Karen M. Kost

Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases.

Objectives/Hypothesis: An evaluation of 500 adult, intubated, intensive care unit patients undergoing endoscopic percutaneous tracheotomy using the multiple and single dilator techniques was conducted to assess the feasibility and safety of the procedure as it compares with surgical tracheotomy. Endoscopy was used in all cases and evaluated as an added safety measure in reducing complications.

High prevalence of obstructive sleep apnea among patients with head and neck cancer.

OBJECTIVES To determine the prevalence of obstructive sleep apnea (OSA) in patients with cancer of the oral cavity and oropharynx scheduled for primary surgical resection. To correlate the presence of OSA and the occurrence of postoperative morbidities in this patient population. METHODS This was a prospective study involving 17 patients with malignancies of the oral cavity and oropharynx scheduled for primary surgical resection. Consecutive patients were approached to undergo overnight polysomnography to determine the apnea-hypopnea index (AHI). OSA was defined by an AHI value > or = 20 events per hour. Postoperative morbidities were evaluated in a blinded fashion for the patients completing surgery. RESULTS OSA was present in 13 of 17 patients, yielding a striking prevalence of 76% in this patient group. The mean AHI for patients with OSA was 44.7 +/- 3.5 (standard error) events per hour, with a mean nadir oxygen saturation of 88.2 +/- 1.8%, consistent with moderate to severe sleep-disordered breathing. The OSA and non-OSA patients were similar with respect to age and body mass index. The mean size of the primary tumour was 3.3 cm in patients with an AHI < 20 and 3.5 cm in those with an AHI > or = 20 (p = not significant). Overall, postoperative complications, defined as prolonged intensive care unit stay (> 24 hours), need for mechanical ventilation, and cardiopulmonary morbidities, were observed in 67% of OSA and 25% of non-OSA patients. CONCLUSIONS These findings point to a strong association between OSA and malignancies of the oral cavity and oropharynx. This relationship was independent of the size of the primary malignancy in this patient population with tumours ranging from 1 to 7 cm (p = not significant). When comparing the two groups (AHI < 20 and AHI > or = 20), there was a tendency for the group with OSA to have an increase in postoperative morbidities. Further research is warranted to further evaluate the postoperative morbidities and mortalities associated with OSA in this patient population and to determine the potential roles for preoperative treatment with continuous positive airway pressure and tracheotomy.

Laryngeal inflammation assessed using the reflux finding score in obstructive sleep apnea

OBJECTIVES: To evaluate the relationships between laryngeal inflammation assessed using the Reflux Finding Score (RFS), laryngeal sensory function, and apnea severity in patients with obstructive sleep apnea (OSA). METHODS: Endoscopic sensory testing (EST) was performed with subsequent blinded scoring from video of RFS. An RFS > 7 was indicative of increased inflammatory change. RESULTS: Of 34 patients evaluated, 29 had OSA (apneahypopnea index [AHI] ≥ 15 events/h) at polysomnography. Increased inflammation was present in 26/29 (90%), with changes suggestive of laryngopharyngeal reflux. There were significant correlations between: inflammation and OSA severity (eg, RFS vs AHI, r = 0.57, P < 0.001); inflammation and laryngeal sensory impairment (EST detection threshold and pressure required to elicit the laryngeal adductor reflex, LAR); and the degree of sensory impairment and OSA severity. CONCLUSIONS: Laryngeal inflammation is prevalent among OSA patients and correlates with laryngeal sensory dysfunction, attenuation of the LAR, and apnea severity. EBM rating: C-4

Radiotherapy versus surgery for early T1-T2 glottic carcinoma.

OBJECTIVES To compare surgery and radiotherapy as treatments for early T1-T2 glottic cancer in terms of local and regional control, complications, cost, and voice outcome. METHODS Retrospective comparative review of 36 patients with T1 or T2 glottic carcinoma diagnosed between 1992 and 2003 at the McGill University Health Centre. Twelve patients postsurgery (group 1) and 26 patients postradiotherapy (group 2) were compared in terms of local and regional control and complications related to treatment. The costs of surgery and radiotherapy, including all personnel and equipment, were estimated. A cross-sectional study was undertaken of 11 patients with a history of T1 or T2 glottic carcinoma: 5 patients postsurgery, 4 patients postradiotherapy, and 2 patients postradiotherapy and surgery. Vocal fold function and voice quality were assessed by an otolaryngologist using videostroboscopy and a standardized questionnaire (Voice Handicap Index) and by an experienced speech-language pathologist using the Visipitch II computer program (Kay Elemetrics Corp., Lincoln Park, NJ). RESULTS Retrospective study: The recurrence rate following primary treatment was 37.5% for group 1 and 22% for group 2. Group 1 patients presented with 25% of local complications (vocal fold scars) and no systemic complications. Patients in group 2 presented with local and systemic complications: 35% for local and 27% for systemic. One patient had mild carotid stenosis, and one patient had mild esophageal stenosis. The cost of treatment with radiotherapy was five times higher than the cost of surgery. Cross-sectional study: Vocal fold function assessed by videostroboscopy was superior in group 2. However, patients in group 1 scored higher on the subjective (Voice Handicap Index questionnaire) and objective (Visipitch parameters) voice assessments. CONCLUSION Surgery and radiotherapy are both very effective in terms of local and regional control for early glottic carcinoma. However, surgery tends to be more cost-effective, with less complications and possibly a better voice outcome.

