Artificial intelligence and ChatGPT: An otolaryngology patient's ally or foe?

BACKGROUND: As artificial intelligence (AI) is integrating into the healthcare sphere, there is a need to evaluate its effectiveness in the various subspecialties of medicine, including otolaryngology. Our study intends to provide a cursory review of ChatGPT's diagnostic capability, ability to convey pathophysiology in simple terms, accuracy in providing management recommendations, and appropriateness in follow up and post-operative recommendations in common otolaryngologic conditions. METHODS: Adenotonsillectomy (T&A), tympanoplasty (TP), endoscopic sinus surgery (ESS), parotidectomy (PT), and total laryngectomy (TL) were substituted for the word procedure in the following five questions and input into ChatGPT version 3.5: "How do I know if I need (procedure)," "What are treatment alternatives to (procedure)," "What are the risks of (procedure)," "How is a (procedure) performed," and "What is the recovery process for (procedure)?" Two independent study members analyzed the output and discrepancies were reviewed, discussed, and reconciled between study members. RESULTS: In terms of management recommendations, ChatGPT was able to give generalized statements of evaluation, need for intervention, and the basics of the procedure without major aberrant errors or risks of safety. ChatGPT was successful in providing appropriate treatment alternatives in all procedures tested. When queried for methodology, risks, and procedural steps, ChatGPT lacked precision in the description of procedural steps, missed key surgical details, and did not accurately provide all major risks of each procedure. In terms of the recovery process, ChatGPT showed promise in T&A, TP, ESS, and PT but struggled in the complexity of TL, stating the patient could speak immediately after surgery without speech therapy. CONCLUSIONS: ChatGPT accurately demonstrated the need for intervention, management recommendations, and treatment alternatives in common ENT procedures. However, ChatGPT was not able to replace an otolaryngologist's clinical reasoning necessary to discuss procedural methodology, risks, and the recovery process in complex procedures. As AI becomes further integrated into healthcare, there is a need to continue to explore its indications, evaluate its limits, and refine its use to the otolaryngologist's advantage.

Airway fires in otolaryngologic surgery: A database review.

PURPOSE: An estimated 34 % of reported operating room fires involve the airway. Despite the inherent risks in otolaryngologic surgery, education regarding prevention and management of airway fires is limited in graduate medical training. One contributing factor is a lack of reporting of such rare events in our literature. METHODS: The U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for reports of adverse events related to fires occurring during surgical procedures of the airway from January 1, 2010, to March 31, 2020. RESULTS: 3687 reports were identified and 49 unique reports of airway fire were included. Sustained fires were described in 16 (32.7 %) reports and 33 (67.3 %) described transient flares. 2 fires extended beyond the airway and 9 (18.4 %) were noted to have occurred at the start of the case. Fires were reported most commonly during tonsillectomy (n = 22 [44.9 %]), vocal fold excision (n = 5 [10.2 %]), and adenoidectomy (n = 4 [8.2 %]). 46 reports attributed flare initiation to a specific element of the fire triangle. 16 patient and 2 operator injuries were reported. Saline washing was utilized in 7 (14.3 %) cases overall. Patients were extubated immediately in 2 (12.5 %) of the 16 reports of sustained fires. 0 mortalities were reported. CONCLUSION: Airway fires were reported in a variety of upper airway procedures performed regularly by otolaryngologists. The triggering factor that led to fire was identified as a spark or char in about half of the reported cases, and only 2 reports described immediate removal of the endotracheal tube.

Cost-Effectiveness of Steroids for Prolonging the Surgery-Free Interval in Subglottic Stenosis.

OBJECTIVES: Repeat endoscopic dilation (ED) in the operating room for subglottic stenosis (SGS) remains an economic burden to patients. The cost-effectiveness (CE) of adjuvant serial intralesional steroid injections (SILSI) to prolong the surgery-free interval (SFI) in SGS patients requiring ED has yet to be studied. METHODS: Details of the cost of SILSI and ED were received from our tertiary academic center. SFI, cost of intervention, and the effect of SILSI on prolonging SFI were collected from a systematic review by Luke et al. SGS etiologies in the review included idiopathic, iatrogenic, or autoimmune. A break-even analysis, comparing the cost of SILSI alone with the cost of repeat ED, was performed to determine if SILSI injections were cost-effective in prolonging the SFI. RESULTS: Average extension of the SFI with SILSI was an additional 219.3 days compared to ED alone based on a systematic review of the literature. 41/55 (74.5%) cases did not require further ED once in-office SILSI management began. SILSI administered in a 4-dose series in 3-to-7-week intervals (~$7,564.00) is CE if the reported recurrence rate of SGS requiring ED (~$39,429.00) has an absolute risk reduction (ARR) of at least 19.18% with the use of SILSI. Based on the literature, SILSI prevents ~3 out of every 4 cases of SGS at sufficient follow-up from undergoing repeat ED, resulting in an ARR of ~75%. CONCLUSIONS: SILSI is economically reasonable if it prolongs the SFI of at least one case of recurrence out of 5. SILSI, therefore, can be CE in extending the interval for surgical ED. LEVEL OF EVIDENCE: NA Laryngoscope, 133:3436-3442, 2023.

