Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia.

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

Hematologic malignancies of the larynx: A single institution review.

BACKGROUND: Primary hematologic malignancies of the larynx are rare diagnoses, accounting for less than 1% of all laryngeal tumors. They most commonly present as submucosal masses of the supraglottis, with symptoms including hoarseness, dysphagia, dyspnea and rarely cervical lymphadenopathy. PURPOSE: METHODS: Retrospective case series of patients in a tertiary academic laryngeal practice with hematologic malignancy of the larynx presenting over a 10 year period; charts were reviewed for diagnosis, symptoms, treatment, and outcomes. RESULTS: 12 patients were found to have primary presentation of a hematologic malignancy within the larynx between 2009 and 2019. A submucosal mass was the most common finding, and hoarseness was the most common symptom. Local control of disease was high. Airway obstruction was managed with tracheostomy. Several patients required tube feeding prior to disease control. Most patients underwent radiation therapy and chemotherapy, although surgery alone was effective in patients with isolated disease. CONCLUSIONS: Hematologic malignancies of the larynx are rare but treatable. Biopsy is the mainstay of diagnosis, and imaging may be helpful to exclude diseases with a similar physical presentation (i.e., laryngocele). Prognosis depends on diagnosis but is generally favorable.

Outcomes in modified transoral resection of diverticula for Zenker's diverticulum.

PURPOSE: Transoral resection of Zenker's diverticulum (TORD) was first reported in 2010. We present results for our modified approach to transoral resection (MTORD)-full-thickness cricopharyngeal myectomy, diverticulum sac excision, and suture closure of the pharyngotomy-and evaluate its safety and efficacy compared to endoscopic stapling and open approaches. METHODS: A retrospective study was performed in patients who underwent transoral resection of Zenker's diverticulum using MTORD, endoscopic stapler-assisted diverticulotomy (ESD), or trancervical diverticulectomy (TCD) from July 2009 to August 2017. Pre-operative evaluation included barium swallow and subjective characterization of swallowing dysfunction using the EAT-10 and Reflux Symptom Index (RSI). Complications, length of hospitalization, recurrence, and revision rates were also evaluated. RESULTS: Of 92 patients reviewed, 18 underwent MTORD, 45 underwent ESD and 29 underwent TCD. Major complications were only observed in ESD and TCD. Recurrence which required revision surgery was only observed in ESD. EAT-10 and RSI scores significantly improved and RSI scores normalized post-operatively for all approaches in short-term (< 1 year) follow-up. CONCLUSIONS: MTORD is a safe and effective option for complete Zenker's diverticulectomy. Complication rates are low. To date, no patient has required reoperation, although more cases and longer term follow-up are needed for more complete comparison to ESD and traditional open excision.

Association of Overlapping Surgery With Perioperative Outcomes.

Importance: Overlapping surgery, in which more than 1 procedure performed by the same primary surgeon is scheduled so the start time of one procedure overlaps with the end time of another, is of concern because of potential adverse outcomes. Objective: To determine the association between overlapping surgery and mortality, complications, and length of surgery. Design, Setting, and Participants: Retrospective cohort study of 66 430 operations in patients aged 18 to 90 years undergoing total knee or hip arthroplasty; spine surgery; coronary artery bypass graft (CABG) surgery; and craniotomy at 8 centers between January 1, 2010, and May 31, 2018. Patients were followed up until discharge. Exposures: Overlapping surgery (≥2 operations performed by the same surgeon in which ≥1 hour of 1 case, or the entire case for those <1 hour, occurs when another procedure is being performed). Main Outcomes and Measures: Primary outcomes were in-hospital mortality or complications (major: thromboembolic event, pneumonia, sepsis, stroke, or myocardial infarction; minor: urinary tract or surgical site infection) and surgery duration. Results: The final sample consisted of 66 430 operations (mean patient age, 59 [SD, 15] years; 31 915 women [48%]), of which 8224 (12%) were overlapping. After adjusting for confounders, overlapping surgery was not associated with a significant difference in in-hospital mortality (1.9% overlapping vs 1.6% nonoverlapping; difference, 0.3% [95% CI, -0.2% to 0.7%]; P = .21) or risk of complications (12.8% overlapping vs 11.8% nonoverlapping; difference, 0.9% [95% CI, -0.1% to 1.9%]; P = .08). Overlapping surgery was associated with increased surgery length (204 vs 173 minutes; difference, 30 minutes [95% CI, 24 to 37 minutes]; P < .001). Overlapping surgery was significantly associated with increased mortality and increased complications among patients having a high preoperative predicted risk for mortality and complications, compared with low-risk patients (mortality: 5.8% vs 4.7%; difference, 1.2% [95% CI, 0.1% to 2.2%]; P = .03; complications: 29.2% vs 27.0%; difference, 2.3% [95% CI, 0.3% to 4.3%]; P = .03). Conclusions and Relevance: Among adults undergoing common operations, overlapping surgery was not significantly associated with differences in in-hospital mortality or postoperative complication rates but was significantly associated with increased surgery length. Further research is needed to understand the association of overlapping surgery with these outcomes among specific patient subgroups.

