Identification and analysis of Nonlinear behaviors of vocal fold biomechanics during phonation to assess efficacy of surgery for benign laryngeal Diseases.

BACKGROUND: Current voice assessments focus on perceptive evaluation and acoustic analysis. The interaction of vocal tract pressure (PVT) and vocal fold (VF) vibrations are important for volume and pitch control. However, there are currently little non-invasive ways to measure PVT. Limited information has been provided by previous human trials, and interactions between PVT and VF vibrations and the potential clinical application remain unclear. Here, we propose a non-invasive method for monitoring the nonlinear characteristics of PVT and VF vibrations, analyze voices from pathological and healthy individuals, and evaluate treatment efficacy. METHOD: Healthy volunteers and patients with benign laryngeal lesions were recruited for this study. PVT was estimated using an airflow interruption method, VF vibrational frequency was calculated from accelerometer signals, and nonlinear relationships between PVT and VF vibrations were analyzed. Results from healthy volunteers and patients, as well as pre- and post-operation for the patients, were compared. RESULTS: For healthy volunteers, nonlinearity was exhibited as an initial increase and then prompt decrease in vibrational frequency at the end of phonation, coinciding with PVT equilibrating with the subglottal pressure upon airflow interruption. For patients, nonlinearity was present throughout the phonation period pre-operatively, but showed a similar trend to healthy volunteers post-operatively. CONCLUSION: This novel method simultaneously monitors PVT and VF vibration and helps clarify the role of PVT. The results demonstrate differences in nonlinear characteristics between healthy volunteers and patients, and pre-/post-operation in patients. The method may serve as an analysis tool for clinicians to assess pathological phonation and treatment efficacy.

Effects of a swallowing and oral-care program on resuming oral feeding and reducing pneumonia in patients following endotracheal extubation: a randomized, open-label, controlled trial.

BACKGROUND: The resumption of oral feeding and free from pneumonia are important therapeutic goals for critically ill patients who have been successfully extubated after prolonged (≥ 48 h) endotracheal intubation. We aimed to examine whether a swallowing and oral-care (SOC) program provided to critically ill patients extubated from prolonged mechanical ventilation improves their oral-feeding resumption and reduces 30-day pneumonia incidence. METHODS: In this randomized, open-label, controlled trial, participants were consecutively enrolled and randomized to receive the SOC program or usual care. The interventions comprised three protocols: oral-motor exercise, sensory stimulation and lubrication, and safe-swallowing education. Beginning on the day following patient extubation, an SOC nurse provided the three-protocol care for seven consecutive days or until death or hospital discharge. With independent outcome assessors, oral-feeding resumption (yes, no) corresponded to level 6 or level 7 on the Functional Oral Intake Scale (censored seven days postextubation) along with radiographically documented pneumonia (yes, no; censored 30 days postextubation), abstracted from participants' electronic medical records were coded. RESULTS: We analyzed 145 randomized participants (SOC group = 72, control group = 73). The SOC group received, on average, 6.2 days of intervention (14.8 min daily) with no reported adverse events. By day 7, 37/72 (51.4%) of the SOC participants had resumed oral feeding vs. 24/73 (32.9%) of the control participants. Pneumonia occurred in 11/72 (15.3%) of the SOC participants and in 26/73 (35.6%) of the control participants. Independent of age and intubation longer than 6 days, SOC participants were likelier than their control counterparts to resume oral feeding (adjusted hazard ratio, 2.35; 95% CI 1.38-4.01) and had lower odds of developing pneumonia (adjusted odds ratio, 0.28; 95% CI 0.12-0.65). CONCLUSIONS: The SOC program effectively improved patients' odds that oral feeding would resume and the 30-day pneumonia incidence would decline. The program might advance dysphagia care provided to critically ill patients extubated from prolonged mechanical ventilation. TRIAL REGISTRATION: NCT03284892, registered on September 15, 2017.