Complications associated with energy-based devices during thyroidectomy from 2010-2020.

Objective: Harmonic Focus (Ethicon, Johnson and Johnson, Cincinnati, OH, USA), LigaSure Small Jaw (Medtronic, Covidien Products, Minneapolis, MN, USA), and Thunderbeat Open Fine Jaw (Olympus, Japan) are electrosurgical instruments used widely in head and neck surgery. The study aims to compare device malfunctions, adverse events to patients, operative injuries, and interventions related to Harmonic, LigaSure, and Thunderbeat use during thyroidectomy. Methods: The US Food and Drug Administration's Manufacture and User Facility Device Experience (MAUDE) database was queried for adverse events associated with Harmonic, LigaSure, and Thunderbeat from January 2005 to August 2020. Data were extracted from reports pertaining to thyroidectomy. Results: Of the 620 adverse events extracted, 394 (63.5%) involved Harmonic, 134 (21.6%) LigaSure, and 92 (14.8%) Thunderbeat. The reported device malfunctions most frequently associated with Harmonic was damage to the blade (110 (27.9%)), LigaSure was inappropriate function (47 (43.1%)), Thunderbeat was damage to the tissue or Teflon pad (27 (30.7%)), respectively. Burn injury and incomplete hemostasis were the most commonly reported adverse events. The operative injury reported most frequently when using Harmonic and LigaSure was burn injury. No operator injuries were reported with Thunderbeat use. Conclusion: The most frequently reported device malfunctions were damage to the blade, inappropriate function, and damage to the tissue or Teflon pad. The most frequently reported adverse events to patients was a burn injury and incomplete hemostasis. Interventions aimed at improving physician education may help reduce adverse events attributed to improper use.

Complications associated with PEAK PlasmaBlade from 2010 to 2020 from MAUDE.

The pulse-electron avalanche knife (PEAK) PlasmaBlade 3.0 and 4.0 (Medtronic, Minneapolis, MN) is an electrosurgical technology that is widely used in surgery. Our study aimed to summarize device malfunctions, patient injuries, and interventions related to PEAK PlasmaBlade 3.0 and 4.0. The US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database was queried for reports of PlasmaBlade adverse events from June 6, 2010, to August 30, 2020. Data were extracted from reports pertaining to PlasmaBlade 3.0 and 4.0. A total of 384 medical device reports were identified, from which 424 adverse events were extracted. Of those, 348 (82.1%) were device malfunctions, 53 (12.5%) were patient injuries, and 23 (5.4%) were operator injuries. Device malfunctions were most frequently caused by delaminated coating (110, 25.9%), followed by ignition or fire (56, 13.2%). Operator injury was most frequently caused by thermal injury (19, 4.5%), followed by laceration (4, 0.9%). Pacemakers (22, 57.9%) were the most common devices causing interference. PEAK PlasmaBlade 3.0 and 4.0 have demonstrated utility during surgeries but are associated with adverse events. Interventions that aim to educate physicians on potential risks may help reduce the incidence of complications. Future studies with standardized reporting protocols are warranted.

Rare presentation of angiomatosis in the paranasal sinuses mimicking juvenile nasopharyngeal angiofibroma in a 16 year old male.

