Abstract
Adult-Onset Laryngeal Papillomatosis Treated with Coblation
Clara Capucho, MD (presenter); Ana Rita Lameiras, MD; Pedro Escada, MD, PhD
Objectives: (1) Demonstrate the effectiveness of coblation plasma technology (radiofrequency cold ablation) in the treatment of adult-onset laryngeal papillomatosis and (2) analyze the advantages of this technique.
Methods: Case report of adult-onset laryngeal papillomatosis treated with coblation at a tertiary referral center. Outcome measurements considered in the study were symptoms resolution, disease recurrence, and postoperative complications.
Results: A 32-year-old man presented with symptoms of effort dyspnea and dysphonia. Indirect rigid laryngoscopy revealed papillomatous lesions in both vocal cords. The lesions were removed using coblation technology. The glow discharge plasma ablated the papillomatous lesions with simultaneous coagulation and preservation of the underlying tissue. Laryngeal papillomatosis without dysplasia was confirmed by histologic analysis, and human papillomavirus type 6 DNA was isolated from the specimen. No complications were recorded. At 6 months after surgery, there were no signs of recurrence and the patient remained without dyspnea and with improvement of Grade, Roughness, Breathiness, Asthenia, and Strain score.
Conclusions: Coblation is a promising surgical technique for the treatment of laryngeal papillomatosis. The main advantages of this technique include operation at lower temperatures than other radiofrequency technologies, precise removal of soft tissue with limited damage of the underlying tissues, bloodless field, and reduced risk of airway fire.
Association of Laryngotracheal Stenosis with Low Socioeconomic Status and Inflammatory Comorbid Disease
Nicolas-George Katsantonis, MD (presenter); Christopher Wootten, MD; David O. Francis, MD, MS; Alexander Gelbard, MD
Objectives: The relationship between socioeconomic status (SES) and laryngotracheal stenosis (LTS) has not been explored. LTS is an umbrella term describing a set of devastating diseases resulting from upper airway obstruction at the level of the larynx or upper trachea. It can be idiopathic (idiopathic subglottic stenosis), be autoimmune (eg, granulomatosis with polyangitis), or follow iatrogenic injury (eg, endotracheal intubation). While research in myriad other diseases has shown important effects of SES on both individual and population health outcomes, the relationship of SES to different mechanisms of airway injury has not been explored. The study objective is to investigate the association between SES and the distinct clinical subgroups of adult laryngotracheal stenosis.
Methods: An age-, sex-, and gender-matched case-control study of 400 cases and 400 controls was used to investigate the association between SES and the various etiologies of LTS. A multivariate, stepwise logistic regression model was adjusted for age, gender, race, tracheostomy (y/n), length of intubation, primary diagnosis, and comorbidity.
Results: Patients with LTS arising after intubation tend to be under- or uninsured, arise from low-income geographical areas, and have a significantly increased incidence of comorbid inflammatory disease compared to matched controls or other LTS subtypes.
Conclusions: Lower SES is significantly associated with airway injury following endotracheal intubation. Further studies are needed to elucidate mechanisms across various populations responsible for this association.
Awake vs. Asleep Voice Outcomes for Injection Laryngoplasty
Jason M. Abramowitz, MD (presenter); Daniel P. Ballard, MD; Arman Sobhani; Sean Lewis, MD; Boris Bentsianov, MD; Richard M. Rosenfeld, MD, MPH
Objectives: To assist otolaryngologists in counseling patients with hoarseness who would benefit from injection laryngoplasty on whether or not to perform the procedure in the office versus the operating room by synthesizing evidence from published literature on comparative voice outcomes.
Methods: Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards of English language articles that compared voice outcomes for injection laryngoplasty in office versus the operating room. Two independent investigators assessed study eligibility, rated the quality using Methodological Index for Non-Randomized Studies, and abstracted data for comparative analysis.
Results: Of a total of 253 unique articles, 2 studies met inclusion criteria, including 1 historical cohort and 1 prospective cohort study. Each study had a low risk of bias. One study measured voice outcomes using Voice Handicap Index, while the other study measured voice outcomes using Voice-Related Quality of Life. The most common indication for injection laryngoplasty was unilateral vocal fold weakness. Both studies showed a significant improvement in respective voice outcome measure, with no significant difference between voice measures when comparing in-office injection with injection in the operating room. One study noted adverse events to be higher in the office group, with the most common complication being aborted procedure.
Conclusions: Our systematic review makes it unlikely that large differences exist in postprocedure voice outcomes for injection laryngoplasty in the office versus the operating room, but the limited evidence has inadequate statistical power to exclude smaller differences.
Buccal Mucosa Graft in Management of Posterior Glottal Insufficiency
Samuel N. Helman, MD (presenter); William Karle, MD; Michael Pitman, MD
Objectives: Posterior glottal insufficiency manifests as a weak, breathy, and raspy voice with air hunger. It causes significant patient morbidity, and the currently available medical and surgical therapies are of questionable efficacy. This study reports the insetting of a buccal mucosa graft into the posterior glottic gap resulting in decreased glottal insufficiency and improved phonation.
Methods: This is a detailed case report of 2 female patients undergoing laryngofissure with buccal mucosa graft and temporary tracheotomy for the treatment of acquired posterior glottal insufficiency. The Voice Handicap Index and Grade, Roughness, Breathiness, Asthenia, and Strain scale were followed 2 years postoperatively and compared with preoperative voice parameters. In addition, a review of literature accessible through PubMed was performed to investigate the various modalities for repair of posterior glottic insufficiency and compare them with our current technique.
Results: Treatment of the 2 patients’ posterior glottic insufficiency was effective and safe without complication. Phonation was dramatically improved with a concomitant decrease in patient morbidity.