Tracheoesophageal fistula length decreases over time.

The objectives of this study were to demonstrate that the length of the tracheoesophageal voice prosthesis changes over time and to determine whether the prosthesis length over time increased, decreased, or showed no predictable change in size. A retrospective chart review was performed at a tertiary care referral center. Patients who underwent either primary or secondary tracheoesophageal puncture between January 2006 and August 2014 were evaluated. Patients were excluded if the tracheoesophageal prosthesis size was not consistently recorded or if they required re-puncturing for an extruded prosthesis. Data analyzed included patient demographics and the length of the tracheoesophageal voice prosthesis at each change. A total of 37 patients were identified. The mean age was 64 years. Seventy-six percent were male. 24 % underwent primary tracheoesophageal puncture and 76 % underwent secondary tracheoesophageal puncture. The length of the prosthesis decreased over time (median Kendall correlation coefficient = -0.60; mean = -0.44) and this correlation between length and time was significant (p = 0.00085). Therefore, in conclusion, tracheoesophageal prosthesis length is not constant over time. The tracheoesophageal wall thins, necessitating placement of shorter prostheses over time. Patients with a tracheoesophageal voice prosthesis will require long-term follow-up and repeat sizing of their prosthesis. Successful tracheoesophageal voicing will require periodic reevaluation of these devices, and insurers must, therefore, understand that long-term professional care will be required to manage these patients and their prostheses.

Safety of outpatient airway dilation for adult laryngotracheal stenosis.

OBJECTIVES: To evaluate the safety of outpatient airway dilation for adult patients with subglottic or tracheal stenosis. METHODS: The records of patients treated with airway dilation between October 2003 and September 2013 were reviewed. Outcomes of patients who underwent dilation as inpatients versus outpatients were compared. Emergency room visits, readmissions, and 3 or more primary care physician visits within 30 days postoperatively were specifically evaluated. Postoperative hemorrhage, airway edema, recurrent laryngeal nerve paralysis, reintubation, tracheostomy, tracheal rupture, pneumomediastinum, pneumothorax, acute respiratory distress, or death were also reviewed. RESULTS: One hundred fourteen dilations performed in 53 patients with airway stenosis were included. Outpatient dilation was performed in 93 (82%); 21 (18%) underwent the procedure in the inpatient setting. Complications were low among both inpatient and outpatient groups (10% vs 1%, P=.09). No complications occurred during the overnight stay of the inpatient group. CONCLUSIONS: Outpatient airway dilation is a safe and feasible procedure. It can be routinely performed on an ambulatory basis.

The hybrid tracheoesophageal puncture procedure: indications and outcomes.

