Closed- or open-glottis pushing for vaginal delivery: a planned secondary analysis of the TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery study.

BACKGROUND: The effect on obstetrical outcomes of closed- or open-glottis pushing is uncertain among both nulliparous and parous women. OBJECTIVE: This study aimed to assess the association between open- or closed-glottis pushing and mode of delivery after an attempted singleton vaginal birth at or near term. STUDY DESIGN: This was an ancillary planned cohort study of the TRAAP (TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery) randomized controlled trial, conducted in 15 French maternity units from 2015 to 2016 that enrolled women with an attempted singleton vaginal delivery after 35 weeks' gestation. After randomization, characteristics of labor and delivery were prospectively collected, with special attention to active second-stage pushing and a specific planned questionnaire completed immediately after birth by the attending care provider. The exposure was the mode of pushing, classified into 2 groups: closed- or open-glottis. The main endpoint was operative vaginal delivery. Secondary endpoints were items of maternal morbidity, including severe perineal laceration, episiotomy, postpartum hemorrhage, duration of the second stage of labor, and a composite severe neonatal morbidity outcome. We also assessed immediate maternal satisfaction, experience of delivery, and psychological status 2 months after delivery. The associations between mode of pushing and outcome were analyzed by multivariate logistic regression to control for confounding bias, with multilevel mixed-effects analysis, and a random intercept for center. RESULTS: Among 3041 women included in our main analysis, 2463 (81.0%) used closed-glottis pushing and 578 (19.0%) open-glottis pushing; their respective operative vaginal delivery rates were 19.1% (n=471; 95% confidence interval, 17.6-20.7) and 12.5% (n=72; 95% confidence interval, 9.9-15.4; P<.001). In an analysis stratified according to parity and after controlling for available confounders, the rate of operative vaginal delivery did not differ between the groups among nulliparous women: 28.7% (n=399) for the closed-glottis and 27.5% (n=64) for the open-glottis group (adjusted odds ratio, 0.93; 95% confidence interval, 0.65-1.33; P=.7). The operative vaginal delivery rate was significantly lower for women using open- compared with closed-glottis pushing in the parous population: 2.3% (n=8) for the open- and 6.7% (n=72) for the closed-glottis groups (adjusted odds ratio, 0.43; 95% confidence interval, 0.19-0.90; P=.03). Other maternal and neonatal outcomes did not differ between the 2 modes of pushing among either the nulliparous or parous groups. CONCLUSION: Among nulliparous women with singleton pregnancies at term, the risk of operative vaginal birth did not differ according to mode of pushing. These results will inform shared decision-making about the mode of pushing during the second stage of labor.

Cancer of the Larynx-20-Year Comparative Survival and Mortality Analysis by Age, Sex, Race, Stage, Grade, Cohort Entry Time-Period, Disease Duration and ICD-O-3 Topographic Primary Sites-Codes C32.0-9: A Systematic Review of 43,103 Cases for Diagnosis Years 1975-2017: (NCI SEER*Stat 8.3.9).