Proton Pump Inhibitor-unresponsive Laryngeal Symptoms Are Associated With Psychological Comorbidities and Sleep Disturbance: A Manometry and Impedance-pH Monitoring Study

Background/Aims: Laryngeal symptoms are largely treated with empiric proton pump inhibitor (PPI) therapy if no apparent pathology shown on ear, nose, and throat evaluation and reflux-related etiologies are suspected. However, treatment response remains unsatisfactory. This study aimed to investigate the clinical and physiological characteristics of patients with PPI-refractory laryngeal symptoms. Methods: Patients with persistent laryngeal symptoms despite PPI treatment for ≥ 8 weeks were recruited. A multidisciplinary evaluation comprising validated questionnaires for laryngeal symptoms (reflux symptom index [RSI]), gastroesophageal reflux disease symptoms, psychological comorbidity (5-item brief symptom rating scale [BSRS-5]) and sleep disturbance (Pittsburgh sleep quality index [PSQI]), esophagogastroduodenoscopy, ambulatory impedance-pH monitoring, and high-resolution impedance manometry were performed. Healthy asymptomatic individuals were also recruited for comparison of psychological morbidity and sleep disturbances. Results: Ninety-seven adult patients and 48 healthy volunteers were analyzed. The patients had markedly higher prevalence of psychological distress (52.6% vs 2.1%, P < 0.001) and sleep disturbance (82.5% vs 37.5%, P < 0.001) than the healthy volunteers. There were significant correlations between RSI and BSRS-5 scores, and between RSI and PSQI scores (r = 0.26, P = 0.010, and r = 0.29, P = 0.004, respectively). Fifty-eight patients had concurrent gastroesophageal reflux disease symptoms. They had more prominent sleep disturbances (89.7% vs 71.8%, P < 0.001) than those with laryngeal symptoms alone but similar reflux profiles and esophageal motility. Conclusions: PPI-refractory laryngeal symptoms are mostly associated with psychological comorbidities and sleep disturbances. Recognition of these psychosocial comorbidities may help optimize management in these patients.

Effects of surgery on the relationship between subglottic pressure and fundamental frequency in vocal fold dynamics in patients with benign laryngeal diseases.

PURPOSE: Subglottic pressure (Ps) and fundamental frequency (F0) play important roles in governing vocal fold (VF) dynamics. Theoretical description, model simulation, excised larynx and animal models have been used in previous studies, yet clinically applicable measurements are still lacking. This study aimed to evaluate the effects of surgery for benign laryngeal lesions by investigating the relationship between F0 and Ps. METHODS: Patients with benign laryngeal lesions who underwent phonosurgery were prospectively recruited. Participants were instructed to sustain voicing the vowel /o/ at three incremental frequencies four semitones apart in the modal register (F01, F02, F03). F0 was estimated by VF vibration on the accelerometer. Ps change was achieved and measured using the airflow interruption method. RESULTS: Thirteen patients with a mean age (SD) of 43.5 (12.4) years were included. The change in F0 per unit change of Ps, which is the slope (Hz/kPa) of the regression line of the frequency-pressure data pairs, decreased as the tension of the VF increased. The slopes significantly increased after the operation for F01 and F02 (36.43 ± 14.68 preoperatively, 53.91 ± 30.71 postoperatively, p = 0.011 and 26.02 ± 10.71; 34.85 ± 17.92, p = 0.046, respectively). In addition, there was a significant decrease in phonation threshold pressure and improvements in the grade, roughness, breathiness, asthenia, strain scale, and the voice handicap inventory-10. CONCLUSIONS: The relationship between F0 and Ps may serve as an objective assessment of the outcomes in the treatment of benign laryngeal diseases with clinical relevance.

Anatomical and physiological characteristics in patients with Laryngopharyngeal Reflux Symptoms: A case-control study utilizing high-resolution impedance manometry.