Rare presentation of pediatric angiomatosis of the paranasal sinus and skull base presenting mimicking juvenile nasopharyngeal angiofibroma (JNA). This is a 16-year-old male who presented to the emergency room with acutely worsening headaches, decreased visual acuity, subjective diplopia on lateral gaze, and a skull base mass centered in the sphenoid cavity. Endoscopic biopsy at an outside facility was aborted due to profuse bleeding. Upon transfer to a tertiary care center, contrast MR demonstrated a heterogeneously and avidly enhancing vascular mass centered around the sphenoid and skull base originating from the internal maxillary artery with significant bilateral extension into the adjacent paranasal sinuses, sella, and cavernous sinus. History of presentation and imaging was suggestive of JNA. Patient underwent preoperative embolization followed by endoscopic endonasal transphenoidal resection with a skull base trained otolaryngologist and neurosurgeon. Final pathology confirmed angiomatosis. This is only the second reported case of paranasal sinus angiomatosis in the literature. Angiomatosis has a high rate of recurrence and failure of timely diagnosis can lead to requirement of repeated surgical intervention. Re-operations are associated with increased costs, patient dissatisfaction, and poorer surgical/clinical outcomes. Because angiomatosis can mimic JNA, hemangiomas, or other vascular tumors, it is essential to maintain a broad differential diagnosis that includes angiomatosis when evaluating sinonasal tumors.

An Updated Review of Subglottic Stenosis: Etiology, Evaluation, and Management.

Purpose of Review: To assimilate the newly published literature regarding subglottic stenosis (SGS), including basic science and translational research on mechanisms of etiology, clinical diagnostics, and therapeutic treatments. Recent Findings: The role of inflammation in development of iatrogenic and idiopathic SGS (iSGS) is continuing to be studied. The IL-23/IL-17A inflammatory axis appears to be a potential mechanism for development of iSGS. Additionally, as anticipated in an inflammatory milieu, PD-1/PD-L1 expression is upregulated. If the PD-1/PD-L1 axis is important in SGS pathogenesis, then it may represent a potential target for immunotherapeutic inhibition, given its success in cancer treatment. In terms of surgical management, prospective studies show that endoscopic approaches have more frequent recurrence compared to open techniques. Summary: SGS arises from various etiologies, and further understanding of its pathogenesis can aid in the development of novel therapies. It is imperative to obtain a thorough history for each patient presenting with respiratory complaints, as misdiagnosis can delay proper treatment. Endoscopic and open surgical techniques continue to be investigated in a growing number of prospective clinical trials to determine optimal treatment protocols. In-office injections are gaining popularity and show promise in the treatment of SGS.

Sex Bias in Laryngology Research and Publishing.

OBJECTIVE: To investigate sex bias in laryngology research and publishing. MATERIALS AND METHODS: Articles published in 2019 in seven mainstream otolaryngology journals were reviewed. Original manuscripts were included. Study type (medical, speech-language pathology, basic science, or pedagogy), subject sex, ≥50% sex-matching (SM≥50), sex-based analysis, and bibliometric data including author sex were recorded. RESULTS: Of 1619 publications reviewed, 259 patient-centered original laryngology studies were included, totaling 7,130,991 subjects (3,411,741 [47.8%] male; 3,718,694 [52.1%] female; 556 [0.0%] unreported). 29 studies included subjects of a single sex and 14 did not report sex. 114 (44%) studies met SM≥50, and 95 (37%) used sex-based analysis; no differences were found among study types or location. Sex-based analysis was used less in single-institution (33%) than database studies (62%, P = 0.01). No difference in SM≥50 was found among single or multi-institution, or database. There were 1340 total authors (578 [43%] female). First, corresponding, and senior authors were 47%, 39%, and 35% female, respectively. Studies that had female first and/or senior authors did not differ in rates of SM≥50 or sex-based analysis or mean enrollment of females compared to studies with male first and senior authors. The proportion of female physician first and senior authors did not differ from the proportion of female Association of American Medical Colleges otolaryngology faculty, but was non-significantly smaller than the proportion of female laryngology fellows at four academic institutions. CONCLUSION: Laryngology research exhibits sex bias in subject enrollment and sex-based analysis. Female authorship was representative of national demographics and author sex did not influence the rate of sex bias.

I'm All Ears: A Population-Based Analysis of Consumer Product Foreign Bodies of the Ear.

OBJECTIVES: The purpose of this study was to assess the nationwide incidence of ear foreign body (FB) presentations to the emergency department (ED) and analyze the most common FB consumer products encountered. METHODS: The National Electronic Injury Surveillance System (NEISS) was evaluated for ED visits that included "ear foreign bodies" from 2010 through 2019. The most frequent foreign bodies were identified and organized by demographics. RESULTS: A total of 20,545 ear FB cases were found, with an estimated 608,860 ED visits nationwide. Female patients (56%) were more likely to have jewelry and first aid equipment FBs. Males between the ages of 5 and 15 years were significantly (P < 0.05) more likely to have paper products, pens/pencils, and desk supplies in their ears. CONCLUSION: Ear FBs represent a substantial proportion of healthcare expenditures. Although children are the most commonly affected individuals, all ages require further education and preventive measures.