Conclusions: Laryngofissure with buccal mucosa graft is a viable treatment option for posterior glottic insufficiency.
A Case of Asystole during Direct Laryngoscopy in a Healthy Patient
Zahrah Taufique, MD, MBA (presenter); Gregory R. Dion, MD; Milan R. Amin, MD
Objectives: (1) Present a case of asystole during direct laryngoscopy in an otherwise healthy patient at an outpatient surgery center. (2) Review literature on asystole during direct laryngoscopy.
Methods: This case report describes a 67-year-old woman with no prior cardiac history who underwent induction with succinylcholine and remifentanil direct laryngoscopy for vocal fold augmentation. During suspension laryngoscopy, the patient went into asystole, and advanced care life support measures were started. She regained a cardiac rhythm after chest compressions and epinephrine. She was transferred from the outpatient surgery center to a hospital for further care, remained intubated for 1 night requiring pressors, and regained her normal heart function over the next few days.
Results: A structured literature review uncovered few reports of asystole during suspension laryngoscopy. None of these are in the otolaryngology literature, despite the rare cases occurring to otolaryngology procedures. While bradycardia is not uncommon during suspension laryngoscopy, likely secondary to stimulation of afferent visceral sensory parasympathetic fibers of the vagus nerve, asystole, especially in healthy patients, is exceedingly rare. This hypothesis is supported by a report of asystole during vagal nerve stimulator placement. Proper staff training, recognition, and response to such complications, even in an outpatient surgery center, can allow for successful management of unforeseen events.
Conclusions: Asystole during direct laryngoscopy is an exceedingly rare complication not always predictable from medicine or cardiac risk indices. Awareness, rapid recognition, and early implementation of advanced care life support is crucial to avoid further complications.
A Case of Laryngeal Rhabdomyoma in a 92-Year-Old Man
Barcleigh P. Landau, MD (presenter); Nancy Jiang, MD; Sara Smith, MD
Objectives: To describe a rare case of laryngeal rhabdomyoma in a 92-year-old man that was initially thought to be a granular cell tumor.
Methods: A case report is described herein and a review of the literature was performed.
Results: A 92-year-old man presented to the emergency department with new-onset hoarseness and a 1-year history of dysphasia with solids. Chest radiograph showed soft-tissue fullness effacing the supraglottic airway. Computed tomography scan confirmed a 4 × 3 × 3-cm mass centered in the right supraglottis. Nasopharyngoscopy revealed a large mass extending from the right pyriform sinus into the supraglottis, obstructing any visualization of the true vocal cords. The patient was taken to the operating room for awake tracheostomy and direct laryngoscopy with biopsy of the laryngeal mass. On microscopic evaluation of the pathologic specimen, the mass was thought to be a granular cell tumor. However, immunohistochemistry revealed the tumor to be a rhabdomyoma. The patient was taken back to the operating room for endoscopic resection of the rhabdomyoma with carbon dioxide laser. He was decannulated 2 days after surgery and recovered without complication.
Conclusions: Extracardiac rhabdomyomas are rare benign tumors of mature skeletal muscle origin. Microscopically, it can often be confused for other benign neoplasms, especially granular cell tumors. The diagnosis, therefore, requires immunohistochemical staining. The prognosis is excellent, with few reported recurrences after surgical excision.
Chronic Esophageal Foreign Body as a Source of Severe Tracheomalacia
Joseph C. Park, MD (presenter); Allison Speer, MD; Andrea T. Badillo, MD; Eva I. Rubio, MD; Maria Pena, MD
Objectives: To describe a rare cause of severe acquired tracheomalacia from a chronic esophageal foreign body. Chronic esophageal foreign bodies are associated with poor feeding, failure to thrive, and respiratory complaints but rarely cause tracheomalacia. We describe an unusual case of severe tracheomalacia in which a chronic esophageal foreign body presented with stridor and intermittent regurgitation.
Methods: A 3-year-old boy presented with a 3-month history of progressively worsening stridor, dyspnea on exertion, and intermittent regurgitation without dysphagia. Fiber-optic laryngoscopy was unremarkable. Direct laryngoscopy and bronchoscopy revealed severe tracheomalacia from the cervical trachea to the thoracic inlet with tracheal compression to 1 mm. The distal trachea, carina, and mainstem bronchi were uninvolved. Magnetic resonance imaging revealed severe narrowing of the lower cervical trachea with right-sided displacement from significant esophageal inflammation with possible perforation. An esophagram revealed no contrast extravasation but was concerning for an intramural versus extraluminal foreign body. Computed tomography was performed to delineate the location and demonstrated a butterfly-shaped curvilinear hyperdense foreign body in the left neck with adjacent inflammation, but the location remained unclear. Flexible esophagoscopy identified an intraluminal foreign body just below the cricopharyngeus. Hard plastic toy bunny ears were removed; no perforation was seen. The patient was extubated the next day and discharged postoperative day 6 tolerating a soft diet.
Conclusions: Chronic esophageal foreign bodies are associated with feeding difficulties, failure to thrive, and even stridor if there is extrinsic compression of the airway. In rare instances, severe tracheomalacia may develop.
Correlation of Histopathology and Outcomes in Subglottic Stenosis
Keith A. Chadwick, MD (presenter); Joshua S. Schindler, MD; Cailin Sibley, MD, MHS
Objectives: (1) Understand the etiologies of subglottic stenosis and describe histopathologic findings in each. (2) Recognize whether histopathologic findings correlate with accuracy of diagnosis and clinical outcomes.
