A Medicare Physician Fee Schedule Analysis of Reimbursement Trends in Laryngology from 2000 to 2021.

OBJECTIVE: The purpose of this study is to characterize Medicare reimbursement trends for laryngology procedures over the last two decades. METHODS: This analysis used CMS' Physician Fee Schedule (PFS) Look-Up Tool to determine the reimbursement rate of 48 common laryngology procedures, which were divided into four groups based on their practice setting and clinical use: office-based, airway, voice disorders, and dysphagia. The PFS reports the physician service reimbursement for "facilities" and global reimbursement for "non-facilities". The annual reimbursement rate for each procedure was averaged across all localities and adjusted for inflation. The compound annual growth rate (CAGR) of each procedure's reimbursement was determined, and a weighted average of the CAGR for each group of procedures was calculated using each procedure's 2020 Medicare Part B utilization. RESULTS: Reimbursement for laryngology procedure (CPT) codes has declined over the last two decades. In facilities, the weighted average CAGR for office-based procedures was -2.0%, for airway procedures was -2.2%, for voice disorders procedures was -1.4%, and for dysphagia procedures was -1.7%. In non-facilities, the weighted average CAGR for office-based procedures was -0.9%. The procedures in the other procedure groups did not have a corresponding non-facility reimbursement rate. CONCLUSION: Like other otolaryngology subspecialties, inflation-adjusted reimbursements for common laryngology procedures have decreased substantially over the past two decades. Because of the large number of physician participants and patient enrollees in the Medicare programs, increased awareness and further research into the implications of these trends on patient care is necessary to ensure quality in the delivery of laryngology care. LEVEL OF EVIDENCE: NA Laryngoscope, 134:247-256, 2024.

The Development of Head and Neck Cancer in Patients with the Isolated Complaint of Globus Pharyngeus.

OBJECTIVES: Globus pharyngeus (GP) is a perplexing problem that accounts for 4% of referrals to otolaryngologists. Workup can be extensive and may not be definitive in terms of etiology. The concern that lingers is that of a subtle cancer, which can prolong anxiety and increase testing cost. The aim of this study was to identify the incidence of head and neck cancer (HNC) in patients diagnosed with GP. METHODS: Longitudinal data were captured from two academic institutions, identifying patients with a new diagnosis of globus pharyngeus in 2015. The patient cohort was tracked for at least 4 years to assure follow-up and ability to determine if a HNC developed. Additional demographic data was also collected to determine most common consults, treatments, and testing employed. RESULTS: Excluding patients with previous diagnosis of HNC, 377 patients were identified who presented with GP in 2015 that had at least 4 years of follow-up. Demographics were predominantly women (64.65%), with a mean age of 56.48 years at diagnosis, and the most common provider specialty on the first visit was otolaryngology (39.52%). Four patients ultimately developed HN cancer, for an overall incidence of 1% for the 4-year period of 2015-2019. CONCLUSIONS: Given the long-term follow-up of this population, the overall incidence of developing a head and neck cancer, with a presenting symptom of globus, is low. This is the largest study to date to report the percentage of patients endorsing GP to then subsequently develop HNC. This helps otolaryngologists to reassure patients who have a normal comprehensive exam, flexible endoscopy, and targeted studies. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1147-1154, 2024.

Transmission risk of COVID-19 infection with office-based flexible laryngoscopy.