BACKGROUND/PURPOSE: This study aimed to explore the anatomical and physiological characteristics of patients with laryngopharyngeal reflux (LPR) symptoms, such as hoarseness, throat clearing, throat pain, globus, and chronic cough, with the novel high-resolution impedance manometry (HRIM). METHODS: Consecutive patients exhibited at least one LPR symptom for ≥4 weeks after 2-month proton-pump inhibitor treatment were enrolled during November 2014 and March 2018 from single tertiary medical center. All patients completed validated symptom questionnaires, esophagogastroduodenoscopy, and HRIM. Healthy volunteers were also recruited for comparison of esophageal parameters on HRIM. RESULTS: Eighty-nine LPR patients and 63 healthy volunteers were analyzed. Compared with healthy volunteers, LPR patients had significantly shorter upper and lower esophageal sphincters (UES and LES), a shorter intraabdominal esophagus (all P < 0.01), higher 4-s integrated relaxation pressures (IRP-4s) (P = 0.011) of the LES. After adjusted for age, sex, body weight, body height and alcohol consumption, multiple regression analysis showed that age, LES IRP-4s and the UES length were independent risk factors for LPR symptoms (OR 1.056, 95% CI 1.019-1.094; OR 1.107, 95% CI 1.004-1.222; OR 0.432, 95% CI 0.254-0.736, respectively). In subgroup analysis, patients with moderate LPR symptoms had lower IRP-4s (6.64 ± 4.55 vs. 8.69 ± 5.10, P = 0.049) and more failed peristalsis (27.33 ± 29.26 vs. 11.36 ± 21.20, P = 0.004) than those with mild LPR symptoms. CONCLUSION: Our study suggests that esophageal structural factors and LES IRP-4s may contribute to the occurrence of LPR symptoms. Patients with moderate LPR symptoms were more likely to present with failed peristalsis.

Predicting feeding-tube dependence in patients following endotracheal extubation: a two-item swallowing screen.

BACKGROUND: To meet the surging demands for intubation and invasive ventilation as more COVID-19 patients begin their recovery, clinicians are challenged to find an ultra-brief and minimally invasive screen for postextubation dysphagia predicting feeding-tube dependence persisting for 72 h after extubation. METHODS: This study examined the predictive validity of a two-item swallowing screen on feeding-tube dependence over 72 h in patients following endotracheal extubation. Intensive-care-unit (ICU) patients (≥ 20 years) successfully extubated after ≥ 48 h endotracheal intubation were screened by trained nurses using the swallowing screen (comprising oral stereognosis and cough-reflex tests) 24 h postextubation. Feeding-tube dependence persisting for 72 h postextubation was abstracted from the medical record by an independent rater. To verify the results and cross-check whether the screen predicted penetration and/or aspiration during fiberoptic endoscopic evaluation of swallowing (FEES), participants agreeing to receive FEES were analyzed within 30 min of screening. RESULTS: The results showed that 95/123 participants (77.2%) failed the screen, which predicted ICU patients' prolonged (> 72 h) feeding-tube dependence, yielding sensitivity of 0.83, specificity of 0.35, and accuracy of 0.68. Failed-screen participants had 2.96-fold higher odds of feeding-tube dependence (95% CI, 1.13-7.76). For the 38 participants receiving FEES, the swallowing screen had 0.89 sensitivity to detect feeding-tube dependence and 0.86 sensitivity to predict penetration/aspiration, although specificity had room for improvement (0.36 and 0.21, respectively). CONCLUSION: This ultra-brief swallowing screen is sufficiently sensitive to identify high-risk patients for feeding-tube dependence persisting over 72 h after extubation. Once identified, a further assessment and care are indicated to ensure the prompt return of patients' oral feeding. TRIAL REGISTRATION: NCT03284892, registered on September 15, 2017.

Long-term swallowing-related outcomes in oral cancer patients receiving proactive swallowing therapy.

OBJECTIVES: The present study aimed to evaluate the impact of proactive swallowing rehabilitation on swallowing function and quality of life (QoL) in oral cancer patients in the first two years after definitive treatment. MATERIALS AND METHODS: Consecutive adult patients with locally advanced oral cancer who received radical surgery, free flap reconstruction, and adjuvant radiotherapy were recruited prospectively, to whom proactive swallowing rehabilitation was provided. Body weight (BW); fiberoptic endoscopic evaluation of swallowing (FEES), functional oral intake scale (FOIS), and diet level; 10-item eating assessment tool (EAT-10), and MD Anderson Dysphagia Inventory (MDADI); and adherence at baseline, 1, 3, 6, 12, and 24 months were evaluated. RESULTS: A total of 104 patients were included during May 2018 to July 2020. Compared to the baseline, significant deterioration in BW, FOIS, and MDADI was noted at one month. However, a trend of recovery was observed in FOIS from one month, and in BW and MDADI from three months. A total of 94% patients were free of tube feeding at 12 months but with a diet requiring special preparations or compensation. Safe swallowing could be achieved in approximately 90% of the participants after six months with diet modification or compensatory maneuvers. BW at 18 and 24 months did not differ significantly from baseline. CONCLUSION: Proactive swallowing therapy is feasible for patients with locally advanced oral cancer receiving definitive treatments. It facilitates safe oral intake and adequate nutrition. Patients who performed swallowing exercises had a faster and better recovery in swallowing function and swallowing-related QoL.