Methods: The study is a retrospective consecutive case series in a tertiary academic institution approved by the institutional review board. Adult patients with subglottic stenosis undergoing operative direct laryngoscopy between January 2006 and December 2015 were included (n = 152). The results of histopathologic examination of biopsies were reviewed and compared directly against outcome measures. The amount of tissue obtained for biopsy was also collected. Outcome measures reviewed included the number of dilations required, time between dilations, need for open procedure, and the use of adjunctive therapies (steroids or mitomycin C).
Results: Of 152 patients undergoing 278 procedures, biopsy was obtained in 107 patients (70.4%). Eighty-eight (82.2%) biopsies showed “chronic inflammation” on histopathology. Granulomatosis with polyangiitis (GPA) was confirmed by biopsy in only 8 patients (7.5%). Five (4.7%) biopsies revealed normal respiratory mucosa. No outcome measures correlated with the results of histopathologic results (P > .05). The amount of tissue provided for biopsy did not correlate with the likelihood of providing a diagnostic result of GPA (P > .05).
Conclusions: This study did not identify significant correlation between the results of histopathology examination and outcomes. Visual inspection with histopathology alone appears to be inadequate in providing diagnostic information for most patients. Therefore, further study in this area to develop new methods of testing biopsy samples in subglottic stenosis is warranted to provide diagnostic data to the physician and suggest strategies for management.
Ehlers-Danlos Syndrome and the Laryngologist: A Case Series
Tang Zhi’En Joyce, MBBS, MRCS (presenter); Shalini Arulanandam, MBBS; Guri S. Sandhu, MBBS, MD, FRCS; Martin Birchall, MA, MD, FRCS
Objectives: This is the first series to our knowledge of potential presentations of Ehlers-Danlos syndrome to the laryngologist. The 9 patients in this series presented to the tertiary referral airway and voice services of 2 hospitals in London, United Kingdom, from 2012 to 2015. Five patients presented with dysphagia, 1 patient with dysphonia, 1 patient with impaired vocal cord mobility, 1 patient with chronic throat pain, and the last patient with glottic and subglottic stenosis. Routine investigations such as nasal and upper gastrointestinal endoscopy, pH studies, laryngeal electromyography, and radiologic investigations were of limited diagnostic value in the evaluation of these patients’ complaints. Clinical findings on examination of the upper aerodigestive tract were also subtle, such as that of generalized laxity of laryngeal and esophageal musculature and incoordination of vocal fold movement. Management of these patients was mainly conservative and included therapy and counseling. Surgical intervention was undertaken in 3 of these cases to improve the airway and swallowing. Laryngologic and upper digestive tract complaints are relatively common, although varied, in Ehlers-Danlos syndrome; hence, awareness of the other systemic manifestations of the syndrome would aid the laryngologist faced with a diagnostic dilemma in a yet-undiagnosed patient.
Elevated Tissue Mast Cell Levels in Patients with Supraglottic Edema
Nicolas-George Katsantonis, MD (presenter); Christopher Wootten, MD; James Lewis, MD; Alexander Gelbard, MD
Objectives: To identify the presence of mast cells in laryngeal tissue in a limited subset of patients with persistent and severe supraglottic edema, all without clear etiology.
Methods: Twelve patients underwent supraglottic biopsy and peripheral blood measurement of high-sensitivity C-reactive protein (hsCRP) during workup of their obstructive edema. Mast cell counts were determined via c-kit (CD-117) immunohistochemistry staining.
Results: Twelve patients demonstrated elevated mast cell concentrations in supraglottic tissue biopsies (mean cells per high-power field: 25.17 ± 18.66). Affected patients showed concomitant elevation in systemic inflammatory markers (mean hsCRP: 24.9 mg/L ± 16.2 mg/L) in the absence of local or systemic infection. Interestingly, 8 of 12 patients showed objective improvement with use of inhaled cromolyn sodium, an established mast cell stabilizer used in treatment of atopic disease. Seven were able to be decannulated.
Conclusions: Mast cells may play a pathogenic role in a subset of patients with inflammatory upper airway disease.
Epithelial-Mesenchymal-Transition Is Not a Source of Airway Fibroblast Accumulation in Idiopathic Subglottic Stenosis
Nicolas-George Katsantonis, MD (presenter); Christopher Wootten, MD; Gaelyn Garrett, MD; James Netterville, MD; David O. Francis, MD, MS; Alexander Gelbard, MD
Objectives: Idiopathic subglottic stenosis (iSGS) is a debilitating extrathoracic obstruction, arising without antecedent injury or disease. Persistent mucosal inflammation and a fibrotic response are hallmarks of the disease. Key to all fibrotic diseases is the presence of extracellular matrix–producing fibroblasts. Prior work demonstrated increased fibroblasts in the iSGS scar, though the origin of the fibroblast population has not been characterized. Fibroblast accumulation can occur through 3 distinct pathways: proliferation of resident tissue fibroblasts, influx of circulating fibrocytes, or via epithelial-mesenchymal-transition (EMT), a process whereby fully differentiated epithelial cells transition to activated fibroblasts. Delineating the source of pathogenic fibroblasts is critical to developing directed therapy. The study’s objective is to determine the role of EMT in fibroblast accumulation in the iSGS scar.
Methods: Using quantitative polymerase chain reaction (qPCR), we analyzed subglottic scar from iSGS patients (n = 9) and healthy controls (n = 23) for mRNA transcripts characterizing epithelial and mesenchymal tissue and known EMT transcription factors. qPCR findings were confirmed at the protein level with immunohistochemistry.