BACKGROUND: .-Laryngeal malignancy, "voice box" cancer, is uncommon with 12,620 estimated new cases and 3770 deaths in the United States in 2021,1 and represents only 6.2% of all respiratory system malignancies. The most significant risk factors are alcohol and tobacco consumption. Almost all cases (98%) of laryngeal cancer arise in the squamous epithelium, and in this analysis more than 75% are of well-or-moderately differentiated histopathology (Grades I&II). Local stage cancer (SEER Historic Staging) was more common than regional and distant stages combined (55.3% vs 44.7%). Tumors may arise above, below or at the level of the vocal folds and are described as supraglottic (encompassing the epiglottis, false vocal cords, ventricles, aryepiglottic fold and arytenoids), the glottis (encompassing the true vocal cords and the anterior and posterior commissures), and the subglottic region. In the National Cancer Institute's Surveillance, Epidemiology, End-Results (NCI-SEER) Data Research, 9 Registries, Nov 2019 Sub (1975-2017),2 laryngeal cancer occurred more commonly in men than in women, 80.7% vs 19.3%, respectively with a 4.2 to 1 ratio. Additionally, there are racial disparities with African Americans presenting at a younger age and having a higher incidence and mortality than Caucasians. In the 1975-2017 period, overall median patient age was 64.4 years with White Americans-64.8 years and Black Americans-61.5 years. Unfortunately, the 5-year relative survival rate has declined 4%, and excess death rate has risen 13% since 1975 with overall incidence declining.As a consequence, observed median survival is approximately 6.5-years for the total study-period pinpointing the need for further specialty research. This study follows the World Health Organization International Classification of Diseases for Oncology-3rd Edition (ICD-O-3)3 topographical identification, coding, labeling and listing of 43,103 patient-cases accessible for analysis in the United States National Cancer Institute's Surveillance, Epidemiology and End Results program (NCI SEER Research Data, 9 Registries, 1975-2017). These are located in 6 primary anatomical sites: C32.0-Glottis, C32.1-Supraglottis, C32.2-Subglottis, C32.3-Laryngeal cartilage, C32.8-Overlapping lesion of larynx, C32.9-Larynx, NOS. OBJECTIVES: .-To update short- and long-term mortality and survival indices, and identify changing risk patterns for laryngeal cancer patients in a retrospective US population-based analysis, 1975-2017, using prognostic data stratified by ICD-O-3 Primary Site, age, sex, race, stage, histologic grade, two cohort entry time-periods (1975-1996 to 1997-2017), and disease duration to 20-years. METHODS: .-SEER*Stat v8.3.94 software (built March 12, 2021) was used to access SEER Research Data, 9 Registries, Nov. 2019 submission (1975-2017). For displaying risk, general methods and standard double decrement life table methodologies for converting and displaying ICD-O-3 coded laryngeal cancer primary site annual data to aggregate average annual mortality and survival units in durational-intervals of 0-1, 1-2, 2-5, 0-5, 5-10, 10-15, and 15-20 years were employed. The reader is referred to the "Registrar Staging Assistant (SEER*RSA)" for local-regional-distant Extent of Disease (EOD) sources used in the development of staging descriptions, and Summary Stage 2018 Coding Manual v2.0 released September 1, 2020. Cancer staging & grading procedural explanations, statistical significance and 95% confidence levels5 are described in previous Journal of Insurance Medicine articles6,7 and other publications.8,9 Poisson confidence intervals at the 95% level based on the number of observed deaths are used in this study but not displayed here to conserve space on the mortality tables. Excluded were all death certificate only and those alive with no survival time. RESULTS: .-Total SEER annual age-adjusted incidence rates from 1980 to 2017 have diminished from 5.25 patient-cases/100,000/year to 2.59/100,000 per year, and in the same period annual age-adjusted US death rates declined from 1.61 deaths/100.000/year to 0.91 deaths/100,000/year (Ref. 10, CSR Tables 12.5-6), However, in the 0-5-year disease durational interval for all staged cases in both cohort time-periods (Table 5), excess death rates (EDR) rose from 80 per 1000 persons per year in the 1975-96 cohort, to 89 per 1000 persons per year in the 1997-17 cohort, (a 10% rise in excess mortality in 42 years). Further, in the 5-10-year disease durational interval, EDR rose from 39 per 1000 persons per year to 45 per 1000 persons per year with corresponding cohort declines in cumulative survival ratios (SR), and overall declines in median observed and relative survival times in the later cohort (not shown). The epidemiologic burden of malignancy is >4-fold higher in males and increases in parallel with aging, peaking after 65 years. The most significant risk factors for laryngeal cancer are tobacco and alcohol consumption. CONCLUSION: .-Although annual incidence and mortality rates from 1980 to 2017 have diminished, there is no concomitant improvement in larynx cancer survival (SR) and mortality (EDR) indices, with rising mortality and diminishing survival in all staged cases at 5-years disease duration between the 1975-96 and 1997-2017 analytic cohorts. Larynx cancer remains a burdensome clinical, social, and public health challenge.

Does the type of pushing at delivery influence pelvic floor function at 2 months postpartum? A pragmatic randomized trial-The EOLE study.

INTRODUCTION: Maternal pushing techniques during the second stage of labor may affect women's pelvic floor function. Our main objective was to assess the impact of the type of pushing used at delivery on the mother's medium-term pelvic floor function. MATERIAL AND METHODS: This is a secondary analysis of a randomized clinical trial (clinicaltrials.gov: NCT02474745) that took place in four French hospitals from 2015 through 2017 (n = 250). Women in labor with a singleton fetus in cephalic presentation at term who had undergone standardized training in both of these types of pushing were randomized after cervical dilation ≥7 cm. The exclusion criteria were a previous cesarean, a cesarean delivery in this pregnancy or a fetal heart rate anomaly. In the intervention group, open-glottis (OG) pushing was defined as a prolonged exhalation contracting the abdominal muscles to help move the fetus down the birth canal. Closed-glottis (CG) pushing was defined as Valsalva pushing. The principal outcome was the stage of pelvic organ prolapse (POP) assessed by the Pelvic Organ Prolapse-Quantification 2 months after delivery. A secondary outcome was incidence of urinary incontinence (UI). The results of our multivariable, modified intention-to-treat analysis are reported as crude relative risks (RRs) with their 95% confidence intervals. RESULTS: Our analysis included 207 women. Mode of birth was similar in both groups. The two groups did not differ for stage II POP: 10 of 104 (9.4%) in the OG group compared with 7 of 98 (7.1%) in the CG group, for a RR 1.32, 95% confidence interval [CI] 0.52-3.33, and an adjusted RR of 1.22, 95% CI 0.42-3.6. Similarly, the incidence of UI did not differ: 26.7% in the OG group and 28.6% in the CG group (aRR 0.81, 95% CI 0.42-1.53). Subgroup analysis suggests that for secundiparous and multiparous women, OG pushing could have a protective effect on the occurrence of UI (RR 0.33, 95% CI 0.13-0.80). CONCLUSIONS: The type of directed pushing used at delivery did not impact the occurrence of pelvic organ prolapse 2 months after delivery. OG pushing may have a protective effect against UI among secundiparous and multiparous women.

