Upper airway injury is a recognized complication of prolonged endotracheal intubation, yet little attention has been paid to the consequences of laryngeal injury and functional impact. The purpose of ...our study was to prospectively define the incidence of acute laryngeal injury and investigate the impact of injury on breathing and voice outcomes.
Prospective cohort study.
Tertiary referral critical care center.
Consecutive adult patients intubated greater than 12 hours in the medical ICU from August 2017 to May 2018 who underwent laryngoscopy within 36 hours of extubation.
Laryngoscopy following endotracheal intubation.
One hundred consecutive patients (62% male; median age, 58.5 yr) underwent endoscopic examination after extubation. Acute laryngeal injury (i.e., mucosal ulceration or granulation tissue in the larynx) was present in 57 patients (57%). Patients with laryngeal injury had significantly worse patient-reported breathing (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 1.05; interquartile range, 0.48-2.10) and vocal symptoms (Voice Handicap Index-10: median, 2; interquartile range, 0-6) compared with patients without injury (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 0.20; interquartile range, 0-0.80; p < 0.001; and Voice Handicap Index-10: median, 0; interquartile range, 0-1; p = 0.005). Multivariable logistic regression independently associated diabetes, body habitus, and endotracheal tube size greater than 7.0 with the development of laryngeal injury.
Acute laryngeal injury occurs in more than half of patients who receive mechanical ventilation and is associated with significantly worse breathing and voicing 10 weeks after extubation. An endotracheal tube greater than size 7.0, diabetes, and larger body habitus may predispose to injury. Our results suggest that acute laryngeal injury impacts functional recovery from critical illness.
Objectives/Hypothesis
Laryngotracheal stenosis (LTS) is largely considered a structural entity, defined on anatomic terms (i.e., percent stenosis, distance from vocal folds, overall length). This has ...significant implications for identifying at‐risk populations, devising systems‐based preventive strategies, and promoting patient‐centered treatment. The present study was undertaken to test the hypothesis that LTS is heterogeneous with regard to etiology, natural history, and clinical outcome.
Study Design
Retrospective cohort study of consecutive adult tracheal stenosis patients from 1998 to 2013.
Methods
Subjects diagnosed with laryngotracheal stenosis (ICD‐9: 478.74, 519.19) between January 1, 1998, and January 1, 2013, were identified. Patient characteristics (age, gender, race, follow‐up duration) and comorbidities were extracted. Records were reviewed for etiology of stenosis, treatment approach, and surgical dates. Stenosis morphology was derived from intraoperative measurements. The presence of tracheostomy at last follow‐up was recorded.
Results
One hundred and fifty patients met inclusion criteria. A total of 54.7% had an iatrogenic etiology, followed by idiopathic (18.5%), autoimmune (18.5%), and traumatic (8%). Tracheostomy dependence differed based on etiology (P < 0.001). Significantly more patients with iatrogenic (66%) and autoimmune (54%) etiologies remained tracheostomy‐dependent compared to traumatic (33%) or idiopathic (0%) groups. On multivariate regression analysis, each additional point on Charlson Comorbidity Index was associated with a 67% increased odds of tracheostomy dependence (odds ratio 1.67; 95% confidence interval 1.04–2.69; P = 0.04).
Conclusions
Laryngotracheal stenosis is not a homogeneous clinical entity. It has multiple distinct etiologies that demonstrate disparate rates of long‐term tracheostomy dependence. Understanding the mechanism of injury and contribution of comorbid illnesses is critical to systems‐based preventive strategies and patient‐centered treatment.
Level of Evidence
4. Laryngoscope, 125:1137–1143, 2015
Because of the recurrent nature of idiopathic subglottic stenosis, routine follow-up is necessary for monitoring progression of stenosis. However, no easily accessible, standardized objective measure ...exists to monitor disease progression.
To determine whether peak expiratory flow (PEF) can be used as a reliable and easily accessible biometric indicator of disease progression relative to other validated spirometry measures in patients with idiopathic subglottic stenosis.
Prospectively collected data on PEF, expiratory disproportion index (EDI), and total peak flow (TPF) from 42 women with idiopathic subglottic stenosis without comorbid lower airway or parenchymal lung disease who were treated at a single tertiary referral center between 2014 and 2018 were analyzed. The mean follow-up period was 18.2 months (range, 2-40 months). Ten patients initially screened were not included in the analysis owing to comorbid glottic or supraglottic stenosis or nonidiopathic etiology.
