Does Idiopathic Subglottic Stenosis Length and Location Change with Serial Endoscopic Interventions?

OBJECTIVES/HYPOTHESIS: The aim was to assess changes in physical parameters of subglottic stenosis (SGS) following serial endoscopic surgical intervention. STUDY DESIGN: This was a retrospective chart review. METHODS: A retrospective review of 52 idiopathic subglottic stenosis (iSGS) patients undergoing multiple endoscopic (excision/dilation) procedures between 2014 and 2022 was completed. Parameters including proximal stenosis distance from the vocal process and total stenosis length collected intraoperatively were compared over serial treatments. Differences between patient variables affecting distances from the vocal process and mean stenosis length were statistically analyzed utilizing nonparametric estimators including the Mann Whitney U, Fisher exact, and linear regression models. RESULTS: For the cohort of iSGS patients (N = 52), the mean age was 55.1 (±15.1). The patients were predominantly female (96.2%) and Caucasian (84.6%). Patients underwent an average of 3.4 (±1.3) endoscopic procedures for long-term treatment of iSGS (range: 1 to 5 procedures). Patients undergoing a total of two (2) total procedures within the data collection window demonstrated a statistically significant decrease in mean stenosis length between the first and second procedures (p = 0.014). Changes in distance of the stenosis from the glottis was not found to be statistically significant (p = 0.833). There was a statistically significant decrease in mean length of stenosis from the 1st to the 2nd procedure by approximately 0.11 cm (p = 0.0003). No additional statistically significant differences in stenosis length or location were detected. CONCLUSIONS: Serial endoscopic excision/dilation procedures (the mainstay of iSGS surgical management) do not appear to significantly lengthen intraluminal stenosis nor change the distance of the stenosis from the glottis. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1769-1772, 2024.

Sinonasal complications of severe acute respiratory syndrome coronavirus-2: A single center case series.

Background: The emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has resulted in an unprecedented global pandemic. Most infected patients are either asymptomatic or have mild upper respiratory infection symptoms. However, life-threatening sequelae have been observed. In this report, we reviewed nine cases of patients with severe complications from sinonasal disease in the setting of acute SARS-CoV-2 infection. Methods: IRB approval was obtained prior to study initiation. A retrospective chart review was performed of patients admitted to a tertiary hospital with complex sinonasal symptoms that required otolaryngologic evaluation and management in the setting of concomitant SARS-CoV-2 infection. Results: Nine patients, ranging from ages 3 to 71 years, with sinonasal disease and simultaneous SARS-CoV-2 infection were identified. Initial presentations ranged from asymptomatic infection to mild/moderate disease (nasal obstruction, cough) or more severe sequelae including epistaxis, proptosis, or neurologic changes. SARS-CoV-2 tests were positive from one to 12 days after symptom onset, with three patients receiving SARS-CoV-2-directed treatment. Complex disease presentations included bilateral orbital abscesses, suppurative intracranial infection, cavernous sinus thrombosis with epidural abscess, systemic hematogenous spread with abscess development in four distinct anatomic locations, and hemorrhagic benign adenoidal tissue. Eight of nine patients (88.8%) required operative intervention. Patients with abscesses also required prolonged, culture-directed antibiotic courses. Conclusion: Though most SARS-CoV-2 infections are asymptomatic and/or self-limited, there is significant morbidity and mortality in patients with severe disease sequela as outlined in our reported cases. This suggests early identification and treatment of sinonasal disease in this patient population is critical to minimizing poor outcomes. Further research on the pathophysiology of these atypical presentations is needed. Level of Evidence: 4 (Case Series).

Symptomatic and Histological Tissue Reaction to Upper Eyelid Platinum Weight.

OBJECTIVES: To present a case of non-infectious platinum eyelid weight rejection, the first reported case in otolaryngology literature. METHODS: A case of a non-infectious tissue reaction to a platinum eyelid weight was identified. RESULTS: A platinum eyelid weight was placed in a 72-year-old female for paralytic lagophthalmos. The patient presented with persistent edema and skin discoloration on post-operative day 8, though no drainage, tenderness, or other signs of infection were present. The weight was eventually explanted with rapid resolution of symptoms. Pathology demonstrated granulomatous inflammation with histiocytosis and foreign-body giant cells, consistent with tissue reaction to the platinum weight. CONCLUSIONS: Platinum eyelid weights are commonly used to treat paralytic lagophthalmos. While non-infectious tissue reactions to platinum are less common than with gold weights, they are still possible and should be treated with weight removal.

