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Dysphagia after anterior cervical spine surgery (ACSS) may be secondary to pharyngoesophageal diverticulum. Our objectives are to (1) highlight the heterogeneity in clinical presentation, (2) discuss pathophysiology and management, and (3) present a comprehensive literature review of these diverticula. All patients undergoing pharyngoesophageal diverticulum repair between 2013 and 2019 were identified. Cases with ACSS history underwent detailed review of clinical presentation, assessment, and management. Literature review and analysis of all reported ACSS-associated pharyngoesophageal diverticula was performed. Two hundred forty-three cases of pharyngoesophageal diverticulum repair were performed during the study period; 13 cases were ACSS-associated. Four types of clinical presentation were identified: (Type A) Spinal hardware present, with videofluoroscopic evidence of exposed hardware; (Type B) Spinal hardware present, without videofluoroscopic evidence of exposed hardware; (Type C) Spinal hardware absent due to prior spinal hardware removal or ACSS performed without hardware; and (Type D) Concurrent esophago-esophageal fistula (EEF) present. All of our cases were evaluated using modified barium swallow study and esophagoscopy and definitively managed with endoscopic diverticulotomy. Literature review identified 21 cases of ACSS-associated pharyngoesophageal diverticulum repair from 18 publications. The majority of cases were identified using barium esophagram (N = 18, 86%) and managed with open diverticulectomy (N = 19, 90%). There were no reports of EEF. ACSS-associated pharyngoesophageal diverticulum must be evaluated with fluoroscopy and endoscopy, which determine presentation type. Presentation type guides management. Esophageal perforation requires hardware removal and perforation repair with flap placement. Endoscopic diverticulotomy was found essential to definitive management.Level of Evidence: 4.
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Perforación del Esófago , Divertículo de Zenker , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugía , Esofagoscopía , Humanos , Complicaciones Posoperatorias/etiología , Divertículo de Zenker/etiología , Divertículo de Zenker/cirugíaRESUMEN
The global pandemic of coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 remains a challenge for prevention due to asymptomatic or paucisymptomatic patients. Anecdotal and preliminary evidence from multiple institutions shows that these patients present with a sudden onset of anosmia without rhinitis. We aim to review the pathophysiology of anosmia related to viral upper respiratory infections and the prognostic implications. Current evidence suggests that SARS-CoV-2-related anosmia may be a new viral syndrome specific to COVID-19 and can be mediated by intranasal inoculation of SARS-CoV-2 into the olfactory neural circuitry. The clinical course of neuroinvasion of SARS-CoV-2 is yet unclear, however an extended follow up of these patients to assess for neurological sequelae including encephalitis, cerebrovascular accidents and long-term neurodegenerative risk may be indicated.
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Mechanical properties of the human vocal fold cover layer were experimentally investigated in uniaxial and biaxial tensile tests. The results showed a coupling effect between the stress conditions along the anterior-posterior and transverse directions, with vocal fold elongation increasing vocal fold stiffness along both directions, thus allowing more efficient control of the fundamental frequency of voice through vocal fold elongation. This study also shows that vocal folds were nearly isotropic at resting conditions, thus a tendency to vibrate with incomplete glottal closure, but became increasingly anisotropic with increasing vocal fold elongation.
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Fonación , Pliegues Vocales/fisiología , Calidad de la Voz , Anisotropía , Fenómenos Biomecánicos , Módulo de Elasticidad , Humanos , Masculino , Persona de Mediana Edad , Estrés Mecánico , Resistencia a la Tracción , Vibración , Pliegues Vocales/anatomía & histologíaRESUMEN
This study investigated the impact of selective epithelial injury on phonation in an excised human larynx apparatus. With intact epithelium, the vocal folds exhibited a symmetrical vibration pattern with complete glottal closure during vibration. The epithelium was then enzymatically removed from one, then both vocal folds, which led to left-right asymmetric vibration and a decreased closed quotient. Although the mechanisms underlying these vibratory changes are unclear, these results demonstrate that some component of an intact surface layer may play an important role in achieving normal symmetric vibration and glottal closure.
