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OBJECTIVE: Pediatric nonselective laryngeal reinnervation (NSLR) has gained popularity in recent years; however, long-term outcomes have not been reported. METHODS: Patients greater than 1 year post reinnervation were recruited. Families were asked to report Pediatric Voice-Related Quality of Life (PVRQOL) and provide an audio recording of connected speech. PVRQOL and voice measures were compared with preoperative and early postoperative outcomes (<12 months) using analysis of variance (ANOVA) for repeated measures and post hoc tests for linear trend. RESULTS: Sixty-six patient families were contacted. Twelve patients responded with PVRQOL; six (50%) were female. Median age at surgery was 6.4 (range 1.9-15) and at follow-up 13.5 (range 10-18), with a median of 6.8 years (range 3-9.1) since surgery at follow-up. Mean preoperative PVRQOL was 68.1 (95% CI 52.3-84.0), early postoperative 86.5 (73.2-99.7), and long-term 90 (82.7-97.3). ANOVA showed no significant difference between values (p = 0.1228), but post hoc testing showed improving outcomes over time (p-for-trend 0.0304). PVRQOL was stable between early postoperative and long-term values (p = 0.3399). Four voice samples were adequate for analysis. Mean preoperative cepstral peak prominence (CPP) was 5.2 (95% CI 3.4-7.0), early postoperative 8.5 (5.5-11.5), and long-term 6.8 (2.77-10.89, p = 0.3340, p-for-trend 0.2988) Low-to-high spectral ratio was 22.3 preoperatively (14.0-30.5), 23.0 early postoperative (17.4-28.7), and 28.8 long-term (17.4-40.2, p = 0.1174, p-for-trend 0.0364). Cepstral spectral index of dysphonia (CSID) was 83.0 preoperatively (44.1-121.8), 39.4 early postoperative (20.4-58.3), and 45.53 long-term (-0.05-91.1, p = 0.4457, p-for-trend 0.1464). CONCLUSIONS: Years after NSLR, PVRQOL, low-to-high spectral ratio, and CSID show no evidence of degradation over time. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.
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INTRODUCTION: Vagal nerve stimulator (VNS) implantation is a vital therapy for epilepsy refractory to other treatments; however, it is associated with a very high rate of voice changes. Relatively few of these patients are evaluated for vocal fold motion impairments. In this series, we evaluate 5 such patients with a novel phenotype of forced abduction with VNS stimulation. METHODS: Retrospective case series. RESULTS: Five patients with a VNS implant who underwent operative direct or in-office rigid laryngoscopy and had vocal fold motion impairment associated with VNS activation are included. All 5 patients had vocal fold mobility with VNS off and a fixed with activation. All patients exhibited vocal fold abduction with VNS activation. Patient 2 has since undergone laryngeal reinnervation, which helped her intermittent dysphonia but left a small glottic gap. A type 1 thyroplasty corrected this gap and improved her voice further. Patient 3 has undergone laryngeal reinnervation for which early results show improvement in perceptual and patient reported outcomes. Patients 4 and 5 have both undergone laryngeal reinnervation with improvement in voice. CONCLUSION: Previous reported cases of stimulated immobility associated with VNS use describe only adduction of the vocal fold. This series expands the previous work showing the VNS activation can also cause stimulated immobility in an abducted position, for which reinnervation and other medialization procedures offer promising treatment.
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Nonselective laryngeal reinnervation (NSLR) shows comparable voice results to thyroplasty after one year without permanent implants. In the rare case of a second ipsilateral vocal fold paralysis after NSLR, we present the first recorded revision NSLR. Case report. A 51 year old woman with a history of right NSLR in 2017 for vocal fold paralysis after an anterior cervical diskectomy and fusion (ACDF) presented for re-evaluation prior to a revision of her ACDF. Ipsilateral revision was recommended to reduce the risk of bilateral vocal fold paralysis. Post-operatively, she was noted to have vocal fold immobility. Her maximum phonation time at that time was 9 s. Her voice was moderately breathy and moderately asthenic. Fundamental frequency (F0) was 211 Hz. Jitter was 2.868%, and shimmer 14.429%. Noise to harmonic ratio was 0.366. Cepstral peak prominence was 2.689. After being offered thyroplasty or revision reinnervation, she opted for revision reinnervation due to a strong preference for her reinnervated voice. She underwent a revision cross-neck NSLR with a commercial nerve graft in September 2022. One year later, her MPT was found to be 7.6 s, with mild breathiness and asthenia. F0 was 190 Hz. Jitter decreased to 2.42%, shimmer to 6.478%, and NHR to 0.165. Cepstral peak prominence increased to 4.427. VHI decreased from 35 pre-operatively to 7 post-operatively. We present the first case of a revision NSLR. Notable improvement has been found in objective voice measures and patient-reported outcomes post-operatively, demonstrating feasibility in similar patients. Laryngoscope, 2024.