Objective evaluation of biomaterial effects after injection laryngoplasty - Introduction of artificial intelligence-based ultrasonic image analysis.

OBJECTIVE: Hyaluronic acid (HA) can be degraded over time. However, persistence of the effects after injection laryngoplasty (IL) for unilateral vocal fold paralysis (UVFP), longer than expected from HA longevity, has been observed. The purpose of the study was to develop a methodology with clinical utility for objective evaluation of the temporal change in HA volume after IL using artificial intelligence (AI)-based ultrasonic assessment. DESIGN, SETTING AND PARTICIPANTS: Imaging phantoms simulating injected HA were built in different volumes for designing the algorithm for machine learning. Subsequently, five adult patients who had undergone IL with HA for UVFP were recruited for clinical evaluation. MAIN OUTCOME MEASURES: Estimated volumes were evaluated for injected HA by the automatic algorithm as well as voice outcomes at 2 weeks, and 2 and 6 months after IL. RESULTS: On imaging phantoms, contours on each frame were described well by the algorithm and the volume could be estimated accordingly. The error rates were 0%-9.2%. Moreover, the resultant contours of the HA area were captured in detail for all participants. The estimated volume decreased to an average of 65.76% remaining at 2 months and to a minimal amount at 6 months while glottal closure remained improved. CONCLUSION: The volume change of the injected HA over time for an individual was estimated non-invasively by AI-based ultrasonic image analysis. The prolonged effect after treatment, longer than HA longevity, was demonstrated objectively for the first time. The information is beneficial to achieve optimal cost-effectiveness of IL and improve the life quality of the patients.

Estimating vocal fold stiffness: Using the relationship between subglottic pressure and fundamental frequency of phonation as an analog.

OBJECTIVE: The stiffness of the vocal folds is an important factor in voice production, yet clinically applicable measurements are still lacking. It has been demonstrated in an in vivo canine model that fundamental frequency (F0 ) increased linearly as subglottic pressure (Ps ) increased, but with a lesser slope for higher levels of vocal fold tension. In this study, the relationship between F0 and Ps was investigated using the airflow interruption method in awake patients non-invasively. DESIGN: Healthy volunteers enrolled for evaluation. SETTING: Single-centre. PARTICIPANTS: Thirty-three healthy volunteers aged 20 and older were recruited, with one excluded for a recent asthma attack. MAIN OUTCOME MEASURES: The relationships between F0 and Ps , described as the slope (Hz/kPa), were investigated when the participants sustained voicing the vowel/o/at 3 incremental frequencies 4 semitones apart in the modal register (F1, F2 and F3). RESULTS: Thirty-two healthy volunteers (20 females, 12 males) aged 20-47 years were enrolled for final analyses. There was a statistically significant difference in the slopes of the linear regression lines of F0 -Ps , depending on the frequency with which the vowel/o/ was produced (P < .001). The slope differed significantly between F2 and F1 (P < .001; P = .015), F3 and F1 (P < .001; P = .002) and F3 and F2 (P < .001; P = .005) for both women and men, respectively. CONCLUSIONS: It was demonstrated that the higher the vocal fold tension, the smaller the slope between F0 and Ps . Using the relationship between F0 and Ps as an analog of vocal fold stiffness is potentially practical for clinical application.

Effects of a swallowing and oral care intervention for patients following endotracheal extubation: a pre- and post-intervention study.