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Laringe/fisiología , Pliegues Vocales/fisiología , Anciano , Cadáver , Femenino , Humanos , Mucosa Laríngea/fisiología , Masculino , Persona de Mediana Edad , Fonación/fisiología , Vibración , Grabación en VideoRESUMEN
OBJECTIVE: Numerous pharmacological and cell-based treatments have shown promise in preventing vocal fold (VF) scarring when applied at the time of injury. A common clinical scenario, however, is the finding of mature scar impeding voicing. Many treatments are less effective in remodeling existing scar tissue. This objective of this study is to determine if a cell-based outer vocal fold replacement (COVR) effectively restores VF function when applied to existing scar. METHODS: Eighteen rabbits were allocated to three groups: unilateral COVR implant at the time of cordectomy (acute COVR); unilateral cordectomy followed by COVR implant 2 months later (chronic COVR); and unilateral cordectomy followed by sham implant surgery 2 months later (chronic scar). Larynges were harvested 2 months after implant or sham surgery. RESULTS: All larynges in the COVR groups demonstrated human leukocyte antigen labeling on immunohistochemistry (IHC). COVR groups had increased hyaluronic acid content compared with normal. VF stiffness as measured by elastic moduli in acute COVR and chronic COVR were similar to their contralateral unoperated VF. CONCLUSION: COVR implantation in both acutely injured and chronically scarred VF demonstrate persistence of implanted cells, restored tissue biomechanics, and increased hyaluronic acid content. LEVEL OF EVIDENCE: NA Laryngoscope, 134:764-772, 2024.
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Cicatriz , Pliegues Vocales , Animales , Conejos , Humanos , Cicatriz/prevención & control , Cicatriz/cirugía , Cicatriz/patología , Pliegues Vocales/patología , Ácido Hialurónico/farmacologíaRESUMEN
Intractable hiccups are a rare yet debilitating pathology with a broad differential and often indicate a more serious underlying pathology, which can range from neoplasms to structural abnormalities. In this case report, we present a 64-year-old male with seven months of intractable hiccups determined to be caused by eventration of the right hemidiaphragm. The patient was treated with baclofen to treat the hiccups pharmacologically. He was also prescribed voice therapy to establish rescue breathing techniques and reduce laryngospasm. Finally, he was referred to thoracic surgery for further evaluation and potential surgical intervention should his diaphragmatic eventration worsen or cause hypoxemia. To our knowledge, this is the first reported case of an association between diaphragmatic eventration and intractable hiccups. It is important to highlight this addition to the broad differential of intractable hiccups and to emphasize an interdisciplinary approach to workup and treatment of intractable hiccups.
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Objectives: Vocal fold (VF) scarring, manifested by increased collagen, decreased glycosaminoglycans (GAGs), and disrupted elastic fibers, remains a negative consequence of VF injury or resection. The objective of this study is to compare four reconstructive options after Vf mucosal resection in rabbits. A Cell-Based Outer Vocal fold Replacement (COVR) using human adipose-derived mesenchymal stromal cells (hASCs) in fibrin scaffold is directly compared with a decellularized scaffold implant, hASC injection, and resection alone without reconstruction. The primary hypothesis is that the cells-in-scaffold construct better reconstitutes the VF structure than either cells or scaffold alone, or than healing by secondary intention. Methods: A total of49 rabbits received bilateral VF cordectomy, followed by either COVR implant, decellularized scaffold implant, hASC injection, or no reconstruction (injured control group). Larynges were harvested after 6 weeks. Results: Histology demonstrated greater lamina propria thickness, less collagen deposition, and more GAGs in COVR animals versus all other treatment groups. Evidence of persistent human cells was found in about half of the cell-treated animals. RNA levels of fibrosis pathway and macrophage phenotype markers were statistically unchanged among treatment groups at 6 weeks. Conclusion: These data support the efficacy of COVR implantation in restoring VF microstructure in rabbits. The intact COVR was required; isolated components of decellularized scaffold or injected hASC still produced histologic scarring. We propose that the unique bilayered cell structure within fibrin enables controlled matrix remodeling to minimize wound contraction and fibrosis, and to promote GAG deposition. Level of Evidence: Basic science study.
