To systematically review the symptoms and types of laryngeal injuries resulting from endotracheal intubation in mechanically ventilated patients in the ICU.
PubMed, Embase, CINAHL, and Cochrane ...Library from database inception to September 2017.
Studies of adult patients who were endotracheally intubated with mechanical ventilation in the ICU and completed postextubation laryngeal examinations with either direct or indirect visualization.
Independent, double-data extraction and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias assessment followed the Cochrane Collaboration's criteria.
Nine studies (seven cohorts, two cross-sectional) representing 775 patients met eligibility criteria. The mean (SD; 95% CI) duration of intubation was 8.2 days (6.0 d; 7.7-8.7 d). A high prevalence (83%) of laryngeal injury was found. Many of these were mild injuries, although moderate to severe injuries occurred in 13-31% of patients across studies. The most frequently occurring clinical symptoms reported post extubation were dysphonia (76%), pain (76%), hoarseness (63%), and dysphagia (49%) across studies.
Laryngeal injury from intubation is common in the ICU setting. Guidelines for laryngeal assessment and postextubation surveillance do not exist. A systematic approach to more robust investigations could increase knowledge of the association between particular injuries and corresponding functional impairments, improving understanding of both time course and prognosis for resolution of injury. Our findings identify targets for future research and highlight the long-known, but understudied, clinical outcomes from endotracheal intubation with mechanical ventilation in ICU.
Objectives
To investigate the role of laryngopharyngeal reflux (LPR) in the development of benign lesions of the vocal folds (BLVF).
Methods
PubMed, Cochrane Library, and Scopus were searched by ...three independent investigators for articles published between January 1990 and November 2018 providing substantial information about the role of LPR in the development of nodules, polyps, cysts, Reinke's edema, and sulcus vocalis. Inclusion, exclusion, diagnostic criteria and clinical outcome evaluation of included studies were analyzed using Preferred Reporting Items for Systematic Reviews and Meta‐Analyses criteria.
Results
Of the 155 relevant publications, 42 studies were included. Thirty‐five were clinical studies and seven were experimental research studying the impact of reflux on vocal fold tissue. Only seven clinical studies utilized objective LPR diagnoses (pH monitoring), suggesting an association between LPR and the development of nodules, polyps, and Reinke's edema. These studies were characterized by a substantial heterogeneity due to discrepancies in inclusion/exclusion criteria, diagnostic methods, and clinical outcome evaluation. The few basic science studies on this topic support that LPR creates an environment that may predispose to BLVF through changes in defense mechanisms of the vocal folds, cell‐to‐cell dehiscence, inflammatory reaction of the vocal folds, and reaction to phonotrauma.
Conclusions
Caustic mucosal injury from LPR could cause increased susceptibility of the vocal fold mucosa to injury and subsequent formation of nodules, polyps, or Reinke's edema. However, the heterogeneity and the low number of high‐quality studies limit the ability to draw definitive conclusions. Future clinical and experimental studies are needed to better identify the role of reflux in development of BLVF.
Laryngoscope, 129:E329–E341, 2019
To review the current literature about the epidemiology, clinical presentation, diagnosis, and treatment of laryngopharyngeal reflux (LPR).
PubMed, Cochrane Library, and Scopus.
A comprehensive ...review of the literature on LPR epidemiology, clinical presentation, diagnosis, and treatment was conducted. Using the PRISMA statement, 3 authors selected relevant publications to provide a critical analysis of the literature.
The important heterogeneity across studies in LPR diagnosis continues to make it difficult to summarize a single body of thought. Controversies persist concerning epidemiology, clinical presentation, diagnosis, and treatment. No recent epidemiologic study exists regarding prevalence and incidence with the use of objective diagnostic tools. There is no survey that evaluates the prevalence of symptoms and signs on a large number of patients with confirmed LPR. Regarding diagnosis, an increasing number of authors used multichannel intraluminal impedance-pH monitoring, although there is no consensus regarding standardization of the diagnostic criteria. The efficiency of proton pump inhibitor (PPI) therapy remains poorly demonstrated and misevaluated by incomplete clinical tools that do not take into consideration many symptoms and extralaryngeal findings. Despite the recent advances in knowledge about nonacid LPR, treatment protocols based on PPIs do not seem to have evolved.
The development of multichannel intraluminal impedance-pH monitoring and pepsin and bile salt detection should be considered for the establishment of a multiparameter diagnostic approach. LPR treatment should evolve to a more personalized regimen, including diet, PPIs, alginate, and magaldrate according to individual patient characteristics. Multicenter international studies with a standardized protocol could improve scientific knowledge about LPR.
Globus pharyngeus is the uncomfortable sensation of a "lump in the throat," and at present it has many recognized pathophysiologic causes. However, until relatively recently, this condition was often ...labeled "globus hystericus" and was thought to be a manifestation of hysteria or anxiety. In this commentary, we briefly review the history surrounding the initial treatment of globus pharyngeus sensation as a hysterical condition rooted in anxiety/psychological causes; then, we briefly review the emerging evidence that roots globus pharyngeus sensation within a constellation of pathophysiologies that are related to pharyngoesophageal inflammation and irritation rather than psychological disorders.