BACKGROUND: For patients who survive a critical illness and have their oral endotracheal tube removed, dysphagia is highly prevalent, and without intervention, it may persist far beyond hospital discharge. This pre- and post-intervention study with historical controls tested the effects of a swallowing and oral care (SOC) intervention on patients' time to resume oral intake and salivary flow following endotracheal extubation. METHODS: The sample comprised intensive care unit patients (≥ 50 years) successfully extubated after ≥ 48 h endotracheal intubation. Participants who received usual care (controls, n = 117) were recruited before 2015, and those who received usual care plus the intervention (n = 54) were enrolled after 2015. After extubation, all participants were assessed by a blinded nurse for daily intake status (21 days) and whole-mouth unstimulated salivary flow (2, 7, 14 days). The intervention group received the nurse-administered SOC intervention, comprising toothbrushing/salivary gland massage, oral motor exercise, and safe-swallowing education daily for 14 days or until hospital discharge. RESULTS: The intervention group received 8.3 ± 4.2 days of SOC intervention, taking 15.4 min daily with no reported adverse event (coughing, wet voice, or decreased oxygen saturation) during and immediately after intervention. Participants who received the intervention were significantly more likely than controls to resume total oral intake after extubation (aHR 1.77, 95% CI 1.08-2.91). Stratified by age group, older participants (≥ 65 years) in the SOC group were 2.47-fold more likely than their younger counterparts to resume total oral intake (aHR 2.47, 95% CI 1.31-4.67). The SOC group also had significantly higher salivary flows 14 days following extubation (ß = 0.67, 95% CI 0.29-1.06). CONCLUSIONS: The nurse-administered SOC is safe and effective, with greater odds of patients' resuming total oral intake and increased salivary flows 14 days following endotracheal extubation. Age matters with SOC; it more effectively helped participants ≥ 65 years old resume total oral intake postextubation. TRIAL REGISTRATION: NCT02334774, registered on January 08, 2015.

Nonintubated laryngomicrosurgery with Transnasal Humidified Rapid-Insufflation Ventilatory Exchange: A case series.

BACKGROUND: Nonintubation anaesthesia for laryngomicrosurgery (LMS) provides both excellent visualization of the surgical field and complete examination on vocal cord. However, adequate oxygenation remains challenging during nonintubated LMS. Recently, transnasal humidified rapid-insufflation ventilator exchange (THRIVE) has been reported effectively maintaining apneic oxygenation in patient with difficult airways. The feasibility and safety of nonintubated LMS with THRIVE was evaluated in this case series. METHODS: From September 2016 to February 2017, a total of 23 patients receiving nonintubated LMS were included. Anaesthesia was induced and maintained through target-controlled propofol infusion and muscle relaxation with THRIVE oxygen support. Perioperative data were collected from medical records and analysed. RESULTS: The mean (±SD) duration of the operation was 12.4 (±4.4) min. The mean (±SD) total anaesthesia time (from induction to emergence) was 24.1 (±6.4) min. 22 patients received nonintubated LMS with surgical satisfaction without intraoperative desaturation. One patient who underwent laryngeal tumour biopsy experienced a single episode of desaturation. A 5.5-mm tracheal tube was needed for short-term mechanical ventilation to regain SpO2 to 100%. No significant complication was noted in all patients. All patients discharged as per schedule on the next day after surgery as intubated LMS patients in our hospital. CONCLUSION: Nonintubated LMS with THRIVE is a feasible and safe alternative to intubated LMS with a small size tracheal tube to provide a better surgical field. However, for patients with easy-bleeding tumor, intubated LMS remains suggestive for better airway protection.

Ultrasonographic Evaluation of Upper Airway Structures in Children With Obstructive Sleep Apnea.

Importance: Adenotonsillar hypertrophy is an important cause of obstructive sleep apnea (OSA) in children. However, residual OSA and abnormal polysomnographic findings have been reported in up to 75% of cases after adenotonsillectomy. Other anatomical and functional factors that influence upper airway structures, including the lateral pharyngeal wall, have rarely been studied in children with OSA. Objective: To determine whether the upper airway structures can be evaluated using head and neck ultrasonography and if there is an association between the ultrasonographic measurements for these structures and severity of OSA seen on polysomnography in children. Design, Setting, and Participants: Prospective, single-center, observational study of 82 children younger than 18 years with a diagnosis of sleep-disordered breathing (20 with primary snoring, 62 with OSA, as determined by the apnea-hypopnea index) and admitted to a tertiary teaching hospital for adenotonsillectomy. Exposures: Ultrasonography and polysomnography. Main Outcomes and Measures: Ultrasonographic measurements of upper airway structures. Results: Of the 82 children studied, 62 (76%) were boys; mean (SD) age, 7.7 (6.2). There was no significant difference found in tonsillar dimensions or volume between the children with OSA and those with primary snoring. However, the mean (SD) total lateral pharyngeal wall and the total neck thicknesses at the retropalatal level were both greater in children with OSA than in those with primary snoring at rest (24.9 [4.4] mm vs 21.3 [2.6] mm; difference, 3.61 mm; 95% CI of difference, 1.48-5.74 mm for lateral pharyngeal wall; and 59.9 [14.4] mm vs 49.9 [11.2] mm; difference, 10.9 mm, 95% CI of difference, 3.8-17.9 mm for the total neck). Conclusions and Relevance: Estimated tonsillar volume measured using ultrasonography had no relationship with the apnea-hypopnea index in childhood sleep-disordered breathing. However, the lateral pharyngeal wall was significantly thicker in children with OSA than in those with primary snoring at rest.