OBJECTIVES: This report aimed to describe a novel and efficient method of tracheoesophageal puncture using a hybrid device assembled from 2 commercially available puncture kits; to demonstrate the utility of this technique in the performance of primary and secondary procedures, under general and local anesthesia, with and without flap reconstruction; and to evaluate the efficacy of concurrent puncture and valve placement. METHODS: Thirty-four patients who underwent either primary or secondary tracheoesophageal puncture for voice restoration. Charts were reviewed retrospectively for complications, time to first valve change, operative time, and blood loss. RESULTS: Using this novel hybrid device, simultaneous puncture and valve placement was achieved in 34 consecutive patients. There was 1 major complication; blood loss was negligible; and the procedure could be accomplished in all cases. There were no cases of prosthesis failure as a result of the insertion technique. CONCLUSION: Concurrent tracheoesophageal puncture and voice prosthesis placement is a simple and efficient method of voice restoration in the laryngectomized patient and can be more easily accomplished with a hybrid device assembled from the components of 2 commercially available puncture kits. It can be performed under local as well as general anesthesia. The procedure is adaptable to a variety of clinical situations.

Pill Ingestion and Caustic Laryngeal Injury.

OBJECTIVE: To highlight an unusual mechanism of laryngeal injury. METHODS: Case report and literature review. RESULTS: A 66-year-old male ingested an over-the-counter preparation of bile acids as a dietary supplement. The capsule lodged in the patient's pharynx, and he sustained a caustic injury to the supraglottic and glottic larynx. His injury was managed conservatively, and his symptoms gradually resolved over a period of 8 weeks. A follow-up laryngoscopy at 8 weeks and 6 months showed no signs of injury. A barium swallow at 8 weeks was normal at that time and videostroboscopy results normalized with resolution of the injury as well. CONCLUSIONS: Caustic injury to the upper aerodigestive tract from pill ingestion is uncommon, and laryngeal injury even less so. Urgent evaluation should be undertaken, and appropriate therapies instituted promptly. Laryngeal injury can respond to conservative therapy, but there is a lack of clinical information to evaluate optimum treatment of this unusual injury.

The Clinical Impact of Vascular Endothelial Growth Factor/Receptor (VEGF/R) Inhibitors on Voice.

Background: Vascular endothelial growth factor/receptor (VEGF/R) inhibitors are used in chemotherapy protocols to limit tumor angiogenesis. Recent evidence shows they are associated with hoarseness, but their impact on vocal cord function has not been fully identified. Objectives: To describe the preliminary laryngeal findings in patients undergoing chemotherapy with VEGF/R inhibitors, and to describe possible mechanisms of their effect on vocal fold function. Methods: A retrospective case series was conducted in a tertiary medical center between July 2008 and August 2022. Cancer patients developing hoarseness while undergoing chemotherapy with VEGF/R inhibitors underwent videolaryngostroboscopy. Results: The study included four patients. There were three females and one male, treated for breast, lung, and unknown primary cancer, respectively. All 4 patients developed hoarseness 2-7 days after initiating treatment with the VEGF/R inhibitor drugs aflibercept (n = 1) and bevacizumab (n = 3). In all patients, videolaryngostroboscopy revealed vocal fold bowing and pronounced glottic insufficiency. There were no signs of mucositis or paralysis. In three patients, treatment involved speech therapy, with or without vocal fold augmentation. The average follow-up was 10 months (range 8-12 months). In 2 patients, there was a return of normal voice quality with resolution of vocal fold bowing. In one patient, who remained on chemotherapy, there was persistent bowing. Conclusions: VEGF/R inhibitors are associated with vocal fold bowing and glottic insufficiency. This appears to be a reversible side effect. To our knowledge, this is only the second clinical description of the effect of VEGF/R inhibitors on vocal fold function.

Safety and Utility of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) for Laser Laryngeal Surgery.

