Immune Checkpoint Inhibitor Induced Supraglottitis: A Case Series.

OBJECTIVE: To report a series of two cases of unusual airway complications with immunotherapy. METHOD: Case series and review of literature. RESULTS: We report two cases of significant supraglottitis in patients treated with immunotherapy. The first patient is a 62-year-old male receiving treatment for a stage 4 melanoma with Nivolumab and Relatlimab. He presented in Otolaryngology clinic for subacute dysphonia and dysphagia. Flexible laryngoscopy showed significant airway edema, mucopurulent secretions, and inflammation. He was admitted inpatient and treated with high dose systemic steroids and intravenous antibiotics. Daily airway examination with flexible laryngoscopy showed improvement with this medical management. The patient was discharged with antibiotics and a steroid taper. Treatment with immunotherapy was held due to this severe and potentially life-threatening complication. The second patient is a 76-year-old male with bladder cancer treated with Pembrolizumab. Four months after beginning treatment, he experienced hoarseness and throat discomfort. His laryngoscopic examination showed diffuse supraglottic swelling. He was treated inpatient with high dose systemic steroids, intravenous antibiotics, and antifungals, which resulted in improvement of supraglottic swelling. He remained on his immunotherapy treatment. Repeat examination demonstrated persistent supraglottic swelling without airway obstruction. Regarding airway-related complications with immunotherapy, the literature reports three other cases of tracheitis related to immune checkpoint inhibitors. CONCLUSION: This is the first case series of supraglottitis in patients treated with immune checkpoint inhibitors. This adds to the emerging literature of the potential respiratory implications of these medications. Laryngoscope, 2024.

Laser Versus Cold Steel for Endoscopic Management of Subglottic Stenosis.

OBJECTIVE: Endoscopic management of subglottic stenosis (SGS) includes a wide range of techniques. This 17-year review compares treatment outcomes between carbon dioxide (CO2) laser and cold steel. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care center. METHODS: A chart review was performed for all patients undergoing endoscopic treatment of SGS at Cleveland Clinic between July 12, 2000 and September 1, 2017. Data collected included demographics, stenosis etiology, stenosis severity, comorbidities, treatment modality, and airway procedure history. The primary endpoint was repeated treatment-free survival (RTFS) within 2 years using a Kaplan-Meier analysis and Cox proportional hazard model. RESULTS: A total of 139 patients (median [interquartile range] aged 48.7 [37.8, 57.0] years; 83.4% female) were included in the analysis, with etiologies including idiopathic (56.8%), granulomatosis with polyangiitis (25.2%), and intubation (16.5%). All patients underwent either cold steel (107 patients) or CO2 laser (32 patients) lysis of stenosis with concurrent dilation. RTFS within 2 years was 50.2% for CO2 laser and 31.9% for cold steel (hazard ratio [HR] and 95% confidence interval [CI]: 1.69, 0.96-2.97, P = .07). In patients with no prior airway procedures, there was no difference in RTFS between laser and cold knife (P = .41). However, in patients with prior airway procedures, RTFS was significantly greater in the laser group, even after adjusting for age, smoking history, and stenosis etiology (50.0% vs 16.8%, adjusted HR and CI: 2.82, 1.14-6.98, P = .025). CONCLUSION: Endoscopic lysis of SGS with CO2 laser should be considered in revision cases.

Surgical Management of Airway Stenosis During Pregnancy: A Scoping Review.

OBJECTIVE: There are several options for surgical management of subglottic stenosis, including endoscopic and open procedures. However, treatment algorithms, outcomes, and anesthetic management of subglottic stenosis during pregnancy are not well described. DATA SOURCES: MEDLINE, EMBASE, and the Cochrane databases. REVIEW METHODS: A scoping review of management of subglottic stenosis during pregnancy was performed, and then reported in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria consisted of those with subglottic or tracheal stenosis aged greater than 18 years, those in whom management was performed during pregnancy, and those who reported delivery related outcomes. RESULTS: After systematic review and detailed search of 330 identified articles, 15 articles met inclusion criteria and were included in the final analysis. All studies were case reports or case series (level 4 evidence). This study identified 27 patients. The median age was 29 and the median gestational age at intervention was 28 weeks. Left lateral positioning and fetal heart rate monitoring were used in nearly every case. The most common intervention performed was endoscopic balloon dilation. In many cases, jet ventilation or transnasal humidified rapid insufflation ventilatory exchange was satisfactory for maintenance of the airway. Three women ultimately required tracheostomy prior to labor and delivery. There was no fetal death or complications reported in these studies, and all but one woman proceeded to deliver at term. CONCLUSION: Endoscopic balloon dilation during pregnancy is safe and effective, resulting in optimized respiratory outcomes for the mother and safe delivery of the fetus. The third trimester appears to be safe for airway intervention. Laryngoscope, 134:1014-1022, 2024.

The Role of Bilateral Superior Laryngeal Nerve Block in Managing Refractory Chronic Cough.