Double-blind, placebo-controlled study with alginate suspension for laryngopharyngeal reflux disease.

OBJECTIVE: Treatment for laryngopharyngeal reflux disease (LPRD) is challenging because of delays in recognition and poor responsiveness to proton-pump inhibitor therapy. The aim of this study was to determine the efficacy and safety of liquid alginate suspension for treating LPRD. METHODS: A double-blind, placebo-controlled, prospective study comparing 8 weeks of treatment with Alginos Oral Suspension (TTY Biopharm Co. Ltd., Taipei, Taiwan) (sodium alginate 1,000 mg three times daily) with a placebo was conducted on patients who fulfilled the criteria of at least one symptom consistent with LPRD, a total reflux symptom index (RSI) score of > 10, and a total reflux finding score (RFS) of > 5. Those with erosive gastroesophageal reflux disease, as evidenced through screened transnasal upper gastrointestinal endoscopy, were excluded. Efficacy was assessed by RSI, RFS, and ambulatory multichannel intraluminal impedance and pH (MII-pH) monitoring. RESULTS: A total of 80 patients aged 22 to 72 years were enrolled. Compared with baseline, both Alginos (TTY Biopharm Co. Ltd.) and the placebo significantly reduced the total RSI (P < 0.001) and the total number of reflux episodes shown by MII-pH monitoring (P < 0.05) after 8 weeks of treatment. However, liquid alginate suspension was unable to show superiority over the placebo. The incidence of various adverse events from Alginos (TTY Biopharm Co. Ltd.) was relatively low (7.7%) and mild. CONCLUSION: This study showed that liquid alginate suspension was well tolerated by LPRD patients. It effectively improved symptoms and reflux numbers but was unable to show superiority over placebo. As observed in previous studies, a great placebo effect was present. The importance of lifestyle modification could not be overlooked. LEVEL OF EVIDENCE: 2. Laryngoscope, 128:2252-2260, 2018.

Bedside screen for oral cavity structure, salivary flow, and vocal production over the 14days following endotracheal extubation.

PURPOSE: To describe the sequelae of oral endotracheal intubation by evaluating prevalence rates of structural injury, hyposalivation, and impaired vocal production over 14days following extubation. MATERIALS AND METHODS: Consecutive adults (≥20years, N=114) with prolonged (≥48h) endotracheal intubation were enrolled from medical intensive care units at a university hospital. Participants were assessed by trained nurses at 2, 7, and 14days after extubation, using a standardized bedside screening protocol. RESULTS: Within 48-hour postextubation, structural injuries were common, with 51% having restricted mouth opening. Unstimulated salivary flow was reduced in 43%. For vocal production, 51% had inadequate breathing support for phonation, dysphonia was common (94% had hoarseness and 36% showed reduced efficiency of vocal fold closure), and >40% had impaired articulatory precision. By 14days postextubation, recovery was noted in most conditions, but reduced efficiency of vocal fold closure persisted. Restricted mouth opening (39%) and reduced salivary flow (34%) remained highly prevalent. CONCLUSIONS: After extubation, restricted mouth opening, reduced salivary flow, and dysphonia were common and prolonged in recovery. Reduced efficiency of vocal cord closure persisted at 14days postextubation. The extent and duration of these sequelae remind clinicians to screen for them up to 2weeks after extubation.

Pediatric tracheotomy: A comparison of outcomes and lengths of hospitalization between different indications.