Postoperative Inhaled Steroids Following Glottic Airway Surgery Reduces Granulation Tissue Formation.

OBJECTIVES: Transoral laser surgery for glottic stenosis (transverse cordotomy and anteromedial arytenoidectomy (TCAMA)) is often complicated by granulation tissue (GT) formation. GT can cause dyspnea and may require surgical removal to alleviate airway obstruction. Inhaled corticosteroids (ICS) have been shown to reduce benign vocal fold granulomas, however its use to prevent GT formation has not been described. We aimed to analyze the effect of immediate postoperative ICS on GT formation in patients undergoing transoral laser surgery for glottic stenosis. METHODS: A retrospective analysis of patients that had transoral laser surgery for glottic stenosis from 2000 to 2019 was conducted. Surgical instances were grouped into those that received postoperative ICS and those that did not. Demographics, diagnosis, comorbidities, intraoperative adjuvant therapy, and perioperative medications were collected. Differences in GT formation and need for surgical removal were compared between groups. A multivariate exact logistic regression model was performed. RESULTS: Forty-four patients were included; 16 required 2 glottic airway surgeries (60 surgical instances). Of the 23 instances where patients received immediate postoperative ICS, 0 patients developed GT; and of the 37 instances that did not receive postoperative ICS, 15 (40.5%) developed GT (P < .0001). Eight (53.3%) of these cases returned to the OR for GT removal. ICS use was solely associated with the absence of GT formation (P = .042) in the multivariate analysis. CONCLUSIONS: Immediate postoperative use of ICS seems to be a safe and effective method to prevent granulation tissue formation and subsequent surgery in patients following transoral laser airway surgery for glottic stenosis.

Combined Transverse Cordotomy- Anteromedial Arytenoidectomy for Isolated Glottic Stenosis.

OBJECTIVES/HYPOTHESIS: Glottic stenosis is a discrete cause of airway compromise. We aimed to determine the surgical outcomes of transverse cordotomy with anteromedial arytenoidectomy (TCAMA), performed in the setting of isolated glottic stenosis resulting from two discrete etiologies: bilateral vocal fold paralysis (BVFP) and posterior glottic stenosis (PGS). STUDY DESIGN: Retrospective, analytic cohort study. METHODS: Twenty-six patients with isolated glottic stenosis were treated with TCAMA between 2006 and 2019. A retrospective analysis determined decannulation rates and intervals, voice outcomes, swallowing outcomes, and reoperation rates postoperatively. Outcomes between the two etiologic cohorts were compared. RESULTS: Of the 26 patients, 16/26 patients were diagnosed with PGS and 10/26 with BVFP. Eighteen patients required tracheotomies during their clinical course (11/16 PGS, and 7/10 BVFP), and 100% were ultimately decannulated. The PGS cohort required two-sided interventions more frequently than the BVFP cohort (45.5% vs. 0%, P = .066). Trach-dependent PGS patients required a longer time to achieve decannulation than BVFP patients by a factor of 2.38, although the difference was not statistically significant (102.3 days vs. 42.9 days, respectively, P = .113). Patients demonstrated a significant change in maximum phonation time but no statistically significant differences with preoperative versus postoperative voice outcomes like voice-related quality of life. All patients ultimately returned to their baseline swallow function postoperatively. CONCLUSION: TCAMA is an effective treatment for surgical rehabilitation of glottic stenosis caused by both BVFP and PGS. Patient-reported outcomes of postoperative vocal function remain consistent following surgical intervention. Additional, prospective studies with greater power are warranted to validate the contrasting outcomes observed when applying this discrete surgical technique across two distinct diagnostic cohorts in this retrospective study. LEVEL OF EVIDENCE: 4. Laryngoscope, 131:2305-2311, 2021.

A Complication of Mycobacterium chelonae Infection Following Orbital Floor Fracture Repair.

