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Anaesthesia Reports 2020This report describes the care provided to a 64-year-old woman presenting with airway obstruction following recovery from COVID-19 pneumonitis, prolonged tracheal...
This report describes the care provided to a 64-year-old woman presenting with airway obstruction following recovery from COVID-19 pneumonitis, prolonged tracheal intubation and tracheostomy weaning. Her initial admission was with COVID-19 pneumonitis during the first surge of cases in early 2020, and was complicated by multiple bilateral segmental pulmonary emboli, a 28-day stay in intensive care, 16 days of mechanical ventilation and finally, a tracheostomy with subsequent weaning of respiratory support and rehabilitation. On presentation, her symptoms of airway obstruction were because of significant granuloma of the posterior glottis and subglottis, as well as a mild lambdoid deformity at the site of her previous tracheostomy. The key learning points described relate to the use of apnoeic oxygenation during the COVID-19 pandemic, managing the shared airway, as well as the management of post-intubation laryngotracheal complications.
PubMed: 33210096
DOI: 10.1002/anr3.12082 -
Indian Journal of Otolaryngology and... Dec 2020Schwannomas are a frequent cause of swellings in the head and neck region. Due to the abundance of peripheral, cranial and autonomic nerves in this region, schwannomas...
Schwannomas are a frequent cause of swellings in the head and neck region. Due to the abundance of peripheral, cranial and autonomic nerves in this region, schwannomas can present in variety of locations, posing a diagnostic and therapeutic challenge to the surgeon. Unusual sites in head and neck region can have varied presentation depending on the site of origin. We identified unusual extracranial locations of head and neck schwannomas, their presenting features and surgical management. Retrospective review of cases of extracranial head and neck schwannomas operated in the Department of Otolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, a tertiary referral centre between July 2015 and June 2019. A total of 42 cases of extracranial head and neck schwannomas were operated. Among them, 9 cases were found to arise from uncommon sites, such as parotid gland (n = 1), infratemporal fossa (n = 2), external auditory canal (n = 1), subglottis (n = 1), false vocal cord (n = 1), frontal recess (n = 1), maxillary sinus (n = 1) and retromolar trigone (n = 1). All patients underwent excision via relevant approaches. Nerve of origin was identified in 4/9 cases. One case had postoperative neurological deficit. No recurrences were noted in mean follow-up of 19 months. Schwannomas ought to be considered as a differential diagnosis for swellings/ mass in any part of head and neck region. Comprehensive evaluation with appropriate imaging and histology should be done in all cases. Preoperative counselling and consent regarding neurological deficit pertaining to possible nerve of origin is required in each case.
PubMed: 33088768
DOI: 10.1007/s12070-020-01820-1 -
Ear, Nose, & Throat Journal Jun 2022The hemangioma is the most common vascular tumor, involving the head and neck in 60% of cases. It is rare in the larynx. In children, hemangiomas are more frequent on... (Review)
Review
INTRODUCTION
The hemangioma is the most common vascular tumor, involving the head and neck in 60% of cases. It is rare in the larynx. In children, hemangiomas are more frequent on the subglottis, whereas in adults the most common site is the supraglottis. Laryngeal hemangioma with cavernous features isolated to the free edge of the vocal fold is a very rare clinical finding. We present 2 cases of glottic hemangioma. Both patients reported severe hoarseness.
CASES
In the first patient, an extensive blue-purple mass was seen on the right vocal cord. The patient was posted for microlaryngeal surgery with carbon dioxide (CO) laser. Second patient had a large, smooth, flesh-colored polypoid mass emanating from the left vocal cord. The patient was posted for microlaryngeal surgery. After 2 months, both patients showed a considerable voice improvement.