Measurements of PEF, EDI, and TPF were taken at preoperative visits and at all other visits.
Forty-two women (mean age, 51.5 years; 98% white n = 41) met the inclusion criteria. The area under the curve for PEF was 0.855 (95% CI, 0.784-0.926). The optimal cutoff value was 4.4 liters per second (264 L/min), with a sensitivity and specificity of 84.4% and 82.0%, respectively. The area under the curve for EDI was 0.853 (95% CI, 0.782-0.925). For TPF, this was 0.836 (95% CI, 0.757-0.916).
This study provides evidence supporting the use of PEF as a simple, efficient, and accessible way of monitoring progression of idiopathic subglottic stenosis and predicting receipt of surgical intervention. Sensitivity and specificity of PEF were comparable to those of the more complex measures of TPF and EDI.
Introduction:
Double aortic arch is a rare congenital malformation of the aortic arch that most frequently presents in childhood. Early surgical intervention typically yields excellent outcomes.
...Objectives:
To describe aortotracheal fistula as a rare, yet serious complication of vascular ring and subsequent aortic aneurysm in an adult patient.
Methods:
Clinical history, as well as radiographic and endoscopic imaging were obtained to describe the development, diagnosis, and clinical course of this patient’s aortotracheal fistula. Additionally, follow up data was obtained to document the healing of this fistula after surgical repair.
Results:
We describe a case of a 46-year-old male with DiGeorge Syndrome and a double aortic arch, repaired in childhood, which developed into an aortotracheal fistula after tracheostomy placement as an adult.
Conclusions:
This case demonstrates that dangerous complications of a double aortic arch can persist into adulthood, even after surgical repair in infancy. Each patient’s unique anatomy must be considered when thinking about airway management and prevention of complications of this rare congenital anomaly.
Bilateral Vocal Fold Paralysis Following Electrocution Injury Kloosterman, Nicole; Esianor, Brandon; Gelbard, Alexander ...
OTO open : the official open access journal of the American Academy of Otolaryngology--Head and Neck Surgery Foundation,
April‐June 2021, Volume:
5, Issue:
2
Journal Article
Peer reviewed
Open access
This study was exempt by Vanderbilt University Medical Center Institutional Review Board (IRB #210379). A 19-year-old previously healthy man experienced an electrocution injury after contact with a ...homemade wood-carving device consisting of jumper cables, a car battery, and wires obtained from a microwave. He subsequently went into cardiopulmonary arrest requiring resuscitation and intubation. Initial exam was notable for electrical burns to lips and bilateral palms. The patient was extubated 3 days following the injury and reported throat pain without difficulty breathing. Two weeks after the accident, he developed progressively worsening dyspnea, which he self-managed with his father’s continuous positive airway pressure (CPAP) device. He reportedly visited external emergency departments a total of 6 times, over 3 months, for acute respiratory distress before presenting to our clinic for further management. On evaluation, he reported worsening dyspnea and dysphagia with an associated 20-lb weight loss. In-office laryngoscopy revealed bilateral vocal fold immobility with fixation in the paramedian position.The patient was taken to the operating room for direct laryngoscopy and tracheostomy. Intraoperative assessment revealed normal mobility of bilateral cricoarytenoid joints without evidence of scarring. A 6-0 cuffless Shiley tracheostomy tube was subsequently placed given degree of respiratory distress and hope for the return of vocal fold function. Postoperatively, the patient reported improvement in his breathing and swallow. Unfortunately, his vocal fold motion showed no signs of improvement at 2-, 4-, and 12-month follow-up visits (Figure 1). The patient was interested in undergoing cordotomy but was lost to follow-up.