ABSTRACT: Mycobacterium chelonae is a rare, atypical nontuberculous bacterium that has been reported to be an underlying cause of persistent wound infections. Although there are several studies highlighting the role of M chelonae as the putative cause of other postoperative wound infections, to our knowledge there are no reports of infection following implant placement for repair of an orbital floor fracture. The authors present a unique case describing the management of a persistent postoperative infection in a young, immunocompetent patient with an orbital floor fracture repaired with a Stryker Medpor Titan implant. The patient was initially treated with broad-spectrum antibiotics with minimal clinical improvement. Following culture-proven M chelonae, a second surgical intervention was undertaken to remove the implant and later, a third intervention for scar revision. The patient has remained free of infection utilizing a long-term tailored 2-drug antibiotic regimen. This case emphasizes the need for recognition of M chelonae as a potential pathogen in certain clinical situations and the difficulty in eradicating M chelonae in the context of infected implantable devices. The comprehensive treatment protocol required to ensure adequate therapy is reviewed.

Predictors of Increased Surgical Drain Output following Type I Thyroplasty for Glottic Insufficiency.

OBJECTIVE: To determine predictors of increased drain output following type I thyroplasty for glottic insufficiency. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective review was conducted for patients who underwent type I thyroplasty for glottic insufficiency from 2014-2019. The primary outcome was 24-hour drain output. Increased drain output was defined as >50th percentile for the sample. Univariate logistic regression models and linear regression models were used. RESULTS: There were 84 patients with a mean age of 58.9 (SD 16.9) years. Twenty-four-hour drain output ranged from 0 to 29 mL with a mean of 9.47 (SD 6.49) mL. Patients with a history of tobacco use (OR 3.33; 95% CI, 1.24-8.95; P = .017) and prior neck surgery (OR 3.52; 95% CI, 1.26 to 9.83; P = .016) were significantly more likely to have increased drain output following surgery; these patients had a mean increase in 24-hour drain output of 3.51 mL (95% CI, 0.52 to 6.51; P = .022) and 1.74 mL (95% CI, -1.41 to 4.89; P = .274), respectively. Type of implant (Gore-Tex vs. Silastic; P = .425) and operative technique (unilateral vs. bilateral; P = .506) were not significantly associated with drain output. CONCLUSION: History of tobacco use and prior surgery of the neck predict increased drain output following type I thyroplasty surgery. These patients may derive the most benefit from surgical drain placement. More research is needed to confirm these findings and elucidate potential mechanisms. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1557-1560, 2021.

Pain Agreements and Time-to-Event Analysis of Substance Misuse in a Primary Care Chronic Pain Program.

BACKGROUND: Types and correlates of pain medication agreement (PMA) violations in the primary care setting have not been analyzed. METHODS: A retrospective analysis was completed to examine patient characteristics and correlates of PMA violations, a proxy for substance misuse, over a 15-year period in an outpatient General Medicine Pain Service within the Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill. Patients who signed the PMA were managed for chronic pain from 2002 through 2017 (N = 1,210). The incidence of PMA violations was measured over a 15-year span. Substance misuse was defined a priori in the study as urine toxicology screen positive for illicit or nonprescribed controlled substances, patient engagement in prescription alteration, doctor-shopping, or diversion. RESULTS: Most patients received a prescription for a controlled substance (77.4%). During enrollment, 488 (40.3%) patients had one or more violations of their PMA. One-third (33.4%) of pain service patients had a violation within 365 days of signing the agreement. Active tobacco smokers had double the incidence of agreement violation within the first 30 days of enrollment. Almost one-half (49.8%) of violations were due to inconsistent use of controlled substances. Patients with any prior DWI/DUI or drug-related offense had a significantly increased rate of substance misuse (P < 0.0001). CONCLUSIONS: PMA violations were common among a population of patients managed for chronic nonmalignant pain. Universal opioid prescribing precautions, including PMAs, require further investigation to assess their roles in mitigating the potential patient and societal harms associated with opioid prescribing.

Office-based laryngology: Technical and visual optimization by patient-positioning maneuvers.

