumab, vocal rest, and proton pump inhibitors. Both had improvement in voice and resolution of the eschar and ulceration. Shallow sulci and mild breathiness persisted in one patient. CONCLUSION: With increasing use of potent systemic anti-angiogenic compounds, clinicians should be vigilant of this important complication of therapy. Time to onset of symptoms and reversibility of symptoms vary by patient and require further study. There may be long-term voice sequelae.

A Novel Low-Cost Technique to Allow for Jet Ventilation.

BACKGROUND/OBJECTIVE: Traditional jet ventilation requires the use of a catheter that is inserted either through an endotracheal tube or laryngoscope. Specially designed laryngoscopes with a built-in luer lock adapter to which the high-pressure tubing may be attached exist but are not always available. We present our experience with an adapter which allows connection of the high-pressure tubing to the suction side port of suitable laryngoscopes that is easily assembled using readily available materials in the operating room. METHOD: We designed a jet ventilator adapter using a high-pressure jet ventilation tubing assembly and a 3-way stopcock extension set which we have used for the past 13 years. A retrospective case series of all adult patients who underwent direct laryngoscopy and/or bronchoscopy using this jet ventilation adapter between January 2017 and August 2021 was performed. RESULT: A total of 100 consecutive patients underwent laryngoscopy and bronchoscopy using jet ventilation between January 2017 and August 2021 was identified. The mean age was 56.3 years, and the mean BMI was 31.2. The most common diagnoses were idiopathic subglottic/tracheal stenosis (46.4%), acquired tracheal stenosis (34.1%), and acquired subglottic stenosis (14.8%). The median duration of the surgical procedure was 53 minutes with an interquartile range of 23. The CO2 laser was used in all cases. There was no disconnection of the adapter, episodes of postoperative respiratory compromise, or extraluminal air on chest radiography for any of our cases. Oxygen saturations remained above 90% intraoperatively for all cases. CONCLUSION: Our simple jet ventilator adapter connects the jet ventilator to the suction side port of suitable laryngoscopes and eliminates the need for a jet ventilation catheter or specialized laryngoscope at a minimal cost.

Postoperative management of Zenker's diverticulum: Results of the American Bronchoesophagological Association survey.

INTRODUCTION: Although treatment of Zenker's diverticulum (ZD) is commonly performed by otolaryngologists using a variety of surgical techniques, there is little published data on the postoperative management of patients. We sought to determine practice patterns among members of the American Bronchoesophagological Association (ABEA) after surgery for ZD. METHODS: An online questionnaire was designed via JotForm™ and subsequently sent to active members of the ABEA. Responses were analyzed using descriptive statistics. RESULTS: Twenty-three members (6.6 %) completed the survey. Most (73.9 %) were fellowship trained in laryngology and reported performing >5 procedures per year. Most laryngologists reported employing multiple techniques including transcervical (TC) (73.9 %), endoscopic stapling (ES) (65.2 %), endoscopic CO2 laser (EL) (56.5 %), and endoscopic harmonic scalpel (EH) (4.3 %). Postoperatively, 52.3 % of respondents placed patients in 23-hour observation after TC, 66.7 % after ES, 69.2 % after EL, and 100 % after EH. 47.1 % of respondents used standard overnight admission after TC, as compared to 13.3 % after ES, 23.1 % after EL and 0 % after EH. Postoperative esophagography was utilized by 70.6 % of respondents after TC, 20 % after ES, 38.5 % after EL, and 100 % after EH. A peroral diet was started postoperatively on the day of surgery by 26.7 % respondents after ES but not after any of the other techniques. CONCLUSION: Most laryngology trained respondents employ multiple techniques for the treatment of ZD including at least 1 endoscopic technique. Respondents were more likely to hospitalize patients after a transcervical than endoscopic approach. Postoperative esophagography was utilized in most patients after TC, but not after ES or EL. Most respondents admit patients for 23-hour observation and start a peroral diet on postoperative day 1 regardless of technique.

COVID-19 Tracheostomy Outcomes.

