Airway and Swallowing Outcomes in Children With Combined Laryngomalacia and Laryngeal Cleft.

Laryngomalacia (LM) and laryngeal cleft (LC) can independently cause dysphagia but rarely can occur concomitantly. We discuss the presentation, decision-making, and swallow outcomes following surgical correction of combined LM and LC. We present four patients with combined LM and an LC who underwent both primary supraglottoplasty (SGP) and laryngeal cleft repair (LCR). Each patient presented with recurrent choking or coughing with feeds. Stridor was only present in two patients. Patients with SGP saw the resolution of stridor when present, but dysphagia persisted in all four cases. LCR clinically and objectively resolved all symptoms of dysphagia. We found that flexible fiberoptic laryngoscopy is not always reliable at detecting combined pathology. Patients presenting with persistent dysphagia following SGP should be suspected of having interarytenoid pathology. We recommend a staged surgical approach with SGP before LCR.

Combined Endoscopic Laser and Cryotherapy Management of Pediatric Central Airway Obstruction Secondary to a Histoplasmosis-Related Broncholith.

Broncholithiasis due to pulmonary histoplasmosis causing central airway obstruction and broncho-mediastinal fistula is a rare complication in the pediatric population. A 16-year-old previously healthy female was referred to a university hospital for worsening cough and shortness of breath for over a two-year period. Radiologic investigation revealed a calcified subcarinal lymph node eroding into the left mainstem bronchus causing central airway obstruction and collapse of the left lower lobe. Direct laryngoscopy and bronchoscopy showed a large obstructive lesion in the left mainstem bronchus. Debulking of the endobronchial lesion was performed with neodymium-doped yttrium aluminum garnet (Nd:YAG) laser and cryotherapy. Pathology examination was consistent with broncholith. Great clinical and radiological response to the procedure was evident with complete re-expansion of the left lung and resolution of symptoms.

3D Bioprinting in Otolaryngology: A Review.

The evolution of tissue engineering and 3D bioprinting has allowed for increased opportunities to generate musculoskeletal tissue grafts that can enhance functional and aesthetic outcomes in otolaryngology-head and neck surgery. Despite literature reporting successes in the fabrication of cartilage and bone scaffolds for applications in the head and neck, the full potential of this technology has yet to be realized. Otolaryngology as a field has always been at the forefront of new advancements and technology and is well poised to spearhead clinical application of these engineered tissues. In this review, current 3D bioprinting methods are described and an overview of potential cell types, bioinks, and bioactive factors available for musculoskeletal engineering using this technology is presented. The otologic, nasal, tracheal, and craniofacial bone applications of 3D bioprinting with a focus on engineered graft implantation in animal models to highlight the status of functional outcomes in vivo; a necessary step to future clinical translation are reviewed. Continued multidisciplinary efforts between material chemistry, biological sciences, and otolaryngologists will play a key role in the translation of engineered, 3D bioprinted constructs for head and neck surgery.

Making the case for multidisciplinary pediatric aerodigestive programs.

Multidisciplinary pediatric aerodigestive centers have been proposed to address the needs of children with complex multi-system problems affecting the respiratory and upper gastrointestinal tracts. The setup of a multidisciplinary service allows for the complex coordination needed between different subspecialties. This allows for rapid communication and family-centered decision making and agreement on further diagnostic and/or therapeutic next steps such as offering triple endoscopy when indicated. Triple endoscopy entails performing rigid upper airway assessment, flexible bronchoscopy and upper gastrointestinal endoscopy and has been linked to reduced time to diagnosis/treatment, reduced costs and anesthesia exposure. This review summarizes the available literature on the structure and benefits of multidisciplinary pediatric aerodigestive services.

Management of tonsillar lipoma: is tonsillectomy essential?

Tonsillar lipomas are rare benign tumors, with only a limited number of cases reported in the literature. Excision of the lipoma along with tonsillectomy has been proposed as the usual treatment option. We report a case of tonsillar lipoma which was managed by excision of the lesion without the need for a tonsillectomy. No recurrence was reported at a 2-year followup. A worldwide literature review was done to better define the clinical and histopathological features of these lesions. The authors propose that routine tonsillectomy is not required for these benign lesions and that simple excision of the stalk of the lipoma is sufficient.

A simplified approach to minimally invasive parathyroidectomy.