Results: Transcription factors associated with EMT (Twist, Goosecoid, Snail) showed no significant elevation in iSGS tissue compared with controls (P = .09, P = .30, P = .20, respectively) similar to E-cadherin and desmoplakin (epithelial cell markers; P = .67, P = .19), whereas vimentin, integrin alpha chain V, and integrin-β-1 (known mesenchymal markers) were significantly depressed compared with controls (P = .0029, P = .0074, P = .01).
Conclusions: EMT does not appear to contribute significantly to iSGS scar fibroblasts. Future study will be necessary to delineate the contribution of resident tissue fibroblasts and circulating peripheral fibrocytes to the fibrotic tissue remodeling in iSGS.
Factors Affecting the Recurrence Time of Early Glottic Cancer
Min-Su Kim; Tack-Kyun Kwon, MD, PhD (presenter)
Objectives: Recurrences of head and neck cancers generally appear within 5 years after initial treatment. However, recurrences of some early glottic cancers are observed more than 5 years after initial treatment. Little is known about late recurrences in patients with early glottic cancer. This study aimed to analyze recurrences of early glottic cancer and prognostic factors that had significant impacts on local tumor control and time to relapse.
Methods: Using propensity score analysis, 330 patients with early glottic cancer were retrospectively analyzed. Propensity scores were estimated using a logistic regression model and applied to a covariate adjustment method.
Results: Overall, 127 patients treated with laser surgery and 203 patients treated with radiotherapy had 5- and 10-year local recurrence-free rates of 82.0% and 74.0%, respectively. T2 stage was significantly prognostic for local recurrence. Among patients with recurrent disease, laser treatment (P = .047) and anterior commissure noninvolvement (P = .007) significantly affected the time to relapse even after propensity score analysis. The early recurrence group comprised 49 patients (76.5%) with evidence of cancer recurrence within 5 years. The late recurrence group comprised 15 patients (23.5%), with evidence of cancer recurrence beyond 5 years. Among the late recurrent patients, 11 (73.3%) were concordant and 4 (26.7%) were discordant.
Conclusions: Given the considerable rate of late recurrences and the prognostic factor, follow-up of early glottic cancer cases should be extended beyond 5 years after initial treatment, especially for cases involving laser surgery.
Functional Results of Transoral Procedures for Pharyngeal Dysphagia
Shun-Ichi Chitose, MD, PhD (presenter); Kiminori Sato; Mioko Fukahori; Shintaro Sueyoshi; Buichiro Shin; Takeharu Ono; Hirohito Umeno, MD
Objectives: Evaluate noninvasive transoral procedures using endoscopic cricopharyngeal myotomy (ECPM) in combination with transoral injection laryngoplasty (IL) and/or pharyngeal flap surgery (PFS) in patients with pharyngeal dysphagia.
Methods: Among 31 pharyngeal dysphagia patients (cerebrovascular diseases, 18; head neck and thoracic surgeries, 8; idiopathic cricopharyngeal dysphagia, 5) at the Kurume University Hospital from January 2010 to July 2015, 20 underwent ECPM alone, 4 underwent ECPM with IL, and 7 underwent ECPM, IL, and PFS (age range, 41-85 years). A 4-grade satisfaction survey and body mass index (BMI) assessment were performed at 6 months postoperatively. Swallowing function was evaluated over time using the functional oral intake score (FOIS) and penetration aspiration scale (PAS).
Results: In the satisfaction survey, 39% patients reported an “excellent” outcome, 23% “good,” 35% “fair,” and 3% “poor.” Mean BMI was significantly increased from 20.2 to 22.0 (P < .05). Mean FOIS was 2.8 preoperatively and 4.5, 5.5, and 5.8 at 2 weeks, 1, and 6 months postoperatively. Nine of 13 patients with severe dysphagia who had been tube fed recovered their swallowing and oral intake capacity postoperatively. Mean PAS was 4.7 preoperatively and 3.1, 2.4, and 2.2 at 2 weeks, 1, and 6 months postoperatively. These results suggest that patients achieved significant early improvements at 2 weeks postoperatively (both P < .05).
Conclusions: Transoral procedures can be performed selectively as concurrent operations, depending on the clinical manifestations of pharyngeal dysphagia, with early improvements in the postoperative course.
Laryngeal Cartilage Mass Presenting as a Vocal Fold Cyst: Case Report
Dominique Sanchez, (presenter); Anna Garcia, MD; Glendon M. Gardner, MD
Objectives: To describe a case of a cartilaginous laryngeal mass presenting as a vocal fold cyst.
Methods: We describe a clinical case in which a patient with chronic dysphonia refractory to voice therapy presented with features suggestive of a vocal fold cyst. Review of current literature of dysphonia, vocal fold cysts, and cartilaginous laryngeal masses was performed.
Results: The patient elected for microsurgical removal, wherein the suspected vocal fold cyst was determined to be a solid mass arising from the thyroid cartilage. Histopathologic findings demonstrated cartilage with evidence of lamellar bone formation.
Conclusions: Cartilaginous masses of the larynx are rare entities. These entities include chondroma and chondrosarcoma. In the current literature, presentation as a benign vocal fold cyst is unique.
Laryngeal Manifestations of IBD: A Case Series
Vini Balakrishnan, MS (presenter); Prem Tripathi, MD; Megan Wood, MD; Gaelyn Garrett, MD; Sunil Verma, MD
Objectives: (1) Describe 2 cases of Crohn’s disease and 1 case with ulcerative colitis involving the larynx. (2) Perform a review of literature of the rare laryngeal manifestations of inflammatory bowel disease (IBD).
Methods: This report describes 3 patients with history of IBD who presented with laryngeal symptoms. Examination revealed nonspecific laryngeal lesions in each patient. Histopathologic analysis of the laryngeal lesions confirmed the diagnosis of IBD larynx. A combination of topical and systemic therapy was effective in alleviating symptoms in these patients.
