Doron Halperin

Feasibility of a single-stage tracheostomy decannulation protocol with endoscopy in adult patients.

Gradual decrease in tube size and tube capping are considered the standard of care for tracheostomy decannulation. Both of these actions result in increased airway resistance. Immediate decannulation may offer a more tolerable approach.

Lesions of the posterior glottis: clinical and pathologic considerations and treatment outcome.

OBJECTIVEnTo assess the clinical profile, presentation, prognosis, and response to treatment of patients with posterior glottic lesions and the prevalence of malignancy in this group.nnnSTUDY DESIGNnRetrospective cohort.nnnMETHODSnStudying medical records, videostroboscopic examinations, and pathologic reports of patients diagnosed and treated between 2008 andxa02011.nnnRESULTSnForty-six patients had lesions limited to the posterior glottis. Forty-one of the cases were diagnosed clinically or pathologically as inflammatory granulation tissue; three were cysts; one carcinoma in situ; and one invasive squamous cell carcinoma. Of the inflammatory granulation patients, 71% had lesions defined as spontaneous and 29% were considered iatrogenic. Reflux symptoms and reflux signs, as well as psychological stress were significantly more prevalent in the spontaneous group. Fifty percent of the patients with spontaneous lesions had psychological stress, compared with 8% in the iatrogenic group (P valuexa0=xa00.009). Smoking was a significant risk factor in the iatrogenic group (54% vs 21% P valuexa0=xa00.03). Nine percent of the lesions were treated with primary surgery. Ninety-one percent were treated with primary conservative management, of whom 31% were eventually referred to surgery. Overall, 91% of the patients were treated successfully. All cases of iatrogenic lesions responded to conservative management or a single surgical intervention. All patients that required multiple interventions were spontaneous.nnnCONCLUSIONSnThe results of this study suggest that only a small percent of posterior glottic lesions are malignant, thus the decision about biopsy should be based on clinical judgment. Also, spontaneous granulomas are more refractory to treatment, which can be explained by the repetitive exposure to the etiologic factors.

Does narrow band imaging improve preoperative detection of glottic malignancy? A matched comparison study

The primary suspicion for glottic malignancy during office laryngoendoscopy is based on lesion appearance. Previous studies investigating laryngeal use of narrow band imaging (NBI) are mostly descriptive. The additive value of NBI relative to white light (WL) requires further investigation.

Volumetric analysis of the maxillary, sphenoid and frontal sinuses: A comparative computerized tomography based study☆

OBJECTIVEnTo study volume characteristics of the maxillary, sphenoid and frontal sinuses among healthy Caucasians adults, using computed tomography (CT) scans.nnnMETHODSnA retrospective, case series study in a single academic center, CT scans of 201 consecutive adult subjects, performed between January and September 2014, were reviewed for the volume and dimensions of the paranasal sinuses. Patients with documented sinus pathology or lack of pneumatization were excluded. The study population was subdivided by gender and age (50 men age 25-64; 51 men age ≥65; 50 women age 25-64, and 50 women age ≥65).nnnRESULTSnThe mean volume of maxillary, sphenoid and frontal sinuses in the four groups were 12.75±4.38 cc; 4.00±1.99 cc and 2.92±2.57 cc, respectively. In both genders, older patients demonstrated a significantly lower volume of the maxillary and sphenoid sinuses (14.81±3.96 cc vs. 11.82±4.28 cc and 4.84±1.97 vs. 3.84±1.89 cc respectively; p<0.001). No age related difference was found in the frontal sinus. Males had significantly larger sinus volumes than females (p<0.001): maxillary 14.38±(4.64) vs. 12.23±(3.82) cc, sphenoid 4.74±(2.06) vs. 3.55±(1.73) cc, frontal 3.74±(2.97) vs. 3.21±(2.79) cc. No synergistic effect of age and gender was found.nnnCONCLUSIONnVolumes of the paranasal sinuses correlates with age and gender. Age related volume degeneration is expected in the maxillary and sphenoid sinuses. This volume reduction may influence future surgical and therapeutic approaches in the geriatric population.

