Scoping Review of Surgical Rehabilitation of Post Intubation Phonatory Insufficiency.

OBJECTIVES: Post intubation phonatory insufficiency (PIPI) or posterior glottic diastasis describes posterior glottic insufficiency (PGI) caused by prolonged intubation causing medial arytenoid ulceration, mucosal scarring, and incomplete cricoarytenoid joint adduction. The purpose of this review is to showcase diagnostic findings, surgical rehabilitation, and gaps in our treatment algorithm of PIPI. DATA SOURCES: Embase, PubMed, Scopus, Web of Science. REVIEW METHODS: Two independent reviewers completed a systematic search of the literature studying PIPI. Reported intubation history, laryngeal defect, clinical symptoms, surgical intervention, and outcomes were gathered from included studies. RESULTS: Nine studies met our inclusion criteria for full review, (45 patients) all of which were case reports/series. All patients had posterior glottic defects, most commonly loss of medial arytenoid tissue, causing varying degrees of PGI. Eleven patients had vocal fold (VF) immobility or hypomobility. Treatment interventions were observation (1), speech therapy (2), VF or posterior glottic injection augmentation (15), medialization laryngoplasty (4), arytenoid repositioning (6), endoscopic (19) or open (3) posterior cricoid reduction, local mucosal rotation flap (11), or free mucosal graft (2) to fill the glottic defect. Observation, voice therapy, and augmentation or type 1 laryngoplasty failed to improve symptoms. Other surgical techniques improved symptoms with varying outcomes. CONCLUSION: PIPI is a difficult injury to diagnosis and treat. Conservative measures and augmentation/laryngoplasty often fail to fix the PGI. Our review supports symptom improvement with reconstruction of the posterior glottic defect with cricoid reduction or mucosal grafts. Future investigation is needed to better define the diagnosis and successful treatment algorithm. Laryngoscope, 2023.

Hoarseness: When to observe and when to refer.

The terms hoarseness and dysphonia are used interchangeably, and both describe a type of altered vocal quality affecting one-third of patients. While hoarseness may be secondary to benign conditions such as reflux or viral laryngitis, it may suggest benign or malignant vocal-fold pathology. It is important for caregivers to know how to evaluate, treat, and when to refer patients for direct visualization via laryngoscopy. In this article, we review basic laryngeal anatomy and function, symptoms of vocal-fold pathology, and current guidelines from the American Academy of Otolaryngology-Head and Neck Surgery on the diagnosis and treatment of dysphonia, including patient referral.

Initial hearing preservation outcomes of cochlear implantation with a slim perimodiolar electrode array.

OBJECTIVE: To assess the slim modiolar array as a hearing preservation electrode. METHODS: Retrospective chart review of adult, post-lingual CI recipients implanted with slim modiolar array Sept 2016 to July 2017 in a tertiary referral center. Baseline audiograms were obtained within six months of initial CI evaluation. Patients with low frequency pure tone average (LFPTA) (125, 250, 500 Hz) <80 dB were considered HP candidates. Postoperative audiograms were obtained within 48 h before activation. Successful HP was considered as (1) retention of LFPTA threshold <80 dB and (2) change in threshold from pre- to post-operative. RESULTS: Sixty-three patients received the slim perimodiolar array and 42 were HP candidates. Post-operative audiograms were obtained for 39 of 42 patients an average of 28.92 days after surgery. 56.4% of HP candidates retainedLFPTA <80 dB. Mean ΔLFPTA was 24.15 dB (±16.14; p < 0.001). 56.4% of HP candidates experienced Δ LFPTA <20 dB; 69.2% <30 dB. Functional hearing preservation was more successful in lower frequencies where starting thresholds were better - 78% with LFPTA <50 dB retained serviceable hearing at activation. The postoperative change was similar in each low frequency (Δ125 Hz: mean 21.25 +/- 14.76 (N = 28); Δ250 Hz: 26.28 +/- 19.29 (N = 39); Δ500 Hz: 25.00 +/- 17.73 (N = 39)). CONCLUSIONS: The slim perimodiolar array is moderately effective at immediate hearing preservation. In subjects with preoperative audiometric profiles similar to those in prior EAS trials, immediate HP is comparable.

Laryngeal Botulinum Toxin Injection for Vocal Tremor: Utility of Concurrent Strap Muscle Injection.

OBJECTIVES/HYPOTHESIS: Vocal tremor is a neurologic disorder that can be treated with laryngeal botulinum toxin injections (LBTX). We sought to describe our experience with thyroarytenoid and concurrent strap muscle injection. STUDY DESIGN: Retrospective chart review. METHODS: A chart review was performed of all patients with a primary diagnosis of vocal tremor treated with LBTX from 2012 through 2017. RESULTS: Twenty-one patients were included (mean age 69 years, 100% female). Thirteen patients (62%) had a minor component of spasmodic dysphonia in addition to their tremor. Fourteen patients had vertical and horizontal components to their tremor, and two had horizontal tremor alone. The remaining five patients did not have clear characterization of their tremor. A total of 49 injections were reviewed (25 thyroarytenoid [TA], 24 thyroarytenoid and strap muscle [TA+S]), and patients reported subjective voice benefit with 48 (96%) of these (92% TA, 100% TA+S). When available, the postprocedural change from baseline Voice Handicap Index-10 and Consensus Auditory Perceptual Evaluation of Voice scores were calculated (mean overall: -1.9, -7.8; TA: -2.7, -3.5; TA+S: -1.4, -10.3, respectively). Subjective patient improvement ratings (scale 0%-100%) were obtained for 46 injections, with a mean of 70% improvement per injection. Of patients with both horizontal and vertical tremor, outcomes were improved with TA+S injection versus TA alone (mean improvement 74% vs. 35%, P < .005). CONCLUSIONS: There is utility in the characterization of vertical and horizontal components of vocal tremor. Patients with both appear to have increased benefit with injection of strap muscles in addition to thyroarytenoid muscles. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1433-1437, 2019.