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The coronavirus disease-19 (COVID-19) pandemic has prompted new interest among anesthesiologists and intensivists in controlling coughing and expectoration of potentially infectious aerosolized secretions during intubation and extubation. However, the fear of provoking laryngospasm may cause avoidance of deep or sedated extubation techniques which could reduce coughing and infection risk. This fear may be alleviated with clear understanding of the mechanisms and effective management of post-extubation airway obstruction including laryngospasm. We review the dynamic function of the larynx from the vantage point of head-and-neck surgery, highlighting two key concepts: 1. The larynx is a complex organ that may occlude reflexively at levels other than the true vocal folds; 2. The widely held belief that positive-pressure ventilation by mask can "break" laryngospasm is not supported by the otorhinolaryngology literature. We review the differential diagnosis of acute airway obstruction after extubation, discuss techniques for achieving smooth extubation with avoidance of coughing and expectoration of secretions, and recommend, on the basis of this review, a clinical pathway for optimal management of upper airway obstruction including laryngospasm to avoid adverse outcomes.
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Dysphagia, defined as difficulty swallowing, is a common symptom negatively impacting millions of adults annually. Estimated prevalence ranges from 14 to 33 percent in those over age 65 to over 70 percent in a nursing home setting. The elderly, those with neurodegenerative diseases, head and neck cancer patients, and those with autoimmune conditions such as Sjögren's syndrome are disproportionately affected. Oropharyngeal dysphagia refers specifically to difficulty in initiating a swallow due to dysfunction at or above the upper esophageal sphincter, and represents a large proportion of dysphagia cases. Current treatments are limited and are often ineffective. Stem cell therapy is a new and novel advancement that may fill a much-needed role in our treatment regimen. Here, we review the current literature regarding stem cell treatments for oropharyngeal dysphagia. Topics discussed include tissue regeneration advancements as a whole and translation of these principles into research surrounding tongue dysfunction, xerostomia, cricopharyngeal dysfunction, and finally an overview of the challenges and future directions for investigation. Although this field of study remains in its early stages, initial promising results show potential for the use of stem cell-based therapies to treat oropharyngeal dysphagia and warrant further research.
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OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has caused physicians and surgeons to consider restructuring traditional cancer management paradigms. We aim to review the current evidence regarding the diagnosis and management of head and neck cancer, with an emphasis on the role of the multidisciplinary team (MDT) during a pandemic. DATA SOURCES: COVID-19 resources from PubMed, Google Scholar, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Head and Neck Society were examined. REVIEW METHODS: Studies and guidelines related to the multidisciplinary management of head and neck cancer in the COVID-19 setting were reviewed. A total of 54 studies were included. Given the continuously evolving body of literature, the sources cited include the latest statements from medical and dental societies. RESULTS: The unpredictable fluctuation of hospital resources and the risk of the nosocomial spread of SARS-CoV-2 have direct effects on head and neck cancer management. Using an MDT approach to help define "essential surgery" for immediately life- or function-threatening disease processes in the context of available hospital resources will help to maximize outcomes. Early enrollment in an MDT is often critical for considering nonsurgical options to protect patients and health care workers. The role of the MDT continues after cancer treatment, if delivered, and the MDT plays an essential role in surveillance and survivorship programs in these challenging times. CONCLUSION: Head and neck cancer management during the COVID-19 pandemic poses a unique challenge for all specialists involved. Early MDT involvement is important to maximize patient outcomes and satisfaction in the context of public and community safety.
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Infecciones por Coronavirus/epidemiología , Manejo de la Enfermedad , Neoplasias de Cabeza y Cuello/diagnóstico , Neoplasias de Cabeza y Cuello/terapia , Neumonía Viral/epidemiología , Betacoronavirus , COVID-19 , Humanos , Pandemias , Guías de Práctica Clínica como Asunto , SARS-CoV-2RESUMEN
Importance: The novel coronavirus disease 2019 (COVID-19) has proven to be highly infectious, putting health care professionals around the world at increased risk. Furthermore, there are widespread shortages of necessary personal protective equipment (PPE) for these individuals. Filtering facepiece respirators, such as the N95 respirator, intended for single use, can be reused in times of need. We explore the evidence for decontamination or sterilization of N95 respirators for health care systems seeking to conserve PPE while maintaining the health of their workforce. Observations: The filtration properties and fit of N95 respirators must be preserved to function adequately over multiple uses. Studies have shown that chemical sterilization using soap and water, alcohols, and bleach render the respirator nonfunctional. Decontamination with microwave heat and high dry heat also result in degradation of respirator material. UV light, steam, low-dry heat, and commercial sterilization methods with ethylene oxide or vaporized hydrogen peroxide appear to be viable options for successful decontamination. Furthermore, since the surface viability of the novel coronavirus is presumed to be 72 hours, rotating N95 respirator use and allowing time decontamination of the respirators is also a reasonable option. We describe a protocol and best practice recommendations for redoffing decontaminated N95 and rotating N95 respirator use. Conclusions and Relevance: COVID-19 presents a high risk for health care professionals, particularly otolaryngologists, owing to the nature of viral transmission, including possible airborne transmission and high viral load in the upper respiratory tract. Proper PPE is effective when used correctly, but in times of scarce resources, institutions may turn to alternative methods of preserving and reusing filtering facepiece respirators. Based on studies conducted on the decontamination of N95 respirators after prior outbreaks, there are several options for institutions to consider for both immediate and large-scale implementation.