Inhalation injury is independently associated with burn mortality, yet little information is available on the incidence, risk factors, or functional outcomes of thermal injury to the airway. In ...patients with thermal inhalation injury, we sought to define the incidence of laryngotracheal stenosis (LTS), delineate risk factors associated with LTS development, and assess long-term tracheostomy dependence as a proxy for laryngeal function. Retrospective cohort study of adult patients treated for thermal inhalation injury at a single institution burn critical care unit from 2012 to 2017. Eligible patients' records were assessed for LTS (laryngeal, subglottic, or tracheal stenosis). Patient characteristics, burn injury characteristics, and treatment-specific covariates were assessed. Descriptive statistics, Mann-Whitney U-tests, odds ratio, and chi-square tests compared LTS versus non-LTS groups. Of 129 patients with thermal inhalation injury during the study period, 8 (6.2%) developed LTS. When compared with the non-LTS group, patients with LTS had greater mean TBSA (mean 30.3, Interquartile Range 7-57.5 vs 10.5, Interquartile Range 0-15.12, P = .01), higher grade of inhalation injury (mean 2.63 vs 1.80, P = .05), longer duration of intubation (12.63 vs 5.44; P < .001), and greater inflammatory response (mean white blood cell count on presentation 25.8 vs 14.9, P = .02, mean hyperglycemia on presentation 176.4 vs 136.9, P = .01). LTS patients had a significantly higher rate of tracheostomy dependence at last follow-up (50 vs 1.7%, P < .001). Six percent of patients with thermal inhalation injury develop LTS. LTS was associated with more severe thermal airway injury, longer duration of intubation, and more severe initial host inflammation. Patients with inhalation injury and LTS are at high risk for tracheostomy dependence. In burn patients with thermal inhalation injury, laryngeal evaluation and directed therapy should be incorporated early into multispecialty pathways of care.
IntroductionIdiopathic subglottic stenosis (iSGS) is an unexplained progressive obstruction of the upper airway that occurs almost exclusively in adult, Caucasian women. The disease is characterised ...by mucosal inflammation and localised fibrosis resulting in life-threatening blockage of the upper airway. Because of high recurrence rates, patients with iSGS will frequently require multiple procedures following their initial diagnosis. Both the disease and its therapies profoundly affect patients’ ability to breathe, communicate and swallow. A variety of treatments have been advanced to manage this condition. However, comparative data on effectiveness and side effects of the unique approaches have never been systematically evaluated. This study will create an international, multi-institutional prospective cohort of patients with iSGS. It will compare three surgical approaches to determine how well the most commonly used treatments in iSGS ‘work’ and what quality of life (QOL) trade-offs are associated with each approach.Methods and analysisA prospective pragmatic trial comparing the ‘Standard of Care’ for iSGS at multiple international institutions. Patients with a diagnosis of iSGS without clinical or laboratory evidence of vasculitis or a history of endotracheal intubation 2 years prior to symptom onset will be included in the study. Prospective evaluation of disease recurrence requiring operative intervention, validated patient-reported outcome (PRO) measures as well as patient-generated health data (mobile peak flow recordings and daily steps taken) will be longitudinally tracked for 36 months. The primary endpoint is treatment effectiveness defined as time to recurrent operative procedure. Secondary endpoints relate to treatment side effects and include PRO measures in voice, swallowing, breathing and global QOL as well as patient-generated health data.Ethics and disseminationThis protocol was approved by the local IRB Committee of the Vanderbilt University Medical Center in July 2015. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and directly to patient with iSGS via social media-based support groups.Trial registration number NCT02481817.
Objectives/Hypothesis
Black patients generally present with advanced head and neck cancer resulting in decreased survival. The objective of this study was to determine whether equal access to ...laryngeal cancer care in a tertiary care Veterans Affairs (VA) Medical Center would result in similar survival for white and black patients.
Study Design
Retrospective chart review.
Methods
Patient and tumor characteristics, compliance with National Comprehensive Cancer Network (NCCN) guidelines, and survival outcomes were collected for 205 male patients with squamous cell carcinoma of the larynx treated between 2000 and 2012 at the Michael E. DeBakey Veterans Affairs Medical Center.
Results
Black patients constituted 33% of the entire cohort, were older (mean age, 65.1 vs. 62.1 years), and consumed less tobacco (46.6 vs. 65.8 mean pack‐years) than white patients. Disease stage and compliance with NCCN guidelines were not affected by race. Mean follow up time was 3.6 years. A higher recurrence rate was noted among white patients (24% vs. 15%, P < .05). Neither disease‐free survival (DFS) nor overall survival (OS) was significantly different between black and white patients (DFS 69% vs. 68%, P = .7; OS 68% vs. 77%, P = .1).
Conclusions
Utilization of a multidisciplinary approach to laryngeal cancer care at the VA medical center allows for high compliance with NCCN guidelines and excellent oncologic outcomes. Ethnicity did not impact stage at presentation, treatment selection, or treatment intensity in this patient cohort. Our data suggest that cancer care at a VA medical center results in clinical outcomes that do not significantly vary based on patient race.
Level of Evidence
2b. Laryngoscope, 123:2170–2175, 2013
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