Options for treatment of a small glottic gap.

Background: Glottic insufficiency, or glottic gap as it is commonly called, is a common cause of dysphonia, producing symptoms of soft voice, decreased projection, and vocal fatigue. The etiology of glottic gap can occur from issues related to muscle atrophy, neurologic impairment, structural abnormalities, and trauma related causes. Treatment of glottic gap can include surgical and behavioral therapies or a combination of the two. When surgery is chosen, closure of the glottic gap is the primary goal. Options for surgical management include injection medialization, thyroplasty, and other methods of medializing the vocal folds. Methods: This manuscript reviews the current literature regarding the options for treatment of glottic gap. Discussion: This manuscript discusses options for treatment of glottic gap, including the indications for temporary and permanent treatment modalities; the differences between the available materials for injection medialization laryngoplasty and how they affect the vibratory function of the vocal folds and vocal outcome; and the evidence that supports an algorithm for treatment of glottic gap. Level of Evidence: 3a-Systematic review of case-control studies.

Dysplastic Lesions of the Larynx.

There have been many advancements in the clinical and histologic diagnosis of laryngeal dysplasia (LD), but diagnosis still necessitates invasive histologic evaluation. Furthermore, despite improved histologic identification of dysplastic lesions, the exact details of pathophysiologic progression and the risk of malignant transformation is still uncertain. These unknowns create a barrier to establishing an ideal grading and classification system, which prevents the establishment of a precise and consistent treatment paradigm. Identifying these gaps in knowledge serves to highlight where further studies are warranted, ideally focusing on a better understanding of the biological behavior of LD. This would ultimately allow for the creation of a reliable grading and classification system and for the formalization of management and treatment guidelines for LD.

Laryngotracheal Recurrent Papillomatosis: A Case Study and Survey of Surgical and Systemic Management.

This case report presents a 72-year-old man with longstanding recurrent respiratory papillomatosis (RRP). He has undergone multiple procedures for the condition, including an apparent urgent surgical airway followed by tracheoplasty repair. Modern management of complicated RRP should include both local debulking and systemic approaches. Systemic bevacizumab (Avastin) has shown some initial success as an effective treatment option, in addition to other medications such as pembrolizumab. Other future care strategies may include an HPV vaccination and other adjuvants; vaccination has been reported to have the possibility of drastically reducing the incidence of RRP.

N95 respirator reuse, decontamination methods, and microbial burden: A randomized controlled trial.

PURPOSE: To evaluate the effectiveness and ease of N95 respirator decontamination methods in a clinic setting and to identify the extent of microbial colonization on respirators associated with reuse. METHODS: In a prospective fashion, N95 respirators (n = 15) were randomized to a decontamination process (time, dry heat, or ultraviolet C light [UVC]) in outpatient clinics. Each respirator was re-used up to 5 separate clinic sessions. Swabs on each respirator for SARS-CoV-2, bacteria, and fungi were obtained before clinic, after clinic and post-treatment. Mask integrity was checked after each treatment (n = 68). Statistical analyses were performed to determine factors for positive samples. RESULTS: All three decontamination processes reduced bacteria counts similarly. On multivariate mixed model analysis, there were an additional 8.1 colonies of bacteria (95% CI 5.7 to 10.5; p < 0.01) on the inside compared to the outside surface of the respirators. Treatment resulted in a decrease of bacterial load by 8.6 colonies (95% CI -11.6 to -5.5; p < 0.01). Although no decontamination treatment affected the respirator filtration efficiency, heat treatments were associated with the breakdown of thermoplastic elastomer straps. Contamination with fungal and SARS-CoV-2 viral particles were minimal to non-existent. CONCLUSIONS: Time, heat and UVC all reduced bacterial load on reused N95 respirators. Fungal contamination was minimal. Heat could permanently damage some elastic straps making the respirators nonfunctional. Given its effectiveness against microbes, lack of damage to re-treated respirators and logistical ease, UVC represents an optimal decontamination method for individual N95 respirators when reuse is necessary.

Segmental hemangiomas of the upper airway.

OBJECTIVES/HYPOTHESIS: To characterize the anatomic distribution of segmental hemangiomas of the larynx and to describe indications for treatment modalities. STUDY DESIGN: Retrospective chart review. METHODS: We performed a retrospective chart review of patients with cutaneous hemangiomas at a tertiary care center over a 4-year period. Only patients with upper airway hemangiomas were studied. We reviewed the anatomic distribution of hemangiomas within the upper airway and the treatment course of each patient. RESULTS: Of 1,226 patients with cutaneous hemangiomas, 108 (9%) were segmental in distribution. There were 56 patients (52%) who had a V3 distribution pattern, and 16 patients (29%) with upper airway involvement. All of these patients had associated V3 or mandibular segmental hemangiomas. As with the cutaneous manifestation, the distribution of hemangioma within the upper airway was segmental. This included the following anatomic sites: oral cavity, oropharynx, hypopharynx, intrinsic structures of the larynx, and subglottis. Many of these patients had diffuse mucosal involvement, including tracheal involvement. A total of 13 out of 16 patients underwent medical intervention, and seven also required surgical intervention. Medical management included systemic (12 patients) and intralesional (two patients) steroids. One patient received chemotherapy prior to referral. Surgical treatment included tracheostomy (four patients prior to referral) and laser ablation of subglottic involvement (total of four patients). CONCLUSIONS: A high percentage of patients with V3 cutaneous hemangiomas (29%) will manifest with upper airway involvement, the distribution of which is segmental. Treatment should take this diffuse pattern of involvement into consideration.

Staged surgical management of hypopharyngeal traction diverticulum.

A 50-year-old woman who had undergone cervical spine fixation 6 years earlier presented with dysphagia, regurgitation of undigested food, halitosis, and weight loss. Operative examination demonstrated a hypopharyngeal diverticulum with spinal hardware visible in a defect in the mucosa. She underwent an open cervical approach to removal of the hardware. Endoscopic staple diverticulotomy as described by Scher and Richtsmeier was performed 8 weeks later in the ambulatory surgical setting. After a period of enteral feeding via a nasogastric tube in the initial postoperative period, she was able to resume oral nutrition in the interim between the surgical procedures. After the second procedure, she was able to resume a normal diet immediately and she experienced minimal symptoms. It is established that traction diverticulum is appropriately treated by removing the inciting anatomic factor(s). We propose that staged surgical management begin with the removal of the nidus followed by marsupialization of the diverticulum pouch. Standard staple diverticulotomy is a viable option for the second stage. This technique allows the patient to minimize the length of, or avoid, the second hospitalization for diverticulum management.