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Descontaminación/métodos , Respiradores N95/virología , COVID-19/transmisión , Protocolos Clínicos , Dispositivos de Protección de los Ojos , Guantes Protectores , Desinfección de las Manos , Humanos , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Respiradores N95/provisión & distribución , SARS-CoV-2 , Factores de TiempoRESUMEN
IMPORTANCE: Thirty-day hospital readmissions have substantial direct costs and are increasingly used as a measure of quality care. However, data regarding the risk factors and reasons for readmissions in head and neck cancer surgery reconstruction are lacking. OBJECTIVE: To describe the rate, risk factors, and causes of 30-day readmission in patients with head and neck cancer following free or pedicled flap reconstruction. DESIGN, SETTING, AND PARTICIPANTS: This retrospective, population-based cohort study analyzed medical records from the Nationwide Readmissions Database of 9487 patients undergoing pedicled or free flap reconstruction of head and neck oncologic defects between January 1, 2010, and December 31, 2014. Data analysis was performed in October 2017. EXPOSURES: Pedicled or free flap reconstruction of an oncologic head and neck defect. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day all-cause readmissions. Secondary outcomes included risk factors, causes, and costs of readmission. Multivariate regression analyses were conducted to determine factors independently associated with 30-day readmissions. RESULTS: Among 9487 patients included in the study (6798 male; 71.7%), the median age was 63 years (interquartile range, 55-71 years), and the 30-day readmission rate was 19.4% (n = 1839), with a mean cost per readmission of $15â¯916 (standard error of the mean, $785). The most common indication for readmission was wound complication (26.5%, n = 487). On multivariate regression, significant risk factors for 30-day readmission were median household income in the lowest quartile (vs highest quartile: odds ratio [OR], 1.58; 95% CI, 1.18-2.11), congestive heart failure (OR, 1.68; 95% CI, 1.14-2.47), liver disease (OR, 2.02; 95% CI, 1.22- 3.33), total laryngectomy (OR, 1.40; 95% CI, 1.12-1.75), pharyngectomy (OR, 1.47; 95% CI, 1.08-2.01), blood transfusion (OR, 1.30; 95% CI, 1.04-1.64), discharge to home with home health care (vs routine: OR, 1.32; 95% CI, 1.04-1.67), and discharge to a nursing facility (vs routine: OR, 1.77; 95% CI, 1.30-2.40). CONCLUSIONS AND RELEVANCE: Using the Nationwide Readmissions Database, we demonstrate that approximately 1 in 5 patients undergoing head and neck cancer surgery reconstruction is readmitted within 30 days of surgery. Readmissions are most commonly associated with wound complications. Socioeconomic status, complex ablative procedures, and patient comorbidities are independent risk factors for readmission. These findings may be useful to clinicians in developing perioperative interventions aimed to reduce hospital readmissions and improve quality of patient care.