Conclusions: Extraintestinal manifestations are common in IBD; however, laryngeal involvement is rare and can present at any time during the course of the disease. Because the laryngeal manifestations are nonspecific and subtle, a strong degree of suspicion is required for its diagnosis. This highlights the need for proactive prophylactic examination of the larynx to identify laryngeal lesions and initiate treatment early to reduce associated morbidities of the disease.
Laryngeal Vocalization in Dysphagic Tracheoesophageal Diversion
Toshiro Umezaki, MD, PhD (presenter); Kazuo Adachi, MD; Naoko Matsubara, MD, PhD; Nobuhiro Sato, SLP; Takashi Nakagawa, MD, PhD
Objectives: The laryngotracheal separation is the only surgical technique that can completely prevent both apparent and silent aspirations. However, it causes a serious handicap: that vocal function has been completely lost. For better quality, we applied the combined surgical procedures with tracheoesophageal diversion (laryngotracheal separation with tracheoesophageal anastomosis) followed by tracheoesophageal shunt (T-E shunt) to reacquire vocal function.
Methods: This study was designed with clinical review and evaluation. We applied tracheoesophageal diversion at first for a 66-year-old man who suffered from cerebral infarct with intractable aspiration and severe dysphagia and was tracheostomized due to repetitive pneumonia. His nutrition was managed through percutaneous endoscopic gastrostomy (PEG). Then we performed second-stage operation of T-E shunt with a 1-way valve (Prvox) to prevent esophagotracheal reflux. In this condition, we evaluate his vocal parameters and stroboscopic findings.
Result: After tracheoesophageal diversion, in the videofluoroscopic study his swallowing function was drastically improved and he could intake foods per orally. At present, he is free from PEG. He has been able to vocalize through the T-E shunt, tracheoesophageal anastomosis, and his glottis, by obstructing tracheostomy with his forefinger in the expiratory phase. We confirmed his voice was generated by his own vocal folds by the stroboscopy. Maximum phonation time was about 10 seconds, and mean flow rate at 85 dB was 155 mL/s.
Conclusion: Our novel surgical approach can be a new strategy for dysphagic patients with intractable aspiration that enables them to reacquire their own voice without aspiration.
Lesions of the Aryepiglottic Fold
Ahmed Abdelmoneim Teaima, MS (presenter)
Objectives: Management of lesions in the aryepiglottic fold region is challenging as they are rare and may have extensive origins from benign to vascular to malignant. This study addressed the proper management of these lesions. This was done to patients with aryepiglottic lesions at Ain Shams University Hospitals, Cairo, Egypt, in the past 5 years. Pre- and postoperative laryngeal examination, pre–computed tomography scan and diffusion-weighted magnetic resonance imaging, and angiography were done. The surgeries were done endoscopically assisted. All of these lesions were perfectly handled without any effect on swallowing or airway.
Medialization Laryngoplasty with Hydroxylapatite Microspheres
Clara Capucho, MD (presenter); Ana Rita Lameiras, MD; Pedro Escada, MD, PhD
Objectives: Demonstrate the effectiveness of medialization laryngoplasty with hydroxyapatite microspheres (Radiesse Voice) in vocal fold insufficiency treatment.
Methods: Retrospective analysis of cases of medialization laryngoplasty with hydroxyapatite microspheres carried out between December 2014 and October 2015 in a tertiary referral center. Outcome measurements considered in the study were postoperative laryngoscopy findings, Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) score, and complications.
Results: Medialization laryngoplasty with hydroxyapatite microspheres was performed in 8 patients (mean age: 61.1 ± 16.6 years). Level of vocal use was I and II in 62.5% (n = 5). The most frequent cause of glottal insufficiency was presbylarynx, followed by vocal cord atrophy due to extensive resection of primary disease and recurrent nerve paresis. The surgery consisted in hydroxyapatite microspheres injection in the Reinke space, near the vocal apophysis and in the middle portion of the vocal cord. The procedure was performed in all patients after attempt of vocal rehabilitation and, in cases of recurrent nerve paresis, after 6 months of installation. Patients were instructed to not use their voice during the first 3 days after the procedure. No complications were recorded. Clinical improvement was observed in all cases, with complete glottal escape resolution in 75.0% (n = 6). All patients presented improvement of GRBAS score.
Conclusions: Medialization laryngoplasty with hydroxyapatite microspheres is a simple technique effective in the treatment of mild and moderate glottal insufficiency, with good morphologic and functional results.
Multidisciplinary Team Approach for Safe Airway Management
Kosuke Uno, MD (presenter); Koichiro Saito, MD, PhD; Haruna Yabe, MD; Takeyuki Kono, MD; Kaoru Ogawa, MD, PhD
Objectives: To verify the suitability and impact of our intramural multidisciplinary protocol for elective tracheostomy in the intensive care unit (ICU). In addition, to assess the safety of both surgical tracheostomy (ST) and percutaneous dilatational tracheostomy (PDT) on highly diseased patients.
Methods: From April 2012 to March 2015, 86 patients were admitted to the ICU of Keio University Hospital and underwent elective tracheostomy. STs were performed by otolaryngologists in the operating room (OR), whereas PDTs were performed by anesthesiologists at the bedside in the ICU. Multidisciplinary decisions to accomplish tracheostomies were performed following our previously reported intramural protocol. Period of endotracheal intubation before tracheostomy (intubation period), delay from the decision to perform a tracheostomy to the procedure being performed (waiting period), and ICU stay after tracheostomy were evaluated. Perioperative complications were also examined.
