[Double aortic arch and aortotracheal fistula as cause of fatal massive bleeding: a rare and dangerous association]. / Doble arco aórtico y fistula aortotraqueal como causa de hemorragia masiva fatal: una asociación rara y peligrosa.

Vascular rings are unusual congenital malformations. Among them, double aortic arch (DAA) is often difficult to diagnose due to its low incidence of symptoms. DAA can be associated with tracheal or esophageal compression and, in severe cases, could require tracheal intubation or chronic use of a nasogastric tube. This scenario favors the development of aortotracheal fistulas (ATF) or aortoe-sophageal fistulas (AEF). OBJECTIVE: To present a clinical case with an unusual association of DAA with ATF and to reinforce the importance of maintaining high diagnostic suspicion in patients with massive aerodigestive bleeding without an obvious source. CLINICAL CASE: A 32-week preterm newborn who required prolonged mechanical ventilation and presented intermittent episodes of massive oropharyngeal bleeding with hemodynamic compromise associated with lower airway obstruction without pulmonary hemorrhage. The patient underwent upper endoscopy and exploratory laparotomy without evidence of bleeding. Flexible nasopharyngolaryngoscopy and direct laryngoscopy also showed no abnormalities. A CT angiography showed complete DAA with indentation of the left dominant arch over the trachea, without severe stenosis or evidence of a fistula. AEF was suspected, so exploratory surgery was considered. However, the patient died before surgery due to a massive pulmonary hemorrhage. The autopsy revealed the presence of ATF. CONCLUSIONS: In patients with massive aerodigestive bleeding without an obvious source, the presence of DAA and possible AEF/ ATF should be considered. Imaging studies have a poor performance for this diagnosis, so surgery should be considered for diagnosis and treatment in these patients.

Management of Contralateral Reactive Vocal Fold Lesions, a Retrospective Study.

OBJECTIVE: To evaluate the anatomical and voice results of conservative management of patients diagnosed with contralateral reactive lesions (CRL) in our voice unit. METHODS: A retrospective chart review was conducted of all new adult patients with benign vocal fold lesions with or without CRL, treated in the voice unit at Universidad Católica Clinical Hospital between 2015 and 2019. Patients were divided into two groups, without CRL (group A) and with CRL (group B). Analysis of preoperative and 1 month after surgery videostroboscopy, GRBASI, Voice Handicap Index-10 (VHI-10), Voice Related Quality of Life (VRQOL) surveys and management of CRL was conducted. RESULTS: A total of 62 patients were included, 45 (72.6%) had CRL. When compared, bivariate and multivariate analysis revealed that age was significantly associated as a mild protective factor of presenting a CRL (P < 0.05). No significative differences were found between preoperative group A and B perceptual voice analysis or voice surveys. In terms of CRL management, 30 (66.6%) were injected, conservative management with observation was performed in 12 patients (26.7%) and, three (6.7%) were surgically resected. After 1 month follow-up, 32 (71.1%) had complete CRL resolution, eight (17.8%) had CRL persistence and, five (11.1%) had CRL recurrence. Postoperative vocal outcomes, GRBASI, VHI-10 and VRQOL showed significative improvement as compared with preoperative data for each group. No differences were seen between group A and B in terms of postoperative vocal outcomes. CONCLUSION: CRL are prevalent, and their management is controversial. On our study 72.6% of BFVL presented with CRL and 93.3% of them were conservatively managed. Improvement in perceptual voice analysis and quality of life surveys were similar in both groups.

Postintubation Phonatory Insufficiency: A Challenging Diagnosis.

