Hagit Shoffel-Havakuk

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.

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☆

OBJECTIVE To study volume characteristics of the maxillary, sphenoid and frontal sinuses among healthy Caucasians adults, using computed tomography (CT) scans. METHODS A 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). RESULTS The 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. CONCLUSION Volumes 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.

Single Stage Transoral Laser Microsurgery for Early Glottic Cancer

Objectives: The purpose of the study was to present the outcome of our management protocol of a single stage transoral laser microsurgery (SSTLM), with the intention of complete removal of a lesion, considered to be an early glottic cancer. Methods: Between January 2015 to February 2017 patients with the clinical appearance of an early glottic cancer, who were candidates for (SSTLM) management protocol, were included in this study. Type of cordectomy was determined by pre- and intra-operative evaluation of the extent of lesion in cord layers. Results: Thirty patients (6 females, 24 males; mean age 65 years) underwent SSTLM. Twenty-two patients had malignant histopathological diagnosis of severe dysplasia or Cis in 4 patients, microinvasice carcinoma in 3 patients and invasive carcinoma in 15 patients (T1a tumor in 14 and T1b tumor in 1). Eight patients had a nonmalignant histological diagnosis of keratosis without atypia in 2 patients, mild dysplasia in 2 patients and moderate dysplasia in 3 patients. Based on pre- and intra-operative evaluation, 14 subepithelial (type I), 10 subligamental (type II), and 6 transmuscular (type III) cordectomies were performed. Comparison of cordectomies types with postoperative histopathologic diagnosis showed an adequate extent of resection in 26 out of 30 patients (87%). Considering only patients without recent background of direct laryngoscopy and biopsy, an adequate resection was performed in 90% of patients. None of the patients was further treated by external beam radiation. At average follow-up of 21 months, none of the patients developed local recurrence. Conclusion: In selected cases, a SSTLM for clinical appearance of an early glottic cancer, allows a reliable histopathologic diagnosis and a high local control rate with favorable cost effectiveness. A careful pre- and intraoperative evaluation for selecting the appropriate cases for this management is required in order to avoid under- or over-treatment.

Early and Late Recurrent Epistaxis Admissions: Patterns of Incidence and Risk Factors

Objective Epistaxis is a common complaint, yet few studies have focused on the incidence and risk factors of recurrent epistaxis. Our objective was to determine the patterns of incidence and risk factors for recurrent epistaxis admission (REA). Study Design Case series with chart review. Settings Single academic center. Subjects and Methods The medical records of patients admitted for epistaxis between 1999 and 2015 were reviewed. The follow-up period was defined as 3 years following initial admission. REAs were categorized as early (30 days) and late (31 days to 3 years) following initial admission. Logistic regression was used to identify potential predictors of REAs. Results A total of 653 patients were included. Eighty-six patients (14%) had REAs: 48 (7.5%) early and 38 (6.5%) late. Nonlinear incidence curve was demonstrated for both early and late REAs. Based on logistic regression, prior nasal surgery and anemia were independent risk factors for early REAs. According to multivariate analysis, thrombocytopenia was significantly associated with late REAs. Conclusion Early and late REAs demonstrate different risk predictors. Knowledge of such risk factors may help in risk stratification for this selected group of patients. All patients at risk should be advised on possible preventive measures. Patients at risk for early REA may benefit from a more proactive approach.

Potential Causative Factors for Saccular Disorders: Association with Smoking and Other Laryngeal Pathologies

OBJECTIVE To describe risk factors, clinical presentation, and outcome of patients with saccular disorders. STUDY DESIGN Case control with chart review METHODS: A single center retrospective study. Case group included all adult patients, presenting with saccular disorders (saccular cyst or laryngocele), between the years 2010 and 2015. A matched group of patients with vocal fold cyst served as the control. RESULTS Twenty-nine patients met the inclusion criteria: 15 males and 14 females; the mean age was 60.5(±11.2). The median follow-up period was 10 months (range 2-48). Overall, 75.9% (22) had a positive smoking history; 55.2% (16) were active and 20.7% (6) were past smokers. The median pack- years of all smokers in the saccular disorder group was 40 (range 1-67). Saccular disorder patients demonstrated significantly higher prevalence of active smoking when compared to control patients (55.2% versus 17.9%, P = 0.014). Sixty-nine percent of the patients had some synchronous vocal fold comorbidity. The leading vocal fold comorbidity was Reinkes edema in 41% (12). Synchronous vocal fold comorbidities were significantly more prevalent in smokers compared with nonsmokers-82% (18 of 22) and 29% (2 of 7), respectively (P = 0.008). Surgical treatment was performed on 26 patients; all of whom underwent complete resection, either by endoscopic (92%), external (4%), or combined external and endoscopic (4%) approaches. There was a single case of recurrence (4%), 10 months following initial resection. CONCLUSION Saccular disorders are associated with smoking and synchronous vocal fold comorbidity. Complete resection is recommended as surgical outcome is excellent.