Since the beginning of the Coronavirus pandemic, recommendations to ensure safety in clinical practice have fluctuated. Within the Otolaryngology community, a variety of protocols have emerged to assure safety for both patients and healthcare workers while maintaining standard of care practices, especially surrounding aerosolizing in-office procedures. OBJECTIVES: This study aims to describe our Otolaryngology Department's Personal Protective Equipment protocol for both patients and providers during office laryngoscopy and to identify the risk of contracting COVID-19 after implementation of the protocol. METHODS: 18,953 office visits divided between 2019 and 2020 where laryngoscopy was performed were examined and compared to the rate of COVID-19 contraction for both office staff and patients within a 14 day period after the encounter. Of these visits, two cases were examined and discussed; where a patient tested positive for COVID-19 ten days after office laryngoscopy, and one where a patient tested positive for COVID-19 ten days prior to office laryngoscopy. RESULTS: In the year 2020, 8337 office laryngoscopies were performed, 100 patients tested positive within the year 2020, with only these 2 cases of COVID-19 infections occurring within 14 days prior to or after their office visit. CONCLUSION: These data suggest that using CDC-compliant protocol for aerosolizing procedures, such as office laryngoscopy, can provide a safe and effective method for mitigating infectious risk while providing timely quality care for the otolaryngology patient. LEVEL OF EVIDENCE: 3 LAY SUMMARY: During the COVID-19 Pandemic, ENTs have had to balance providing care while minimizing the risk of COVID-19 transmission with routine office procedures such as flexible laryngoscopy. In this large chart review, we show that the risk of transmission is low with CDC-compliant protective equipment and cleaning protocols.

Practice Consolidation in Otolaryngology: The Decline of the Single-Provider Practice.

OBJECTIVE: To observe trends in practice consolidation within otolaryngology by analyzing changes in size and geographic distribution of practices within the United States from 2014 to 2021. STUDY DESIGN: Retrospective analysis based on the Physician Compare National Database from the US Centers for Medicare and Medicaid Services. SETTING: United States. METHODS: Annual files from the Physician Compare National Database between 2014 and 2021 were filtered for all providers that listed "otolaryngology" as their primary specialty. Organization affiliations were sorted by size of practice and categorized into quantiles (1 or 2 providers, 3-9, 10-24, 25-49, and ≥50). Both the number of practices and the number of surgeons within a practice were collected annually for each quantile. Providers were also stratified geographically within the 9 US Census Bureau divisions. Chi-square analysis was conducted to test significance for the change in surgeon and practice distributions between 2014 and 2021. RESULTS: Over the study period, the number of active otolaryngology providers increased from 7763 to 9150, while the number of practices fell from 3584 to 3152 in that time span. Practices with just 1 or 2 otolaryngology providers accounted for 80.2% of all practices in 2014 and fell to 73.1% in 2021. Similar trends were observed at the individual provider level. Regional analysis revealed that New England had the largest percentage decrease in otolaryngologists employed by practices of 1 or 2 active providers at 45.7% and the Mountain region had the lowest percentage decrease at 17.4%. CONCLUSION: The otolaryngology practice marketplace has demonstrated a global trend toward practice consolidation.

The Utility of Comorbidity Indices in Assessing Head and Neck Surgery Outcomes: A Systematic Review.

OBJECTIVE: To evaluate the utility of comorbidity index (CI) scores in predicting outcomes in head and neck surgery (HNS). The CIs evaluated were the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Kaplan-Feinstein Index (KFI), American Society of Anesthesiologists Physical Status (ASA-PS), Adult Comorbidity Evaluation-27 (ACE-27), National Cancer Institute Comorbidity Index (NCI-CI), and the Washington University Head and Neck Comorbidity Index (WUHNCI). METHODS: We report a systematic review according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases (PubMed, Cochrane, and Embase) and manual search of bibliographies identified manuscripts addressing how CI scores related to HNS outcomes. RESULTS: A total of 116 studies associated CI scores with HNS outcomes. CIs were represented in the literature as follows: ASA-PS (70/116), CCI (39/116), ACE-27 (24/116), KFI (7/116), NCI-CI (3/116), ECI (2/116), and WUHNCI (1/116). The most frequently cited justification for calculating each CI (if provided) was: CCI for its validation in other studies, ACE-27 for its utility in cancer patients, and ECI for its comprehensive design. In general, the CCI and ACE-27 were predictive of mortality in HNS. The ECI was most consistent in predicting >1-year mortality. The ACE-27 and KFI were most consistent in predicting medical complications. CONCLUSION: Despite inconsistencies in the literature, CIs provide insights into the impact of comorbidities on outcomes in HNS. These scores should be employed as an adjunct in the preoperative assessment of HNS patients. Comparative studies are needed to identify indices that are most reliable in predicting HNS outcomes. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1388-1402, 2022.