OBJECTIVE(S): The aim was to investigate the utilization and efficacy of bilateral superior laryngeal nerve block in patients with refractory chronic cough. METHODS: A retrospective chart review of 164 patients with refractory chronic cough who underwent bilateral SLN block at a single institution between November 2018 and September 2022 was performed. Demographics, comorbidities, and patient-reported outcomes including pre- and postinjection Leicester Cough Questionnaire (LCQ) scores were collected and analyzed. RESULTS: The cohort underwent an average of 2.97 bilateral injections (range 1-22), containing either corticosteroid and local anesthetic or corticosteroid alone. Notably, 116 of 164 of patients reported an average of 67.3% reduction in their symptoms, with the treatment effect lasting 7.60 weeks on average. The average pre- and postinjection LCQ scores were 9.70 and 13.82, respectively. A lower LCQ score represents a greater impairment of health status due to cough, and the minimum important change is 1.3 points between questionnaires. The average improvement on LCQ following bilateral SLN block was 4.11 points for this cohort. CONCLUSION: The use of in-office bilateral SLN block is an effective treatment that can be used alone or in conjunction with oral medications for the treatment of refractory chronic cough. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1773-1777, 2024.

The Application of Superior Laryngeal Nerve Block for Non-Cough Laryngeal Hypersensitivity.

OBJECTIVE(S): To investigate the effect of superior laryngeal nerve (SLN) block in patients with non-cough complaints relating to laryngeal who have failed conventional medical therapy. METHODS: Retrospective chart review of 46 patients who underwent SLN block for non-cough indications between July 2019 and March 2022 was performed. Demographics, comorbidities, and patient-reported outcomes were collected. The primary diagnoses for this group included: odynophagia, throat pain, cervicalgia, muscle tension dysphonia, globus sensation, hyoid bone syndrome, and Eagle syndrome. RESULTS: The cohort underwent an average of 1.24 bilateral injections (range 0-7) and 0.87 unilateral injections (range 0-4). About 35 of 46 patients reported an average of 51.0% improvement in their symptoms, with the treatment effect lasting 7.60 weeks on average. On subgroup analysis, the patients with spasmodic dysphonia, odynophagia, and hyoid bone syndrome had the best percent improvement on average (75%-77.5%). Patients with globus sensation had the lowest percent improvement on average in response to this therapy, reporting only about 25%. Five patients experienced a mild adverse reaction immediately following injection which resolved spontaneously. CONCLUSION: The use of in-office SLN block for non-cough disorders involving the larynx requires further study with larger sample sizes to better delineate the efficacy of these applications. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1765-1768, 2024.

High Tracheal Resection With Intralaryngeal Extension as an Alternative to Cricotracheal Resection for Treatment of Subglottic Stenosis.

OBJECTIVE: Some patients with subglottic stenosis (SGS) require open airway reconstruction, which traditionally involves resection of the anterior cricoid cartilage. As an alternative, we present a novel technique: cricoid-sparing high tracheal resection with excision of subglottic stenotic tissue from below. A novel set of posterior circumferential cricoid sutures is used to reline the exposed cricoid plate. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care center. METHODS: The surgical technique is described and illustrated. A chart review was performed for all patients who underwent surgery between January 1, 2016, and June 30, 2021. RESULTS: Fourteen patients (100% female) underwent this airway resection and reconstruction surgery during the study time period. After a mean follow-up of 12 months, no patients required tracheostomy. Twelve of 14 patients (86%) had durable airways. Two patients (14%) have required repeated endoscopic procedures for recurrent stenosis and are considered treatment failures. None exhibited postoperative dysfunction to suggest posterior cricoarytenoid muscle injury. Thirteen patients (93%) had a postoperative normal voice or only transient dysphonia. One patient had permanent unilateral vocal fold paralysis. CONCLUSION: Cricoid-sparing high tracheal resection is a safe and effective alternative to cricotracheal resection, especially for predominantly posterior SGS. The cricoid cartilage and cricothyroid muscles are left undisturbed, potentially decreasing the risk of postoperative dysphonia, namely lowered fundamental frequency. This is especially meaningful in the setting of a predominantly female patient population.

Slim Perimodiolar Arrays Are as Effective as Slim Lateral Wall Arrays for Functional Hearing Preservation After Cochlear Implantation.

OBJECTIVE: To compare functional hearing preservation (HP) with a slim perimodiolar array (SPA) and a slim lateral wall array (SLW) in cochlear implantation (CI). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: All adult, post-lingual CI recipients with serviceable preoperative hearing serially implanted with SPA or SLW electrodes from July 2015 through July 2018. INTERVENTIONS: Cochlear implantation. MAIN OUTCOME MEASURES: Hearing preservation (HP). Patients with a low frequency pure-tone average (LFPTA) (125, 250, 500 Hz) threshold less than 80 dB were considered HP candidates based on preoperative audiograms. Postoperative audiograms were obtained before activation. Successful HP was defined as retention of LFPTA less than 80 dB. The change in LFPTA (ΔLFPTA) was also calculated. RESULTS: One hundred twenty one patients were implanted with either the SPA or SLW electrodes, 82 (42,40) of whom were HP candidates with postoperative audiograms. Average (standard deviation, SD) preoperative LFPTA was 54.86 [19.38] and 54.38 [13.58] dB for SLW and SPA respectively, with a mean ΔLFPTA of 24.6 [15.94] and 24.92 [16.66] dB. Successful HP was achieved in 21 (50%) and 22 (55%). Preoperative LFTPA, ΔLFPTA, and postoperative LFPTA were not significantly different (p = 0.89, 0.75, 0.93) between electrodes. CONCLUSIONS: The SPA is as effective at immediate functional HP after CI as a SLW.