DISCUSSION
Vocal cord hemangiomas are very rare, and they usually cause problem in the voice of the patient. A vascular lesion that may mimic a hemangioma may sometimes result from an organizing hematoma following a hemorrhage on the vocal cords due to voice abuse. Laryngeal hemangiomas also need to be distinguished pathologically from polypoidal vascular granulation tissue that may be produced by laryngeal biopsy, intubation, or trauma. Indirect endoscopy is enough to diagnosis. No active treatment is advised for adult laryngeal hemangiomas unless the lesions are symptomatic or show a tendency to involve other parts. There is no uniformly accepted treatment of head and neck hemangiomas. Surgical excision with laser CO microlaryngoscopic techniques gives satisfactory results.
Topics: Adult; Carbon Dioxide; Child; Hemangioma; Humans; Laryngeal Neoplasms; Lasers, Gas; Vocal Cords
PubMed: 32921178
DOI: 10.1177/0145561320952191 -
The Laryngoscope Jul 2021Iatrogenic laryngotracheal stenosis (iLTS) is the pathological narrowing of the glottis, subglottis, and/or trachea due to scar tissue. Patients with type 2 diabetes...
OBJECTIVES
Iatrogenic laryngotracheal stenosis (iLTS) is the pathological narrowing of the glottis, subglottis, and/or trachea due to scar tissue. Patients with type 2 diabetes mellitus (T2DM) are over 8 times more likely to develop iLTS and represent 26% to 53% of all iLTS patients. In this investigation, we compared iLTS scar-derived fibroblasts in patients with and without T2DM.
STUDY DESIGN
Controlled ex vivo study.
METHODS
iLTS scar fibroblasts were isolated and cultured from subglottic scar biopsies in iLTS patients diagnosed with or without type 2 diabetes (non-T2DM). Fibroblast proliferation, fibrosis-related gene expression, and metabolic utilization of oxidative phosphorylation (OXPHOS) and glycolysis were assessed. Contractility was measured using a collagen-based assay. Metabolically targeted drugs (metformin, phenformin, amobarbital) were tested, and changes in fibrosis-related gene expression, collagen protein, and contractility were evaluated.
RESULTS
Compared to non-T2DM, T2DM iLTS scar fibroblasts had increased α-smooth muscle actin (αSMA) expression (8.2× increased, P = .020), increased contractility (mean 71.4 ± 4.3% vs. 51.7 ± 16% Δ area × 90 minute , P = .016), and reduced proliferation (1.9× reduction at 5 days, P < .01). Collagen 1 (COL1) protein was significantly higher in the T2DM group (mean 2.06 ± 0.19 vs. 0.74 ±.44 COL1/total protein [pg/μg], P = .036). T2DM iLTS scar fibroblasts had increased measures of OXPHOS, including basal respiration (mean 86.7 vs. 31.5 pmol/minute/10 μg protein, P = .016) and adenosine triphosphate (ATP) generation (mean 97.5 vs. 25.7 pmol/minute/10 μg protein, P = .047) compared to non-T2DM fibroblasts. Amobarbital reduced cellular contractility; decreased collagen protein; and decreased expression of αSMA, COL1, and fibronectin. Metformin and phenformin did not significantly affect fibrosis-related gene expression.
CONCLUSION
T2DM iLTS scar fibroblasts demonstrate a myofibroblast phenotype and greater contractility compared to non-T2DM. Their bioenergetic preference for OXPHOS drives their increased contractility, which is selectively targeted by amobarbital.
LEVEL OF EVIDENCE
NA Laryngoscope, 131:1570-1577, 2021.
Topics: Adult; Aged; Amobarbital; Biopsy; Case-Control Studies; Cell Proliferation; Cells, Cultured; Cicatrix; Constriction, Pathologic; Diabetes Mellitus, Type 2; Energy Metabolism; Female; Glottis; Glycolysis; Humans; Hypoglycemic Agents; Iatrogenic Disease; Intubation, Intratracheal; Laryngostenosis; Male; Metformin; Middle Aged; Muscle Contraction; Myofibroblasts; Oxidative Phosphorylation; Phenformin; Primary Cell Culture; Trachea; Tracheal Stenosis; Tracheostomy; Young Adult
PubMed: 32857885
DOI: 10.1002/lary.29026 -
The Laryngoscope Mar 2021Characterization of the localized adaptive immune response in the airway scar of patients with idiopathic subglottic stenosis (iSGS).