Initiation of a Night Float System in an Otolaryngology Residency: Resident Perception and Impact on Operative Volume.

OBJECTIVES: Evaluate resident perception on implementation of a night float (NF) system to an otolaryngology residency program. We compared these perceptions to Accreditation Council for Graduate Medical Education (ACGME) case log data. METHODS: A retrospective anonymous survey was sent to residents and alumni graduating between 2015 and 2023. Deidentified ACGME case log information was then examined for key indicator (KI) cases from post graduate year (PGY) 2 and PGY5. RESULTS: Thirty (93.8%) residents and alumni responded. Residents with NF answered more positively compared to those without NF on following duty hour violations: 80-hour work week, 1-in-7 days off, 1 call every 3 days, adequate time between shifts, and allotted time after a 24-hour shift. Residents most commonly agreed that NF has improved patient care, resident education, and resident morale. Although residents with NF were neutral on PGY2 case volume effects, they disagreed that it affected overall case volume. The only KIs that differed for both PGY2 and PGY5s were airway cases (P = .004 vs P = .002) and bronchoscopy (P = .02 vs P = .006), which were significantly higher for those with NF. Thyroid surgery was the only KI higher for the residents without NF and spanned all PGY levels. CONCLUSION: Residents and alumni agreed that NF implementation had a positive effect on duty hour violations. The NF system does not have significant impact on case volume. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2211-2218, 2021.

The power of a checklist: Decrease in emergency department epistaxis transfers after clinical care pathway implementation.

BACKGROUND: Annually, epistaxis costs US hospitals over $100 million dollars. Many patients visit emergency departments (ED) with variable treatment, thus providing opportunity for improvement. OBJECTIVE: To implement an epistaxis clinical care pathway (CCP) in the ED, and analyze its effects on treatment and ED transfers. METHODS: An interdisciplinary team developed the CCP to be implemented at a tertiary hospital system with 11 satellite EDs. The analysis included matched eight-month periods prior to pathway implementation and after pathway implementation. Subjects included patients with ICD-10 code diagnosis of epistaxis. Patients under 18 years old, recent surgery or trauma, or bleeding disorders were excluded. There were 309 patients from the pre-implementation cohort, 53 of which were transferred and 37 met inclusion criteria; 322 from the post-implementation cohort, 37 of which were transferred, and 15 met inclusion criteria. Outcome measures included epistaxis intervention by ED providers and otolaryngologists before and after pathway implementation. RESULTS: CCP implementation resulted in a 61% reduction in patient transfers (p < 0.001). ED providers showed a 51% increase in documentation of anterior rhinoscopy with proper equipment, 34% increased use of topical vasoconstrictors, 40% increased use of absorbable packing, 7% decrease in use of unilateral non-absorbable packing, and 17% decrease in use of bilateral non-absorbable packing. CONCLUSIONS: Prior to CCP implementation, ED treatment of epistaxis varied significantly. CCP resulted in standardized treatment and significant reduction in transfers. A CCP checklist is an effective way to standardize care and prevent unnecessary hospital transfers.

Dysphagia Evaluation: The Added Value of Concurrent MBS and Esophagram.