OBJECTIVE: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is gaining acceptance as a safe method for apneic ventilation and oxygenation during laryngeal procedures, but remains controversial during laser laryngeal surgery (LLS) due to the theoretical risk of airway fire. This study describes our experience with THRIVE during LLS. STUDY DESIGN: Retrospective cohort study. SETTING: Stanford University Hospital, October 15, 2015 to June 1, 2021. METHODS: Retrospective chart review of patients ≥18 years who underwent LLS involving the CO2 or KTP laser with THRIVE as the primary mode of oxygenation. RESULTS: A total of 172 cases were identified. 20.9% were obese (BMI ≥ 30). Most common operative indication was subglottic stenosis. The CO2 laser was used in 79.1% of cases. Median lowest intraoperative SpO2 was 96%. 44.7% cases were solely under THRIVE while 16.3% required a single intubation and 19.2% required multiple intubations. Mean apnea time for THRIVE only cases was 32.1 minutes and in cases requiring at least one intubation 24.0 minutes (p < .001). Mean apnea time was significantly lower for patients who were obese (p < .001) or had a diagnosis of hypertension (p = .016). Obese patients and patients with hypertension were 2.03 and 1.43 times more likely to require intraoperative intubation, respectively. There were no intraoperative complications or fires since the institution of our LLS safety protocol. CONCLUSION: By eliminating the fuel component of the fire triangle, THRIVE can be safely used for continuous delivery of high FiO2 during LLS, provided adherence to institutional THRIVE-LLS protocols.

Adoption and Utilization of Heat and Moisture Exchangers (HMEs) in the Tracheostomy Patient.

OBJECTIVE: Management of tracheostomized patients typically involves a conventional external humidification system (CEHS). CEHS are noisy, negatively impact patient mobility, and increases costs. Additionally, they prevent phonation and the ability to cough. Alternatively, heat and moisture exchange (HME) devices have been used in laryngectomized patients. We present an institutional quality improvement project exploring the use and efficacy of an HME device following tracheostomy. METHODS: Health care professionals and stakeholders from multiple disciplines were identified: otolaryngology, nursing, administration, case management, and speech-language pathology. The focus was on an otolaryngology acute care nursing unit. Protocols for product acquisition, nursing education, care flowcharts, and discharge planning were established. Efficacy was assessed by tracking patient pulmonary status, nursing notes, and questionnaires. RESULTS: Seventy-one tracheostomized patients were enrolled. Two patients (2.8%) were unable to tolerate the HME. There were no complications from mucous plugging or respiratory distress. Eighty-nine percent of nursing staff surveyed preferred the use of an HME device over CEHS, particularly for ease of patient mobility. Additional favorable findings were patient satisfaction, cost savings, reduced noise, communication, and ease of discharge education and planning. DISCUSSION: Replacing CEHS with HMEs provides distinct advantages, with a positive impact on patients, family members, and health care personnel. Resistance to changing from the traditional standard of care was alleviated with education, focused training, and positive outcomes. IMPLICATIONS FOR PRACTICE: These data indicate that an HME device is safe and offers advantages to both patients and nurses over traditional CEHS.

Tracheal stenosis and airway complications in the Coronavirus Disease-19 era.

BACKGROUND: Severe Coronavirus Disease 2019 (COVID-19) infection is associated with prolonged intubation and its complications. Tracheal stenosis is one such complication that may require specialized surgical management. We aimed to describe the surgical management of post-COVID-19 tracheal stenosis. METHODS: This case series describes consecutive patients with tracheal stenosis from intubation for severe COVID-19 infection at our single, tertiary academic medical center between January 1st, 2021, and December 31st, 2021. Patients were included if they underwent surgical management with tracheal resection and reconstruction, or bronchoscopic intervention. Operative through six-month, symptom-free survival and histopathological analysis of resected trachea were reviewed. RESULTS: Eight patients are included in this case series. All patients are female, and most (87.5%) are obese. Five patients (62.5%) underwent tracheal resection and reconstruction (TRR), while three patients (38.5%) underwent non-resection-based management. Among patients who underwent TRR, six-month symptom free survival is 80%; one patient (20%) required tracheostomy after TRR due to recurrent symptoms. Two of the three (66.7%) of patients who underwent non-resection-based management experienced durable relief from symptoms of tracheal stenosis with tracheal balloon dilation, and the remaining patient required laser excision of tracheal tissue prior to experiencing symptomatic relief. CONCLUSIONS: The incidence of tracheal stenosis may increase as patients recover from severe COVID-19 infection requiring intubation. Management of tracheal stenosis with TRR is safe and effective, with comparable rates of success to TRR for non-COVID-19 tracheal stenosis. Non-resection-based management is an option to manage tracheal stenosis in patients with less severe stenosis or in poor surgical candidates.