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Neoplasias de Cabeza y Cuello/cirugía , Costos de Hospital/estadística & datos numéricos , Readmisión del Paciente/economía , Procedimientos de Cirugía Plástica/economía , Complicaciones Posoperatorias/economía , Colgajos Quirúrgicos , Anciano , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Clase SocialRESUMEN
OBJECTIVES/HYPOTHESIS: Determine the rate, diagnoses, and risk factors associated with 30-day nonelective readmissions for patients undergoing surgery for oropharyngeal cancer. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed the Nationwide Readmissions Database for patients who underwent oropharyngeal cancer surgery between 2010 and 2014. Rates and causes of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission. RESULTS: Among 16,902 identified cases, the 30-day, nonelective readmission rate was 10.2%, with an average cost per readmission of $14,170. The most common readmission diagnoses were postoperative bleeding (14.1%) and wound complications (12.6%) (surgical site infection [8.6%], dehiscence [2.3%], and fistula [1.7%]). On multivariate regression, significant risk factors for readmission were major ablative surgery (which included total glossectomy, pharyngectomy, and mandibulectomy) (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.06-1.60), advanced Charlson/Deyo comorbidity (OR: 2.00, 95% CI: 1.43-2.79), history of radiation (OR: 1.58, 95% CI: 1.15-2.17), Medicare (OR: 1.34, 95% CI: 1.06-1.69) or Medicaid (OR: 1.82, 95% CI: 1.32-2.50) payer status, index admission from the emergency department (OR: 1.19, 95% CI: 1.02-1.40), and length of stay ≥6 days (OR: 1.57, 95% CI: 1.19-2.08). CONCLUSIONS: In this large database analysis, we found that approximately one in 10 patients undergoing surgery for oropharyngeal cancer is readmitted within 30 days. Procedural complexity, insurance status, and advanced comorbidity are independent risk factors, whereas postoperative bleeding and wound complications are the most common reasons for readmission. LEVEL OF EVIDENCE: 4. Laryngoscope, 129:910-918, 2019.
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Neoplasias Orofaríngeas/cirugía , Procedimientos Quirúrgicos Otorrinolaringológicos/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Comorbilidad , Bases de Datos Factuales , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Periodo Posoperatorio , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: The impact of treatment delays on survival in oropharyngeal cancer and whether the effect varies by human papillomavirus (HPV) status have yet to be defined. METHODS: Retrospective analysis of the survival impact of time from diagnosis to surgery (DTS), surgery to radiation (SRT), and duration of radiation (RTD) for patients in the National Cancer Database with resected oropharyngeal cancer who underwent adjuvant radiation from 2010 to 2014. RESULTS: We identified optimal thresholds of 30, 40, and 51 days for DTS, SRT, and RTD, respectively, with treatment times exceeding these thresholds associated with significantly worse overall survival. Prolonged SRT and RTD were associated with mortality regardless of HPV status, although rising DTS was only predictive among patients with HPV-negative tumors. CONCLUSIONS: Treatment delays significantly impact survival in oropharyngeal cancer. The consequences of prolonged DTS may be stronger in HPV-negative than HPV-positive disease. These data serve as a foundation for future research and clinical management.
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Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/cirugía , Neoplasias Orofaríngeas/mortalidad , Neoplasias Orofaríngeas/cirugía , Infecciones por Papillomavirus/complicaciones , Tiempo de Tratamiento , Anciano , Carcinoma de Células Escamosas/microbiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Orofaríngeas/microbiología , Papillomaviridae , Infecciones por Papillomavirus/diagnóstico , Infecciones por Papillomavirus/mortalidad , Estudios Retrospectivos , Factores Socioeconómicos , Tasa de SupervivenciaRESUMEN
OBJECTIVES: Delays in the initiation of postoperative radiation have been associated with worse outcomes; however, the effect of the overall treatment package time (interval from surgery through the completion of radiation) remains undefined. The purpose of this study was to determine the impact of package time on survival and to evaluate this effect among different subgroups of head and neck cancer patients. PATIENTS AND METHODS: In this observational cohort study, the National Cancer Database was used to identify 35,167 patients with resected nonmetastatic head and neck cancer who underwent adjuvant radiation from 2004 to 2014. Kaplan-Meier survival estimates and multivariate Cox regression analyses were performed to determine the effect of treatment package time on overall survival. RESULTS: Median package time was 96â¯days (interquartile range, 85-112â¯days). After adjusting for covariates, package times of 11â¯weeks or less were associated with improved survival (adjusted hazard ratio (aHR), 0.90; 95% confidence interval, 0.83-0.97) compared to an interval of 12-13â¯weeks, whereas package times of more than 14â¯weeks were associated with worse survival (aHR, 1.14, 1.14, and 1.22 for 14-15, 15-17, and >17â¯weeks, respectively). A significant interaction was identified between package time and disease site, nodal status, and stage. Specifically, patients with oropharyngeal tumors, advanced stage (III or IV) disease, or nodal involvement experienced more pronounced increases in mortality risk with delays in treatment time. CONCLUSIONS: Treatment package time independently impacts survival. This effect may be strongest for patients with oropharyngeal tumors or advanced stage disease.