Direct versus indirect epiglottis elevation in cervical spine movement during videolaryngoscopic intubation under manual in-line stabilization: a randomized controlled trial.

BACKGROUND: During videolaryngoscopic intubation, direct epiglottis elevation provides a higher percentage of glottic opening score than indirect epiglottis elevation. In this randomized controlled trial, we compared cervical spine movement during videolaryngoscopic intubation under manual in-line stabilization between the two glottis exposure methods. METHODS: Videolaryngoscopic intubation under manual in-line stabilization was performed using C-MAC® D-blade: direct (n = 51) and indirect (n = 51) epiglottis elevation groups. The percentage of glottic opening score was set equally at 50% during videolaryngoscopic intubation in both groups. The primary outcome measure was cervical spine movement during videolaryngoscopic intubation at the occiput-C1, C1-C2, and C2-C5. The secondary outcome measures included intubation performance (intubation success rate and intubation time). RESULTS: Cervical spine movement during videolaryngoscopic intubation was significantly smaller at the occiput-C1 in the direct epiglottis elevation group than in the indirect epiglottis elevation group (mean [standard deviation] 3.9 [4.0] vs. 5.8 [3.4] °, P = 0.011), whereas it was not significantly different at the C1-C2 and C2-C5 between the two groups. All intubations were successful on the first attempt, achieving a percentage of glottic opening score of 50% in both groups. Intubation time was longer in the direct epiglottis elevation group (median [interquartile range] 29.0 [24.0-35.0] vs. 22.0 [18.0-27.0] s, P < 0.001). CONCLUSIONS: When performing videolaryngoscopic intubation under manual in-line stabilization, direct epiglottis elevation can be more beneficial than indirect epiglottis elevation in reducing cervical spine movement during videolaryngoscopic intubation at the occiput-C1. TRIAL REGISTRATION: Clinical Research Information Service (number: KCT0006239, date: 10/06/2021).

Establishment of prognostic nomogram for T1N0M0 glottic squamous cell carcinoma: an SEER database analysis.

OBJECTIVES: The study aimed to construct prognostic models for OS and CSS in patients with T1N0M0 glottic SCC. In addition, we used PSM to re-assess the effect of surgery alone and radiation alone. METHODS: The Surveillance, Epidemiology, and End Results database was searched for patients with confirmed T1N0M0 glottic SCC. Patients with complete data were randomly divided into the training and the validation cohort (7:3), Cox-regression analysis was performed to identified significant predictors of OS and CSS. PSM was used to mimic randomized controlled the trials. Kaplan-Meier survival method and log-rank tests were utilized for survival analysis. RESULTS: A total 1827 patients met the inclusion criteria. Survival analysis indicated that the patients who underwent the primary site surgery had a better OS (P = 0.002) and CSS (P = 0.008), compared with non-surgery patients. Cox-regression analysis proved that age, marital status, T1 stages, surgery, radiation, sequential treatments, and chemotherapy had significant effects on OS. While age, marital status, histologic grade, surgery, radiation, sequential treatments, and chemotherapy were substantially associated with CSS. Patients who received primary site surgery had a better OS and CSS, compared with non-surgical patients. Patients receiving radiation had a better CSS than non-radiation patients. However, patients who received sequential treatments or chemotherapy had a worse OS and CSS, compared with controlled groups. Predictive nomogram models were established to predict patients' prognosis with good consistency between the actual observation and the nomogram prediction. Before PSM, patients who underwent surgery alone had a better OS and CSS than those who received radiation alone. After PSM, patients receiving surgery still had a better OS than those receiving radiation. However, there were no statistically significant differences in CSS. CONCLUSIONS: Nomogram models were developed to predict OS and CSS in patients with T1N0M0 glottic SCC. Primary site surgery could definitely increase OS and CSS, while radiation could significantly increase CSS. Using PSM, surgery alone could significantly enhance OS, as compared to radiation alone. Chemotherapy should not be recommended for early glottic carcinoma.