OBJECTIVES: (1) Assess overall COVID-19 mortality in ventilated patients with and without tracheostomy. (2) Determine the impact of tracheostomy on mechanical ventilation duration, overall length of stay (LOS), and intensive care unit (ICU) LOS for patients with COVID-19. STUDY DESIGN: Case series with planned chart review. SETTING: Single-institution tertiary care center. METHODS: Patients with COVID-19 who were ≥18 years old and requiring invasive positive pressure ventilation (IPPV) met inclusion criteria. Patients were stratified into 2 cohorts: IPPV with tracheostomy and IPPV with intubation only. Cohorts were analyzed for the following primary outcome measures: mortality, LOS, ICU LOS, and IPPV duration. RESULTS: An overall 258 patients with IPPV met inclusion criteria: 46 (18%) with tracheostomy and 212 (82%) without (66% male; median age, 63 years [interquartile range, 18.75]). Average LOS, time in ICU, and time receiving IPPV were longer in the tracheostomy cohort (P < .01). Ability to wean from IPPV was similar between cohorts (P > .05). The number of deaths in the nontracheostomy cohort (54%) was significantly higher than the tracheostomy cohort (29%, P < .01). CONCLUSIONS: While tracheostomy placement in patients with COVID-19 did not shorten overall LOS, mechanical ventilation duration, or ICU LOS, patients with a tracheostomy experienced a significantly lower number of deaths vs those without. One goal for tracheostomy is improved pulmonary toilet with associated shortened IPPV requirements. Our study did not identify this advantage among the COVID-19 population. However, this study demonstrates that the need for tracheostomy in the COVID-19 setting does not portent a poor prognostic factor, as patients with a tracheostomy experienced a significantly higher survival rate than their nontracheostomy counterparts.

Factors Contributing to Late Cancellation and No-Show for Otolaryngologic Surgery: A Prospective Study.

PURPOSE: Late cancellations and no-shows for surgery place a burden on patients, healthcare providers, and the health system. We aim to identify risk factors contributing to this phenomenon. METHODS: Patients who did not arrive for, or canceled within 24 hours of, their surgical appointment between January 2019 and 2020 were identified. Controls were matched by date, procedure, and gender. Demographic information was obtained by phone interview and chart review. Chi-square and Student t-test analyses were used to predict risk factors for cancellation. RESULTS: Thirty-one patients were identified, of whom 21 completed phone interviews. Age, gender, race, language, marital status, and smoking status were not significantly different. Study patients reported more transportation challenges (33.3% vs. 4.8%, p = .01) yet lived closer to the hospital (4.53 miles vs. 14.05 miles, p = .01). Study patients lived in lower income zip codes ($48,145 vs. $63,406, p = .02) and more commonly had Medicaid as their primary insurance (70.9% vs. 38.7%, p = .04). Most commonly, no reason was given for cancellation (22.6%) followed by personal reasons (16.1%) and surgery reconsideration (16.1%). CONCLUSIONS: Transportation trouble and lower income are significant risk factors for surgery late cancellation. Prior no-show must also be considered. A targeted pilot program may help prevent late cancellations.

Tongue symptoms, suspension force and duration during operative laryngoscopy.

PURPOSE: Suspension laryngoscopy is a commonly performed procedure in otolaryngology. During the procedure, the laryngoscope applies direct force to the tongue. Postoperative tongue symptoms include pain, swelling, numbness, taste disturbance, and rarely motor deficits. Duration and magnitude of force applied have previously been associated with post-operative throat and tongue pain, respectively. We sought to correlate postoperative tongue symptoms with magnitude of force applied and/or duration of suspension and investigate any risk factors for tongue morbidity. MATERIALS AND METHODS: A sample of patients undergoing suspension laryngoscopy between 2015 and 2018 were prospectively recruited. Those with preexisting tongue symptoms, disease or surgery were excluded. Patients completed preoperative and postoperative questionnaires evaluating tongue swelling, numbness, motion and taste disturbance. Symptoms were subjectively scored on a visual scale from 0 to 10. Patient demographics, past medical and social history were also recorded. Intraoperative pressures were measured using a spring force scale, positioned between the suspension arm and Mayo stand. Initial and end suspension forces and duration of suspension were recorded. RESULTS: 120 patients met inclusion criteria, of which 63 completed both preoperative and postoperative questionnaires. 6 patients (9.5%) experienced postoperative tongue symptoms. Suspension force and duration of suspension were not significantly predictive of postoperative tongue symptoms. While all symptomatic patients were current or former cigarette smokers, smoking status was not found to be a statistically significant factor. CONCLUSIONS: Neither suspension forces nor duration of suspension were predictive of postoperative tongue morbidity. Further research is needed to evaluate the role of smoking status on postoperative tongue symptoms.

Air Pollution and Angioedema.