OBJECTIVE/HYPOTHESIS: To qualitatively and quantitatively assess the effect of discrete head postures/maneuvers during flexible laryngoscopy on visualization of specific anatomical structures within the laryngopharynx. STUDY DESIGN: Prospective, observational study. METHODS: Flexible laryngoscopy was performed on 18 sequential patients. Videos of the laryngopharynx were captured during the neutral head position and five discrete maneuvers: maximal sniffing, head extension, right turn, left turn, and chin down. Images were analyzed using ImageJ, and differences in the (normalized) anatomical areas of interest were examined with each maneuver (paired t test]. Covariates for surgeon, nostril, and gender were evaluated. RESULTS: There was a significantly increased (P = 0.009) area of view of the anterior space (petiole of epiglottis/anterior laryngeal vestibule) with head extension. Right head turn led to a significantly increased view of the left pyriform sinus (P = 0.00001), whereas left head turn yielded an increased view of the right pyriform sinus (P = 0.0001). The right and left vocal fold/ventricle were better visualized during right head turn (with the scope traversing the right nostril) and left head turn (with the scope traversing the left nostril), respectively. Chin-down posture achieved a more distal view of the airway more frequently than the other maneuvers. CONCLUSION: The anterior space (supraglottic larynx) may be best visualized and accessed with head extension. Right and left head turn improve visualization of the contralateral piriform sinus. Chin down provides improved airway visualization in a plurality of patients. Future studies examining maneuvers are warranted to create a catalog of validated techniques to optimize the efficacy of the office-based proceduralist. LEVEL OF EVIDENCE: 2 Laryngoscope, 129:330-334, 2019.

Short-Acting Opioids Are Associated with Comparable Analgesia to Long-Acting Opioids in Patients with Chronic Osteoarthritis with a Reduced Opioid Equivalence Dosing.

Setting: There are no studies that exist within the primary care setting that address optimal opioid therapy in osteoarthritis patients. In light of the recently released US Centers for Disease Control and Prevention guidelines on opioid use in chronic noncancer pain, there is a pressing need to better characterize the effectiveness of long- and short-acting opioids. Objective: To examine the effectiveness of short-acting opioids (SAO) vs long-acting opioids (LAO) and combination therapies (SAO and LAO) for treating chronic osteoarthritis pain in a retrospective trial. Methods: Average and lowest pain scores approximately one to two weeks prior to patient appointments were collected and averaged for both SAO and LAO patients who were actively enrolled in a pain clinic at an academic medical center. Results: There was no statistical difference between reported average and low pain scores for the SAO vs LAO groups (P = 0.201 and P = 0.296, respectively), although the SAO group on average had a significantly lower morphine equivalence (P < 0.001). Various covariates for both groups were tested in an adjusted model to look at trends in the use of nonopioid medications (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, antidepressants, and adjunct analgesic agents). No significant differences in pain scores existed when comparing covariates for the SAO vs LAO groups. Conclusions: The study suggests that in addition to being effective, short-acting opioid medications may also provide a safer and cheaper alternative to long-acting opioid therapies in the treatment of chronic osteoarthritis. Perspective: This article investigates the effectiveness of short-acting vs long-acting opioids for the treatment of chronic noncancer pain, specifically osteoarthritis. This information could potentially aid practitioners in primary care environments to design equally efficacious and less costly opioid regimens, while simultaneously enhancing patient safety.

The Accuracy of a Fibromyalgia Diagnosis in General Practice.

Objective: To compare the characteristics of people with fibromyalgia (FM) with those with other forms of nonmalignant chronic pain. Design: A prospective cohort study conducted in a chronic pain management clinic within an academic medical center. Setting: Many symptoms of the chronic pain syndrome FM are common to other pain or musculoskeletal syndromes. FM may be misdiagnosed by clinicians. Subjects: Thirty-three patients with a working diagnosis of FM were identified: 26 (78.8%) participated in the study. They were matched by age (mean = 53.0 years) and gender (80.8% female) to a control group with other forms of chronic nonmalignant pain. Methods: Standardized physical examinations for FM were undertaken using the 1990 and revised 2010 American College of Rheumatology (ACR) guidelines. The groups were compared using diagnoses of psychiatric disorders and responses to the Pain Disability Index, Personal Health Questionnaire, Revised Fibromyalgia Impact Questionnaire, and Rapid Estimate Adult Literacy in Medicine. Results: The most common psychiatric disorders were depression (44.4%) and anxiety (27.3%). Incidence of at least one psychiatric condition was 80.8%, and the only difference (P = 0.002) between the two populations was the mean number of tender points: 5.6 (±4.2) vs controls 3.2 (±2.2). Only three (11.5%) participants with a prior diagnosis of FM fulfilled the 1990 ACR diagnostic criteria, increasing to 38.5% when the 2010 criteria were applied; however, 46.1% of controls also met the revised diagnostic criteria. Conclusions: FM is commonly misdiagnosed: all patients with a working diagnosis should be reassessed and reviewed to ensure that the most appropriate treatment is provided.