Search

Introduction: The novel Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, may need intensive care unit (ICU) admission in up to 12% of all positive cases for massive interstitial pneumonia, with possible long-term endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common airway-related complications of such ICU maneuvers are laryngotracheal granulomas, webs, stenosis, malacia and, less commonly, tracheal necrosis with tracheo-esophageal or tracheo-arterial fistulae. Materials and methods: This paper gathers the opinions of experts of the Laryngotracheal Stenosis Committee of the European Laryngological Society, with the aim of alerting the medical community about the possible rise in number of COVID-19-related laryngotracheal stenosis (LTS), and the aspiration of paving the way to a more rationale concentration of these cases within referral specialist airway centers. Results: A range of prevention strategies, diagnostic work-up, and therapeutic approaches are reported and framed within the COVID-19 pandemic context. Conclusions: One of the most important roles of otolaryngologists when encountering airway-related signs and symptoms in patients with previous ICU hospitalization for COVID-19 is to maintain a high level of suspicion for LTS development, and share it with colleagues and other health care professionals. Such a condition requires specific expertise and should be comprehensively managed in tertiary referral centers. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to assess the outcome of treating glottic dysplasia and early squamous cell carcinoma (SCC) with potassium titanyl phosphate (KTP) photoangiolytic laser ablation. Methods: Patient demographics, comorbidities, and tumor characteristics were recorded. Perceptual, patient-reported, and objective voice outcomes were assessed. Use of treatment modalities in addition to the KTP laser, development of locoregional or metastatic SCC, and overall survival were recorded. Results: There were 23 patients with glottic dysplasia and 18 patients with glottic SCC. Mean age at treatment was 69 years. Most patients (95%) were male. Posttreatment fundamental frequency fell from 132 ± 35 to 116 ± 24 Hz (P = .03). Overall, 61% of patients achieved a normal voice. There was a learning-curve, and most treatment failures occurred in the first half of the series. Five-year KTP-only disease-control rates were 87.1% and 53.5% for dysplasia and malignancy, respectively. Five-year overall survival was 56%, with no laryngectomies or deaths due to SCC. Conclusions: Ablating dysplasia and early glottic cancer using a KTP laser is a viable treatment option. It has a learning curve and a failure rate but, in this series, no ultimate loss of oncologic control. Its introduction into clinical practice should be managed carefully in the context of multidisciplinary cancer care. Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

BACKGROUND Basal cell carcinoma (BCC) of the nipple–areola complex is uncommon. It has been suggested that BCCs in this region behave more aggressively, with a higher potential for distant spread, than in other anatomical sites. OBJECTIVE To address questions about etiology, behavior, optimal treatment, and prognosis of this entity. METHODS AND MATERIALS A literature search identifying all cases of BCC of the nipple and nipple–areola complex in the English literature from 1893 to 2008. RESULTS Thirty-four cases of BCC of the nipple, areola, or both were identified, mostly affecting middle-aged men. The majority of patients were treated with tissue-sparing surgery. There was a metastatic rate of 9.1%, and one patient died from the disease (3.0%). CONCLUSIONS The optimal treatment of this condition should be local excision, but patients with this condition should be followed up for primary site recurrence and axillary metastasis, because there is greater incidence than with BCC at other anatomical sites. Furthermore, proven axillary metastasis should be surgically treated. [ABSTRACT FROM AUTHOR]

Keypoints • Sialorrhoea can be a significant problem in both adults and children and can cause both physical and psychosocial problems. • Botulinum toxin has enjoyed an emergence in the treatment of sialorrhoea, a systematic review of the evidence for botulinum toxin reveals two randomised controlled trials (RCTs) and four other trials that fulfilled our inclusion criteria. • Both RCTs demonstrate the effectiveness of botulinum toxin in the management of sialorrhoea. • There was no clear evidence for one antigenic type of botulinum toxin over another and minimal evidence for the optimal dose of botulinum toxin for each antigenic type. No advantage is conferred in using ultrasound guidance in injecting the glands. • None of the RCTs or other studies directly compared submandibular versus parotid injection or directly compared botulinum toxin against surgery. Minor side effects were reported in one of the RCTs but overall botulinum toxin is a safe, minimally invasive and effective means in the treatment of sialorrhoea with the potential to become the treatment of choice. • Our review demonstrates that further randomised controlled trials are required to more fully evaluate this new modality of treatment. [ABSTRACT FROM AUTHOR]

We present a system for classification of bilateral vocal fold mobility impairment. Type 1 obstructions are caused by bilateral laryngeal denervation, most commonly due to bilateral recurrent laryngeal nerve palsy. Type 2 obstructions are caused by crico-arytenoid joint ankylosis. Type 3 obstructions are due to inter-arytenoid granulation tissue. Type 4 lesions are caused by mature inter-arytenoid scar tissue and type 5 lesions are complex or total laryngeal stenoses. [ABSTRACT FROM AUTHOR]

