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.

Coblation Cordotomy for the Management of Bilateral Vocal Fold Immobility.

OBJECTIVE: Bilateral vocal fold immobility (BVFI) has an impact on both the voice and breathing. Many procedures have been developed to manage BVFI including the use of a coblator to perform a unilateral posterior cordotomy. This study evaluated the use of unilateral coblator cordotomy for BVFI. STUDY DESIGN: Retrospective chart review. METHODS: Ninety-four patients having undergone coblation cordotomies for BVFI performed by surgeons at two different institutions. Parameters evaluated were etiology of BVFI, prior tracheotomy, the number of revision procedures, postoperative decannulations, breathing outcomes as measured by Dyspnea Index, and voice outcomes as measured by the Voice Handicap Index. RESULTS: The main causes of immobility were thyroidectomy and prolonged endotracheal intubation. Twenty-one procedures were performed in patients who had a tracheotomy already in place, two required concurrent tracheotomy with cordotomy, and two underwent tracheotomy some time after cordotomy. The mean follow up was 16 months (1-38 months). Of the 25 patients who had a tracheotomy tube placed before or during the course of their care, we were unable to decannulate four of them after initial or revision cordotomy. Twenty of our 94 patients required a secondary revision unilateral cordotomy, usually on the previously un-operated vocal fold. This was more common in bilateral fixation than in paralysis. In 44 patients where Voice Handicap Index data was known both pre- and postoperatively, the median VHI scores improved from 62.2 to 37.4, while the VHI worsened in only four patients. Eight patients had a Dyspnea index performed both pre- and post-operatively and the median score dropped from 18.3 to 12.5. CONCLUSION: Coblation cordotomy is a reasonable option for vocal fold lateralization in BVFI. In our study, this method allowed for decannulation in 21 of 25 patients who had a tracheotomy. The initial coblator cordotomy was sufficient for the majority of patients, with 22% (20/94) requiring a revision procedure. Interestingly, our study also showed promising voice outcomes with improvements in VHI in all but four patients.

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.

Literature-guided recommendations for otolaryngologists during the COVID-19 pandemic: A contemporary review.

OBJECTIVE: The objective of this study was to review the current literature and guidelines on management of the novel coronavirus 2019 (COVID-19 or 2019nCoV) with respect to the field of Otolaryngology. DESIGN: Contemporary literature review. METHODS: Systematic literature review of global medical literature databases and communications were queried to find all available literature recommendations, research, and guidelines applicable to otolaryngologists in the COVID-19 pandemic. RESULTS: Guidance on personal protective equipment, office visits, and surgical scheduling, as well as recommendations for safe airway management and tracheotomy performance during the COVID-19 pandemic were compiled and interpreted. CONCLUSIONS: Little guidance exists for otolaryngologists who are among the highest risk groups during the rapidly evolving COVID-19 pandemic. This synthesis and compilation of global resources serve as a building block for further guidance during the epidemic. LEVEL OF EVIDENCE: NA.

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.

Biofilms and chronic otitis media: an initial exploration into the role of biofilms in the pathogenesis of chronic otitis media.

PURPOSE: The aim of the study was to compare the extent of biofilm infection in percentage of mucosal surface area of adenoids removed from children with otitis media with effusion (OME) vs those with recurrent acute otitis media (RAOM) and obstructive sleep apnea (OSA). MATERIALS AND METHODS: Comparative microanatomical investigation of adenoid mucosa using scanning electron microscopy obtained from 30 children with OME, RAOM, and OSA was used in this study. Seventeen males and 13 females ranging in age from 9 months to 10 years were included in this study. Percentage of biofilm surface area involvement was the main measure. RESULTS: Adenoids removed from patients with OME had moderately dense mature biofilms covering the mucosal surface with a mean of 27.7% of their mucosal surface covered with mature biofilms. These results were distinct from results obtained from patients diagnosed with RAOM and OSA with means of 97.6% and 0.10% of their mucosal surfaces covered with mature biofilms, respectively. These differences were statistically significant at P < .0001. CONCLUSIONS: Adenoids removed from patients with OME were characterized by distinctly different percentage of biofilm mucosal surface area coverage, with significantly more biofilm presence than OSA patients but significantly less biofilm presence than RAOM patients. Although previous investigations have supported a dominant role of nasopharyngeal biofilms in RAOM pathogenesis, these results suggest nasopharyngeal biofilms may play a different role in the pathogenesis of OME and that this clinical entity may be more multifactorial in nature.

Biofilm density in the pediatric nasopharynx: recurrent acute otitis media versus obstructive sleep apnea.

OBJECTIVES: We compared the biofilm surface density of adenoids removed from children with recurrent acute otitis media (RAOM) to that of adenoids removed from children with a diagnosis of obstructive sleep apnea (OSA). METHODS: We performed a comparative microanatomic study of adenoid mucosa using scanning electron microscopy in patients with diagnoses of RAOM and OSA (27 female and 41 male; age range, 3 months to 15 years). RESULTS: The adenoids removed from patients with RAOM had dense, mature biofilms covering nearly their entire mucosal surfaces. More specifically, the adenoids removed from patients with RAOM had an average of 93.53% of their mucosal surface covered, versus an average of 1.01% coverage on the adenoids removed from patients with OSA. These differences were statistically significant (p < 0.0001). CONCLUSIONS: The adenoids removed from patients with RAOM had almost their entire mucosal surface covered with biofilms, versus scant coverage for patients with OSA. Recurrent acute otitis media is notoriously resistant to antibiotic treatment, and aspirates of middle ear fluid repeatedly yield negative cultures. It is these properties that have led biofilms to become increasingly implicated in the pathogenesis of RAOM. Thus, the resistance of biofilms to antimicrobials, together with their planktonic shedding of organisms, may be an important mechanism in the development of RAOM.

Demonstration of nasopharyngeal and middle ear mucosal biofilms in an animal model of acute otitis media.

OBJECTIVES: We performed this study to determine the role of nasopharyngeal and middle ear (ME) biofilms in acute otitis media (AOM). METHODS: Sixty female 6-month-old chinchillas, free of ME disease, were utilized. Experimental animals were inoculated with influenza A followed by Streptococcus pneumoniae 7 days later. Control animals were inoculated with Sorensen's phosphate buffer. Daily otoscopy and tympanometry was performed, and the animals were painlessly sacrificed on days 1, 2, 5, 8, and 14. All mucosae were harvested and prepared for scanning electron microscopy. RESULTS: The ME inflammation, initially detected on day 2 after bacterial inoculation, peaked on day 8. Eight percent of the dually inoculated chinchillas displayed type B tympanograms, and 40% displayed type C. Otoscopic evaluation of tympanic membrane inflammation was rated from 0 to 4 (0 = normal and 4 = severe drainage and/or inflammation) according to an otoscopic grading system. Ten percent of the experimental chinchillas had a grade 2 score, 20% had grade 3, and 6.7% had grade 4. The controls demonstrated no abnormal tympanometric or otoscopic findings. Scanning electron microscopic imaging showed dense biofilms on 83% of the nasopharynges and 67% of the MEs on day 8 in the experimental animals. All animals with ME biofilms had biofilms in the nasopharynx. The controls did not demonstrate biofilm formation. CONCLUSIONS: The study parallels the natural pathogenesis of AOM in humans. The demonstration of mucosal biofilms in both the nasopharynx (58%) and the ME (47%) of animals with ME inflammation and/or infection lends further support to the importance of mucosal biofilms in the pathogenesis of AOM.