Complications Associated with PROPEL Mometasone Furoate Bioabsorbable Drug-eluting Sinus Stents From 2012 to 2020.

BACKGROUND: Till date, there have been no studies that have analyzed a database to examine postmarket adverse events associated with PROPEL mometasone furoate bioabsorbable drug-eluting sinus stents. OBJECTIVE: To determine the postmarket complications associated with PROPEL mometasone furoate bioabsorbable drug-eluting sinus stents. METHODS: The US Food and Drug Administration's Manufacturer and User Facility Device Experience database was searched for adverse events associated with PROPEL bioabsorbable drug-eluting sinus stents between January 1, 2012 and December 31, 2020. Data were extracted and analyzed from medical device reports (MDRs) that involved sinus stents. RESULTS: After 47 MDRs were identified, 25 reports involving PROPEL bioabsorbable drug-eluting sinus stents were reviewed, from which 40 adverse events were recorded. Of these, there were 32 adverse events to patients and 8 device malfunctions. The most common adverse events to patients included infection (21.8%), oropharyngeal obstruction (15.6%), and headache/pain (12.5%). The most common device malfunction reported was migration and expulsion of the stent (87.5%). CONCLUSIONS: PROPEL sinus stents have been shown to be effective in preventing sinus outflow obstruction after functional endoscopic sinus surgery. Both adverse events to patients and device malfunctions are reported infrequently. A more comprehensive understanding of rare postmarket complications seen with PROPEL sinus stents may further aid informed decision-making regarding their usage.

Adverse Events Associated With Electromyogram Endotracheal Tubes in Thyroid and Parathyroid Surgery.

OBJECTIVE: Thyroid and parathyroid surgeries are frequently performed with the aid of electromyogram endotracheal tubes. However, the most common adverse events have not been reported comprehensively. This study aimed to summarize the device adverse events, patient complications, and subsequent interventions related to electromyogram endotracheal tubes. METHODS: In this retrospective cross-sectional analysis, the US Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for electromyogram endotracheal tube adverse events between 2010 and 2020. Data were extracted for devices used in thyroid and parathyroid surgery. RESULTS: Of 198 included reports, the most common device-related adverse events were loss of response to nerve stimulation (34.8%), cuff perforation (18.2%), and tube lumen obstruction (13.6%). Of 98 patient complications, the most common included ventilation failure (n = 50), airway trauma (n = 22), and recurrent laryngeal nerve injury (n = 5). There was 1 periprocedural death reported. Reported interventions include reintubation performed in 60.1% of all device adverse events, extended hospitalization in 27.3% of airway trauma events, and 5 tracheostomies performed for ventilation failure events. Forty-one events resulted in case delays and 13 events led to aborted cases. The most reported adverse events occurred in 2018 (n = 35) and 2015 (n = 30). CONCLUSIONS: The most commonly reported adverse events associated with electromyogram endotracheal tubes include loss of response to nerve stimulation, cuff perforation, ventilation failure, and airway trauma. Subsequent interventions include reintubation, tracheostomy, extended hospitalization, and aborted cases. Surgical teams should consider these adverse events when consenting patients and using these devices in thyroid and parathyroid cases.

Adverse Events Associated With Ossicular Prostheses: Utility of a Federal Database.

OBJECTIVES: Ossicular prostheses have demonstrated utility in ossicular chain reconstruction, but their use also is associated with complications. This study aims to explore the utility of the U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database for the systematic analysis of complications associated with ossicular prostheses. It also summarizes adverse events to patients (AEPs) and device malfunctions (DMs) reported in the MAUDE database, and attempts to examine the consequences brought about by these events and to identify likely root causes. STUDY DESIGN: Retrospective analysis of the MAUDE database. METHODS: The MAUDE database was queried for reports from January 2010 to May 2020. Data were extracted from reports involving the use of ossicular prostheses. RESULTS: Seventy-three medical device reports, reports submitted to the Food and Drug Administration detailing suspected device-associated malfunctions, injuries, and deaths, involved ossicular prostheses and were included for analysis, from which 126 adverse events were extracted. Of these, 50 (39.7%) were AEPs, while 76 (60.3%) were DMs. The most common AEPs were foreign body and hearing loss, while the DMs reported most commonly were broken prosthesis and displaced prosthesis. Of the 76 DMs, 19 (25%) were attributed to mishandling by the operator, while 6 (7.9%) were due to a defective device. Broken prosthesis was the DM most commonly attributed to mishandling by the operator in 16 (32.7%) cases. CONCLUSION: Ossicular prostheses are used extensively for ossicular chain reconstruction, but also are associated with adverse events. The MAUDE database in its current form does not appear sufficient for the systematic review of adverse events associated with ossicular prostheses. A more standardized reporting format with clearly defined categories and inclusion of relevant variables might improve the quality of information provided by the MAUDE database.