OBJECTIVES/HYPOTHESIS
Characterization of the localized adaptive immune response in the airway scar of patients with idiopathic subglottic stenosis (iSGS).
STUDY DESIGN
Basic Science.
METHODS
Utilizing 36 patients with subglottic stenosis (25 idiopathic subglottic stenosis [iSGS], 10 iatrogenic post-intubation stenosis [iLTS], and one granulomatosis with polyangiitis [GPA]) we applied immunohistochemical and immunologic techniques coupled with RNA sequencing.
RESULTS
iSGS, iLTS, and GPA demonstrate a significant immune infiltrate in the subglottic scar consisting of adaptive cell subsets (T cells along with dendritic cells). Interrogation of T cell subtypes showed significantly more CD69 CD103 CD8 tissue resident memory T cells (T ) in the iSGS airway scar than iLTS specimens (iSGS vs. iLTS; 50% vs. 28%, P = .0065). Additionally, subglottic CD8 clones possessed T-cell receptor (TCR) sequences with known antigen specificity for viral and intracellular pathogens.
CONCLUSIONS
The human subglottis is significantly enriched for CD8 tissue resident memory T cells in iSGS, which possess TCR sequences proven to recognize viral and intracellular pathogens. These results inform our understanding of iSGS, provide a direction for future discovery, and demonstrate immunologic function in the human proximal airway. Laryngoscope, 131:610-617, 2021.
Topics: Adult; Aged; Airway Obstruction; Antigens, CD; Antigens, Differentiation, T-Lymphocyte; CD8 Antigens; Cicatrix; Constriction, Pathologic; Female; Glottis; Humans; Immunohistochemistry; Immunologic Memory; Integrin alpha Chains; Laryngostenosis; Lectins, C-Type; Male; Middle Aged; T-Lymphocyte Subsets
PubMed: 32603507
DOI: 10.1002/lary.28840 -
Laryngoscope Investigative... Jun 2020Squamous cell carcinoma (SCC) of larynx is a common head and neck cancer. For cases that are node negative, the role of definitive concurrent chemoradiation is unclear...
BACKGROUND
Squamous cell carcinoma (SCC) of larynx is a common head and neck cancer. For cases that are node negative, the role of definitive concurrent chemoradiation is unclear and not supported by guidelines but used at provider discretion. To address this knowledge gap, we examined the oncological outcomes with additional chemotherapy and factors correlated with the chemotherapy administration.
METHODS
We queried the National Cancer Database for patients with early stage (T2N0M0) laryngeal SCC treated nonsurgically. Multivariable logistic regression identified predictors of chemotherapy. Multivariable Cox regression evaluated predictors of survival. Propensity matching accounted for indication biases.
RESULTS
We identified 7181 patients meeting the eligibility criteria, of which 1568 (22%) patients received chemotherapy in addition to radiation. Predictors of chemotherapy use included younger age, Caucasian race, more remote year of treatment, higher grade, sites other than glottis, treatment at a community cancer center, and use of intensity-modulated radiation therapy. Median overall survival was not significantly different in the two arms analyzed-65 months (95% confidence interval [CI] 60, 72months) with chemotherapy compared to 70 months without chemotherapy (95% CI 66, 75 months, <.37). Predictors for survival on propensity-matched multivariable analysis were increased age, male sex, less education, lower income, higher comorbidity score, receipt of treatment at a community center, and nonglottic sites.
CONCLUSIONS
This study shows no clear survival benefit with chemotherapy in early stage disease. Although this implies that chemotherapy should not be routinely delivered, individualized judgment and prospective studies are recommended as the biology behind this interesting finding is undefined.