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Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirugía , Neoplasias Orofaríngeas/radioterapia , Neoplasias Orofaríngeas/cirugía , Tiempo de Tratamiento , Anciano , Carcinoma de Células Escamosas/tratamiento farmacológico , Carcinoma de Células Escamosas/patología , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Perdida de Seguimiento , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante , Estadificación de Neoplasias , Neoplasias Orofaríngeas/tratamiento farmacológico , Neoplasias Orofaríngeas/patología , Cuidados Posoperatorios , Modelos de Riesgos Proporcionales , Radioterapia Adyuvante , Tasa de Supervivencia , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Survival outcomes for adjuvant chemoradiotherapy (aCRT) and adjuvant radiotherapy (aRT) were compared in patients with oropharyngeal squamous cell carcinoma (OPSCC) with intermediate-risk features. METHODS: We identified 2164 patients with OPSCC in the National Cancer Database without positive margins or extracapsular extension and with at least one intermediate-risk feature: pT3-T4 disease, ≥two positive lymph nodes, level IV/V nodal disease, and/or lymphovascular invasion. We assessed predictors of aCRT use and covariables impacting overall survival. RESULTS: aCRT was commonly used for both human papillomavirus (HPV)-positive (62.0%) and HPV-negative (64.3%) patients with OPSCC. Higher N stage, level IV/V neck disease, and younger age strongly predicted aCRT utilization. There was no significant survival benefit associated with aCRT vs aRT in HPV-positive (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.62-1.38; P = .71) or HPV-negative (HR, 0.75; 95% CI, 0.51-1.10; P = .15) disease. CONCLUSIONS: Despite high rates of utilization, aCRT is not associated with better survival vs aRT for OPSCC with intermediate-risk features, including HPV-negative tumors.
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Carcinoma de Células Escamosas/terapia , Quimioradioterapia Adyuvante , Neoplasias Orofaríngeas/terapia , Radioterapia Adyuvante , Anciano , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/cirugía , Femenino , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Neoplasias Orofaríngeas/mortalidad , Neoplasias Orofaríngeas/cirugía , Puntaje de Propensión , Sistema de Registros , Factores de RiesgoRESUMEN
OBJECTIVE: A vibratory vocal fold replacement would introduce a new treatment paradigm for structural vocal fold diseases such as scarring and lamina propria loss. This work implants a tissue-engineered replacement for vocal fold lamina propria and epithelium in rabbits and compares histology and function to injured controls and orthotopic transplants. Hypotheses were that the cell-based implant would engraft and control the wound response, reducing fibrosis and restoring vibration. STUDY DESIGN: Translational research. METHODS: Rabbit adipose-derived mesenchymal stem cells (ASC) were embedded within a three-dimensional fibrin gel, forming the cell-based outer vocal fold replacement (COVR). Sixteen rabbits underwent unilateral resection of vocal fold epithelium and lamina propria, as well as reconstruction with one of three treatments: fibrin glue alone with healing by secondary intention, replantation of autologous resected vocal fold cover, or COVR implantation. After 4 weeks, larynges were examined histologically and with phonation. RESULTS: Fifteen rabbits survived. All tissues incorporated well after implantation. After 1 month, both graft types improved histology and vibration relative to injured controls. Extracellular matrix (ECM) of the replanted mucosa was disrupted, and ECM of the COVR implants remained immature. Immune reaction was evident when male cells were implanted into female rabbits. Best histologic and short-term vibratory outcomes were achieved with COVR implants containing male cells implanted into male rabbits. CONCLUSION: Vocal fold cover replacement with a stem cell-based tissue-engineered construct is feasible and beneficial in acute rabbit implantation. Wound-modifying behavior of the COVR implant is judged to be an important factor in preventing fibrosis. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:153-159, 2018.