OBJECTIVES/HYPOTHESIS: Dysphagia is associated with increased mortality and healthcare costs. The modified barium swallow study (MBS) is the gold standard in assessing oropharyngeal dysphagia, but does not evaluate the esophagus. A barium esophagram can visualize the esophagus but does not evaluate the oropharyngeal swallow, nor does it utilize the expertise of speech and language pathologists. Providers may order one or both studies yet still risk missing critical pathology. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective chart review was conducted at an academic medical center between January 2016 and June 2019 focused on patients who had both MBS and esophagram as imaging for dysphagia evaluation. Analysis determined whether MBS and esophagram performed concomitantly improved diagnostic clarity. RESULTS: A total of 5,183 patients underwent 6,066 swallow studies for dysphagia in the study period. Of which, 124 of these patients had concurrent MBS and esophagram. 10.5% of concurrent studies demonstrated a congruent negative evaluation. 59.7% of patients had an unremarkable MBS or esophagram paired with abnormal findings within the corresponding esophagram or MBS, respectively. 29.8% had both MBS and esophagrams that demonstrated an abnormality, but with unique pathologies identified by each study. In total, 85.1% of unremarkable MBS or esophagrams were paired with abnormal findings in the corresponding esophagram or MBS, respectively. CONCLUSION: Selection of diagnostic testing is variable among providers and may be influenced by healthcare systems. This analysis revealed that MBS and esophagrams provide unique diagnoses. Concurrent MBS and esophagrams may improve diagnostic accuracy, yet minimize additional studies. National practices around dysphagia diagnostics are inconsistent and would benefit from standardization. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2666-2670, 2021.

Discharge by Noon: A Checklist Initiative by the Otolaryngology Service.

OBJECTIVES/HYPOTHESIS: Hospital length of stay (LOS) and throughput are critical issues for hospitals. Late hospital discharges contribute to bottlenecks in the emergency department, overcrowd surgical and procedural areas, and limit patient tertiary-care center transfers. Our goal was to increase discharge by noon (DCBN) percentage from 8% to over 50% in a sustainable manner. STUDY DESIGN: Retrospective Review. METHODS: We used a multiple time series design and a quality improvement approach. An interdisciplinary improvement team (IIT) identified the main causes contributing to late discharge and then developed and implemented multiple interventions to increase the percentage of DCBN. Admissions and discharge information were obtained for all patients in the otolaryngology service (January 2014-September 2017). The intervention was implemented in July 2015. The primary outcome was the percentage of DCBN per month. Secondary outcomes were LOS, case-mix index (CMI), patient experience, and 30-day readmissions. We analyzed the impact of our intervention and outcomes at the preintervention, peri-intervention, and postintervention periods. RESULTS: One thousand four hundred sixty-four admissions to the otolaryngology service were included. Throughout the intervention period, the percentage of patients DCBN increased. Analysis of the intervention showed significant DCBN change of 15% in the first versus 42% in the last 12-months (P < .001), and shorter LOS (-1.4 days, P < .001) and lower CMI (-0.6, P < .001) in the DCBN group. Patient satisfaction scores improved by 4% (P < .05), and no difference in 30-day readmission rates (P = .29) was shown. CONCLUSIONS: This multifaceted intervention improved early discharge and patient experience. Our checklist of key behaviors could be applied throughout other services and hospitals with reproducible success. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E76-E82, 2021.

"Hot Zones" for Otolaryngologists: Assessing the geographic distribution of aerosol-generating procedures amidst the COVID-19 pandemic.