OBJECTIVE: To identify environmental factors that may precipitate angioedema. STUDY DESIGN: Case series with chart review. SETTING: An urban tertiary care medical center. SUBJECTS AND METHODS: After institutional review board approval was obtained, a chart review of all patients who presented to Temple University Hospital with angioedema from January 2012 to December 2014 was performed. Patient demographics and hospital course were gathered. Environmental data on the dates of presentation, including precipitation, humidity, and air pollution, were obtained from regional Environmental Protection Agency online data banks and used for statistical analysis. RESULTS: In total, 408 patients, representing 450 episodes of angioedema, met the inclusion criteria for the study. Most patients were female (58%), African American (74%), and on an angiotensin-converting enzyme inhibitor (ACE-I) upon presentation (61%). Days with unhealthy levels of air pollution were associated with an increased likelihood of angioedema presentation (odds ratio [OR], 1.82; confidence interval [CI], 1.01-3.30; P = .046). Subgroup analysis revealed that elevated ground-level ozone was the primary air pollutant significantly associated with angioedema presentations (OR, 4.95; CI 1.92-12.76; P = .0009). Higher ground-level ozone was also associated with ACE-I angioedema presentations (P = .017) but not with non-ACE-I angioedema presentations (P = .86). Air quality was not predictive of angioedema severity or need for intubation. CONCLUSION: Angioedema is a complex, multifactorial disease resulting in potentially life-threatening complications. This is the first study to demonstrate that higher levels of air pollution, specifically ground-level ozone, are associated with significantly increased rates of angioedema episodes, although not severity.

Spectroscopic Analysis of Human Tracheal Tissue during Decellularization.

OBJECTIVE: To use mid-infrared (IR) spectroscopy to assess changes in the cartilaginous framework of human trachea during decellularization. STUDY DESIGN: Laboratory-based study. SETTING: Research laboratory. METHODS: Six cadaveric human tracheas were decellularized using a detergent enzymatic method (DEM). Tissue samples were obtained from each specimen after 0, 1, 10, and 25 DEM cycles for histologic and spectroscopic analysis. Decellularization was confirmed using hematoxylin and eosin (H&E) and 2-(4-amidinophenyl)-1H-indole-6-carboxamidine (DAPI) staining. Changes in cartilaginous framework were examined using Fourier transform infrared imaging spectroscopy (FT-IRIS) and an attenuated total reflectance (ATR) probe in the mid-IR frequencies. Results were statistically analyzed using 1-way analysis of variance (ANOVA) and principal component analysis (PCA). RESULTS: Six decellularized tracheal scaffolds were successfully created using a DEM protocol. Histologic examination showed near-complete nuclear loss following 25 DEM cycles. As observed with FT-IRIS analysis, the collagen absorbance signal (1336 cm-1) was predominantly in the perichondria and remained stable after 25 DEM cycles ( P = .132), while the absorbance from sugar rings in proteoglycans and nucleic acids in hyaline cartilage (1080 cm-1) showed a significant decrease after 1 DEM cycle ( P = .0007). Examination of the luminal surface of the trachea with an ATR probe showed raw mid-IR spectra consistent with cartilage. PCA showed significant separation of spectra corresponding to treatment cycle along the principal components 1 and 2. CONCLUSION: Mid-IR spectroscopy is a viable method of monitoring changes in extracellular matrix components during the decellularization of human trachea.

Association of gastroesophageal reflux disease and laryngeal cancer.

OBJECTIVE: Studies examining the association of reflux disease with the risk of developing laryngeal cancer have both proven and disproven the null hypothesis. METHODS: This retrospective case-control study examines the association of reflux in two populations exposed to similar risk factors, including tobacco, to the extent that end-organ malignant transformation has occurred. After IRB approval was obtained, a search of our hospital's cancer center's database was performed from 2000 to 2013. A retrospective chart review was then performed and the prevalence of gastroesophageal reflux disease among patients with laryngeal cancer (n = 290) was determined. It was then compared to the prevalence of gastroesophageal reflux disease among patients presenting with lung cancer (n = 2440) during the same time period. A multivariate logistic regression was performed to determine the association of reflux with laryngeal cancer. RESULTS: Taking into consideration tobacco use, there was a strong association between male gender and occurrence of laryngeal cancer as opposed to lung cancer (OR = 3.30; 95% CI 2.53-4.36, P < 0.001). There was a modest association between reflux and laryngeal cancer (OR = 1.65; 95% CI 1.19-2.25, P = 0.003). However, there was no association between reflux and the propensity for carcinoma in specific laryngeal subsites (P = 0.47). CONCLUSIONS: In this study examining a heterogeneous population with end-organ malignancy there was a modest association between reflux and laryngeal cancer. Further research is necessary to determine the biologic relevance of this finding.