Prognostic factors and a dynamic model on cancer-specific survival for T1a N0 M0 glottic cancer: A population-based analysis and clinical validation.

OBJECTIVES: The survival rate varies tremendously in T1a N0 M0 glottic cancer patients, which may be associated with the difference on patients' characters, such as age, treatment, and marital status. The objective of this study is to identify the vital factors and construct a dynamic prognostic model for predicting the cancer-specific survival (CSS) of patients with T1a N0 M0 glottic cancer. DESIGN, SETTING, AND PARTICIPANTS: The data of T1a N0 M0 glottic cancer patients were extracted retrospectively from the SEER database between 2004 and 2015, which were randomly divided into the training dataset (70%) and the validation dataset (30%). The training cohort was used to identify independent prognostic factors and build the prognostic nomogram. While the validation cohort was used to validate the applicability of the newly constructed model. MAIN OUTCOME MEASURES: The model was evaluated with the discrimination, the calibration, and the clinical benefit. The external data collecting from a medical center were used to validate the performance of the prognostic model. RESULTS: Totally, 3286 eligible patients in the data of the SEER database and 139 eligible patients in our external clinical cohort were finally identified. 5 independent prognostic factors (age, marital status, Grade, primary site surgery, and chemotherapy) were identified and applied to develop the dynamic prognostic tool. C-indexes, receiver operating characteristic curves, calibration curves, and decision curve analyses proved that the prognostic nomogram showed excellent predictive accuracy, ability, and prognostic value. Using internal and external cohorts, the validation of the model also proved its reliability. CONCLUSION: Prognostic factors for T1a N0 M0 glottic cancer were identified. The novel web-based prognostic prediction tool may be beneficial in clinical decision-making and has value in risk stratification, personalized treatment, and clinical trial design.

Acoustic correlates of Burmese voiced and voiceless sonorants.

Voiceless sonorant consonants are typologically rare segments, appearing in only a few of the world's languages, including Burmese. In this study, Burmese sonorants and their adjacent vowels are investigated in an attempt to (1) determine what acoustic correlates distinguish voiced and voiceless sonorants and (2) determine whether there are multiple realizations of voiceless sonorants and, if so, establish what acoustic correlates distinguish them. In order to pursue these questions, a production study was carried out and target words were analyzed, demonstrating that Burmese voiceless sonorants have a spread glottis period resulting in turbulent airflow 78 % of the time. Findings from linear mixed-effects models showed that voiced and voiceless sonorants are significantly different in terms of duration of the sonorant, F0 of the sonorant, and strength of excitation measured over the following vowel. A linear discriminant analysis was able to predict voicing category with 86.7 % accuracy, with the duration of the spread glottis period being the best indicator of voicelessness, followed by the cues that were significant in the linear mixed-effects models. In cases when the spread glottis period is absent from voiceless sonorants, the sonorant only has correlates that are associated with voicelessness (such as F0 and strength of excitation) but not correlates that are associated with the spread glottis gesture (such as duration and harmonics-to-noise ratio). These results have implications both for our understanding of the acoustics of Burmese sonorants and for our understanding of voiceless sonorants more generally.

Acquisition of the feature [+spread glottis] in Icelandic.

The feature [+spread glottis] ([+s.g.]) denotes that a speech sound is produced with a wide glottal aperture with audible voiceless airflow. Icelandic is unusual in the degree to which [+spread glottis] is involved in the phonology: in /h/, pre-aspirated and post-aspirated stops, voiceless fricatives and voiceless sonorants. The ubiquitousness of the feature could potentially affect the rate and process of its acquisition. This paper investigates the development of [+s.g.] in Icelandic, both in general and in a range of contexts, in a cross-sectional study of 433 typically developing Icelandic-speaking children aged two to seven years. As a feature, [+s.g.] is acquired early in Icelandic, although specific sound classes lag behind due to other output constraints. Children reach mastery of [+s.g.] by age three except in word-initial post-aspirated stops and voiceless nasals. Findings are interpreted in light of the literature on the feature and its development.

Therapeutic effects of low-temperature plasma radiofrequency ablation and partial laryngectomy for glottis cancer: A comparative study.