OBJECTIVE: Given high COVID-19 viral load and aerosolization in the head and neck, otolaryngologists are subject to uniquely elevated viral exposure in most of their inpatient and outpatient procedures and interventions. While elective activity has halted across the board nationally, the slow plateau of COVID-19 case rates prompts the question of timing of resumption of clinical activity. We sought to prospectively predict geographical "hot zones" for otolaryngological exposure to COVID-19 based on procedural volumes data from 2013 to 2017. METHODS: Otolaryngologic CPT codes were stratified based on risk-level, according to recently published specialty-specific guidelines. Using the Medicare POSPUF database, aerosol-generating procedures (AGPs) were mapped based on hospital referral regions, against up-to-date COVID-19 case distribution data, as of April 24, 2020. RESULTS: The most common AGPs were diagnostic flexible laryngoscopy, diagnostic nasal endoscopy, and flexible laryngoscopy with stroboscopy. The regions with the most AGPs per otolaryngologist were Iowa City, IA, Detroit, MI, and Burlington, VT, while the states with the most COVID-19 cases as of April 24th are New York, New Jersey, and Massachusetts. CONCLUSIONS: Our study provides a model for predicting possible "hot zones" for otolaryngologic exposure based on both COVID-19 case density and AGP-density. As the focus shifts to resuming elective procedures, these potential "hot zones" need to be evaluated for appropriate risk-based decision-making, such as "reopening strategies" and allocation of resources.

Geospatial analysis of COVID-19 and otolaryngologists above age 60.

OBJECTIVE: The 2019 novel coronavirus (COVID-19) is disproportionately impacting older individuals and healthcare workers. Otolaryngologists are especially susceptible with the elevated risk of aerosolization and corresponding high viral loads. This study utilizes a geospatial analysis to illustrate the comparative risks of older otolaryngologists across the United States during the COVID-19 pandemic. METHODS AND MATERIALS: Demographic and state population data were extracted from the State Physician Workforce Reports published by the AAMC for the year 2018. A geospatial heat map of the United States was then constructed to illustrate the location of COVID-19 confirmed case counts and the distributions of ENTs over 60 years for each state. RESULTS: In 2018, out of a total of 9578 practicing U.S. ENT surgeons, 3081 were older than 60 years (32.2%). The states with the highest proportion of ENTs over 60 were Maine, Delaware, Hawaii, and Louisiana. The states with the highest ratios of confirmed COVID-19 cases to the number of total ENTs over 60 were New York, New Jersey, Massachusetts, and Michigan. CONCLUSIONS: Based on our models, New York, New Jersey, Massachusetts, and Michigan represent states where older ENTs may be the most susceptible to developing severe complications from nosocomial transmission of COVID-19 due to a combination of high COVID-19 case volumes and a high proportion of ENTs over 60 years.

The prefabricated supraclavicular artery flap in high-risk tracheal stenosis patients.

OBJECTIVES/HYPOTHESIS: Primary tracheal resection in appropriately selected patients with tracheal stenosis achieves >90% success rate. Risk factors for complications have been identified, making some patients high risk for this procedure. Herein is a review and discussion of a novel treatment method for tracheal stenosis utilizing a prefabricated composite auricular cartilage graft embedded in a supraclavicular artery island flap (pSCAIF) for tracheal reconstruction in high-risk patients. STUDY DESIGN: Retrospective case series. METHODS: After institutional review board approval, cases were analyzed after data collection. Between 2014 and 2016, eight patients underwent airway reconstruction using an auricular cartilage graft prefabricated within a supraclavicular artery island flap reconstruction; all of these were included in the study. Each case was reviewed, and relevant details of patient and disease characteristics, operative course, postoperative course, decannulation, and status at last follow-up were isolated and reported. RESULTS: Seven of eight patients were female. The most common cause of stenosis was iatrogenically induced multilevel stenosis (7/8 patients). All patients had undergone prior airway procedures, were high risk based on comorbid conditions, and underwent grafting and reconstruction with a composite supraclavicular island flap. All patients continue to follow up in a multidisciplinary clinic, and at last follow-up, eight of eight patients were successfully decannulated. CONCLUSIONS: The pSCAIF is a novel method for tracheal reconstruction. The analysis of the prefabricated locoregional approach cohort supports its utility for tracheal reconstruction in patients with complicated multilevel stenosis and adverse comorbidities and characteristics. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:641-648, 2020.

Outcomes of tracheoesophageal puncture in twice-radiated patients.