Laryngotracheal stenosis in burn patients requiring mechanical ventilation.

OBJECTIVE: To identify the incidence of laryngotracheal stenosis (LTS) in burn patients requiring mechanical ventilation at a regional academic burn center. METHODS: A retrospective review of all burn patients requiring endotracheal intubation or tracheostomy for airway management between 2003 and 2009 was performed. A group of trauma patients requiring similar airway instrumentation during the same period of time was used as a control. RESULTS: None of the trauma patients and 2 of the burn patients developed LTS. Both presented with stridor and were diagnosed within 2-5 weeks after extubation. One patient underwent successful carbon dioxide laser radial incision and dilation and continues to do well. The other patient failed endoscopic treatment and required T-tube placement. The incidence of LTS in burn patients requiring mechanical ventilation was 2.98% overall and 4.76% among those with inhalational injury. CONCLUSIONS: Patients become symptomatic within weeks of the initial injury. Treatment is challenging and multiple surgical procedures are often required. A larger study is necessary to determine if the incidence is higher among burn patients.

Ex vivo ovine model for teaching open laryngotracheal surgery.

OBJECTIVE: To develop an animal model for teaching open laryngotracheal surgical procedures. METHODS: The heads and necks from 5 pre-pubescent sheep were harvested after humane anesthesia. After 2-5 days to allow for rigor mortis to resolve, a specimen was supported with sandbags on an operating table. Operative procedures including tracheotomy, medialization laryngoplasty, anterior cartilage grafting, tracheal resection with primary anastomosis, and laryngectomy with closure of the pharynx were attempted. RESULTS: The ovine head and neck provided an accurate model for simulation of all attempted procedures. Ovine tissue resembled that of humans in mechanical properties and handling. Postsurgical endoscopy confirmed graft alignment. CONCLUSIONS: The sheep head and neck provides an inexpensive, realistic, and safe model for surgical training for a variety of open laryngotracheal procedures. This is particularly relevant given the recent emphasis on surgical simulation and the relative rarity of some of these procedures in residency training.

Compositional Assessment of Human Tracheal Cartilage by Infrared Spectroscopy.

Objectives To assess the potential of infrared fiber-optic spectroscopy to evaluate the compositional properties of human tracheal cartilage. Study Design Laboratory-based study. Methods Twenty human cadaveric distal tracheas were harvested (age range 20-78 years; 6 females, 14 males) for compositional analysis. Histologic staining, Fourier transform infrared imaging spectroscopy data on collagen and proteoglycan (PG) content, and near-infrared (NIR) fiber-optic probe spectroscopic data that reflect protein and water content were evaluated. NIR fiber-optic probe data were also obtained from the proximal trachea in 4 human cadavers (age range 51-65 years; 2 females, 2 males) in situ for comparison to distal trachea spectral data. Results In the distal trachea cohort, the spectroscopic-determined ratio of PG/amide I, indicative of the relative amount of PG, was significantly higher in the tissues from the younger group compared to the older group (0.37 ± 0.08 vs 0.32 ± 0.05, P = .05). A principal component analysis of the NIR spectral data enabled separation of spectra based on tracheal location, likely due to differences in both protein and water content. The NIR-determined water content based on the 5200-cm-1 peak was significantly higher in the distal trachea compared to the proximal trachea ( P < .001). Conclusions Establishment of normative compositional values and further elucidating differences between the segments of trachea will enable more directed research toward appropriate compositional end points in regenerative medicine for tracheal repair.

The role of serial physical examinations in the management of angioedema involving the head and neck: A prospective observational study.

