Challenging Voice Cases: Foundation to Finesse in Voice Disorder Care (Nonexclusive)
Clark A. Rosen, MD (Moderator); Dinesh K. Chhetri, MD; Milan R. Amin, MD; Douglas Roth, MA; C. Blake Simpson, MD
Session Description: This panel will highlight foundation principles of voice care and subtle but important concepts of voice care through the medium of challenging voice cases. Each panelist will present a challenging clinical case that will be educational for the participants. These will be drawn from the important laryngological topics of muscle tension dysphonia (functional voice disorders), vocal fold paralysis, and vocal fold lesions. The panel will also involve a speech language–pathologist who specializes in voice disorders to demonstrate the important role of the multidisciplinary nature of voice evaluation and care in selected laryngological conditions. Each case will involve the presenting symptoms and recording of the voice and laryngeal examination, physical examination findings, and laryngeal examination video. The panelist and participants will be invited to ask further questions and develop a differential diagnosis using audience polling. The actual clinical care and outcome will then be presented and discussed. This approach will provide a great educational opportunity for the participants to learn from challenging voice cases in a real-life situation.
Outcome Objectives: (1) Explore the foundational principles of voice disorders diagnosis. (2) Evaluate the role of speech language–pathology care in the diagnosis and treatment of voice disorders. (3) Give examples of the various surgical options for treating voice disorders, including indications, results, and complications.
Chronic Cough and Dysphagia
Gregory R. Dion, MD (Moderator); Maggie A. Kuhn, MD; Milan R. Amin, MD; VyVy N. Young, MD
Session Description: Otolaryngologists are faced with an increasing array of diagnostic tests for patients with chronic cough and/or dysphagia. High-resolution manometry, aerodynamic analysis, dual pH/impedance testing, videofluoroscopy, videostroboscopy, and high-speed digital imaging provide varying information to traditional flexible endoscopy, pulmonary function studies, and computed tomography or magnetic resonance imaging studies. Each of these diagnostic tools measures specific variables involved in cough and deglutition. With increased scrutiny on cost-effective utilization of health care resources, it is crucial to explore the role of these diagnostic tools in efficiently diagnosing laryngologic conditions accurately and in a timely manner while exposing the patient to the lowest cost and risk. The purpose of this panel is to explore optimal implementation of these diagnostic tests in commonly encountered otolaryngology patients through case-based studies evaluating patients with complaints of chronic cough and/or dysphagia.
Outcome Objectives: (1) Examine available diagnostic assessment tools for patients with chronic cough and/or dysphagia through case-based discussions. (2) Determine the benefits and drawbacks of these tools to include expediency, cost, radiation exposure/risks, and clinical utility. (3) Compare diagnostic test utilization paradigms for the common laryngological disorders of chronic cough and dysphagia.
How Data-Driven Multidisciplinary Tracheostomy Teams Transform Care, Prevent Harm, and Save Lives
Brandon S. Hopkins, MD (Moderator); Michael J. Brenner, MD; Tiffany P. Raynor, MD; Vinciya Pandian, PhD, RN
Session Description: A landmark study found that in intensive care units (ICUs), tracheostomy incidents accounted for up to half of all airway-related deaths and hypoxic brain damage. Multidisciplinary adult and pediatric tracheostomy teams have achieved dramatic reductions in adverse events and improved patient outcomes, but dissemination of highly reliable practices has lagged. This panel addresses this gap by providing a strategy for rapid performance improvement with specific building blocks for enhancing care. Five key drivers—multidisciplinary ward rounds, standardized protocols, interdisciplinary education and staff allocation, patient and family involvement, and using data to drive improvement—can result in transformative change. We present data from 4 institutions, providing turnkey solutions and lessons learned from the creation of teams. We cover from the index procedure to decannulation and discharge, discussing obstacles encountered and how they are overcome. After presenting institution-level experience, we report on the largest implementation of these principles to date, drawing on prospectively captured patient-level global data from more than 4500 cases. We take a deep dive into a 3-year-long, 20-hospital-wide multipronged implementation that involved mixed-method analysis, data tracking, and benchmarking to demonstrate powerful, statistically significant effects of reducing hospital and ICU length of stay, ventilator duration, time to cuff deflation, time to first vocalization, time to first oral intake, prevalence of anxiety and depression, and cost savings, projected at >$15000 per patient. Although heterogeneity is a defining feature of tracheostomy, we demonstrate how across age and geographies, multidisciplinary teams are a game changer in tracheostomy care.