INTRODUCTION: Glottic insufficiency is an important cause of dysphonia and can be frequently overlooked in the clinical evaluation. The differential diagnoses of this entity are diverse and include postintubation phonatory insufficiency (PIPI). These patients present with glottic insufficiency symptoms, associated with normal laryngeal imaging evaluation with no evident lesions. There is scarce literature describing this entity, since it is usually underdiagnosed. OBJECTIVES: The aim of this study is to describe two clinical cases diagnosed with PIPI at our center's Voice Unit, discuss their clinical features, diagnostic evaluation, and treatment alternatives. CASE SUMMARY: We report two clinical cases of prolonged orotracheal intubation (OTI) that developed dysphonia, vocal fatigue, a breathy voice, and poor vocal projection after being discharged from the hospital. Laryngoscopic evaluation showed no lesions in the membranous glottis and normal vocal fold mobility. Respiratory glottis was difficult to evaluate because of redundant arytenoids. To improve visualization, a laryngotracheoscopy with transtracheal anesthesia was performed in-office, exposing scar tissue medial to the vocal processes and respiratory vocal fold, confirming PIPI. DISCUSSION: Prolonged OTI can damage the medial arytenoid mucosa producing a posterior glottic gap that determines symptoms of glottic insufficiency. Multiple treatment options have been described yet few achieve a sufficient closure of the defect, so management is initially based on counseling and speech therapy. CONCLUSIONS: PIPI is usually difficult to diagnose and should be sought directly in the clinical evaluation, especially if there are no obvious lesions in the membranous glottis.

Spasmodic Dysphonia: Standardized Spanish Tool for Ambulatory Consult Diagnosis.

INTRODUCTION: Spasmodic dysphonia (SD) is a focal dystonia of the larynx where involuntary spasms of its intrinsic muscles are triggered by specific phonemes. The diagnosis is challenging and is performed by listening to the patient's voice, supported by nasolaryngoscopy. There is no diagnostic tool in Spanish for SD. The objective of our study is to establish phonetically studied vocal tasks in Spanish language to diagnose patients with SD. MATERIAL AND METHOD: This is a prospective study in three groups of patients: 11 with SD, 11 with another vocal disease, and 11 with no vocal disease, recruited in the Voice Unit of Hospital Clínico Universidad Católica. Of the patients with SD, 10 (90.9%) had adductor SD and 1 (9.1%) abductor SD. Vocal tasks phonetically studied by a speech language pathologist as laryngeal spasm triggers were recorded. The audio recordings were randomized and analyzed by nine evaluators: three experts and six otolaryngology residents. The correlation between the different professionals for the correct diagnosis was analyzed. RESULTS: The audio recordings were analyzed and patients with SD presented irregular voice breaks that occurred during the trigger phonemes. Evaluators classified the audio recordings: the expert group presented 100% sensitivity, 95-100% specificity and individual consistency of κ=0.73-0.82. The interrater agreement was 81.8%. The resident group presented 55-100% sensitivity, 58-95% specificity, and individual consistency of κ=0.36-0.82. The interrater agreement was 67.0%. DISCUSSION AND CONCLUSIONS: We obtained a strong to almost perfect interrater agreement in experts and fair to almost perfect in residents. This study shows that the established list of phonetically studied and standardized words can be a useful tool for the diagnosis of SD.

Protection for Otolaryngologic Surgery in the COVID-19 Pandemic.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) has placed unprecedented challenges on the world and the medical community. It is transmitted through droplets, contact, the fecal-oral route, and airborne transmission under certain conditions that allow droplets to combine with air particles to form an aerosol. Viral loads are higher in the nasal area and similar in symptomatic and asymptomatic patients. Medical situations have been classified into high and low risk of generating aerosols. Most procedures and surgery in otolaryngology correspond to high-risk medical situations. This review aims to gather the vast amount of available information and generate recommendations for different surgical procedures according to aerosolization risk and COVID-19 status, with use of specific personal protective equipment in each case. DATA SOURCES: PubMed, MEDLINE, and Embase. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, and Food and Drug Administration. REVIEW METHODS: We conducted a review on the literature on personal protective equipment for otolaryngologic surgery and surgical indication restrictions during the COVID-19 pandemic. CONCLUSIONS: SARS-CoV-2 is an easily transmitted virus. Asymptomatic and symptomatic patients with COVID-19 present an upper airway high viral load, conferring otolaryngologic procedures a high risk of aerosolization. Surgical procedures must be categorized according to aerosolization risk and the possibility of COVID-19 diagnosis, according to use of personal protective equipment. IMPLICATIONS FOR PRACTICE: This review contributes to scientific knowledge regarding the detailed description of protective personal equipment and, most important, surgical recommendations to reduce the risk of infection in the otolaryngology community during the COVID-19 pandemic.