We estimate the population incidence of adult unilateral vocal fold mobility impairment at 5.13 per 100,000 per year. [ABSTRACT FROM AUTHOR]

Importance: The autonomic nervous system maintains internal stability by concurrently prioritizing and managing different functions. It is currently not known whether dysfunction at the aerodigestive junction could overwhelm autonomic control and impair other functions., Objective: To compare baroreflex sensitivity, a prognostically significant index of the autonomic system's ability to stabilize blood pressure, between patients with predominantly esophagogastric (digestive) and patients with predominantly laryngopharyngeal (aerodigestive) symptoms., Design, Setting, and Participants: A cross-sectional study, between 2018 and 2019, of adults undergoing esophagal manometry or transnasal panendoscopy was carried out in a specialist center. The analysis took place between 2023 and 2024., Main Outcomes and Measures: Heart rate and blood pressure were recorded and baroreflex sensitivity and heart rate variability were derived. Esophageal physiology was assessed with high-resolution manometry., Results: There were 30 and 23 patients in the digestive and aerodigestive groups, respectively. The mean (SD) age was 61 (15) years and there were 26 women and 27 men. Compared with patients in the digestive group, more patients in the aerodigestive group had voice or throat symptoms and fewer had classic reflux symptoms (odds ratio [OR], 5.65; 95% CI, 1.82-17.5; OR, 2.07; 95% CI, 1.28-3.33; and OR, 0.60; 95% CI, 0.38-0.95, respectively). Patients in the aerodigestive group had higher mean (SD) resting heart rate (93 [17] vs 75 [13] min-1; difference of means, -18 min-1; 95% CI, -26 to -10), lower resting mean (SD) arterial pressure (94 [16] vs 104 [23] mm Hg, OR, 10; 95% CI, -1 to 21), lower mean (SD) baroreflex sensitivity (3.77 [0.79] vs 9.76 [2.92] s-3mm Hg-1; OR, 6.0 s-3mmHg-1; 95% CI, 4.7-7.2), and lower mean (SD) parasympathetic-spectrum heart rate variability (0.68 [0.15] vs 1.30 [0.53]; OR, 0.62; 95% CI, 0.39-0.85). There was a correlation between reduced lower esophageal relaxation (integrated relaxation pressure) and reduced baroreflex sensitivity (r = -0.33; 95% CI, -0.58 to -0.03)., Conclusions: In this cross-sectional study of adults undergoing esophageal manometry or transnasal panendoscopy, patients with laryngopharyngeal symptoms had reduced baroreflex sensitivity, indicating diminished vagal control compared with patients with esophagogastric symptoms. The overwhelmed vagus hypothesis may explain these responses by considering autonomic functions as competing consumers of the finite regulatory resources of a common controller. The regulatory demands of maintaining a safe airway with concurrent laryngopharyngeal sensorimotor dysfunction, superadded to baseline demands for dual speech and aerodigestive control, could overwhelm and force the system to deprioritize less immediate functions like esophageal relaxation and the baroreflex. Measuring baroreflex sensitivity, now possible in routine clinical practice, could enable phenotyping and objective outcome assessment for laryngopharyngeal dysfunction. A neurophysiological model for considering laryngopharyngeal sensorimotor dysfunction could in turn move patient care toward a more holistic autonomic health footing.