Outcome Objectives: (1) List the building blocks of a multidisciplinary tracheostomy care team. (2) Discuss obstacles encountered in building a tracheostomy care team. (3) Compare the approaches of different hospital systems in the creation of tracheostomy care teams.
Leuko Lot: A Lot of Laryngeal Leukoplakia
Priya D. Krishna, MD (Moderator); Nausheen Jamal, MD; Mark A. Fritz, MD; Ross Mayerhoff, MD
Session Description: Laryngeal leukoplakia is a common cause of hoarseness, and the differential diagnosis is vast. This presentation will attempt to provide a framework for workup of laryngeal leukoplakia. The panel, presented by 4 fellowship-trained laryngologists, is meant to discuss some of the more challenging cases in which it is difficult to distinguish between infectious and neoplastic etiologies and when repeat biopsy vs a more definitive resection is appropriate.
Outcome Objectives: (1) List the 3 most common etiologies of laryngeal leukoplakia both in infectious and noninfectious/neoplastic cases. (2) Categorize laryngeal leukoplakia into infectious or neoplastic etiologies based on discrete history and laryngoscopy. (3) Implement a laryngeal leukoplakia algorithm in deciding observation vs treatment in a given patient.
Management of Laryngeal Conditions With Office-Based Steroid Injections
Matthew R. Naunheim, MD (Moderator); Ramon A. Franco, MD; Guri Sandhu, FRCS; Lindsay Reder, MD
Session Description: Serial intralesional steroid injection (SILSI) is a method for office-based management of inflammatory and rheumatologic disease of the larynx. Its use in subglottic stenosis has gained popularity in recent years because of its ability to stabilize and improve airway narrowing, thus avoiding surgical procedures, or by working as an adjunct treatment after surgery. In addition, SILSI has the potential to be modified for use in other laryngeal conditions, including phonotraumatic lesions and rheumatologic conditions. The panelists will discuss what SILSI is, indications for its use, and recommended treatment schedules. Detailed descriptions of the anesthetic required for SILSI and the procedural technique will be reviewed. Objective outcome measures, including best practices for recording both spirometry and patient-reported outcomes, will be reviewed. Finally, the pearls and pitfalls of SILSI will be discussed, particularly as they pertain to alternatives to treatment (endoscopic or open treatment in the operating room). In conclusion, this panel will present SILSI as a practical and safe adjunct to airway management that can be implemented in otolaryngology offices.
Outcome Objectives: (1) Examine the physiology of airway stenosis and inflammation. (2) Describe SILSI as an adjunct treatment for inflammatory and rheumatologic disease. (3) Recognize inherent limitations and patient factors that may limit the use of SILSI.
Revision Laryngeal Framework Surgery: Pitfalls and Pearls (Nonexclusive)
Clark A. Rosen, MD (Moderator); Mark S. Courey, MD; Nicole C. Maronian, MD
Session Description: This session will explore the unique evaluation and treatment issues associated with revision laryngeal framework surgery, thyroplasty, and arytenoid adduction. In-depth discussion with the panelists will be held regarding the most common reasons for failure of the original surgery, limitations of revision surgery, and strategies to avoid complications and obtain improved voice outcomes with revision laryngeal framework surgery. Additional topics will include working with patients who have had radiation therapy and managing crico-arytenoid joint fixation and intraoperative laryngeal cartilage fractures. The panelists represent more than 60 years of combined experience in laryngeal framework surgery and presently have a practice that involves more revision surgery than primary laryngeal framework surgery. Cases of successful and failed revision laryngeal framework surgery will be presented to supplement the educational points provided by the panelists.
Outcome Objectives: (1) Analyze common primary laryngeal framework surgery failure patterns. (2) Recognize limitations of revision laryngeal framework surgery to avoid complications and establish proper patient expectations. (3) Perform revision laryngeal framework surgery with success knowing the pitfalls.