Has Esophageal Speech Returned as an Increasingly Viable Postlaryngectomy Voice and Speech Rehabilitation Option?

PURPOSE: The literature on postlaryngectomy voice and speech rehabilitation is long-standing. Although multiple rehabilitation options have existed over the years, the acquisition and use of esophageal speech (ES) has decreased significantly over the past 40 years. This reduction coincides with the increased application of tracheoesophageal puncture (TEP) voice restoration. The literature suggests that voice acquisition failures observed secondary to TEP may represent a similar phenomenon that led to ES acquisition failures. METHOD: A comprehensive review of the literature on ES and TEP voice/speech was conducted. Specific attention was directed toward information on ES and TEP speech failures. Information on pharyngoesophageal segment (PES) spasm in the context of ES and TEP voicing failures was of specific importance. RESULTS: Similarities between voicing failures with both ES and TEP were identified. In order to resolve spasm in TEP speech, proactive efforts to eliminate it were undertaken, and regardless of the method used, voicing improvements were observed. These data suggest that both ES and TEP speech acquisition failures may be related to the same control mechanisms influencing the PES. CONCLUSIONS: The elimination of PES spasm provides evidence that justifies the reconsideration of ES. Consequently, ES may return as an increasingly viable postlaryngectomy voice and speech rehabilitation option.

Real-time motion correction for high-resolution larynx imaging.

Motion--both rigid-body and nonrigid--is the main limitation to in vivo, high-resolution larynx imaging. In this work, a new real-time motion compensation algorithm is introduced. Navigator data are processed in real time to compute the displacement information, and projections are corrected using phase modulation in k-space. Upon automatic feedback, the system immediately reacquires the data most heavily corrupted by nonrigid motion, i.e., the data whose corresponding projections could not be properly corrected. This algorithm overcomes the shortcomings of the so-called diminishing variance algorithm by combining it with navigator-based rigid-body motion correction. Because rigid-body motion correction is performed first, continual bulk motion no longer impedes nor prevents the convergence of the algorithm. Phantom experiments show that the algorithm properly corrects for translations and reacquires data corrupted by nonrigid motion. Larynx imaging was performed on healthy volunteers, and substantial reduction of motion artifacts caused by bulk shift, swallowing, and coughing was achieved.

Carbon dioxide laser-assisted endoscopic cricopharyngeal myotomy with primary mucosal closure.

OBJECTIVES: Carbon dioxide laser-assisted endoscopic cricopharyngeal myotomy (ECPM) has emerged as a viable therapy for dysphagia. The risks of the procedure include pharyngoesophageal perforation and mediastinitis, which may discourage adoption of this technique. To address these complications, we examined outcomes of ECPM with primary mucosal closure. METHODS: A case series of 7 patients who underwent ECPM between 2006 and 2008 were reviewed for length of operation, length of hospitalization, postoperative complications, and outcomes by use of the M. D. Anderson Dysphagia Index (MDADI) and the Functional Outcome Swallowing Scale (FOSS). The results were compared to those of a control group of 7 patients treated during the same period via open cricopharyngeal myotomy. RESULTS: All patients who had ECPM were treated successfully without complications. The operative times averaged 128 minutes. The hospitalization averaged 2.1 days. Statistically significant improvements in swallowing were seen (MDADI score from 51.3 to 77.7, p < 0.0006; FOSS score from 3.7 to 1.3, p < 0.0005), and were similar to those in the patients who had the open procedure (FOSS score from 3.0 to 1.0, p <0.006). Trends toward decreased blood loss, a shorter hospital stay, and a lower complication rate were observed in the patients who had ECPM. CONCLUSIONS: ECPM is beneficial as a primary treatment for cricopharyngeal dysfunction. Closure of the mucosal defect may help reduce the incidence of postoperative cervical emphysema and mediastinitis, and does not appear to compromise functional outcome.