OBJECTIVES: To assess outcomes of pediatric tracheotomy and duration of associated hospital stay according to indications. SUBJECTS AND METHODS: In this retrospective study, subjects were 142 consecutive pediatric patients (<18 years old) who underwent tracheotomy at a tertiary referral medical center, National Taiwan University Hospital, in 1997-2012. Age, sex, indications, pre-operative status (oxygen demand, number of repeated intubations), and post-operative status (duration of weaning, length of hospital stay, mortality) were analyzed. RESULTS: The indications included craniofacial anomalies (n = 19, 13.4%), upper airway obstruction (n = 41, 28.9%), neurological deficit (n = 58, 40.8%), prolonged ventilation (n = 15, 10.6%), and trauma (n = 9, 6.3%). Ninety-one patients (64.1%) were successfully weaned off ventilation after tracheotomy (40% in the prolonged ventilation group). Total hospital stay and duration of ventilation before tracheotomy were longest in patients with craniofacial anomalies (150.9 ± 98.8 days, p = 0.004; 108.8 ± 88.2, p < 0.001). The early tracheotomy group had a shorter duration of post-tracheotomy mechanical ventilation support than the late tracheotomy group (14.4 ± 19.0, n = 49 vs. 34.9 ± 58.6, n = 80, p = 0.004). Decannulation was successful in 20 patients (14.1%), with the highest rate in the upper airway obstruction group (n = 14, 34.1%) and lowest in the prolonged ventilation group (none). Thirteen patients (9.2%) died during admission from causes unrelated to tracheotomy. CONCLUSION: Outcomes of pediatric tracheotomy and duration of hospitalization depend on indications. Children with craniofacial anomalies had earlier tracheotomy age and longer mechanical ventilation before tracheotomy resulted in longer hospitalization. Earlier tracheotomy can shorten the duration of post-tracheotomy mechanical ventilation in several conditions.

Impacts of disease severity on postoperative complications in children with sleep-disordered breathing.

OBJECTIVES/HYPOTHESIS: To investigate the effects of diseases severity on postoperative complications following adenotonsillectomy (T&A) in children with sleep-disordered breathing (SDB). STUDY DESIGN: Retrospective study. METHODS: Children aged <18 years were enrolled and underwent T&A for treating SDB. Polysomnography was used to classify the disease severity: primary snoring (apnea-hypopnea index [AHI] <1), mild (AHI = 1-5), moderate (AHI = 5-10), and severe obstructive sleep apnea [OSA] (AHI ≥10). Postoperative bleeding was graded using a severity scale (level I, self-reported bleeding; level II, requiring inpatient admission; level III, requiring reoperation). Primary bleeding is defined as hemorrhage occurring within the initial 24 postoperative hours. Perioperative respiratory complications are defined as oxygen saturation of less than 90%, 92%, or 95% in the recovery room. Major respiratory complications include laryngospasm, pulmonary edema, pneumonia, and intubation at recovery stage. RESULTS: A total of 610 children were included, of whom 42 (6.9%), eight (1.3%), and six (1.0%) children showed levels I, II, and III postoperative bleeding, respectively. Only one child had primary bleeding. The incidence and timing of postoperative bleeding did not differ significantly for children with different OSA severities. The rate of perioperative respiratory complications ranged from 1.6% to 14.3% on the basis of their definitions. The Cochran-Armitage test supported the trend that perioperative respiratory complications increase with the AHI. Six children developed major respiratory complications, which were not significantly associated with OSA severity. CONCLUSIONS: Children with severe OSA have increased risks of perioperative respiratory complications. However, OSA severity does not influence major respiratory complications or postoperative bleeding in children. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2646-2652, 2017.

Swallowing dysfunction following endotracheal intubation: Age matters.

