Safety of Adult Ambulatory Direct Laryngoscopy: Revisits and Complications.

IMPORTANCE: Direct laryngoscopy, once an inpatient procedure, is now commonly performed in the outpatient setting. To ensure that safety follows the adoption of novel techniques and practice patterns, it is important to analyze the complication and revisit rates of these ambulatory surgery practices. OBJECTIVE: To determine revisit rates and complications after ambulatory adult direct laryngoscopy procedures. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cross-sectional analysis of cases of adult patients who had undergone a direct laryngoscopic procedure extracted from multistate ambulatory surgery and hospital databases (State Ambulatory Surgery Databases for New York, Florida, Iowa, and California for 2010 and 2011). The analysis was performed on December 1, 2014. Index cases were linked to the corresponding State Emergency Department Databases and the State Inpatient Databases for visit encounters occurring within a 7-day postoperative window. All index cases were ambulatory surgery, without overnight stay or 23-hour observation. PARTICIPANTS: Adult patients who had undergone a direct laryngoscopy procedure. EXPOSURES: Direct laryngoscopy performed in an ambulatory setting. Patients who underwent flexible laryngoscopy, lesion destruction, laryngectomy, cordectomy, or a secondary nonlaryngoscopy procedure were specifically excluded. MAIN OUTCOMES AND MEASURES: Data regarding sex, age, revisit occurrence with associated complications, and mortality were analyzed. RESULTS: A total of 7743 cases of ambulatory laryngoscopy were identified (mean age, 60.4 years; 61% were male). The 7-day revisit rate was 3.0% (232 revisits). Serious airway complications occurred in 0.27% of cases (n = 21) and accounted for 9.1% of revisits. The rates of other major complications and minor complications were 0.15% (n = 12) and 0.75% (n = 58), respectively. There were no cases of anoxic brain injury. Two deaths occurred at the time of the revisit (7-day mortality rate, 0.03%; 95% CI, 0.01%-0.09%). CONCLUSIONS AND RELEVANCE: Adult ambulatory direct laryngoscopy has a favorable safety profile. Serious airway complications occur in fewer than 3 patients per 1000 cases. The risk of death following outpatient laryngoscopy is extremely low. Outpatient laryngoscopy is not universally suited for all patients, and careful preoperative selection and counseling are imperative.

Outcome of permanent tracheostomy for treatment of upper airway obstruction in cats: 21 cases (1990-2007).

OBJECTIVE: To determine clinical outcome of permanent tracheostomy in cats with upper airway obstruction. DESIGN: Retrospective case series. ANIMALS: 21 cats. PROCEDURES: Medical records were reviewed for information on history, signalment, clinical signs, results of preoperative clinicopathologic testing, cause of upper airway obstruction, surgical procedure, postoperative complications, and outcome. RESULTS: Causes of upper airway obstruction included neoplasia (squamous cell carcinoma [n = 6] or malignant lymphoma [2]), inflammatory laryngeal disease (5), laryngeal paralysis (4), trauma (3), and a laryngeal mass of unknown cause (1). Fourteen cats had dyspnea in the immediate postoperative period; dyspnea most often resulted from mucous plugs at the stoma or elsewhere in the respiratory tract. Eleven cats died, including 6 cats that died while hospitalized after surgery and 5 cats that died after discharge; 7 cats were euthanatized, most often because of progression of neoplasia; and 2 were still alive at the time of the study. The remaining cat was lost to follow-up after discharge from the hospital. Overall, median survival time for the 20 cats for which information was available was 20.5 days (range, 1 day to 5 years). Cats that underwent permanent tracheostomy because of inflammatory laryngeal disease were 6.61 times as likely to die as cats that underwent permanent tracheostomy for any other reason. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that permanent tracheostomy was an uncommon procedure in cats with upper airway obstruction that was associated with high complication and mortality rates.

Laryngeal, laryngotracheal, and tracheal masses in cats: 27 cases (1998-2003).

Medical records of 27 cats with masses of the larynx and trachea were examined. Six cats had inflammatory masses, and 21 cats had neoplastic lesions. A definitive diagnosis was reached in 22 cats with a single biopsy. The median age of the cats was 12.0 years (range 6 to 20 years). Dyspnea was the most common clinical sign. Accurate diagnoses were best obtained through direct laryngeal or tracheal examination combined with histological examination of tissue biopsies. Kaplan-Meier survival data for all inflammatory and neoplastic lesions showed a median survival of 5 days, with 7.4% of cats alive at 1 year.

