Adult Esophageal Foreign Bodies.

This manuscript reviews and outlines the necessary tools to efficiently assess and manage an adult patient where an esophageal foreign body is suspected. It reviews the vulnerable populations and relevant diagnostics and provides a triage diagram to aid in timely intervention. Management with esophagoscopy is reviewed as well as potential complications that may arise. Lastly, to illustrate the concepts of this section, a case study is presented to highlight the salient points.

Examining readmissions following outpatient microlaryngeal surgery.

Objective: The objective of this study was to examine readmissions following microlaryngeal surgery. It was hypothesized that airway surgical procedures would have higher rates of readmission. Design: Retrospective review. Methods: Outpatient microlaryngeal surgeries from May 1, 2018 to November 27, 2022 were reviewed. Readmissions related to the original surgery within a 30-day postoperative period were examined. Patient demographics, body mass index, American Society of Anesthesiologist class, comorbidities, type of surgery, ventilation techniques, and operative times were examined and compared. Results: Out of 480 procedures analyzed, 19 (4.0%) resulted in a readmission, 9 (1.9%) of which were for glottic stenosis management. Undergoing an airway procedure was significantly associated with a readmission (p = .002) and increased the odds of readmission by 5.99 (95% confidence interval [CI]: 2.22-16.16, p < .001). Current/former smoking status increased the odds of readmission by 4.50 (95% CI: 1.33-15.19, p = .016). Each additional minute of operating time increased the odds of readmission by 1.03 (95% CI: 1.00-1.05, p = .04). Conclusion: Readmissions from microlaryngeal surgery are seldom reported but nonetheless occur. Identifying factors that may place a procedure at risk for readmission can help improve surgical quality of care. Level of Evidence: 4.

To Tube, or Not to Tube: Comparing Ventilation Techniques in Microlaryngeal Surgery.

OBJECTIVES/HYPOTHESIS: The objective of this study was to compare ventilation techniques utilized in microlaryngeal surgery. STUDY DESIGN: Retrospective cohort study. METHODS: Two-hundred surgeries performed from May 1, 2018 to March 1, 2020 and stratified as intubated, intermittently intubated (AAIV) or apneic. Patient demographics, comorbidities, anesthetic agents, intraoperative parameters/events, and complications were studied and compared across the three groups using inferential analyses. RESULTS: Median body mass index in the AAIV group was significantly higher (33 vs. 29; P = .0117). Median oxygen nadirs were lower in AAIV cases (81% vs. 91-92%) while CO2 peak measurements were lower (33 mmHg vs. 48 mmHg) in the fully apneic cohort which were significantly shorter cases (P < .0001). CO2 peak measurements were comparable between AAIV and intubated cohorts (median 48.5 mmHg vs. 48.0 mmHg). Median apnea times were significantly prolonged by 2-5.5 minutes using nasal cannula and THRIVE/Optiflow in fully apneic cases when compared to no supplementary oxygenation (P = .0013). Systolic blood pressures following insertion of laryngoscope were higher (159.5 vs. 145 mmHg) and postoperative diastolic pressures were lower (68.5 vs. 76.5 mmHg) in fully apneic cases than intubated cases. No differences existed between frequencies of complications. CONCLUSIONS: This study compares intubated, intermittently apneic, and fully apneic surgeries. No statistically significant differences were noted in comorbid conditions. While intraoperative hemodynamic fluctuations were more pronounced in the fully apneic cohort, and oxygenation distributions were lower in the AAIV cohort, no significant differences existed between events and complications. Apneic techniques are as safe and effective as traditional intubation. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2773-2781, 2021.

Injection Pharyngoplasty With Autologous Fat as Treatment for Stress Velopharyngeal Insufficiency in Brass and Woodwind Musicians.