The Anatomic Distribution of Malignant and Premalignant Glottic Lesions and Its Relations to Smoking

Objective To describe the anatomic location and distribution of glottic dysplasia and early glottic cancer. Study Design Case series with chart review. Setting Tertiary care referral center. Subjects and Methods Review of 167 glottic dysplasia or carcinoma patients between 2008 and 2013. Lesions were described in terms of location and size, and a novel grid system was used to map out anatomic distribution. Results Seventy-eight patients with dysplasia and 89 with early glottic carcinoma were included. One hundred twenty-eight were smokers and 39 nonsmokers. The medial aspect of the vocal fold was more involved than the superior aspect, 95% versus 71%, respectively (P < .001). The superior aspect was more involved in smokers, 77% versus 51% in nonsmokers (P = .0016). Using a grid system, the most involved area was the midpoint of the membranous vocal fold at the transition between the superior and medial aspects. Ninety-seven percent of the lesions occupied this specific area, with no difference between smokers and nonsmokers. The vocal process mucosa was involved in 48 patients. Exclusive vocal process involvement was limited to 2 cases. All other 46 patients demonstrated extensive disease, encompassing more than half of the vocal fold’s length. Carcinomatous lesions tended to be larger relative to dysplastic lesions. Otherwise, all lesion types showed a similar pattern of distribution. Conclusions Premalignant and malignant glottic lesions tend to involve the medial aspect of the vocal fold and the midpoint of the membranous part in particular. In smokers, lesions tend to be larger on presentation and are more likely to involve the superior aspect.

Menstrual Cycle, Vocal Performance, and Laryngeal Vascular Appearance: An Observational Study on 17 Subjects

OBJECTIVEnTo assess the anatomical and functional features of the vocal folds during different phases of the female menstrual cycle.nnnMETHODSnAn observational study of 17 healthy fertile female volunteers not using hormonal contraception was carried out. Each volunteer underwent two examinations: first, during the early days of the menstrual cycle when progesterone levels are low (p-depletion), and second, during premenstruation when progesterone levels are high (p-peak). The workup included blood hormone levels, Voice Handicap Index, acoustic analysis, rigid telescopy, stroboscopy, and narrow band imaging. The videos were evaluated by blinded observers.nnnRESULTSnThe participants mean age was 31.7u2009±u20095.6 (range 23-43). Progesterone levels were 13- to 45-fold higher in p-peak relative to p-depletion. No significant differences were detected in Voice Handicap Index scores, stroboscopic reports, or acoustic analysis between p-peak and p-depletion examinations. Analyzing the rigid telescopy and narrow band imaging videos, the observers tended to estimate the different laryngeal subsites more vascularized during the p-peak examination. Moreover, this tendency was significantly correlated with blood progesterone levels during the p-depletion examinations; the lower the blood progesterone levels were during p-depletion, the higher the probability for the observers to estimate the p-peak examinations more vascularized (P valueu2009=u20090.024).nnnCONCLUSIONSnAlterations in laryngeal vascular characteristics are evident throughout the menstrual cycle and may suggest increased congestion during premenstrual days. Variations in progesterone levels during the menstrual cycle correlate with laryngeal vascular changes. Hormone-related alterations in vocal folds vascularity may have a role in the variability of vocal performance in certain women.

Analysis of cigarette smoking mechanism by real time video-endoscopic documentation.

Abstract Objective: To view, document and analyze the smoking mechanism as seen via video-endoscopic examination during the action of cigarette smoking. Study design: Observational study. Methods: Twenty-two healthy smoking volunteers were examined with a trans-nasal video-laryngoscope while breathing, sniffing and cigarette smoking. Smoking a whole cigarette was recorded in each participant. The different stages of smoking were defined and their duration was measured. The glottic opening angle was calculated during breathing, sniffing and smoking. Results: A smoking cycle with four distinct stages was recognized. The stages included an oral smoke accumulation, pharyngo-laryngeal jet inhalation, infralaryngeal spread, and finally humidified exhalation stage. The stages mean duration was 1.93(±1.21), 0.39(±0.31), 2.00(±1.12) and 4.5(±2.70) seconds, respectively. The glottic opening angle during smoke inhalation was wider in 16% (pu2009=u20090.02) compared to normal inhalation during breathing. The glottic opening during smoke exhalation was comparable to what was observed during normal exhalation. The reduction in the glottic opening was more significant during the action of smoking compared with normal breathing (pu2009=u20090.042). Conclusions: Smoking follows a consistent sequence of events, defined by specific anatomic configuration and relatively persistent duration. The fast turbulent flow of the smoke over the narrow glottic aperture and at the areas of bifurcation at the trachea and bronchi may have a role in the high relative risk for carcinoma in these areas.