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OBJECTIVES: Implementing enhanced recovery after surgery (ERAS) protocols and decreasing length of stay (LOS) have become a priority for major surgeries, including microvascular free tissue transfer (MVFTT) reconstruction of the head and neck. We describe an ERAS protocol with the goal to further reduce length of stay beyond national medians. METHODS: Retrospective chart review between August 2016 and February 2023, including all patients who underwent MVFTT after oral cavity, skull base, salivary gland, and cutaneous ablative surgery. An ERAS protocol was implemented in March 2020. RESULTS: A total of 383 patients were included. Approximately 59.8% underwent oral cavity MVFTT, 34.5% cutaneous and lateral skull base, and 5.8% maxillary and anterior skull base. A total of 209 (54.7%) patients had surgery prior to implementation of the ERAS protocol and 174 (45.3%) after. Median LOS decreased from 9 days (interquartile interval [IQR] 8-11) to 6 (IQR 5-7.5, p < 0.0001) following oral cavity MVFTT. For cutaneous and lateral skull base reconstruction, median LOS decreased from 6 days (IQR 5-8) to 3 (IQR 3-7, p < 0.0001). For anterior skull base and sinonasal MVFTT, median LOS decreased from 8 (IQR 7-9) to 5 days (IQR 4.5-7, p = 0.0005). Rate of discharge to skilled nursing or subacute rehabilitation facilities decreased (24% before ERAS, 9.2% after, p < 0.0001). Thirty-day readmission rate was similar before and after implementation (10.5% vs. 10.3, p = 0.954). Discharge to facility was associated with readmission (OR 2.34, 95% CI 1.12-4.89, p = 0.024). CONCLUSION AND RELEVANCE: Implementation of the ERAS protocol was associated with decreased LOS. There was no increase in rate of readmission. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.
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OBJECTIVES: Juvenile-onset recurrent respiratory papillomatosis (JoRRP) is a rare, costly condition linked to human papillomavirus. Standard of care is serial surgical debridement. Many adjunctive therapies have been trialed, with recent success with systemic bevacizumab. This paper examines healthcare spending associated with systemic bevacizumab use for JoRRP and compares it to healthcare spending for surgical care alone to determine whether bevacizumab has a financial benefit. METHODS: Five patients treated with systemic bevacizumab for JoRRP were identified at a single institution. Spending data was derived from the electronic medical record. Sensitivity analysis was performed using variation in spending and frequency of treatments. RESULTS: Patients had an average of 4.2 treatments per year prior to bevacizumab (95% confidence interval [CI] 1.4-7.0) and 1.1 after (0.2-2.0). Patients underwent an average of 9.2 bevacizumab treatments in their first year after initiation, 4.0 in the second, and 4.5 in their third. Mean payment per debridement was $3198 ($2856-3539), with mean total surgical payment per year of $17,966 ($11,673-24,259) prior to initiating bevacizumab. Mean payment on a single bevacizumab infusion visit was $6508 ($6063-6952). Mean total surgical and bevacizumab spending per year after bevacizumab initiation were $83,951 ($12,938-154,964). CONCLUSIONS: Accounting for variations in the number of treatments per year with bevacizumab after initiation, healthcare spending after bevacizumab initiation is similar to spending on surgery alone for JoRRP in patients with severe disease.
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OBJECTIVE: The purpose of this study is to determine whether tracheostomy stomal maturation affects the risk of tracheocutaneous fistula (TCF) in children. METHODS: A retrospective chart review was conducted for all children who both underwent a tracheostomy and were decannulated between 2012 and 2021 at a tertiary children's hospital. Charts were analyzed for demographics, surgical technique, and development of a TCF. TCF was defined as a persistent fistula following 3 months after decannulation. RESULTS: 179 children met inclusion criteria. The median (interquartile range) age at tracheostomy was 1.5 (82.4) months, average (standard deviation [SD]) duration of tracheotomy was 20.0 (20.6) months, and length of follow-up after decannulation (range; SD) was 39.3 (4.4-110.0; 26.7) months. 107 patients (60.0%) underwent stomal maturation and 98 patients developed a TCF (54.7%). Younger age at tracheostomy placement was significantly associated with increased risk of TCF, mean (SD) age 28.4 (51.4) version 80.1 (77.5) months (p < 0.001). Increased duration of tracheostomy was significantly associated with increased risk of TCF, 27.5 (18.4) version 11.0 (18.2) months (p < 0.001). Stomal maturation was not significantly associated with the risk of TCF, including on multivariable analysis adjusting for age at tracheostomy and duration of tracheostomy (p = 0.089). CONCLUSION: Tracheostomy stomal maturation did not affect the risk of TCF in children, even after adjusting for age and duration of tracheostomy. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:2941-2944, 2024.