Objectives/hypothesis: To perform a national review of the incidence and treatment of primary tracheal cancer and to identify gaps in service provision and factors associated with survival., Study Design: Retrospective analysis of Hospital Episode Statistics data for England between 1996 and 2011., Methods: Information about age, sex, morbidity, provider trust, diagnostic delay, nature of hospital admission and treatment, and palliation-free survival were recorded. The relationship between variables and survival was explored with Cox regression., Results: There were 874 patients, giving an incidence of 0.9 per million. Mean age at diagnosis was 66 ± 13, and there were 456 (52%) males. Mean presentation to diagnosis latency was 2.5 ± 8 months, and 40% of patients presented as emergency admissions. There were 19 cases of oesophageal involvement and 241 cases of bronchopulmonary involvement; and 188 patients developed distant metastases. There were 60 curative resections (6.9%), which was the most significant predictor of palliation-free survival (hazard ratio: 0.23; 95% confidence interval 0.13-0.38). Other prognostic variables included age, sex, emergency admission, interventional bronchoscopy, chemotherapy, oesophageal involvement, and distant metastases. Ten-year palliation-free survival was 60.8% with curative resection and 19.5% overall. Eighty-six percent of patients were treated in units that treated fewer than one patient per year., Conclusion: Tracheal cancer is under-recognized and under-treated. Early diagnosis, access to interventional bronchoscopy, and surgical treatment in specialist units may improve the survival of patients with this condition., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To assess the impact of pre-procedural remote ischemic preconditioning on the incidence of myocardial complications following percutaneous coronary intervention., Background: Ischemic preconditioning of a remote vascular territory improves the subsequent ischemic tolerance of distant organs., Method: The Myocardial Event Reduction with Ischemic Preconditioning Therapy (MERIT) trial recruited 80 consecutive patients undergoing elective angioplasty with drug-eluting stents to receive two 5-min lower limb tourniquet occlusions or an un-inflated tourniquet (controls) 1 h before the procedure. The primary outcome was troponin T level at 24 h. Secondary outcomes were intra-procedural chest pain and ST-segment deviation., Results: 6 patients in the control group and 2 in the ischemic preconditioning group had pre-procedural raised troponin T (p = 0.23). This increased to 16 (40%) in the control group and 5 (12.5%) in the study group at 24 h (p = 0.01). Fewer patients in the study group experienced intra-procedural chest pain (1 vs. 7, p = 0.056). Mean ST-segment deviation time was 13 ± 35 s in the study group and 58 ± 118 s in the control group (p = 0.02). At a mean follow-up of 11 months, the major adverse cardiac event rate did not differ significantly between the groups., Conclusion: These data suggest that ischemic preconditioning reduces the absolute risk of post-procedure cardiomyocyte necrosis by 27.5%, and reduces intra-procedural chest pain and ST-segment deviation in patients undergoing percutaneous coronary interventions. We suggest its routine use in percutaneous coronary intervention, although the long-term prognostic impact in this patient group warrants further investigation.

Objective: Myocardial injury, detected by rises in cardiac troponin I (TnI), is common and associated with decreased survival following open AAA surgery. We examined the relationship between perioperative myocardial injury and postoperative outcome., Design: Observational Cohort Study., Methods: Forty-three consecutive patients who underwent elective open AAA repair were screened for perioperative myocardial injury or infarction using serial TnI measurements (taken on days 1, 3, and 7), ECG and clinical assessment. The primary outcome was survival free of cardiac failure, or myocardial infarction (MI) at follow-up., Results: Twenty (47%) of the 43 patients had a TnI elevation. Of these, 11 (26%) patients met the criteria for MI. At a mean (+/-SD) follow-up of 1.5+/-0.8 years, 12 (28%) subjects had experienced at least one endpoint event. Survival free of cardiac failure or MI was 55% in patients who had TnI rises compared to 87% in those without (P=0.02). Logistic regression revealed that TnI elevation was an independent predictor of outcome with an odds ratio of 5.4 (95% CI 1.2-2.4, P=0.03)., Conclusion: Perioperative myocardial injury after elective open AAA repair predicts outcome after surgery. Routine TnI measurement should be considered in all patients, especially in those with high cardiovascular risk.

Background: Myocardial and renal injury commonly contribute to perioperative morbidity and mortality after abdominal aortic aneurysm repair. Remote ischemic preconditioning (RIPC) is a phenomenon whereby brief periods of ischemia followed by reperfusion in one organ provide systemic protection from prolonged ischemia. To investigate whether remote preconditioning reduces the incidence of myocardial and renal injury in patients undergoing elective open abdominal aortic aneurysm repair, we performed a randomized trial. METHOD AND RESULTS; Eighty-two patients were randomized to abdominal aortic aneurysm repair with RIPC or conventional abdominal aortic aneurysm repair (control). Two cycles of intermittent crossclamping of the common iliac artery with 10 minutes ischemia followed by 10 minutes reperfusion served as the RIPC stimulus. Myocardial injury was assessed by cardiac troponin I (>0.40 ng/mL), myocardial infarction by the American College of Cardiology/American Heart Association definition and renal injury by serum creatinine (>177 micromol/L) according to American Heart Association guidelines for risk stratification in major vascular surgery. The groups were well matched for baseline characteristics. RIPC reduced the incidence of myocardial injury by 27% (39% versus 12% [95% CI: 8.8% to 45%]; P=0.005), myocardial infarction by 22% (27% versus 5% [95% CI: 7.3% to 38%]; P=0.006), and renal impairment by 23% (30% versus 7%; [95% CI: 6.4 to 39]; P=0.009). Multivariable analysis revealed the protective effect of RIPC on myocardial injury (OR: 0.22, 95% CI: 0.07 to 0.67; P=0.008), myocardial infarction (OR: 0.18, 95% CI: 0.04 to 0.75; P=0.006) and renal impairment were independent of other covariables., Conclusions: In patients undergoing elective open abdominal aortic aneurysm repair, RIPC reduces the incidence of postoperative myocardial injury, myocardial infarction, and renal impairment.