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Trasplante de Células Madre Mesenquimatosas , Membrana Mucosa/cirugía , Ingeniería de Tejidos/métodos , Pliegues Vocales/cirugía , Animales , Femenino , Adhesivo de Tejido de Fibrina/uso terapéutico , Masculino , Membrana Mucosa/patología , Conejos , Factores Sexuales , Andamios del Tejido , Investigación Biomédica Traslacional , Trasplante Autólogo , Pliegues Vocales/patología , Cicatrización de HeridasRESUMEN
Tracheoesophageal prosthesis (TEP) is the most common voice restoration method following total laryngectomy. Prosthesis extrusion and aspiration occurs in 3.9% to 6.7% and causes dyspnea. Emergency centers are unfamiliar with management of the aspirated TEP. Prior studies report removal of aspirated TEP prostheses under general anesthesia. Laryngectomees commonly have poor pulmonary function, posing increased risks for complications of general anesthesia. We present a straightforward approach to three cases of aspirated TEP prosthesis removed in the ambulatory setting. In each case, aspirated TEP was diagnosed with flexible bronchoscopy under local anesthesia at the time of consultation, and all prostheses were retrieved atraumatically using a biopsy grasper forceps inserted via the side channel of the bronchoscope. The aspirated TEP prosthesis can be safely and efficiently removed via bedside bronchoscopy.
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OBJECTIVES:: Cell therapies using mesenchymal stromal cells (MSCs) have been proposed as a promising new tool for the treatment of vocal fold scarring. However, the mechanisms by which MSCs promote healing as well as their duration of survival within the host vocal fold have yet to be defined. The aim of this work was to assess the persistence of embedded MSCs within a tissue-engineered vocal fold mucosal replacement in a rabbit model of vocal fold injury. METHODS:: Male rabbit adipose-derived MSCs were embedded within a 3-dimensional fibrin gel, forming the cell-based outer vocal fold replacement. Four female rabbits underwent unilateral resection of vocal fold epithelium and lamina propria and reconstruction with cell-based outer vocal fold replacement implantation. Polymerase chain reaction and fluorescent in situ hybridization for the sex-determining region of the Y chromosome (SRY-II) in the sex-mismatched donor-recipient pairs sought persistent cells after 4 weeks. RESULTS:: A subset of implanted male cells was detected in the implant site at 4 weeks. Many SRY-II-negative cells were also detected at the implant site, presumably representing native female cells that migrated to the area. No SRY-II signal was detected in contralateral control vocal folds. CONCLUSIONS:: The emergent tissue after implantation of a tissue-engineered outer vocal fold replacement is derived both from initially embedded adipose-derived stromal cells and infiltrating native cells. Our results suggest this tissue-engineering approach can provide a well-integrated tissue graft with prolonged cell activity for repair of severe vocal fold scars.
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Cicatriz/terapia , Células Madre Mesenquimatosas/fisiología , Ingeniería de Tejidos/métodos , Trasplante de Tejidos/métodos , Disfunción de los Pliegues Vocales/terapia , Pliegues Vocales , Animales , Cicatriz/patología , Cicatriz/fisiopatología , Conejos , Regeneración/fisiología , Resultado del Tratamiento , Disfunción de los Pliegues Vocales/etiología , Disfunción de los Pliegues Vocales/fisiopatología , Pliegues Vocales/patología , Pliegues Vocales/fisiología , Pliegues Vocales/trasplanteRESUMEN
BACKGROUND: Tongue fibrosis resulting from head and neck cancer, surgery, radiation, chemotherapy, or a combination thereof devastates one's quality of life. Therapeutic options are limited. Here we investigate human bone marrow-derived multipotent stromal cells (MSC) as a novel injectable treatment for post-injury tongue fibrosis. METHODS: MSCs were grown in culture. Eighteen athymic rats underwent unilateral partial glossectomy. After two weeks for scar formation, a single injection was performed in the tongue scar. Three treatment groups were studied: low and high concentration MSC, and control media injection. Tongues were harvested for evaluation at three weeks post-treatment. RESULTS: Dense fibrosis was achieved in control animals at five weeks. High concentration MSC reduced cross sectional scar burden (P = .007) and pathologic score for inflammation and fibrosis. CONCLUSION: This study establishes the feasibility of a novel rodent tongue fibrosis model, and begins to assess the utility of human MSCs to reduce scar burden. LEVEL OF EVIDENCE: N/a.