Pediatric bilateral vocal cord granulomas presenting as airway foreign body following prolonged intubation due to COVID-19 related multisystem inflammatory syndrome.

BACKGROUND: This report is a case of bilateral vocal cord granulomas (VCG) in a 9-year-old child presenting as an airway foreign body and stridor following prolonged intubation due to COVID-19 pneumonia complicated by multisystem inflammatory syndrome in children (MIS-C). CASE PRESENTATION: This case reports a 9-year-old male who presented to the emergency department with acute stridor concerning for airway obstruction. X-ray findings suggested an airway foreign body; however, on rigid bronchoscopy, ball-valving bilateral VCG obstructing 90% of the glottic airway were identified. After excision of the VCGs, the patient's symptoms resolved with no postoperative complications. CONCLUSION: With suspected foreign body aspiration in a pediatric patient with a history of prolonged intubation, it is important to consider a broad differential diagnosis. VCGs are rare complications of prolonged intubation that could be in children with prior history of intubation following COVID-19 pneumonia.

Cost-effectiveness of Inpatient Tympanostomy Prophylaxis.

OBJECTIVE: Tympanostomy is the most common pediatric ambulatory surgery. Post-tympanostomy otorrhea is a prevalent complication leading to high costs to patients for treatment. The cost-effectiveness of intraoperative prophylaxis for both patient and institution has not been examined. STUDY DESIGN: An analytical observational study of data collected from the literature and purchasing records. METHODS: A break-even analysis was performed to determine the required absolute risk reduction (ARR) and final infection rate in post-tympanostomy otorrhea to make intraoperative prophylaxis using ofloxacin and ciprofloxacin dexamethasone otic version cost effective with the following outpatient treatments: ofloxacin, ciprofloxacin-dexamethasone ophthalmic version, and ciprofloxacin-dexamethasone otic version. Absolute risk reduction is a statistic used to express the difference in risk between a treatment and control. The conservative initial infection rate used was 10%. RESULTS: Ofloxacin intraoperative prophylaxis was not cost effective when prescribing ofloxacin outpatient treatment with an ARR of 0.20. Ofloxacin intraoperative prophylaxis was cost-effective with an ARR of 0.08 for ciprofloxacin-dexamethasone ophthalmic version outpatient treatment. Ofloxacin intraoperative prophylaxis was cost-effective for ciprofloxacin-dexamethasone otic version outpatient treatment with an ARR of 0.01.Ciprofloxacin-dexamethasone intraoperative prophylaxis was not cost-effective when prescribing ofloxacin outpatient treatment with an ARR of 1.52. Ciprofloxacin-dexamethasone intraoperative prophylaxis was not cost-effective when prescribing ciprofloxacin-dexamethasone ophthalmic version outpatient treatment with an ARR of 0.60. Ciprofloxacin-dexamethasone intraoperative prophylaxis was cost effective when prescribing ciprofloxacin-dexamethasone otic version outpatient treatment with an ARR of 0.09. CONCLUSION: Intraoperative prophylaxis can be cost effective for preventing post-tympanostomy otorrhea. Physicians can use this economic model to determine the cost-effectiveness of these interventions for their patients and institutions.

Adverse Effects of Chronic Steroid use Following Thyroidectomy.