Importance: Stress velopharyngeal insufficiency (SVPI) is an uncommon but often career-threatening condition affecting professional brass and woodwind musicians. Objectives: To review the evaluation of and treatment for SVPI in professional musicians with lipoinjection to the posterior pharyngeal wall. Design, Setting, and Participants: A retrospective medical record and literature review. Two professional musicians with SVPI treated with autologous lipoinjection to the posterior pharyngeal wall were included. Nasopharyngoscopy was performed while patients played their instrument both before and after injection. Main Outcomes and Measures: To assess the effectiveness of autologous fat injection to the posterior pharyngeal wall to treat stress velopharyngeal insufficiency in 2 professional instrumentalists. Successful treatment was the absence of VPI during playing as visualized by flexible nasopharyngoscopy. Results: After autologous lipoinjection of the posterior pharyngeal wall, 1 patient resumed full play with complete resolution, now 3 years after lipoinjection pharyngoplasty. The other patient received temporary resolution. Both had no surgical complications. Stress VPI is often a career-threatening condition for professional brass and woodwind musicians, with a cited incidence of 34%. Various treatment options in the literature include observation, speech and language pathology referral for pharyngeal strengthening, lipoinjection of the soft palate, and more invasive options, such as sphincter pharyngoplasty, pharyngeal flaps and V-Y pushback. Conclusions and Relevance: Autologous fat injection pharyngoplasty of the posterior pharyngeal wall may be a less invasive treatment option for musicians with SVPI.

Vocal fold paresis: a review of clinical presentation, differential diagnosis, and prognostic indicators.

PURPOSE OF REVIEW: Vocal fold paresis is a complex, controversial, and unique clinical entity. Guidance in assessing and evaluating these patients is provided in this comprehensive review of the current literature discussing the varying clinical presentation, the broad differential and general prognosis. RECENT FINDINGS: Patients with vocal fold paresis can present with elements of hyperfunction, which can often mask an underlying paresis. As such, repetitive phonatory tasks and videostroboscopic examination are critical for the assessment of patients with a suspected paresis. When analyzing stroboscopic findings, anatomical and motion asymmetries can strongly suggest the presence of a paresis. However, it is important to remember that other disorders can sometimes mimic or create a visual asymmetry when a true paresis may not be present. Laryngeal electromyography (LEMG) can serve as a valuable adjunct to confirm a paresis with the most reliable indicator being a decreased recruitment pattern. The differential is vast, including infectious, iatrogenic, systemic rheumatologic, and neurologic conditions. LEMG along with time of onset and the underlying cause of the paresis can be valuable prognostic indicators. SUMMARY: Patients with paresis often present with symptoms of a hyperkinetic voice disorder. Regardless of the myriad of causes, their assessment hinges upon close clinical evaluation with videostroboscopy aided with LEMG.

The costs and utility of imaging in evaluating dizzy patients in the emergency room.

OBJECTIVES/HYPOTHESIS: To determine the usefulness and the costs of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of patients with dizziness in the emergency department (ED). STUDY DESIGN: Retrospective chart review. METHODS: Charts of patients with a specific health maintenance insurance plan presenting with dizziness and vertigo to a large health system's ED between January 2008 and January 2011 were reviewed. Patient demographics, signs/symptoms, and CT and MRI results were assessed. CT and MRI charges were determined based on positive versus unremarkable findings. Data analysis included stepwise logistic regressions. RESULTS: Of 1681 patients identified, 810 (48%) received CT brain/head scan totaling $988,200 in charges. Of these, only 0.74% yielded clinically significant pathology requiring intervention. However, 12.2% of MRI studies yielded discovery of significant abnormalities. Logistic regression analysis revealed that older patients (P = .001) were more likely to receive a CT scan. CONCLUSIONS: In the 3-year period studied, CT scans for ED patients with dizziness and vertigo yielded a low predictive value for significant pathology. These data reveal a great opportunity for cost savings by developing stricter guidelines for ordering CT scans for this set of ED patients. The use of MRI in all cases of dizziness was found to be neither practical nor useful. However, appropriately directed MRI of the brain is recommended in patients with dizziness and other neurological signs or symptoms.