OBJECTIVES/HYPOTHESIS: To assess the feasibility of a simplified approach for the use of a rapid intraoperative parathyroid hormone (IOPTH) assay based on a single 10-minute post-excision level using the workup parathyroid hormone level (wPTH) as the baseline in minimally invasive parathyroidectomy (MIP) and to compare the predictive value of this criterion with other recommended criteria. STUDY DESIGN: Case series with chart review. METHODS: A single surgeon's prospectively maintained parathyroidectomy database at an academic center was reviewed over a 2-year period from June 2009 through June 2011. RESULTS: A total of 102 patients undergoing MIP met the inclusion criteria. An IOPTH threshold of a ≥ 50% drop at 10 minutes post-excision from the wPTH baseline resulted in acceptable false positive (1.9%) and false negative (0.9%) rates. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of this modified criterion was 98.9%, 71.4%, 98%, 83.3%, and 97%, respectively. CONCLUSIONS: In our patient cohort, the pre-incision and pre-excision IOPTH levels did not seem to change the overall accuracy of predicting surgical success in MIP if a single 10-minute post-excision IOPTH level is used along with the wPTH, and is commensurate with the commonly used Miami and Vienna criteria. A single intraoperative blood sample demonstrating a ≥50% drop from the wPTH at 10 minutes post-excision should be explored further as a feasible simplified criterion that avoids multiple IOPTH samples.

Assessment of aspiration risk from dynamic modulation of endotracheal tube cuff pressure.

OBJECTIVES/HYPOTHESIS: To assess the risk of aspiration using a novel valve circuit that dynamically modulates endotracheal tube cuff pressure during the ventilatory cycle using bench and live animal models. STUDY DESIGN: Animal model. METHODS: The bench model consisted of a cuffed endotracheal tube inserted into an artificial trachea. Leakage of liquid around the cuff was measured after 4 hours of constant or dynamic modulation of cuff pressure at variable peak end expiratory pressures. In the porcine model, eight animals were ventilated with the modulating valve circuit and compared to eight controls ventilated with a constant cuff pressure (25 cm of water). Aspiration was monitored quantitatively using a pH probe (measured as voltage) and visually using fluoroscopy. RESULTS: There was no difference in the amount of fluid leakage around the endotracheal tube cuff in the constant or dynamically modulated pressure-cuff groups in the bench or animal models. CONCLUSION: Dynamically modulating endotracheal tube-cuff pressures to minimize tracheal mucosal damage does not increase the tendency to leak around the cuff compared to endotracheal tube cuffs inflated to a constant pressure. LEVEL OF EVIDENCE: N/A.

Quantitative assessment of pulmonary aspiration: A novel porcine model.

OBJECTIVES: Pulmonary aspiration is a common cause of ventilator-associated pneumonia in the intensive care setting. Current bench and animal models of aspiration are based on the qualitative assessments. The purpose of the present study was to develop a porcine model for the real-time quantitative assessment of aspiration. METHODS: Five sus scrofa piglets were anaesthetized and underwent placement of a pH probe through the endotracheal tube so that the distal tip of the probe resided at the carina. The pH probe was sutured to the posterior tracheal wall via an open approach and the position of the probe tip was verified by flexible endoscopy. 10 mL of acidic solution (pH = 2.7) was delivered through a catheter attached to the outside of the endotracheal tube so that the solution remained between the endotracheal tube and trachea proximal to the inflated endotracheal tube cuff. The pH probe was connected to a pH metre, a multifunctional data acquisition device with an analogue output signal measuring the voltage generated, and a computer for analysis. Leakage of fluid past the endotracheal tube cuff (aspiration) was therefore continuously assessed quantitatively by detecting voltage changes over a period of time. RESULTS: The mean voltage of the tracheal mucosa at the beginning of the experiment (maximum voltage) was 916.6 mV ± 24.5 mV (range 891.0-945.7 mV). There was a slight drop in voltage at the end of the 2 h period to 840.8 ± 22.6 mV (range = 812.3-867.3 mV). After deflation of the endotracheal tube cuff, the mean voltage dropped to 497.3 mV ± 24.8 mV (range 435.7-567.1 mV) with a mean drop in voltage of 419.3 mV ± 32.6 mV (range 368.9-455.3 mV). CONCLUSIONS: This porcine model allows for the continuous quantitative assessment of aspiration over time. Such a model may be of value for the evaluation of techniques for reducing aspiration.

Chondrosarcoma of the arytenoid cartilage.

Chondrosarcoma is the most frequently encountered nonepithelial tumor of the larynx. Still, laryngeal chondrosarcoma is a rare disease, accounting for less than 1% of all laryngeal neoplasms; only about 600 cases have been reported in the world literature. The two most common sites of origin are the cricoid cartilage (69% of cases) and the thyroid cartilage (9%); arytenoid cartilage origin has been seen in less than 3% of cases. The diagnosis of laryngeal chondrosarcoma is easy to miss because of its infrequent occurrence, its indolent pattern of growth, and the difficulty in differentiating it histopathologically from chondroma. However, suspicion of arytenoid chondrosarcoma may be raised by a finding of its characteristic appearance as a smooth, hard, mucosa-covered supraglottic mass that is fairly recognizable on indirect laryngoscopy. We report a new case of chondrosarcoma of the arytenoid cartilage in a 47-year-old man, and we discuss the clinical features, diagnosis, and management of this uncommon tumor.