LEVEL OF EVIDENCE
2C (Outcomes Research).
PubMed: 32596486
DOI: 10.1002/lio2.327 -
European Archives of... Dec 2020To describe the technique and outcomes of percutaneous tracheostomy under laryngosuspension.
PURPOSE
To describe the technique and outcomes of percutaneous tracheostomy under laryngosuspension.
METHODS
A consecutive series of patients who underwent percutaneous tracheostomy under laryngosuspension were reviewed for outcomes. The procedure is performed under general anesthesia and laryngosuspension. An 8.5 oral endotracheal tube is inserted and the cuff is inflated in the supraglottis, allowing access to the whole trachea and subglottis. The tube is taped to the laryngoscope. A rigid endoscope is inserted in the endotracheal tube through a swivel connector connected to the tube and the ventilation circuit. Percutaneous tracheostomy kit is used to perform dilatational tracheostomy at the desired level of the trachea under direct visual endoscopic control.
RESULTS
Forty-eight patients underwent percutaneous tracheostomy under laryngosuspension. Thirty-two cases were performed in an emergency after securing the airway with endotracheal intubation. In all other cases, tracheostomy was performed as a part of an elective procedure affecting the airway or in patients requiring prolonged ventilation. More than half of patients were considered high risk by virtue of one or more of the following: morbid obesity, prior neck surgery, prior neck radiotherapy, progressive head and neck cancer, or laryngotracheal stenosis. Complications occurred in seven cases.
CONCLUSION
Percutaneous tracheostomy under laryngosuspension has the advantage of optimal control of patient ventilation and hemostasis throughout the procedure. High-quality endoscopic vision and easy access to the airway under laryngosuspension allow tracheostomy to be performed with maximum safety.
Topics: Dilatation; Humans; Intubation, Intratracheal; Laryngoscopes; Trachea; Tracheostomy
PubMed: 32577900
DOI: 10.1007/s00405-020-06141-1 -
International Journal of Surgery Case... 2020Aspirated foreign bodies continue to pose challenges to Otorhinolaryngologists and are potentially life threatening thus an otorhinolaryngological emergency. The main...
Spontaneous expulsion of an intrabronchial sharp metallic foreign body and migration to the gastrointestinal tract at Muhimbili National Hospital: Case report and literature review.
INTRODUCTION
Aspirated foreign bodies continue to pose challenges to Otorhinolaryngologists and are potentially life threatening thus an otorhinolaryngological emergency. The main stay of treatment of foreign bodies (FBs) in the tracheobronchial tree remains to be bronchoscopy while bearing in mind earlier and safer removal of such foreign bodies. Spontaneous expulsion of an Intrabronchial foreign body is a rare entity with few cases reported in the available literatures.
PRESENTATION OF CASE
We are reporting a rare case of a 3-year old male child who presented to otorhinolaryngology department with a 2-days history of foreign body inhalation (sharp metallic pin) prior admission which undergone spontaneous migration and went to be excreted in feaces after passing through the gastrointestinal tract.
DISCUSSION
It is unwise, dangerous and inadvisable to wait for spontaneous expulsion in cases of intrabronchial foreign body but while preparing for endoscopy, a constant watch should be kept over the patient and every forceful bout of cough should be looked with suspicion of spontaneous expulsion and a danger of foreign body lodgment into subglottis during such rare but possible occurrence should be kept in mind.
CONCLUSION
It's always worth to rule out the possibility of foreign body inhalation in children with sudden onset of difficulty in breathing to avoid diagnostic delays.