Ectopic Laryngeal Ossification after Bone Morphogenetic Protein-2.

We report two cases of ectopic bone formation in the head and neck following treatment with recombinant human bone morphogenetic protein-2 (rhBMP-2). Surgical pathologic data, laryngoscopy imaging, CT imaging, and patient medical history were obtained. First, we report osseous metaplasia in the vocal fold in a 67-year-old male following mandibular dental implants with rhBMP-2; second, a case of severe bony overgrowth of the larynx and fusion to the anterior cervical spine (ACS) in a 73-year-old male following multiple anterior cervical discectomies and fusions with rhBMP-2. Ectopic bone formation following rhBMP-2 has been previously reported. Adverse events like local swelling and edema leading to dysphagia and even airway obstruction after cervical spine application of rhBMP-2 have also been widely reported. Due to the uncommon nature of abnormal bony growth in soft tissue areas of the head and neck and the previously documented adverse effects of rhBMP-2 use, especially in the cervical spine, we consider the two unusual case presentations of ectopic bony formation highly likely to be linked with rhBMP-2. We urge awareness of the adverse effects caused by rhBMP-2, and urge caution in dosing.

Surgical rehabilitation of voice and swallowing after jugular foramen surgery.

OBJECTIVES: We sought to determine the patient population that will benefit from surgical rehabilitation of voice and swallowing after jugular foramen tumor (JFT) resection. METHODS: We performed a retrospective case study of patients with a history of JFT resection. The patients' files were reviewed for data on preoperative and postoperative function of cranial nerves VII and IX through XII, voice and swallowing function, and surgical procedures for voice and swallowing rehabilitation and their timing. RESULTS: Twenty-one patients underwent JFT resection. Thirty-eight percent presented with deficits of cranial nerves VII and IX through XII, and 61% developed new postoperative deficits. Three patients recovered glossopharyngeal nerve function, 2 recovered vagus nerve function, and 1 recovered facial nerve function. Surgical rehabilitation procedures were undertaken in 8 patients. Patients who eventually underwent surgical rehabilitation procedures for voice and swallowing tended to have larger tumors, tumors within the nerve bundle in the jugular foramen, and multiple nerve deficits. CONCLUSIONS: Most patients with multiple deficits of cranial nerves VII and IX through XII after JFT resection are unlikely to regain spontaneous nerve function, will experience long-term dysphonia and dysphagia, and will elect to undergo corrective surgery to improve voice and swallowing. Preoperative evaluation and close postoperative follow-up can identify patients who would benefit from early surgical rehabilitation.

Outcomes of Overlapping Surgery in Otolaryngology.

OBJECTIVE: To compare outcomes in otolaryngology between overlapping and nonoverlapping surgeries. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. SUBJECTS AND METHODS: All patients undergoing otolaryngologic procedures at Stanford University Hospital between January 2009 and June 2016 were included (n = 13,479). Cases were divided into 2 cohorts: overlapping (n = 1806, 13.4%) vs nonoverlapping (n = 11,673, 86.6%). Variables reviewed were type of operation performed, multidisciplinary team involvement, complications, reoperations, readmissions, and deaths. RESULTS: The total complication rate over 7.5 years studied was 3.3% (n = 450). Complication rates were lower for overlapping cases (0.77%) compared to nonoverlapping cases (3.73%) with an odds ratio of 0.2014, which was statistically significant (P < .0001). When examined by subspecialty, the complication rate for rhinology and endoscopic skull base procedures was approximately 10 times lower when overlapping (0.30%) was compared to nonoverlapping (3.15%), with an odds ratio of 0.094 (P = .0001). There was no difference in complication rates for other surgical subspecialties. There were no deaths associated with overlapping surgery. The rate of major complications requiring reoperation was similarly lower for overlapping procedures (0.276%) compared to nonoverlapping procedures (1.35%) with an odds ratio of 0.2023 (P = .0004). Readmission rates were lower for overlapping cases (0.49%) when compared to nonoverlapping cases (1.09%), with an odds ratio of 0.4553 (P = .0229). CONCLUSIONS: Patients undergoing overlapping surgery had lower overall complication rates, lower reoperation rates, lower readmission rates, and no mortalities. The institutional experience presented provides evidence that with appropriate patient and case selection, otolaryngologists may safely perform overlapping surgery without increased risk of adverse patient outcomes.