OBJECTIVE: To elucidate the progression of angioedema of the head and neck with routine management and to assess the utility of serial physical exams and fiberoptic laryngoscopy in its management. METHODS: This study was a prospective observational research. From 2013 to 2014, a prospective observational study was conducted at a tertiary referral center. Forty patient were approached, 7 refused, 33 (18-90 years old) were enrolled. Patients presented with angioedema involving the head and neck over a 12 month period were asked to participate in the study. Physical examination and fiberoptic laryngoscopy were performed at presentation and then repeated at least 1 h later. RESULTS: Thirty-three patients with head and neck angioedema from any cause were enrolled (mean age 58, range 23-89 years). The upper lip was the most commonly involved site (58%). On reevaluation, 82% of patients reported subjective improvement in symptoms. The association between subjective improvement and the physical exam, including fiberoptic laryngoscopy findings, was statistically significant (P < 0.001). CONCLUSION: In stable patients with angioedema of any head and neck subsite, self-reported symptoms are associated with clinical stability or improvement as assessed by physical signs and fiberoptic laryngoscopy. Patients' symptoms may be an appropriate surrogate to monitor clinical status without the need for routine serial physical examinations or fiberoptic laryngoscopy, though further study is needed.

Auricular reconstruction after human bite amputation using the Baudet technique.

OBJECTIVE: This study aimed to present a case of a successful re-implantation of an amputated auricle following a human bite using the Baudet technique. METHODS: Case report and review of the literature. RESULTS: The patient had a very satisfactory postoperative result in terms of appearance and function of the reattached auricle. Cartilage loss was minimal. CONCLUSION: Reattachment of an amputated auricle as a composite graft following a traumatic human bite is feasible. The Baudet technique is a simple alternative that avoids the complexity of microsurgical anastomosis while improving upon the high failure rate associated with simple reattachment.

Angiotensin converting enzyme inhibitor-related angioedema: onset, presentation, and management.

OBJECTIVE: This study aimed to determine the duration of use, presentation, and management of angiotensin converting enzyme (ACE) inhibitor-related angioedema patients at an urban academic medical center. METHODS: Retrospective chart review. RESULTS: Eighty-eight patients who presented with ACE inhibitor-related angioedema between January 1, 2012, and December 31, 2012, were identified. They presented anywhere from 1 day to 20 years after starting an ACE inhibitor. About half the patients (50.7%) presented after taking an ACE inhibitor for at least 1 year. Fifty-five patients were female (62.5%). Twenty-eight patients (31.8%) had an airway intervention with 27 intubated and 1 requiring cricothyroidotomy. Six patients were intubated after more than 1 flexible laryngoscopy. The percentage of patients with involvement of the face, lips, tongue, floor of mouth, soft palate/uvula, and larynx were 12.5%, 60.2%, 39.7%, 6.8%, 17.0%, and 29.5%, respectively. Sixty-eight percent of patients with laryngeal edema were intubated. The majority of patients were treated with a corticosteroid and H1 and H2 receptor antagonists. CONCLUSION: Angioedema can occur at any time after starting ACE inhibitor use, with nearly half occurring after 1 year of use. Laryngeal involvement occurred in a minority of patients, but most of these patients were felt to require airway protection.

Use of flexible esophagoscopy by otolaryngologists.

OBJECTIVES: We used questionnaires to determine current practice patterns for esophagoscopy by otolaryngologists in the United States, with attention to foreign body management. METHODS: A 10-item questionnaire designed to determine the prevalence of flexible esophagoscopy use among otolaryngologists, with a particular focus on foreign body removal, was created and sent via e-mail to all members of the American Academy of Otolaryngology-Head and Neck Surgery. A second, 6-question survey to assess the level of resident training in flexible esophagoscopy was similarly created and sent to all directors of US otolaryngology residency programs. RESULTS: There were a total of 160 respondents to the first survey from all geographic regions, most of whom were in group private practice. Overall, only 21.3% of the respondents were trained to perform flexible esophagoscopy during residency, whereas 43% of those who graduated after 1990 received this training. Most respondents performed flexible esophagoscopy without sedation in the office setting. The most common indications were evaluation of dysphagia, screening for complications of laryngopharyngeal reflux, and panendoscopy for head and neck cancer. Nearly 70% of the respondents were either primarily responsible for foreign body management at their institution or shared this responsibility with a gastroenterology department. Eighty-four percent used the rigid esophagoscope alone for this purpose. More than three quarters of otolaryngology residency programs currently include flexible esophagoscopy in their training, which is performed equally in the operating room and in the office; most favor rigid esophagoscopy for foreign body retrieval but use both techniques. CONCLUSIONS: There has been a rapid increase in the use of flexible esophagoscopy by otolaryngologists. The majority of residency programs currently include flexible esophagoscopy in their training. Otolaryngologists play a major role in esophageal foreign body management and primarily use the rigid esophagoscope for this purpose.