BACKGROUND: Prior to thyroid surgery, a subset of patients chronically uses steroids to manage medical conditions such as Grave's disease, auto-immune conditions, or organ transplantation. Existing literature describes adverse effects of prolonged steroid use on surgical outcomes, however there remains a paucity of data investigating the specific effects of steroid use on postoperative outcomes after thyroidectomy. This study aims to identify complication risks steroid users are predisposed to after thyroidectomy. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program Database (ACS-NSQIP) was queried to identify and isolate all patients who had undergone thyroidectomy procedures by Current Procedure Terminology codes from 2005 through 2018. Univariate analysis was performed to compare steroid uses and non-steroid users. Coarsened exact matching was utilized to homogenize the two cohorts based on demographics and preoperative comorbidities. RESULTS: A total of 153,595 thyroidectomies were initially included. After Coarsened exact matching, 116,861 patients were categorized as non-steroid users, and 2,965 as steroid users. The steroid cohort demonstrated significantly higher rates of any complication (P < 0.001) as well as overall surgical, cardiopulmonary, and renal complications. Individual complications such as superficial surgical site infections (P = 0.013), pulmonary embolism (P = 0.016), deep vein thrombosis (P = 0.011), progressive renal insufficiency (P = 0.006), and unplanned readmission (P = 0.026) were also increased. CONCLUSIONS: Patients with chronic steroid use undergoing thyroidectomy are at an increased risk for surgical, cardiopulmonary, and renal complications. Further research on preoperative steroid management is necessary for optimizing outcomes in this population.

Feel the Burn! Fireworks-related Otolaryngologic Trauma.

OBJECTIVES: Fireworks are used commonly for celebrations in the United States, but can lead to severe injury to the head and neck. We aim to assess the incidence, types, and mechanisms of head and neck injuries associated with fireworks use from 2010 to 2019. METHODS: A retrospective cross-sectional study, using data from the National Electronic Injury Surveillance System, of individuals presenting to United States Emergency Departments with head and neck injuries caused by fireworks and flares from 2010 to 2019. Incidence, types, and mechanisms of injury related to fireworks use in the US population were assessed. RESULTS: A total of 541 patients (349 [64.5%] male, and 294 [54%] under 18 years of age) presented to emergency departments with fireworks-related head and neck injuries; the estimated national total was 20 584 patients (13 279 male, 9170 white, and 11 186 under 18 years of age). The most common injury diagnoses were burns (44.7% of injuries), laceration/avulsion/penetrating trauma (21.1%), and otologic injury (15.2%), which included hearing loss, otalgia, tinnitus, unspecified acoustic trauma, and tympanic membrane perforation. The remaining 19% of injuries were a mix, including contusion, abrasion, hematoma, fracture, and closed head injury. Associations between fireworks type and injury diagnosis (chi-square P < .001), as well as fireworks type by age group (chi-square P < .001) were found. Similarly, associations were found between age groups and injury diagnoses (chi-square P < .001); these included children 5 years and younger and adults older than 30 years. CONCLUSIONS: Fireworks-related head and neck injuries are more likely to occur in young, white, and male individuals. Burns are the most common injury, while otologic injury is a significant contributor. Annual rates of fireworks-related head and neck injuries have not changed or improved significantly in the United States in the past decade, suggesting efforts to identify and prevent these injuries are insufficient.

Tracheotomy in COVID-19 Patients: A Systematic Review and Meta-analysis of Weaning, Decannulation, and Survival.

OBJECTIVES: A systematic review and meta-analysis was conducted to determine the cumulative incidences of decannulation and mechanical ventilation weaning in patients with coronavirus disease 2019 (COVID-19) who have undergone a tracheotomy. Weighted average mean times to tracheotomy, to decannulation, and to death were calculated from reported or approximated means. DATA SOURCES: PubMed, SCOPUS, CINAHL, and the Cochrane library. REVIEW METHODS: Studies were screened by 3 investigators independently. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Studies including patients with COVID-19 who underwent a tracheotomy were identified. Studies without reported mechanical ventilation weaning or decannulation were excluded. Data were pooled using a random-effects model. RESULTS: After identifying 232 unique studies, 18 articles encompassing outcomes for 3234 patients were ultimately included for meta-analysis, with a weighted mean follow-up time of 28.6 ± 6.2 days after tracheotomy. Meta-analysis revealed that 55.0% of tracheotomized patients were weaned successfully from mechanical ventilation (95% CI, 47.4%-62.2%). Approximately 34.9% of patients were decannulated successfully, with a mean decannulation time of 18.6 ± 5.7 days after tracheotomy. The pooled mortality in tracheotomized patients with COVID-19 was 13.1%, with a mean time of death of 13.0 ± 4.0 days following tracheotomy. CONCLUSION: At the current state of the coronavirus pandemic, over half of patients who have required tracheotomies are being weaned off of mechanical ventilation. While 13.1% patients have died prior to decannulation, over a third of all tracheotomized patients with COVID-19 reported in the literature have undergone successful decannulation.