Results: Fifty-two patients got STs and 34 patients got PDTs. While intubation period (ST, 7.8 days; PDT, 7.8 days; P = .90) and ICU stay after tracheostomy (ST, 4.7 days; PDT, 4.3 days; P = .87) were similar in each group, the waiting period was relatively shorter in the ST group (2.0 days) compared with the PDT group (2.4 days, P = .05). While minor perioperative bleeding (ST, n = 4; PDT, n = 1) and wound infection (ST, n = 1; PDT, n = 4) were observed in both groups, severe complications were observed only in the ST group (cardiopulmonary arrest, n = 2).
Conclusions: Our team approach basically achieved smooth airway management. Although our approach could potentially overcome the time-consuming OR scheduling, extra attention should be paid on the patients with serious complications to require ST in the OR.
The ORL Procedure Clinic in a Nationalized Health System
Silvia G. Marinone Lares, MD (presenter); Jacqui Allen, MD; Mamta Patel, MD
Objectives: Describe the utility of an outpatient procedure clinic in a nationalized health service and examine the benefits and cost-effectiveness of the clinic, with particular reference to health economics in a publicly funded system.
Methods: A retrospective analysis was undertaken of all procedures performed in a procedure clinic in a tertiary state-funded hospital between January 2011 and June 2015. Volumes and types of procedures and indications were categorized. Completion rate, conversion rate, and complications were evaluated, and a cost-comparison, cost-effectiveness analysis was performed.
Results: Two hundred ninety-nine appointments were made into the procedure clinic, and 241 procedures were performed during the 53 months. Fourteen booked patients did not attend, 12 no longer required the proposed treatment, and 38 bookings were incorrectly assigned to the clinic. One hundred forty-four procedures were transnasal esophagoscopies with or without biopsies or balloon dilatation. Sixty-four procedures involved the use of the potassium titanyl phosphate laser. Other procedures included transnasal tracheoscopy, transnasal bronchoscopy and injection of vocal folds. Completion rate was 95.4% (230/241) with 11 procedures converted to the operating room and no complications. Outpatient-based treatment resulted in a conservative cost saving of NZD$243,775.
Conclusions: Procedure clinics enable performance of many otolaryngology interventions in the office. Procedures may be performed safely, are cost-effective, and are well tolerated by patients without sedation. This avoids potentially more invasive and costly procedures and frees up operating time for other patients.
Outcome of Tracheostomy Closure in Oral Cancer Surgery Patients
Masaaki Higashino, MD, PhD (presenter); Ryo Kawata, MD, PhD; Tetsuya Terada, MD, PhD; Norio Suzuki, MD
Objectives: We investigated the outcome of tracheal fistula in patients with oral cancer who underwent tracheostomy at the time of initial surgery. Study design: Retrospective study.
Methods: We retrospectively investigated the outcome of tracheal fistula in 57 patients with oral cancer who underwent tracheostomy. The patients were classified into 3 groups, which were patients in whom the tracheal fistula closed spontaneously (group A), patients in whom closure of the tracheal fistula did not occur spontaneously and surgical closure was required (group B), and patients in whom closure of the tracheostomy could not be achieved (group C). The following factors were examined for associations with failure of spontaneous closure: patient demographics, primary tumor site, T classification, N classification, stage classification, presence or absence of neck dissection, presence or absence of reconstructive surgery, presence or absence of postoperative (chemo)radiotherapy, presence or absence of postoperative aspiration pneumonia, and duration of tracheal cannula placement.
Results: Among the 57 subjects, group A were 27 (47.4%), group B were 23 (40.4%), and group C were 7 (12.3%). In group B, surgical closure with a hinge flap was performed in all 23 patients. We found that both neck dissection and postoperative (chemo)radiotherapy were factors that had an independent influence on whether closure of the tracheostomy could be achieved.
Conclusions: Although early removal of the tracheal cannula is advantageous for improving the quality of life of the patient, long-term cannulation does not interfere with spontaneous closure. Accordingly, it is necessary to carefully consider the timing of decannulation.
Salvage Phonosurgery for Over-Injected Autologous Fat
Itaru Watanabe, MD (presenter); Hideki Nakagawa, MD, PhD; Takeyuki Kono, MD; Koichiro Saito, MD, PhD
Objectives: To assess the impact of salvage phonosurgery after excessive injection of autologous fat (AF) into the vocal fold. Furthermore, to remind all head and neck surgeons to care for the unpredictable variety of final glottal function after AF injection laryngoplasty.
Methods: In this case study, we report 2 cases who encountered excessive injection of AF to require salvage surgeries to rescue their voice from disaster. Case 1 was a 62-year-old male patient, and case 2 was a 50-year-old male patient. Both had been forced to use severely impaired voice (case 1, G3R3B1A0S1, jitter = 4.066%, shimmer = 9.795%, noise to harmonic ratio [NHR] = 0.334; case 2, G3R3B1A0S1, jitter = 5.739%, shimmer = 19.044%, NHR = 0.415) for a long time after AF injection laryngoplasty (case 1, 9 months; case 2, 5 years) in other institutions. Laryngeal stroboscopy detected apparent swelling and impaired mucosal wave in the vocal folds (case 1, both sides; case 2, left sided). Furthermore, computed tomography imaging represented submucosal glottal lesions with fat intensity in the diseased larynges. Surgical removal of excessively transplanted AF was performed under the setting of microlaryngeal surgery in these patients. Case 1 required additional surgery to further adjust his glottis function.