Bedside percutaneous dilatational tracheostomy in patients outside the ICU: a single-center experience

Purpose: To assess the safety of medical‐ward bedside percutaneous dilatational tracheostomy (GWB‐PDT). Materials and methods: A retrospective study of all patients who underwent elective GWB‐PDT between 2009 and 2015. A joint otolaryngology–ICU team performed all GWB‐PDTs. The patients were followed until decannulation, discharge or death. Complications were divided into early (within 24 h) and late, and into minor and major. Results: Two hundred and fifty six patients were included in the study. The mean age was 77.7 ± 11.8 Medical history included cardiac comorbidities (42.6%) and cerebrovascular accidents (34.4%). Overall, 48 patients (18.9%) had 60 complications, of which 70% (42/60) were minor (13 early; 29 late complications). Fifteen patients (5.9%) had major complications. Eight patients had early major complications (loss of airway – two patients [0.8%], pneumothorax – two patients [0.8%], resuscitation ‐ one patient [0.4%], and a single patient (0.4%) died within 24 h following PDT). Two additional patients (0.8%) underwent conversion to an open tracheostomy. Seven patients had late complications (airway complications in six patients [2.3%] and major bleeding in a single patient [0.4%]). Of the seven patients with late major complications, three had two major complications. Half of the complications occurred by POD 3. Conclusion: GWB‐PDT is a feasible and safe solution for tracheostomies in general‐ward ventilated patients. HighlightsShortage in ICU beds resulted in intermediate care units and medical wards ventilated patients.These patients are characterized by older age and higher frailty compared with ICU patients.Medical ward bedside percutaneous tracheostomy is conducted by a joint ICU‐otolaryngology team.MWB‐PDT can be performed with an acceptable rate of complications despite non‐ideal conditions.

Intravenous opioid drug abuse as an independent risk factor for supraglottic squamous cell carcinoma-A case-control study

Intravenous opioid drug abuse (IVDA) was previously correlated with laryngeal cancer. However, discrimination of this correlation by anatomical subsites has not yet been described. In this study, we aim to further establish the association between IVDA and laryngeal squamous cell carcinoma (SCC) and to indicate the laryngeal subsites that are predisposed for this correlation.

Correlation Between Pharyngeal Residue and Aspiration In Fiberoptic Endoscopic Evaluation of Swallowing – An Observational Study

OBJECTIVESnTo examine the correlation between pharyngeal residue severity and clearance to penetration/aspiration on fiber-optic endoscopic examination of swallowing (FEES).nnnDESIGNnRetrospective cohort.nnnSETTINGnKaplan Medical Center dysphagia clinic.nnnPARTICIPANTSnPatients (N=110) visiting a dysphagia clinic between 2014 and 2016 undergoing FEES.nnnINTERVENTIONSnFEES were scored for penetration/aspiration with the Penetration Aspiration Scale (PAS), for residue severity using the Yale Pharyngeal Residue Severity Rating Scale (YPR-SRS). The numbers of swallows required to clear the pharynx were recorded. The first and the worst bolus challenges for each consistency (liquid, purée, solid) were analyzed.nnnMAIN OUTCOME MEASURESnYPR-SRS and number of clearing swallows were correlated with the PAS of the same bolus challenge.nnnRESULTSnThe study populations mean age was 67±13.4 years; 54% were men (n=58). A significant correlation was found between the YPR-SRS and the PAS for all consistencies tested, in each anatomical site (vallecula or pyriform sinus) and for both the first and worst bolus challenges (P<.001 for all). The correlation of residue with aspiration was stronger when vallecula and pyriform sinuses scores were summated (Pearson product-moment correlation coefficient=0.573/0.631/0.446 for liquid/purée/solid for worst bolus challenge). Incorporating the number of clearing swallows to the YPR-SRS strengthened the correlation with PAS.nnnCONCLUSIONSnResidue severity and clearance correlate with penetration/aspiration on FEES. The YPR-SRS can be applied to standardize description of residue in FEES and to aid in dysphagia evaluation.