Objectives
Retrograde cricopharyngeal dysfunction (RCPD) is a newly described condition resulting from failure of cricopharyngeal sphincter relaxation during periods of esophageal distension that ...results in the inability to burp. Patients' perspectives on symptom experiences, barriers to care, and treatment benefits were investigated.
Study Design
Qualitative semi‐structured interviews were conducted with patients diagnosed with RCPD who had been treated with botulinum toxin injection into the cricopharyngeus muscle. Interview questions centered on their experience living with RCPD. Conventional content analysis was performed on interview transcripts.
Results
Thematic saturation was reached with 13 participants. All participants were diagnosed with RCPD by an otolaryngologist and underwent botulinum toxin injection into the cricopharyngeus muscle with or without dilation of the upper esophageal sphincter in the operating room. Participants described having no memories of ever being able to burp, and all started experiencing RCPD symptoms during adolescence. Patients with RCPD experienced increased social isolation, lost productivity, and worsened mental health. Unanimously, participants first learned about RCPD on social media. All patients were seen by physicians in non‐otolaryngology specialties regarding their symptoms prior to learning about their RCPD diagnosis and undergoing treatment by an otolaryngologist. Dilation and chemodenervation resulted in complete resolution of RCPD symptoms for 84.6% of participants. Participants emphasized a desire for more health providers to learn about RCPD and the impact it has on quality‐of‐life.
Conclusion(s)
The lived experience of patients with RCPD significantly impacts quality of life and is often met with diagnostic barriers in the medical community. Although social media plays a significant role in increasing awareness of RCPD, physician education about the impact of RCPD is essential to improve diagnosis and treatment.
Level of Evidence
4 Laryngoscope, 134:2136–2143, 2024
Qualitative semi‐structured interviews were conducted with patients diagnosed with retrograde cricopharyngeal dysfunction (RCPD) who had been treated with botulinum toxin injection into the cricopharyngeus muscle. The lived experience of patients with RCPD significantly impacts quality of life and is often met with diagnostic barriers in the medical community. Although social media plays a significant role in increasing awareness of RCPD, physician education about the impact of RCPD is essential to improve diagnosis and treatment.
Background
Diagnosis and treatment of presumed laryngopharyngeal reflux (LPR) remain controversial. Empiric medication trials remain widespread for suspected LPR despite emerging evidence against ...proton pump inhibitor (PPI) safety and for pepsin as a mediator of LPR symptoms. Ongoing concerns exist related to inaccurate diagnosis, the cost and morbidity of potentially unnecessary PPI prescriptions, and availability and interpretation of objective reflux testing.
Objectives
To review contemporary evidence that does and does not support empiric medication trials for presumed LPR.
Methods
PubMed, Scopus and Cochrane Library were searched for literature about benefits, limitations and alternatives to empiric medication trial for LPR, in order to present both sides of this debate and identify best practices.
Results
The majority of physicians perform prolonged empiric medication trial with PPIs for patients with suspected LPR. Because symptoms and signs of LPR are non‐specific, empiric medication trials require exclusion of other conditions that can mimic LPR. Following a PPI empiric medication trial, over one‐third of patients remain non‐responders. The use of hypopharyngeal‐oesophageal multichannel intraluminal impedance‐pH monitoring (HEMII‐pH) has benefits and limitations in objective diagnosis of LPR.
Conclusions
Use of PPIs for single‐agent empiric medication trial does not account for possible non‐responders with non‐acid or mixed LPR. If LPR diagnosis remains uncertain, alginates can be added to PPI trials. HEMII‐pH testing upfront is ideal for patients with suspected LPR, but not always practical; it is indicated when PPI and alginate empiric medication trials have failed or when comorbidities confuse the diagnosis. A more comprehensive, combination therapy empiric medication trial regimen may be needed.
To assess the readability and quality of online materials for Zenker’s diverticulum. A Google search of “Zenker’s diverticulum” was performed and the first 50 websites were reviewed. Readability was ...measured by Flesch Reading Ease (FRES), Flesch-Kincaid Grade Level (FKGL) and the Simple Measure of Gobbledygook (SMOG) scores using an online calculator. Understandability and actionability were assessed with the Patient Education Materials Assessment Tool for Printed Materials (PEMAT-P). Websites were categorized as either patient-targeted or physician-targeted and unpaired t tests were used to compare scores between these two groups. A total of 31 websites (23 patient-oriented sites and 8 physician-oriented sites) were analyzed. The average FRES, FKGL, and SMOG scores were 29.96 ± 14.72, 13.75 ± 2.78, and 12.19 ± 2.02, respectively, for the entire cohort. Readability scores for the patient-oriented sites were better than the physician-oriented sites for each measure (FRES 36.21 ± 8.86 vs 11.96 ± 13.54, FKGL 12.68 ± 1.58 vs 16.85 ± 3.25, and SMOG 11.37 ± 1.26 vs 14.53 ± 1.98;
p
< 0.001 for all comparisons). PEMAT-P understandability and actionability scores for the entire cohort were 68.20% ± 10.19% and 10.75% ± 16.52% respectively, and did not differ between patient-oriented and physician oriented sites. Though patient-oriented sites had better readability than physician-oriented sites for Zenker’s Diverticulum, both categories had readability levels more advanced than what is recommended for medical education materials.