Results: Postoperative stroboscopy presented the symmetric vibration in bilateral vocal folds in both patients. Furthervocal assessment revealed satisfactory results (case 1, G1R1B1A0S1, jitter = 1.788%, shimmer = 4.581%, NHR = 0.083; case 2, G1R1B0A0S0, jitter = 3.546%, shimmer = 8.821%, NHR = 0.030).
Conclusions: Fortunately, salvage surgeries showed satisfactory impacts in both of our cases. However, significant intra- and postoperative care should be taken for AF injection to consider the unpredictable survival of AF.
Sarcomatoid Carcinoma of the Hypopharynx: Case Report
Amanda Dominick (presenter); Rebekah Smith; Christopher G. Tang, MD
Objectives: The purpose of this study is to elucidate a case of sacromatoid carcinoma of the hypopharynx and review literature on this topic.
Methods: A case report at a local community hospital is described with a review of literature.
Results: A 67-year-old woman with a remote history of lung cancer treated with radiation presented with progressive odynophagia and hoarseness. Fiber-optic examination revealed a left hypopharyngeal lesion. In-office biopsy revealed a sarcomatoid carcinoma of the hypopharynx. The patient had further imaging workup and was treated with definitive chemoradiation.
Conclusions: Sarcomatoid carcinoma is a rare morphologic variant of head and neck squamous cell carcinoma. These tumors often pose a challenge in classification, diagnosis, and management. A literature review was performed and the pathology discussed.
Spectroscopic Analysis of Decellularized Human Tracheal Scaffolds
Derrick Tint, MD (presenter); Collin Stabler; Arash Hanifi, PhD; Nancy Pleshko, PhD; Ahmed Soliman, MD
Objectives: (1) Apply infrared spectroscopy to nondestructively assess the decellularization process of a human tracheal scaffold. (2) Analyze changes in connective tissue and nucleic acid spectroscopic signatures during decellularization. (3) Validate spectroscopic data by comparison to gold standard techniques, including histologic staining.
Methods: A decellularized tracheal scaffold was created by rinsing cadaveric human trachea for 25 cycles in 4% sodium deoxycholate followed by 2000 KU of DNase-I. Samples from the scaffold were collected after 0, 1, 10, and 25 cycles. Samples were analyzed using near-infrared and mid-infrared spectroscopic probes and processed for histology. Slides were stained with hematoxylin and eosin (H&E), Mason’s trichrome stain, and DAPI. Principal components analysis (PCA) was performed on second derivative spectra to correlate spectral signatures with the progress of decellularization.
Results: H&E and DAPI staining of tracheal scaffold after 25 rinse cycles showed complete loss of nuclear material from respiratory epithelium and submucosa. There was incomplete removal of nuclear material from within lacunae of the hyaline cartilage. Mason’s trichrome staining revealed degradation of collagen the respiratory epithelium and submucosa without degradation of hyaline cartilage. PCA of spectral data at consecutive data collection points showed significant separation of data sets based on collagen peaks in the mid-infrared (IR) and near-IR regions and of nucleic acid peaks in the mid-IR region.
Conclusions: Mid-IR and near-IR spectroscopy are novel methods of monitoring tracheal scaffold decellularization. The degradation of connective tissue and nucleic acid components in the scaffold can be serially monitored nondestructively using this method.
Tears of a Clown: Thermal Airway Injury in a Fire Breather
Asitha D. L. Jayawardena, MD, MPH (presenter); Glenn T. Schneider, MD, MS; Ross Shockley, MD; Christopher Wootten, MD; Alexander Gelbard, MD
Objectives: (1) Recognize the potential for significant airway thermal injury in the setting of minimal oral/facial burns. (2) Describe principles of management in thermal injuries to the airway.
Methods: Case report of a patient who presented to a tertiary care center.
Results: Clinical features: A 24-year-old male carnival “fire-breather” presented with superficial, partial thickness burn to the face, chest, and left hand comprising 4% of total body surface area. He was intubated in the field for airway protection. In hospital, operative endoscopy revealed diffuse mucosal sloughing throughout the hypopharynx, supraglottis, glottis, subglottis, and proximal trachea. The carina and bilateral mainstem bronchi showed preserved mucosal integrity with diffuse erythema. Notably, the oral cavity and most of the oropharynx was spared. Intervention: The patient received a tracheostomy on postinjury day 5 after twice failing extubation. On postinjury day 10, repeat microlaryngoscopy revealed continued massive mucosal sloughing from the supraglottis to the proximal trachea and development of posterior glottic scar banding resulted in bilateral true vocal fold immobility. Scar bands in posterior glottis and subglottis were lysed, injected with triamcinolone acetate, and dilated with a balloon.
Conclusions: Patients who present with a history of even seemingly minor facial burns should receive a thorough airway evaluation. The efficacy of early intervention in airway injury has been established in iatrogenic intubation injuries. The role of early microlaryngoscopic scar lysis and steroid injection is unclear in the setting of thermal injury but may help limit devastating cicatricial sequelae.
A Unique Case of Traumatic Hypopharyngeal Perforation
Nicholas Wirtz, MD (presenter)
Objectives: (1) Describe a unique case of traumatic hypopharyngeal perforation resulting from a female performing oral sex on a male partner. (2) Discuss the diagnostic workup and operative management of a case of traumatic hypopharyngeal perforation. (3) Discuss the literature relating to injuries of the hypopharynx.
Methods: The following is a case report of an individual who sustained a traumatic hypopharyngeal perforation while performing oral sex on a male partner. The patient is a 48-year-old woman presenting acutely to an emergency department with hemoptysis, odynophagia, and significant subcutaneous emphysema of the neck and chest. The patient was treated with acute operative identification and repair of the defect.
Results: The patient recovered well with no significant complications.