Increased Expression of Estrogen Receptor Beta in Idiopathic Progressive Subglottic Stenosis.

BACKGROUND/OBJECTIVES: Idiopathic progressive subglottic stenosis (IPSS) predominantly affects females in perimenopause. It has, therefore, been hypothesized that estrogen is involved in its pathogenesis. There are two main types of estrogen receptors: ER-α and ER-ß. Abnormal variants of ER-ß have previously been shown to be associated with poor wound healing. Estrogen receptors have recently been identified in subglottic tissue samples, with elevated levels of ER-α and progesterone receptors, and no expression of ER-ß, in stenotic specimens reported in one study. The objective of this study was to confirm the presence of estrogen receptors in the subglottis and investigate levels of expression and types of estrogen receptors in normal and stenotic subglottic tissue. METHODS: Subglottic tissue was obtained from three female and one male cadaver without laryngotracheal pathology to serve as controls. Subglottic tissue specimens from five female patients with IPSS were also analysed. Immunofluorescence stains for ER-α and ER-ß were performed on specimens. Staining patterns were compared qualitatively and semi-qualitatively between control and IPSS specimens. RESULTS: Immunofluorescence stains demonstrated the presence of both ER-α and ER-ß in subglottic tissue. IPSS specimens demonstrated significantly greater staining intensity of ER-α in the epithelium and ER-ß in glands and ducts compared to controls. CONCLUSIONS: This study confirms the presence of estrogen receptors in the subglottis. Increased expression of ER-α in the epithelium and ER-ß in glands and ducts in IPSS compared to controls may help to explain the predisposition to stenosis in these individuals. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:2186-2191, 2020.

Early Injection Laryngoplasty After Surgery: 30 Cases and Proposed Aspiration Assessment Protocol.

Vocal fold movement impairment may significantly compromise postoperative recovery and quality of life of patients following thoracic or cardiothoracic surgery or prolonged intubation. The literature is limited and there is no standard screening protocol for the optimal postoperative swallowing and aspiration evaluations. We performed retrospective review of adult patients undergoing early vocal fold (VF) injection laryngoplasty for acute postoperative Vocal fold movement impairment (<30 days) that had both pre- and postinjection speech language pathologist (SLP) performed swallowing/aspiration evaluations. Records were reviewed for demographics, clinical characteristics, procedural details, and short-term outcome measures of oral intake. In total, 30 patients were included, and had data on swallowing/aspiration studies before and after the VF injection laryngoplasty. Most of the patients were injected within 5 days following the laryngologist evaluation and within 14 days following the iatrogenic recurrent laryngeal nerve injury (23/30, 76.7%). The majority of patients were injected at the bedside by awake transcutaneous injection (22/30, 73.3%), six patients were injected in the operating room under general anesthesia, and two at the outpatient clinic. Pre- and postinjection SLP evaluations included clinical bedside assessment or instrumental evaluation. Following VF injection laryngoplasty, oral diet advancement was noted in 81.8% of the patients that were nil per os before the injection (18/22). No complications were noted. In conclusions, acute VFMI following surgery requires immediate diagnosis and therapeutic strategy to minimize postoperative complications and to overcome impairments in the voice, swallow, and cough. Otolaryngology-SLP interdisciplinary aspiration and swallowing assessment protocol is proposed based on our experience and an extensive literature review.