Objective: To compare the therapeutic effects of low-temperature plasma radiofrequency ablation and partial laryngectomy in the treatment of early glottis carcinoma. Methods: Clinical data of 80 patients with early glottis carcinoma treated in our hospital from June 2019 to January 2021 were analyzed. Patients were retrospectively divided into two groups based on the type of intervention. Forty patients received partial laryngectomy (Control group) and 40 patients received low-temperature plasma radiofrequency ablation (Observation group). Surgical indexes, length of hospital stay, postoperative complications, and visual analog scale (VAS) score of postoperative pain of patients in the two groups were compared. Postoperative stress response indexes, clinical efficacy, and postoperative recovery in two groups were compared and analyzed. Result: The operation time, hospital stay, intraoperative bleeding, and the incidence of postoperative complications in the observation group were significantly lower than those in the Control group (P<0.05). The postoperative pain VAS scores, Levels of malondialdehyde (MDA) and glutathione (GSH) in the observation group were significantly lower than those in the control group (P<0.05), while the level of nitro tyrosine (3-NT) and superoxide dismutase (SOD) were significantly higher than that in the control group (P<0.05). After a one-year follow-up, the excellent and good rate of pronunciation function in the observation group (95%) was significantly higher than control group (75%) (P<0.05). Conclusions: Low-temperature plasma radiofrequency ablation in the treatment of early glottis carcinoma is associated with less trauma, short operation time, less bleeding, short hospital stay and low postoperative stress reaction rate. Compared with partial laryngectomy, it has higher safety and better postoperative vocal cord function recovery.

Comparative evaluation of C-MAC and McGrath MAC videolaryngoscopes with Macintosh direct laryngoscope for endotracheal intubation in adult patients undergoing elective surgeries.

Background and Aims: Videolaryngoscopes have an undisputed role in difficult airway management, but their role in routine intubation scenarios remains underappreciated. McGrath MAC is a lightweight laryngoscope with a disposable blade. It remains to be proven if it performs as efficiently as the reusable videolaryngoscopes like C-MAC and whether it has an advantage over standard Macintosh laryngoscope in predicted normal airways. Material and Methods: We recruited 180 adult patients and randomly divided them into three groups for intubation with either Macintosh laryngoscope (Group-A), C-MAC (Group-B), and McGrath (Group-C). The primary objective was to compare the first attempt success rate. Secondary objectives included Cormack-Lehane (CL) grades, laryngoscopy time, intubation time, ease of intubation, need for optimization manoeuver, and the number of passes to place the endotracheal tube. Results: The two videolaryngoscopes provided a superior first attempt success rate as compared to Macintosh laryngoscope (P = 0.027). The CL grade-I was 100% in group B, 41.7% in group-A and 90% in group-C (B vs C; P = 0.037). Laryngoscopy time was 9.9 ± 2.5 s, 12.6 ± 0.8 s, and 13.1 ± 0.8 s for groups A, B, and C, respectively (B vs C; P = 0.001). Intubation time was 24.4 ± 12 s, 28.3 ± 1.9 s, and 37.3 ± 5.8 s for groups A, B, and C, respectively (P < 0.0001). The number of tube passes was highest in group C. Conclusion: Videolaryngoscopes provided a superior glottic view and resulted in a superior first attempt success rate as compared to Macintosh laryngoscope. When comparing the two videolaryngoscopes, C-MAC resulted in better intubation characteristics (shorter intubation time, better glottic views, and higher first-attempt success rates) and should be preferred over McGrath for intubation in adult patients with normal airways.

Oncological Outcomes of Transoral Laryngeal Microsurgery with Fiber-Optic Diode Laser for Early Glottic Cancer: A Single-Center Experience.

Backgroud/Objectives: Transoral laser laryngeal microsurgery (LTLM) has been widely used in the treatment of early-stage glottic laryngeal squamous cell carcinoma (LSCC) for the past few decades. Although T stage, tumor grade, anterior commissure involvement, type of cordectomy, positive surgical margin, and postoperative additional therapies were accused as the prognostic factors for recurrence, there is still controversy about these data in the literature. The purpose of this study was to evaluate the oncological results of our patients with early glottic LSCC treated with LTLM as a single-modality therapy in a single-center study. METHODS: Patients with early-stage (Tis-1-2/N0) glottic LSCC who underwent LTLM as a primary treatment from 2011 to 2019 were retrospectively reviewed. The clinicopathological factors and oncologic outcomes were analyzed. RESULTS: One hundred and sixty-one patients were enrolled in this study. The 5-year overall (OS), disease-specific (DSS), disease-free (DFS), and laryngectomy-free survival rates were 84.5%, 97.9%, 79.2%, and 93.5%, respectively. The most common stage, histopathological type, and type of endoscopic cordectomy were T1 stage, well-differentiated cancer, and type 2 cordectomy, respectively. A positive surgical margin was defined in 20 (12.4%) patients. There was a significant relationship between histopathological grade and positive surgical margins (p = 0.038). OS and DSS rates of "wait and see" modality were lower, while DFS of radiotherapy was lower than that of other treatment modalities in patients with positive surgical margins, but the differences were not statistically significant. Nineteen (11.8%) patients had a recurrence. DSS was statistically significantly lower in patients with recurrence (p < 0.001). CONCLUSION: The results of our study showed that anterior commissure involvement, surgical margin positivity, and higher T stage statistically did not reduce survival rates in early-stage LSCC patients treated with LTLM. As the histopathological grade of the tumor worsens, the risk of surgical margin positivity increases. RT may have a negative effect on recurrence and organ preservation in the additional treatment of patient with positive surgical margins.