Congenital high airway obstruction syndrome: natural history and management.

BACKGROUND: Congenital high airway obstruction syndrome (CHAOS) is a life-threatening condition with a poorly understood natural history. METHODS: A retrospective review of five patients with CHAOS between 1997 and 2002 was performed. RESULTS: All fetuses had large echogenic lungs, dilated airways, inverted diaphragms, and massive ascites. One fetus with a laryngeal cyst was terminated at 22 weeks. A twin fetus with findings suggestive of a tracheal web had progressive hydrops, which led to fetal demise. The remaining 3 patients delivered via the ex utero intrapartum treatment (EXIT) procedure survived. The first patient tolerated progressive hydrops for 12 weeks in utero. He had tracheal atresia but underwent laryngotracheoplasty successfully. He is the first long-term CHAOS survivor and is speaking at 5 years of age. The 2 patients with relatively stable lung volumes prenatally have laryngeal atresia with a pinpoint posterior laryngeal fistula. Their postnatal clinical courses were much more benign than the first survivor. CONCLUSIONS: The prenatal natural history and postnatal course of CHAOS depends on whether the airway obstruction is complete. The EXIT procedure offers the potential for salvage of this otherwise lethal condition. Hydrops may be well tolerated prenatally for weeks with potential resolution if airway fistulization is present.

Primary carcinoma of the subglottic larynx.

Primary cancer of the subglottic region is very rare and delay in diagnosis often leads to a poor prognosis. We retrospectively reviewed 49 patients with primary cancer of the subglottic larynx observed from 1969 to 1993 in the ORL Clinic of the University of Florence. This number constitutes 1.6% of all laryngeal cancers observed during this period. Four (8.2%) patients were stage T1, 13 (26.5%) T2, 27 (55.1%) T3, and 5 (10.2%) T4. Forty-one patients were eligible for assessing the disease-free five-year survival rate, 17 of whom were treated with surgery alone, 6 with radiotherapy alone and 18 with combination therapy (surgery for the primary tumor and postoperative radiotherapy for cervical nodes). The five-year survival rate for the three treatment types was 47%, 0% and 83.3%, respectively. The overall survival rate was 56.1%. Combination therapy produced a significantly higher (P = 0.001) disease-free survival than surgery alone or radiotherapy alone.

[Inhalation burns: apropos of 198 cases. Incidence of laryngotracheal involvement]. / Les brûlures par inhalation: à propos de 198 cas incidence de l'atteinte laryngo-trachéale.

Inhalation burns and laryngotracheal involvement were studied in a retrospective series of 635 patients hospitalized for skin burns at the Center for Burn Treatment from January 1993 to January 1997. Inhalation burns were observed in 31.1% of the cases. Exclusive laryngeal involvement occurred in 19.6% of the inhalation burns. Both tracheobronchial and laryngeal burns were observed in 27.2%. Patients with inhalation burns also had facial burns (90.9%) and extensive (> 50%) or severe (UBS > 200) skin burns in 39.8% and 29.7% of the cases respectively. Mortality of skin burns was increased six-fold to 19.1% in patients who also had inhalation burns. Intubation was used alone in 60.1% and was followed by tracheotomy in 27.2%. The decision for tracheotomy was essentially based on the probable duration of ventilatory assistance. Tracheotomy was required in case of severe inhalation burns and the predictable duration of intubation was over 8 days. Laryngotracheal stenosis occurring after inhalation burns is complex and extensive, with great variability over time. Laryngotracheal calibration is indicated as first intention therapy.

A case with laryngeal atresia and partial trisomy 9 due to maternal 9;16 translocation.

A newborn with a partial trisomy 9 and a partial trisomy 16q is described. The child died shortly after birth because of laryngeal atresia. The chromosome anomaly was the result of a 3:1 segregation of a maternal translocation t(9;16) (q22;q24). The pertinent literature on both partial trisomy 9 and partial trisomy 16q is reviewed. All cases with partial trisomy 9 were either de novo or the result of a maternal translocation, possibly indicating the influence of imprinting on this chromosomal abnormality. The relationship between the laryngeal atresia and other features in the patient and the chromosome anomalies remains uncertain.