Role of Peri- and Postoperative Antibiotics in Microscopic Laryngeal Surgery.

OBJECTIVES: There are no widely accepted guidelines for the use of peri- and postoperative antibiotics for microdirect laryngoscopy (MDL) to prevent postoperative surgical site infection (SSI). This study examines the incidence of not only SSI, but also respiratory and oropharyngeal infections among patients who underwent MDL. STUDY DESIGN: Retrospective cohort. METHODS: Medical records from a quaternary laryngology practice were reviewed retrospectively for patients who underwent MDL between October 2015 and December 2018. Adults who underwent MDL with excision of nonmalignant masses, vocal fold (VF) reconstruction with buccal graft, superficial VF injection, VF injection augmentation, use of carbon dioxide (CO2) or potassium titanyl phosphate (KTP) laser, and laryngeal dilation were included. Subjects were divided into three groups based on the use of antibiotics during the peri- or postoperative period. Group 1 did not receive peri- or postoperative antibiotics. Group 2 received perioperative antibiotics without postoperative antibiotics. Group 3 received both peri- and postoperative antibiotics. Antibiotic use was determined by surgeon policy, which changed over time, not by patient risk factors. Other data collected include demographics, medical comorbidities, surgical procedure, operative time, American Society of Anesthesiology class, incidence of SSI, respiratory or oropharyngeal infection, and postoperative antibiotic and steroid prescriptions for complications. RESULTS: 190 surgeries met inclusion criteria. Groups 1, 2, and 3 consisted of 113, 57, and 20 subjects, respectively. No SSI were reported. Baseline characteristics of median age, American Society of Anesthesiology, wound class, and gender did not differ between groups. Groups were found to have differed in type of procedure performed, with a predominance of vocal fold excision and superficial injection in Group 1, injection laryngoplasty using autologous fat graft and laryngeal reconstruction in Group 3, and a combination of procedure types in Group 2. Laser treatment with CO2 and/or KTP was utilized in 35% of procedures. The mean operative times (total time in which the laryngoscope remained in the oral cavity) for Groups 1, 2, and 3 were 29 (SD = 13), 42 (SD = 23), and 73 minutes (SD = 78), respectively; this was significantly different among the three groups (P < 0.0001). By logistic regression models, operative time was not significantly associated with the overall use of antibiotics (Χ2 = 1.81, P = 0.18) or corticosteroid (Χ2 = .05, P = .82) prescriptions during follow-up. In Groups 1, 2, and 3, 11%, 14%, and 10% of patients, respectively, required a follow-up antibiotic prescription for non-SSI and 11%, 12%, and 0% of patients, respectively, required a follow-up corticosteroid prescription within 30 days postoperatively. There was no significant difference in patients with diabetes or pulmonary comorbidity and patients without comorbidity in use of postoperative antibiotic (P = .45) or corticosteroid (P > .99) prescription. Within 30 days of follow-up, patients in Group 1 experienced VF hemorrhage (defined as any subepithelial blood in the area of excision) at an incidence of 19%. Complications within 30 days of follow-up showed an incidence of substantial pain ranging between 2%-4% and respiratory or oropharyngeal infection between 10%-12%. Two patients in Group 2 reported emergency department visits for dyspnea. One patient in Group 3 was admitted for tongue and floor of mouth swelling secondary to prolonged suspension. CONCLUSION: There were no incidents of SSI in this cohort. The need for follow-up antibiotic and/or corticosteroid prescription did not differ in relation to use or non-use of perioperative antibiotics, and neither did the incidence of respiratory or oropharyngeal infection. Longer operative time was associated with both peri- and postoperative antibiotic use, but there is no evidence yet that antibiotic use was necessary. These findings suggest that avoidance of routine perioperative and/or postoperative antibiotics may be appropriate; and further research should be encouraged.

Anatomical Study of Two Cricothyroid Approaches to the Cadaver Larynx.