Surgical management of laryngeal bilateral abductor palsy: comparative study between carbon dioxide and diode lasers.

This study aims to compare the results of both CO2 laser and diode laser combined arytenoidectomy with posterior cordectomy in managing patients with bilateral vocal fold paralysis. A prospective study involved 80 bilateral vocal cord immobility patients in adduction. They are divided into two groups according to the laser used, whether CO2 (with a wavelength of 10.6 µm) or diode (with a wavelength of 980 nm). We used mMRC (Modified Medical Research Council) dyspnea scale to assess dyspnea in our patients, while the voice was evaluated by both maximum phonation time and the voice handicap index. Quantitative variables were described using means and standard deviations, while categorical variables were described using frequencies and were compared using the chi-square test, Fisher exact test, and Monte Carlo test. There was a statistically non-significant difference between the studied groups regarding mMRC dyspnea scale and Voice Handicap Index preoperatively and postoperatively. There is a statistically significant difference between the two groups regarding maximum phonation time postoperatively (significantly higher in the CO2 laser group) (p < 0.001). The CO2 laser and diode laser could be used safely for the management of bilateral vocal cord paralysis. The CO2 laser maintains better voice parameters and less postoperative pain, while the diode laser gives less operative time, lower cost, and simplicity of use.

Novel predictive tools and therapeutic strategies for patients with initially diagnosed glottic cancer in the United States.

OBJECTIVE: The objective of this study is to identify valuable prognostic factors, build clinical prediction nomograms, and recommend the optimal therapeutic strategy for patients with initially diagnosed glottic cancer. METHODS: Patients were extracted from the SEER database. Cox regression analyses, survival analyses, an internal validation, the propensity score analysis, and the competing risk analysis were performed. RESULTS: Nine overlapped factors were considered as valuable prognostic factors. Furthermore, nomograms were established for clinical prediction models to assess the 1-, 3-, and 5-year overall survival (OS) and cancer-specific survival (CSS). C-indexes, receiver operating characteristic curves, calibration curves, and decision curve analyses proved that nomograms showed better predictive accuracy, ability, and prognostic value compared to the American Joint Committee on Cancer stage. For patients in stage I, primary site surgery alone would acquire best OS and CSS. For patients in stage II, primary site surgery and/or radiation would gain better OS and CSS. For patients in stage III, radiation plus chemotherapy or primary site surgery (alone or plus radiation) would acquire better OS and CSS. Moreover, for patients in stage IV, primary site surgery plus radiation would gain better OS and CSS. CONCLUSIONS: Nomograms could be useful for patients' counseling and guide therapeutic decision-making. Primary site surgery alone may likely be the optimal therapy for stage I glottic cancer, and primary site surgery and/or radiation may be the recommended therapy for stage II glottic cancer. The combination treatment would be the preferred choice for advanced-stage (stage III & IV) glottic cancer, and the role of chemotherapy needs to be further explored.

A comparison of the survival between laser surgery and radiation in T1aN0M0 glottic cancer: a population-based analysis and meta-analysis.

OBJECTIVE: The objective of this study is to compare the overall survival (OS) and the cancer-specific survival (CSS) for patients of T1aN0M0 glottic cancer who underwent laser surgery (LS) or radiation (RT). METHODS: The data of the population-based analysis were extracted from the SEER database. The studies of the meta-analysis were identified through PubMed, EMBASE, and Cochrane databases. Cox regression analyses, the propensity score analysis (PSM), survival analyses, and the meta-analysis were performed. RESULTS: In the population-based analysis, 2101 eligible patients were included. Multivariable Cox analyses indicated that patients accepting LS alone would obtain better OS (HR 0.77, 95% CI 0.61-0.98, p = 0.03) and CSS (HR 0.26, 95% CI 0.12-0.59, p = 0.001) than those of whom they accepted RT alone. Survival analyses before PSM and after PSM also indicated that patients who underwent LS alone would have better OS and CSS. In the meta-analysis, nine eligible studies were included. Results of the pooled effect showed that significant differences existed between LS and RT groups on OS (OR: 1.84, 95% CI 1.36-2.50, p < 0.001) and CSS (OR 3.84, 95% CI 1.17-12.52, p = 0.026), both distinctly favoring LS. CONCLUSIONS: Compared with RT, LS may acquire better survivals for patients with T1aN0M0 glottic cancer. Simultaneously, more multi-center randomized controlled trials would be warranted to prove the conclusion.