OBJECTIVE: Previous research has demonstrated the safety of tracheoesophageal puncture voice prosthesis (TEP) placement in radiated patients; however, there is a growing population of twice-radiated patients with limited research on the outcomes of TEP-placement in this cohort. METHODS: After Institutional Review Board approval, a retrospective review of 80 patients that underwent TEP from 2006 to 2017 at a single institution was conducted, of which 16 patients underwent two courses of radiation. Outcome measures include TEP removal, complication and duration of usage. RESULTS: Half of twice-radiated patients had ultimate removal of their voice prosthesis with removal occurring at a median of 24.9 months after placement. Reasons for prosthesis removal included widening tracheoesophageal fistula, local recurrence, and dysphagia/esophageal stenosis. Nearly one-third of these patients required surgical intervention for closure of a widening fistula. In contrast, only 17% of once-radiated patients had their prosthesis removed with removal occurring at a median of 28.1 months. This was statistically fewer than the twice-radiated group (p = 0.02). Reasons for removal included patient preference, persistent leakage, recurrence of disease, enlarging tracheoesophageal fistula, poor voice, and dysphagia. Eleven percent of once-radiated patients required surgical intervention for TEP-related complications (p = 0.057). CONCLUSION: In the twice-radiated patient cohort, there is a higher rate of TEP removal and need for surgical intervention for a voice prosthesis-related complication as compared to a once-radiated cohort.

Improving efficiency in epistaxis transfers in a large health system: Analyzing emergency department treatment variability as pretext for a clinical care pathway.

INTRODUCTION: Epistaxis is a common condition with an estimated $100 million in health care costs annually. A significant portion of this stems from Emergency Department (ED) management and hospital transfers. Currently there is no data in the literature clearly depicting the differences in treatment of epistaxis between Emergency Medicine (EM) physicians and Otolaryngologists. Clinical care pathways (CCP) are a way to standardize care and increase efficiency. Our goal was to evaluate the variability in epistaxis management between EM and Otolaryngology physicians in order to determine the potential impact of a system wide clinical care pathway. MATERIALS AND METHODS: A retrospective case study was conducted of all patients transferred between emergency departments for epistaxis over an 18-month period. Exclusion criteria comprised patients under 18 years old, recent sinonasal surgery, bleeding disorders, and recent facial trauma. RESULTS: 73 patients met inclusion criteria. EM physicians used nasal cautery in 8%, absorbable packing in 1% and non-absorbable packing in 92% (with 33% being bilateral). In comparison, Otolaryngologists used nasal cautery in 37%, absorbable packing in 34%, and non-absorbable packing in 23%. Eighty percent of patients treated by an Otolaryngology physician required less invasive intervention than previously performed by EM physicians prior to transfer. CONCLUSIONS: Epistaxis management varied significantly between Emergency Medicine and Otolaryngology physicians. Numerous patients were treated immediately with non-absorbable packing. On post-transfer Otolaryngology evaluation, many of these patients required less invasive interventions. This study highlights the variability of epistaxis treatment within our hospital system and warrants the need for a standardized care pathway.

A targeted initiative to discharge surgical patients earlier in the day is associated with decreased length of stay and improved hospital throughput.

BACKGROUND: The timing of inpatient discharges can impact hospital throughput with later discharges leading to decreased patient satisfaction, increased length of stay (LOS), and longer boarding times. METHODS: A 12-month targeted intervention that included both pre-operative and inpatient components was implemented across all surgical inpatient services to increase the proportion of patients discharged by noon. RESULTS: Discharge by noon rates increased from 14.3% to 21.5% during the 12-month initiative (p < 0.01). The case mix index adjusted LOS (aLOS) decreased from 2.17 to 2.02 days (p < 0.01). ED, PACU, and ICU boarding times were all significantly lower during the initiative (p < 0.01, p < 0.01, p = 0.03 respectively). CONCLUSIONS: A targeted initiative to discharge surgical patients earlier resulted in a 50% increase in the proportion of patients discharged by noon. Associated with this finding were improvements in hospital throughput as measured by aLOS and boarding times in the ED, ICUs, and PACU.