To evaluate postextubation swallowing dysfunction (PSD) 21 days after endotracheal extubation and to examine whether PSD is time-limited and whether age matters.For this prospective cohort study, we evaluated 151 adult critical care patients (≥20 years) who were intubated for at least 48 hours and had no pre-existing neuromuscular disease or swallowing dysfunction. Participants were assessed for time (days) to pass bedside swallow evaluations (swallow 50 mL of water without difficulty) and to resume total oral intake. Outcomes were compared between younger (20-64 years) and older participants (≥65 years).PSD, defined as inability to swallow 50 mL of water within 48 hours after extubation, affected 92 participants (61.7% of our sample). At 21 days postextubation, 17 participants (15.5%) still failed to resume total oral intake and were feeding-tube dependent. We found that older participants had higher PSD rates at 7, 14, and 21 days postextubation, and took significantly longer to pass the bedside swallow evaluations (5.0 vs 3.0 days; P = 0.006) and to resume total oral intake (5.0 vs 3.0 days; P = 0.003) than their younger counterparts. Older participants also had significantly higher rates of subsequent feeding-tube dependence than younger patients (24.1 vs 5.8%; P = 0.008).Excluding patients with pre-existing neuromuscular dysfunction, PSD is common and prolonged. Age matters in the time needed to recover. Swallowing and oral intake should be monitored and interventions made, if needed, in the first 7 to 14 days postextubation, particularly for older patients.

Clinical risk assessment model for pediatric obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: To develop a clinical risk prediction model that identifies children with obstructive sleep apnea (OSA) in a clinical setting by examining the symptoms, physical status, and OSA-18 questionnaire results. DESIGN: Single institutional, cross-sectional study. METHODS: Children aged 2 to 18 years with symptoms of OSA were enrolled. Pediatric OSA was diagnosed through full-night polysomnography. Clinical data, namely demographics, symptoms, OSA-18 survey results, tonsil and adenoid sizes, and the weight of each child, were examined for constructing a simple point-based clinical model for OSA prediction. Variables for the risk model were selected using multivariable logistic regression analyses. RESULTS: Of the 310 participants (mean age, 7.6 ± 3.7 years; boys, 67%), 170 (55%) experienced OSA. Modeling variables were determined using several univariate logistic regression analyses, followed by multivariable logistic regression analyses. A point-based clinical model incorporating the age, tonsil size (5 points maximum), adenoid size (5 and 20 points for age > 6 years and < 6 years, respectively), obesity (5 points for age > 6 years), and breathing pauses (5 points) was developed (area under the curve = 0.832). Moreover, the optimal cutoff points for predicting the apnea-hypopnea index of > 1 and > 5 were 10 (sensitivity, 72.9%; specificity, 65.0%) and 12 (sensitivity, 77.5%; specificity, 56.9%), respectively. Internal validation using the bootstrap method revealed no apparent overfitting problem. CONCLUSION: A novel clinical prediction model was developed for determining the risk of pediatric OSA; the model can be useful in identifying high-risk patients among those with sleep disturbances. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2403-2409, 2016.

Application of ultrasound-guided core biopsy to minimize the non-diagnostic results and the requirement of diagnostic surgery in extrapulmonary tuberculosis of the head and neck.

PURPOSE: Head and neck extrapulmonary tuberculosis (ETB) presenting as lymphadenopathy poses a great threat by potentially increasing the deterioration of clinical outcomes. Tissue sampling for diagnostic confirmation of ETB is the only invasive procedure during the entire clinical course. It is, therefore, necessary to establish ETB sampling methods with accuracy and minimal invasiveness. METHODS: From 2009 to 2014, consecutive patients suspected of ETB receiving ultrasound-guided core biopsy (USCB), fine needle aspiration (FNA), and open biopsy (OB) were enrolled for comparison. RESULTS: There were 52 cases in the USCB group, 58 cases in the FNA group, and 78 cases in the OB group. For USCB, FNA, and OB groups, the diagnostic rates were 84.6 %, 8.6 %, and 100 % and the positive rates of acid-fast stain were 28.6 %, 0 %, and 37.5 %, respectively. The diagnostic rates of culture were 9.6 %, 0 %, and 50 %, respectively. For head and neck ETB, USCB procedure is timesaving, without leaving poor-healing wounds, scars, and the need for general anaesthesia and hospitalization. CONCLUSIONS: This study helps to optimize the ETB sampling method in head and neck based on diagnostic accuracy and minimal invasiveness. USCB can serve as the first-line diagnostic tool for ETB by reducing non-diagnostic results and the need for diagnostic surgery. KEY POINTS: • USCB shows higher diagnostic accuracy of ETB than FNA (84.6 % vs. 8.6 %). • USCB diminishes wound complications caused by surgical intervention for ETB. • USCB avoids general anaesthesia and hospitalization for diagnosing ETB. • USCB saves time and reduces the medical costs of diagnosing ETB.