OBJECTIVE: The purpose of this study was to measure the angle and depth at which the vocal folds are accessed via transcutaneous injection through two different approaches through the cricothyroid membrane. METHODS: Twenty-five cadavers preserved with formalin were studied. The larynges were bisected through the thyroid notch, and the skin and soft tissue were removed. A 27-gauge needle was inserted through the cricothyroid membrane, once from just inferior to the thyroid cartilage and once from just superior to the cricoid cartilage, and advanced to the midpoint of the musculomembranous vocal fold (determined as the halfway point from anterior commissure to vocal process), immediately lateral to the vocalis muscle without penetrating the epithelium. The angle of approach was determined after taking multiple measurements with a Castroviejo caliper. The depth of the needle was measured. RESULTS: Ten male and 15 female cadavers were studied. Their average age was 85.5 ± 12.4 years. The mean distance from midline for an injection performed with 0° of lateral angle was 5.7 ± 0.7 mm for the males, which was significantly greater than for females (4.8 ± 0.8 mm, P = 0.012). The insertion angle for the infrathyroid approach was 22.2 ± 6.9°, which was significantly different from the supracricoid angle, which was 33.0 ± 5.2° (P < 0.001). The mean insertion depth of the subthyroid approach was 11.3 ± 1.8 mm (range 8.0-15.5 mm), which was significantly less than the depth for the supracricoid approach (18.2 ± 2.4 mm, range 11.0-22.0 mm, P < 0.001.). The infrathyroid approach angle for males was 26.0 ± 8.5°, which was significantly greater than the angle for females (19.3 ± 3.4°, P = 0.016.). The supracricoid approach angle for males was 37.5 ± 2.4°, which was significantly greater than the angle for females (29.7 ± 4.1°, P < 0.001.). The insertion depth for males was 19.6 ± 1.4 mm, which was significantly greater than that for females (17.2 ± 2.6 mm, P = 0.021). CONCLUSIONS: Comparison of a supracricoid and infrathyroid approach through the cricothyroid membrane to the middle third of the vocal folds demonstrated significant differences in angle of approach. We also identified a significant difference in the angle of entry between male and female larynges in both approaches, as well as an increased depth of insertion required in males for the supracricoid approach.

Prevalence and Long-term Consequences of Vocal Fold Hemorrhage in Patients who Underwent Microscopic Laryngeal Surgery or Type I Thyroplasty.

OBJECTIVE: Examine incidence of postoperative vocal fold (VF) hemorrhage (PVFH) in patients who underwent microscopic laryngeal surgery and type I thyroplasty and determine the long-term consequences of hemorrhage on the outcome of the surgery. STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: Medical records of patients from a quaternary care laryngology practice who underwent microdirect laryngoscopy (MDL) or type I thyroplasty between November 2015 and December 2018 were reviewed as a consecutive sample. MDL procedures not performed on the VF were excluded. Demographic and medical history data associated with risk of bleeding were collected, and records were reviewed for the incidence of PVFH and long-term consequences of PVFH through Voice Handicap Index-10 (VHI-10) and preoperative and postoperative videostroboscopic findings. We considered each VF surgery as one procedure. Statistical analysis was performed using chi-square analysis for categorical data and a student t test for means. A P value of 0.05 or less was considered significant. RESULT: Total 155 patients were enrolled. The patients underwent 182 MDL surgeries, (122 bilateral and 60 unilateral), and 60 Type 1 thyroplasty surgeries (13 bilateral and 47 unilateral). In the MDL group, 34 of 304 procedures (11%) resulted in VFH. In the thyroplasty group, 10 of 73 procedures (13.7%) were associated with PVFH. Bilateral MDL procedures were associated with a higher incidence of PVFH in comparison with unilateral procedures (P= 0.03), but bilateral thyroplasties were not (P= 0.33). None of the demographic factors significantly increased or decreased risk of PVFH. Comparing the difference between preoperative and 3-6 month postoperative VF mucosal function, and preoperative and 3-6 month postoperative VHI-10 in both MDL and thyroplasty groups, no statistically significant difference was found between patients who had experienced PVFH and those who had not. CONCLUSION: This is the largest investigation into the incidence and long-term consequences of the PVFH. 11% of the patients in the MDL group experienced PVFH; the vibratory margin of the VF was involved in only 1.3%.; and 13.7 % of the procedures in the thyroplasty group resulted in PVFH. However, PVFH was not associated with significant increase in VHI-10 or decrease in VF vibratory function during 3-6 month postoperative follow-up visits. The incidence of PVFH was related significantly to postoperative phonotrauma and upper respiratory infection, but not to gender, age, history of smoking and alcohol consumption, pulmonary and cardiovascular comorbidities, or pre-existing VF varicosities or ectasias.