AI-Based Detection of Aspiration for Video-Endoscopy with Visual Aids in Meaningful Frames to Interpret the Model Outcome.

Disorders of swallowing often lead to pneumonia when material enters the airways (aspiration). Flexible Endoscopic Evaluation of Swallowing (FEES) plays a key role in the diagnostics of aspiration but is prone to human errors. An AI-based tool could facilitate this process. Recent non-endoscopic/non-radiologic attempts to detect aspiration using machine-learning approaches have led to unsatisfying accuracy and show black-box characteristics. Hence, for clinical users it is difficult to trust in these model decisions. Our aim is to introduce an explainable artificial intelligence (XAI) approach to detect aspiration in FEES. Our approach is to teach the AI about the relevant anatomical structures, such as the vocal cords and the glottis, based on 92 annotated FEES videos. Simultaneously, it is trained to detect boluses that pass the glottis and become aspirated. During testing, the AI successfully recognized the glottis and the vocal cords but could not yet achieve satisfying aspiration detection quality. While detection performance must be optimized, our architecture results in a final model that explains its assessment by locating meaningful frames with relevant aspiration events and by highlighting suspected boluses. In contrast to comparable AI tools, our framework is verifiable and interpretable and, therefore, accountable for clinical users.

Comparative efficacy of C-MAC® Miller videolaryngoscope versus McGrath® MAC size "1" videolaryngoscope in neonates and infants undergoing surgical procedures under general anesthesia: A prospective randomized controlled trial.

BACKGROUND: Various anatomical and physiological factors make intubation in infants challenging. C-MAC videolaryngoscope shows better results as compared to the conventional direct laryngoscopy for intubation in infants. McGrath MAC size-1 with a disposable Macintosh type blade has recently been introduced for use in infants and has not been formally evaluated in this population. AIMS: This study aims to evaluate the intubation characteristics of C-MAC Miller and McGrath MAC in neonates and infants with the primary objective to compare the time with the two devices. METHODS: After informed consent from the parents, 140 neonates and infants scheduled for surgical procedures were randomized to undergo intubation with either C-MAC Miller or McGrath MAC after standard general anesthesia. The two devices were compared in terms of total intubation time, Percent of Glottic Opening score, Cormack Lehane grades, time to glottis view, intubation difficulty score, overall success rate, first attempt success rate, and complications. RESULTS: The median glottic view time (6 s [4-9] vs. 6 s [4-9]; p = .40) and intubation time (27 s [25.5-28] vs. 27 s [24.5-29.5]; p = .87) were similar. The mean difference (95% CI) in time to tracheal intubation and time to glottic view was 0.49 s [-3.1 to 2.1] and -1.7 s [-3.8 to 0.47], respectively. However, the Percent of Glottic Opening score, Cormack Lehane grades, and subjective intubation difficulty were significantly better with C-MAC. The first attempt success rates, overall success rates (100% vs. 97.5%), and intubation difficulty scores were comparable. There were two failed intubations with McGrath which were successfully intubated with C-MAC. CONCLUSION: The C-MAC Miller blade showed similar intubation timings, success rates, and intubation difficulty score as compared to McGrath MAC in neonates and infants, though the former provided superior glottic views. Both the videolaryngoscopes may be safely used in infants and neonates for routine intubation scenarios.

Quality of life after transoral CO2 laser posterior cordotomy with or without partial arytenoidectomy for bilateral adductor vocal cord paralysis.

OBJECTIVES: Bilateral adductor vocal cord paralysis (BAVCP) is a rare and challenging condition whose main consequence is reduction of airway patency at the glottic level, often causing respiratory distress, while vocal function tends to remain almost normal. We investigated the effect of transoral glottal widening on quality of life and decannulation rates in patients affected by BAVCP. METHODS: We retrospectively evaluated patients affected by BAVCP and treated by transoral CO2 posterior cordotomy with or without medial partial arytenoidectomy (PC ± MPA) at two referral centers. The primary outcome was change in quality of life, evaluated pre- and post-operatively by the ADVS, VHI-30, and EAT-10 questionnaires. Secondary outcomes were the need for retreatments and, for patients with tracheotomy, the time to decannulation. RESULTS: Thirty-three patients met selection criteria. The etiology was post-surgical in 27 cases (81.8%), idiopathic in 4 (12.1%), a trauma-related in 1 (6.0%), and to other causes in 1 (3.0%). In 22 cases (66.7%), PC was combined with MPA. A significant improvement in responses for the ADVS (p < .0001) and EAT-10 (p < .0001) was observed, whereas the VHI-30 score did not change significantly post-operatively. All nine patients with a tracheostomy were successfully decannulated within 18 months after the surgical procedure. CONCLUSIONS: For patients affected by BAVCP, PC ± MPA by transoral CO2 laser microsurgery is a safe, customizable and minimally invasive treatment that can guarantee an affordable balance between quality of life in terms of phonation and swallowing and acceptable airway patency.