Conclusions: This is a previously undescribed mechanism of traumatic perforation of the hypopharynx. There is not a clear consensus in the literature regarding management of these types of injuries. This particular case was treated with acute surgical intervention resulting in a satisfactory outcome.
Utility of Mobile Computer Assisted Incentive Spirometry
Karam W. Badran, MD (presenter); Chloe Krasnoff; Zachary Taylor, PhD; Maie A. St. John, MD, PhD
Objectives: Understand that mobile computer–assisted, beside incentive spirometry, can be used to detect and calculate the frequency, amplitude, and duration of inspiration.
Methods: A clinical patient-centered model in an academic research setting was used to demonstrate that computer-assisted incentive spirometry could analyze the frequency, amplitude, duration, and calculated volume of inspiration. Sixty inspiratory cycles were recorded from a smartphone (n = 30) and laptop computer (n = 30) using an external microphone and traditional incentive spirometer (Voldyne 5000; Hudson RCI, Temecula, CA). Multiple microphone-spirometer positions were investigated. Recordings were processed and analyzed utilizing Matlab (R2012a, The Mathworks, Inc, Natick, MA).
Results: All inspiratory cycles were captured and recorded successfully. None of the smartphone-recorded inspiratory cycles exceeded 1.5 kHz in broadband noise. Increasing inspiratory sounds’ amplitudes increased with increasing flow over microphone. No power difference was found between the smartphone and computer recordings when investigated 2 cm in front of lips and immediately behind the open-ended spirometry mouthpiece.
Conclusions: Mobile, computer-assisted recording and analysis of inspiratory cycles is a low-cost and reproducible method for detecting detailed characteristics of inspiration. Future investigations of portable and automatically implemented signal processing may improve patient care and postoperative recovery.
Vocal Function after Laser Surgery for Laryngeal Papillomatosis
Takeyuki Kono, MD (presenter); Haruna Yabe, MD; Kosuke Uno, MD; Kaoru Ogawa, MD, PhD; Koichiro Saito, MD, PhD
Objectives: Laryngeal papillomatosis is an increasingly common disease with high frequency of recurrence. Cautious care to balance reliable intervention and well-preserved glottal function is required to manage, especially in cases of tumor located in the vocal cord. The main purpose is to analyze vocal function after laser surgery for laryngeal papillomatosis.
Methods: The laryngeal papillomatosis patients who underwent laser ablation using carbon dioxide and/or potassium titanyl phosphate laser from January 2010 to August 2015 and successfully controlled vocal cord tumor were incorporated in this retrospective study. Pre- and postoperative Grade, Roughness, Breathiness, Asthenia, and Strain scale; videostroboscopic findings; and aerodynamic and acoustic parameters were measured as objective vocal function. Voice-Related Quality-of-Life (V-RQOL) score and Voice Handicap Index-10 (VHI-10) were used to evaluate subjective parameters. Postoperative data were assessed at 6 months after disappearance of tumor. These data were compared with the control group including 10 adults with no vocal dysfunction.
Result: Twenty-five patients’ vocal cord tumors disappeared after operation (mean number of operations, 3.1; range, 1-8). Although all patients had worse vocal function than the control group preoperatively, most patients improved both subjective and objective parameters after operation. However, 3 patients who underwent 1 operation withrelatively aggressive ablation slightly deteriorated in aerodynamic and acoustic parameters with abnormal videostroboscopic findings (poor mucosal wave, incomplete glottal closure), whereas 17 patients who underwent multiple operations showed comparable postoperative vocal functionwith the control group despite the repeated treatment of the vocal cord.
Conclusions: Multidimensional vocal assessment proved laryngeal papillomatosis patients could achieve comparable voice with normal adults even after multiple surgical treatments.
Vocal Function in Glottic Cancer: Japan x Brazil Project
Koichiro Saito, MD, PhD (presenter); Adriana Hachiya, PhD; Yoshie Iino, SLP; Kosuke Uno, MD; Haruna Yabe, MD; Takeyuki Kono, MD; Domingos Hiroshi Tsuji, MD, PhD
Objectives: To evaluate the vocal function in early glottic cancer patients after radiotherapy in 2 different countries/cultures, Japan and Brazil.
Methods: Twenty-seven irradiated T1 glottic cancer patients (Japan, n = 15; Brazil, n = 12) with their posttherapeutic follow-up periods of more than 12 months (Japan, 12-66 months; Brazil, 12-137 months) were involved in this international case series study. Mean age (Japan, 67.4 years; Brazil, 67.1 years) and radiation dose (Japan, 63.5 Gy; Brazil, 64 Gy) of the patients were similar in the 2 groups with Asian culture (Japan) and South American background (Brazil). Objective Grade, Roughness, Breathiness, Asthenia, and Strain score and mucosal wave of the vocal folds, as well as subjective voice handicap index (VHI) score were measured on each patient and compared between the 2 groups.
Results: Although differences were not statistically significant, total score (Japan, 23; Brazil, 12; P = .25), as well as functional (Japan, 8.4; Brazil, 2.8; P = .83), physical (Japan, 9.7; Brazil, 7.4; P = .47), and emotional domains (Japan, 5; Brazil, 1.3; P = .06) of VHI were relatively higher in the Japanese group compared with the Brazilian group. Considering the relatively better score in the objective mucosal wave score in the Japanese group (–0.9) compared with the Brazilian group (–1.4), these findings may represent the difference in the nature/character of the people in 2 different cultures.
Conclusions: Our ongoing study suggested that cultural background may affect the level of posttherapeutic voice-related quality of life, even in the patients treated with universally standardized irradiation procedures. Future tailor-made, anticancer strategy could consider the patient’s cultural background as one of the key parameters for better patient care.