Laryngopharyngeal reflux (LPR) is frustrating, as symptoms are nonspecific and diagnosis is often unclear. Two main approaches to diagnosis are empiric treatment trials and objective reflux testing. ...Initial empiric trial of Proton pump inhibitors (PPI) twice daily for 2-3 months is convenient, but risks overtreatment and delayed diagnosis if patient complaints are not from LPR. Dietary modifications, H2-antagonists, alginates, and fundoplication are other possible LPR treatments. If objective diagnosis is desired or patients' symptoms are refractory to empiric treatment, pH testing with/without impedance should be considered. Additionally, evaluation for non-reflux etiologies of complaints should be performed, including laryngoscopy or videostroboscopy.
Objectives
Transoral laser microsurgery (TLMS) and radiotherapy (XRT) are mainstays of treatment for early glottic carcinoma (EGC). Here, we investigated case‐dependent provider treatment preferences ...and identify factors which impact decision‐making in EGC.
Methods
This cross‐sectional survey of laryngologists, head‐and‐neck surgeons, and radiation oncologists presented five diagrammatic cases of progressively advanced EGC (T1/2, N0). Respondents indicated preference for TLMS or XRT and ranked factors which influenced their recommendation for each case. Analysis utilized descriptive statistics, Fischer's exact tests, and Kruskal–Wallis tests for nonparametric data.
Results
A total of 141 complete responses (69.5% laryngologists) were received. Most respondents practiced in academic settings (93.5%) and within multidisciplinary teams (94.0%). Anterior commissure involvement was the most important a priori tumor factor for case‐independent treatment recommendation (Likert Scale: 4.22/5), followed by Laterality (Likert Scale: 4.02/5). Across all specialties, TLMS was recommended for unilateral T1a lesions. Laryngologists continued recommending TLMS in T2 lesions (41.0%) more than head‐and‐neck surgeons (5.0%) and radiation oncologists (0.0%). Across all cases, survival and voice outcomes were the most important clinical factors impacting treatment decisions. Radiation oncologists weighed voice more heavily than laryngologists in more complex presentations of EGC (rank: 1.6 vs. 2.7, Kruskall–Wallis: p < 0.05).
Conclusions
In more complex clinical presentations of EGC, preference for TLMS compared to XRT differed across specialists, despite similar rankings of factors driving these treatment recommendations. This may be driven by differing experiences and viewpoints on case‐dependent voice outcomes following TLMS versus XRT, suggesting a need for increased understanding of how tumor location and depth impact voice outcomes.
Level of Evidence
5 Laryngoscope, 134:3686–3694, 2024
Laryngeal injury from intubation can substantially impact airway, voice, and swallowing, thus necessitating multidisciplinary interventions. The goals of this systematic review were (1) to review the ...types of laryngeal injuries and their patient-reported symptoms and clinical signs resulting from endotracheal intubation in patients intubated for surgeries and (2) to better understand the overall the frequency at which these injuries occur. We conducted a search of 4 online bibliographic databases (ie, PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature CINAHL, and The Cochrane Library) and ProQuest and Open Access Thesis Dissertations (OPTD) from database inception to September 2019 without restrictions for language. Studies that completed postextubation laryngeal examinations with visualization in adult patients who were endotracheally intubated for surgeries were included. We excluded (1) retrospective studies, (2) case studies, (3) preexisting laryngeal injury/disease, (4) patients with histories of or surgical interventions that risk injury to the recurrent laryngeal nerve, (5) conference abstracts, and (6) patient populations with nonfocal, neurological impairments that may impact voice and swallowing function, thus making it difficult to identify isolated postextubation laryngeal injury. Independent, double-data extraction, and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Collaboration's criteria. Twenty-one articles (1 cross-sectional, 3 cohort, 5 case series, 12 randomized controlled trials) representing 21 surgical studies containing 6140 patients met eligibility criteria. The mean patient age across studies reporting age was 49 (95% confidence interval CI, 45-53) years with a mean intubation duration of 132 (95% CI, 106-159) minutes. Studies reported no injuries in 80% (95% CI, 69-88) of patients. All 21 studies presented on type of injury. Edema was the most frequently reported mild injury, with a prevalence of 9%-84%. Vocal fold hematomas were the most frequently reported moderate injury, with a prevalence of 4% (95% CI, 2-10). Severe injuries that include subluxation of the arytenoids and vocal fold paralysis are rare (<1%) outcomes. The most prevalent patient complaints postextubation were dysphagia (43%), pain (38%), coughing (32%), a sore throat (27%), and hoarseness (27%). Overall, laryngeal injury from short-duration surgical intubation is common and is most often mild. No uniform guidelines for laryngeal assessment postextubation from surgery are available and hoarseness is neither a good indicator of laryngeal injury or dysphagia. Protocolized screening for dysphonia and dysphagia postextubation may lead to improved identification of injury and, therefore, improved patient outcomes and reduced health care utilization.
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