Increased number of volatile organic compounds over malignant glottic lesions

Electronic noses can identify diseases, including head and neck squamous cell carcinoma (SCC) by the fingerprint of volatile organic compounds (VOCs) in exhaled air. However, whether these VOCs originated from the malignant lesion itself remains unclear. The objective was to test for the presence and properties of VOCs directly over the vocal folds in malignant and benign lesions, as a potential tool for noninvasive screening.

Narrow Band Imaging: Demonstration of Laryngeal Micro-vascularization in Normal and Pathological Conditions

Objectives: With blue and green light only, narrow band imaging (NBI) allows better visualization of mucosal micro-vascular architecture. Intra-epithelial papillary capillary loops (IPCL) is a classification of vascular patterns based on previous esophageal NBI studies. The aims of the study were to: (1) Study the normal micro-vascular anatomy of the larynx by means of NBI. (2) Better understand the clinical applications of NBI in laryngeal lesions. (3) Assess the relative advantages and disadvantages of NBI versus white light imaging in the larynx. (4) Assess the relevance of previously described IPCL classification in laryngeal pathologies. Methods: A prospective comparative study including patients who arrived for laryngeal examination at an ENT referral center in 2013. White light images and NBI were compared in each patient to assess relative advantages of each modality. Micro-vascular architecture was described by IPCL classification. Results: A total of 110 patients were included and underwent video-stroboscopy, flexible distal-chip endoscopy, and NBI of the larynx. Thirty-two patients had a normal larynx, 54 had benign conditions, and 24 had malignant lesions. Distinct characteristics of vascular patterns were visualized by NBI in normal tissues, as well as a wide spectrum of benign and malignant conditions. In several patients with malignant and premalignant conditions, NBI revealed more extended disease than what was observed by white light imaging. Conclusions: Using NBI along with white light imaging, while understanding the unique microvascular fingerprint of each laryngeal pathologic condition, can assist the physician in differential diagnosis. In specific conditions, including malignant and premalignant lesions, NBI can bring better assessment of lesions’ size and extension.

Transnasal Office-Based Laryngeal Surgery Using a Distal-Chip Endoscope with a Working Channel

Objectives: The advanced technology of distal-chip flexible naso-endoscope (“chip-on-the-tip” processor), with high resolution digital video recording, allows for more accurate diagnosis, treatment, and follow-up of patients with laryngeal disease. Using this instrument with a working channel introduces a new surgical tool, allowing for a variety of transnasal surgical procedures under topical anesthesia. The aims of the study were to: (1) Describe the spectrum of treatment options for laryngeal pathologies using distal-chip flexible naso-endoscope. (2) Describe the variety of accessories that can be used. (3) Assess the relative advantages, limitations and risks. Methods: A retrospective series reviewing medical files of patients treated with the distal-chip endoscope during 2010 through 2013 for benign laryngeal conditions. Compliance, complications, surgical notes and long term outcome were documented. Results: Forty-six patients were treated by office-based laryngeal surgery during the study period. Surgeries performed: Diagnostic biopsies of the glottis, subglottis, and trachea and treatment of papillomatosis, fibrovascular lesions, granulation tissue, keratosis, stenosis, vocal cord paralysis, and cysts. Instruments used: anesthesia catheter, grasping forceps, injection needles, and lasers. No significant adverse effects or complications were documented. The only factor influencing procedure success was patient cooperation and ability to resist gag reflex. Most patients had transnasal surgery; few had combined transnasal and transoral procedures. Conclusions: The distal chip endoscope with a working channel enables the laryngeal surgeon to perform relatively complex procedures as an office-based surgery while avoiding the consequences of general anesthesia and operating room costs.