THRIVE: A Novel Adjunct in Airway Management for Laryngological Surgery
Margaret L. Naunheim, MD (Moderator); Dale C. Ekbom, MD; Alexander Gelbard, MD; Reza S. A. Nouraei, PhD, FRCS
Session Description: Transnasal humidified rapid insufflation ventilatory exchange (THRIVE) is a method for high-flow oxygen delivery using nasal prongs. This tool is used in intensive care units and emergency departments for patients with respiratory compromise, but it also has utility in the operating room. THRIVE can increase apnea time while preventing desaturation in patients undergoing short laryngological procedures, allowing an unobstructed view of the glottis. It can also prevent quick desaturation in patients who may be a difficult exposure prior to definitive airway management (eg, jet ventilation). The panelists will discuss what THRIVE is, how it works, and the type of patient for whom it is optimal. First, the system itself will be described, followed by an explanation of the physiology behind it. Finally, the panelists will discuss a number of cases in which this tool was successfully used, as well as cases in which it was not ideal. Throughout the session, the pearls and pitfalls of using THRIVE will be discussed. In conclusion, THRIVE is a practical and safe adjunct to airway management that can be implemented immediately; physicians should feel comfortable adding this tool to their repertoire.
Outcome Objectives: (1) Recognize the physiology of airway management using THRIVE. (2) Implement THRIVE as an adjunct to airway management in the operating room. (3) Recognize inherent limitations and patient factors that may restrict appropriateness of THRIVE.
Vocal Fold Leukoplakia: Cases, Controversy, and Management
Lee M. Akst, MD (Moderator); Kenneth W. Altman, MD, PhD; Matthew S. Broadhurst, FRACS; Vyas M. N. Prasad, MSc, FRCS
Session Description: This panel presentation comprehensively reviews evaluation and management of laryngeal leukoplakia. Updated from prior years, this iteration will explore management strategies through focus on a case-based approach. Although “white vocal fold lesions” are common, management remains challenging: Doing “too little” may allow precancerous lesions to progress, while doing “too much” may create unnecessary dysphonia. Using cases, panel discussion, and encompassing a variety of expert opinions and surgical techniques, this panel presentation will provide a framework for balancing oncologic with functional outcomes. It will highlight challenges, controversies, and merging paradigms in laryngeal leukoplakia care. There will be focus on surgical approaches that can be applied in current practice, including use of KTP and CO2 lasers and also discussion of what techniques are appropriate in the absence of a laser. Discussion will also include future technologies and adjuvant care of laryngeal leukoplakia, encompassing narrow-band imaging, optical coherence tomography, chemotherapy, radiotherapy, and photodynamic therapy as they apply to current and future state-of-the-art management.
Outcome Objectives: (1) Describe the risk of laryngeal leukoplakia progression to cancer, with the need to balance oncologic efficacy with function. (2) Review current and emerging techniques for accurate diagnosis, staging, and surveillance of laryngeal leukoplakia. (3) Discuss treatment alternatives for laryngeal leukoplakia in the office and operation rom, mentioning KTP, CO2, and cold-instrument techniques.
Zenker’s Diverticulum: Do You Have All the Tools?
Rebecca J. Howell, MD (Moderator); Brianna K. Crawley, MD; Milan R. Amin, MD; Philip A. Weissbrod, MD
Session Description: Treatment approaches for Zenker’s diverticulum have multiplied over the past 20 years, as interventional gastroenterologists have applied their flexible endoscopic techniques to this pathology. Sufficient data have now been amassed to support the safety and efficacy of the flexible endoscopic approach. Although most otolaryngologists already possess the skills required to apply the flexible endoscopic technique, few have embraced this technology. This session presents the flexible, rigid, and combined approaches to Zenker’s diverticulum, as well as the specific tools required, to ensure that otolaryngologists can offer all options to their patients. Patient selection, advantages, and drawbacks to each approach will be discussed. The goal of this session is to provide clinical information on preoperative, intraoperative, and perioperative (complications) for each technique and to introduce the flexible endoscopic approach to Zenker’s diverticulum in an otolaryngology practice, ensuring that our patients receive the best care in each clinical scenario.
Outcome Objectives: (1) Plan and perform flexible, rigid, or combined endoscopic approaches to Zenker’s diverticulum. (2) Recognize patient characteristics that favor one endoscopic approach over others. (3) Describe adverse events associated with each endoscopic and open approach.