Multi-specialty knowledge on surgical a management: Implementation of an educational initiative.

PURPOSE: Deficiencies in airway management knowledge can result in harm, especially in tracheostomy patients. Our objective is to assess the degree of knowledge in different medical specialties, before and after targeted airway education. MATERIALS AND METHODS: A lecture on tracheostomy management was prepared for Otolaryngology, Anesthesia, Emergency Medicine, General Surgery, Oral and Maxillofacial Surgery (OMFS), Internal Medicine (IM), and Family Medicine (FM). Before the lecture, a 12-question quiz on surgical airway knowledge was administered, and demographics from participants collected. Immediately following the lecture, participants were asked to retake the quiz. Performance was assessed. Population baseline characteristics included, specialty, years of practice, and previous education. RESULTS: A paired t-test evaluating pre- and post-lecture results showed a 34.2% improvement for all participants (n = 168) overall (2.7 points, p < 0.001). Providers with more years of practice performed better. Otolaryngology and OMFS performed the highest on the baseline test while FM and IM performed the lowest. The providers who reported previous standardized training from the hospital system, informal instruction on the ward, or had the topic covered in their degree program performed better compared to those without previous education (ANOVA, 3.5 points, p < 0.01). Providers who underwent formal training in their degree program performed the best. A Likert scale with self-assessment of comfort with surgical airway correlated positively with the performance on the quiz. CONCLUSION: Variability in tracheostomy knowledge based on specialty and years of training exists. We demonstrate that formal education on tracheostomy and surgical airways improved quantitative measures of knowledge.

Airway Management in a Patient With Tracheal Disruption due to Penetrating Neck Trauma With Hollow Point Ammunition: A Case Report.

Rapid sequence induction and intubation was performed for a patient in respiratory distress after a gunshot wound to the neck. Resistance was noted distal to vocal cords. With a bronchoscope unavailable, the endotracheal tube was advanced with a corkscrew maneuver. Subcutaneous emphysema had developed. The endotracheal tube was advanced into the right mainstem with adequate ventilation. Imaging illustrated tracheoesophageal injury. The patient was emergently explored. An intraluminal bullet was removed, lateral wall tracheal defect was repaired, and a tracheostomy was placed. The intubating provider should secure the airway by the method they are most comfortable, have high suspicion of airway injury, and prepare to manage airway disruption.

Consensus statement: Using laryngeal electromyography for the diagnosis and treatment of vocal cord paralysis.

INTRODUCTION: The purpose of this study was to develop an evidence-based consensus statement regarding use of laryngeal electromyography (LEMG) for diagnosis and treatment of vocal fold paralysis after recurrent laryngeal neuropathy (RLN). METHODS: Two questions regarding LEMG were analyzed: (1) Does LEMG predict recovery in patients with acute unilateral or bilateral vocal fold paralysis? (2) Do LEMG findings change clinical management in these individuals? A systematic review was performed using American Academy of Neurology criteria for rating of diagnostic accuracy. RESULTS: Active voluntary motor unit potential recruitment and presence of polyphasic motor unit potentials within the first 6 months after lesion onset predicted recovery. Positive sharp waves and/or fibrillation potentials did not predict outcome. The presence of electrical synkinesis may decrease the likelihood of recovery, based on 1 published study. LEMG altered clinical management by changing the initial diagnosis from RLN in 48% of cases. Cricoarytenoid fixation and superior laryngeal neuropathy were the most common other diagnoses observed. CONCLUSIONS: If prognostic information is required in a patient with vocal fold paralysis that is more than 4 weeks and less than 6 months in duration, then LEMG should be performed. LEMG may be performed to clarify treatment decisions for vocal fold immobility that is presumed to be caused by RLN. Muscle Nerve 53: 850-855, 2016.