Oncologic results and quality of life in patients with T3 glottic cancer after transoral laser microsurgery.

PURPOSE: CO2 transoral laser microsurgery (CO2 TOLMS) is an alternative approach to non-surgical organ preservation in selected T3 glottic squamous cell carcinoma (SCC). This study aimed to assess the oncologic results and quality of life (QOL) of patients with T3 glottic SCC after CO2 TOLMS. METHODS: Of the 44 patients who underwent CO2 TOLMS, 38 underwent QOL evaluations. QOL was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 and head and neck module, Voice Handicap Index-30, and M. D. Anderson Dysphagia Inventory at least 6 months postoperatively. RESULTS: The patients were predominantly male (98%), with a median age of 61 years. Cordectomy type included 1 type III, 4 type IV, 31 type V, and 8 type VI according to European Laryngological Society classification. Two patients (5%) had cervical lymph node metastasis and 21 patients (48%) underwent postoperative radiotherapy. With a mean follow-up of 65 months for all patients, 10 (23%) had tumor recurrence (9 local, 1 distant). After salvage surgery, four patients lived without disease, and the larynx was preserved in two. The 5-year local control and overall and disease-specific survival rates were 78%, 75%, and 84%, respectively. The overall laryngeal preservation rate was 82% (36/44). Most patients had satisfactory QOL. CONCLUSIONS: In selected T3 glottic SCC cases, CO2 TOLMS can achieve favorable oncologic results and a satisfactory QOL.

Prognostic risk factors for initially diagnosed T2N0M0 glottic cancer: competing risk analysis and propensity-score matched cohort analysis.

BACKGROUND: Prognostic risk factors of patients with initially diagnosed T2N0M0 glottic cancer remain unclear. This study was aimed to conduct a comprehensive analysis to identify valuable prognostic risk factors for initially diagnosed T2N0M0 glottic cancer. METHODS: Data of patients with initially diagnosed T2N0M0 glottic cancer were extracted from the Surveillance, Epidemiology, and End Results database. Survival analyses and Cox regression analyses were conducted to evaluate overall survival (OS) and cancer-specific survival (CSS). In consideration of competing events, the competing risk (CR) analysis was applied. Furthermore, propensity-score matching (PSM) was applied to mimic randomized-controlled trials and reduce selection bias. RESULTS: A total of 923 eligible patients met the inclusion criteria. Survival analyses showed that age, marital status, primary site surgery, and radiation were independent predictors of OS. Besides, age, marital status, primary site surgery, radiation, and chemotherapy were independent predictors of CSS. Cox regression analyses and the CR analysis were basically consistent with this result. In addition, an internal validation and PSM were performed to explore the role of chemotherapy. CONCLUSION: We conducted a comprehensive analysis to prove that age, marital status, primary site surgery, radiation, and chemotherapy may be valuable prognostic risk factors for initially diagnosed T2N0M0 glottic cancer. Primary site surgery and radiation should be recommended, whereas chemotherapy was likely not suitable so far. Furthermore, we constructed a CR nomogram to predict survival rates.

Management of bilateral abductor paralysis: posterior cordectomy with partial arytenoidectomy using diode laser.

PURPOSE: This study aims to assess the role of diode laser-assisted posterior cordectomy with partial arytenoidectomy in the management of bilateral vocal fold paralysis patients. METHODS: Posterior cordectomy with partial arytenoidectomy using diode laser was performed to thirty-nine patients with bilateral vocal fold paralysis. Voice was evaluated by maximal phonation time and Arabic version of the voice handicap index, while breathing difficulty was assessed by mMRC (Modified Medical Research Council) dyspnea scale. RESULTS: There is a statistically significant decrease in mMRC from 2.8 ± 0.645 preoperatively to 0.84 ± 0.554 postoperatively (p < 0.001). However, maximum phonation time is significantly decreased from 8.04 ± 0.978 preoperatively to 6.92 ± 0.997 postoperatively (p < 0.001); there is a statistically non-significant increase in vocal handicap index from 37.12 ± 6.26 preoperatively to 37.24 ± 6.22) postoperatively (p > 0.05). CONCLUSIONS: The diode laser is a viable method that should be considered for the management of bilateral vocal cord paralysis. It seems to be a very promising laser device, so we expect that new diode laser wavelengths (980 nm) will continue to emerge, making it a good alternative to the CO2 laser, but with lower cost, accurate manipulation, portability, shorter duration, and simplicity of use. LEVEL OF EVIDENCE: 4.