PubMed: 32563834
DOI: 10.1016/j.ijscr.2020.05.100 -
Anaesthesia Nov 2020Tracheal tubes are routinely used in adults undergoing elective surgery. The size of the tracheal tube, defined by its internal diameter, is often generically selected... (Review)
Review
Tracheal tubes are routinely used in adults undergoing elective surgery. The size of the tracheal tube, defined by its internal diameter, is often generically selected according to sex, with 7-7.5 mm and 8-8.5 mm tubes recommended in women and men, respectively. Tracheal diameter in adults is highly variable, being narrowest at the subglottis, and is affected by height and sex. The outer diameter of routinely used tracheal tubes may exceed these dimensions, traumatise the airway and increase the risk of postoperative sore throat and hoarseness. These complications disproportionately affect women and may be mitigated by using smaller tracheal tubes (6-6.5 mm). Patient safety concerns about using small tracheal tubes are based on critical care populations undergoing prolonged periods of tracheal intubation and not patients undergoing elective surgery. The internal diameter of the tube corresponds to its clinical utility. Tracheal tubes as small as 6.0 mm will accommodate routinely used intubation aids, suction devices and slim-line fibreoptic bronchoscopes. Positive pressure ventilation may be performed without increasing the risk of ventilator-induced lung injury or air trapping, even when high minute volumes are required. There is also no demonstrable increased risk of aspiration or cuff pressure damage when using smaller tracheal tubes. Small tracheal tubes may not be safe in all patients, such as those with high secretion loads and airflow limitation. A balanced view of risks and benefits should be taken appropriate to the clinical context, to select the smallest tracheal tube that permits safe peri-operative management.
Topics: Adult; Elective Surgical Procedures; Equipment Design; Humans; Intubation, Intratracheal; Postoperative Complications
PubMed: 32415788
DOI: 10.1111/anae.15041 -
The Laryngoscope Feb 2021Idiopathic subglottic stenosis (iSGS) is an inflammatory process leading to fibrosis and narrowing of the laryngotracheal airway. There is variability in patient...
OBJECTIVES
Idiopathic subglottic stenosis (iSGS) is an inflammatory process leading to fibrosis and narrowing of the laryngotracheal airway. There is variability in patient response to surgical intervention, but the mechanisms underlying this variability are unknown. In this pilot study, we measure expression of candidate targets at the mucosal surface of the subglottis in iSGS patients. We aim to identify putative biomarkers for iSGS that provide insights into the molecular basis of disease progression, yield a gene signature for the disease, and/or predict a response to therapy.
STUDY DESIGN
In vitro comparative study of human cells.
METHODS
Levels of candidate transcripts and proteins were measured in healthy and stenotic laryngotracheal tissue specimens taken from the mucosal surface in 16 iSGS patients undergoing endoscopic balloon dilation. Pre- and post-operative pulmonary function test and patient reported voice and breathing outcomes were also assessed. Unsupervised clustering was used to define patient subgroups based on expression profile.
RESULTS
Pulmonary function and voice and breathing outcome metrics demonstrated significant post-operative improvement. Transcript levels of αSMA, CCL2, COL1A1, COL3A1, FN1, IFNG, and TGFB1 and protein levels of CCL2, IFNG, and IL-6 were significantly upregulated in stenotic as compared to healthy tissues. Marked heterogeneity was observed in the patterns of expression of candidate markers across individuals and tissue types. Patient subgroups defined by expression profile did not show a statistically significant difference in dilation interval.
CONCLUSION
Pro-inflammatory and pro-fibrotic pathways are significantly upregulated along the mucosal surface of stenotic laryngotracheal tissues, and CCL2 and IFNG merit further investigation as potential iSGS biomarkers.
LEVEL OF EVIDENCE
4 Laryngoscope, 131:342-349, 2021.
Topics: Adult; Aged; Biomarkers; Dilatation; Disease Progression; Endoscopy; Female; Fibrosis; Humans; Laryngeal Mucosa; Laryngostenosis; Larynx; Male; Membrane Proteins; Middle Aged; Pilot Projects; Predictive Value of Tests; Respiratory Function Tests; Trachea; Transcriptome
PubMed: 32369195
DOI: 10.1002/lary.28712