A rare but serious entity: Nasogastric tube syndrome

Since its first description by Hunter in 1790 1 , the nasogastric tube has become a frequently used method of alleviating gastrointestinal symptoms. Because the morbidity associated with its use is low the risks of complications are often underestimated. We present a case of bilateral vocal cord paralysis and supraglottic edema following nasogastric tube insertion—also known as Nasogastric Tube Syndrome (NGTS). Although this complication is rare, it can be life threatening. We discuss this phenomenon in the context of a meta-analysis of reported cases, notably: presenting symptoms, time at development and resolution of symptoms in relation to nasogastric intubation and propose treatment options.

Lateral phase mucosal wave asymmetries in the clinical voice laboratory.

Anecdotally, in some persons it has been observed by the Senior Author (K.K.) that asymmetries of the mucosal wave exist when examined videostroboscopically. In the vast majority of these people, no pathology is ever discovered. Mucosal wave asymmetries could cause concern for the otolaryngologist, who may consider them to be a forewarning of subclinical pathology and subject the patient to unnecessary, expensive, and anxiety-provoking investigations or interventions. The purpose of this study was to establish the prevalence of mucosal wave asymmetries in an asymptomatic population lacking laryngeal pathology. Acoustic spectral analysis is also utilized to determine if the presence of subharmonics might be associated. A hospital-based, cross-sectional study design was used. The subjects had no known vocal or medical pathologies, and were nonsmoking. The study group was composed of 30 males aged 35-50 years and 30 women between 22-55 years. Each of the males underwent acoustic spectral analysis; and all subjects completed a medical questionnaire, subjective talkativeness rating, and videostroboscopic laryngeal examination. 10.5% of the subjects (exact 95% CI = 4.0-21.5%) exhibited mucosal wave variations at stroboscopy, characterized as periodic lateral phase asymmetries found consistently in both the modal and upper registers. There was no association with the chosen acoustic spectral parameters, talkativeness scales, or questionnaire-based variables. Mucosal wave asymmetries may be a variance of normal, and are likely to be far more common in the general population than previously believed. The prevalence detected here is expected to be important in the clinical laryngology practice, where these asymmetries may be frequently encountered and influencing management decisions. There has been little normative data published for variations of the mucosal wave specifically for epidemiological purposes. Clinically, in the absence of such data, otolaryngologists may over interpret videostroboscopic findings, leading to unnecessary investigations or interventions.

Head and neck cancer patients want us to support them psychologically in the posttreatment period: Survey results.

OBJECTIVES No study systematically has investigated the supportive care needs of general head and neck cancer patients using validated measures. These needs include physical and daily living needs, health system and information needs, patient care and support needs, psychological needs, and sexuality needs. Identifying the unmet needs of head and neck cancer patients is a necessary first step to improving the care we provide to patients seen in our head and neck oncology clinics. It is recommended as the first step in intervention development in the Pan-Canadian Clinical Practice Guideline of the Canadian Partnership Against Cancer (see Howell, 2009). This study aimed to identify: (1) met and unmet supportive care needs of head and neck cancer patients, and (2) variability in needs according to demographics, disease variables, level of distress, and quality-of-life domains. METHODS Participants were recruited from the otolaryngology-head and neck surgery clinics of two university teaching hospitals. Self-administered questionnaires included sociodemographic and medical questions, as well as validated measures such as the Supportive Care Needs Survey-Short Form (SCNS-SF34), the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Cancer Therapy-General (FACT-G) and Head and Neck Module (FACT-H&N) (quality of life measures). RESULTS One hundred and twenty-seven patients participated in the survey. 68% of them experienced unmet needs, and 25% revealed a clinically significant distress level on the HADS. The highest unmet needs were psychological (7 of top 10 needs). A multiple linear regression indicated a higher level of overall unmet needs when patients were divorced, had a high level of anxiety (HADS subscale), were in poor physical condition, or had a diminished emotional quality of life (FACT-G subscales). SIGNIFICANCE OF RESULTS The results of this study highlight the overwhelming presence of unmet psychological needs in head and neck cancer patients and underline the importance of implementing interventions to address these areas perceived by patients as important. In line with hospital resource allocation and cost-effectiveness, one may also contemplate screening patients for high levels of anxiety, as well as target patients who are divorced and present low levels of physical well-being, as these patients may have more overall needs to be met.

A simple method to predict pretracheal tissue thickness to prevent accidental decannulation in the obese.

OBJECTIVE: Accidental decannulation is the most common and serious complication associated with tracheostomy in obese patients. We lack a simple way to choose appropriate-size tracheostomy tubes in this patient subset. Our purpose was to 1) establish the range of trachea-to-skin soft tissue thickness (TTSSTT) in obese patients and 2) determine which easily obtained anthropometric measurements are most predictive of TTSSTT. STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary care center. SUBJECTS AND METHODS: Forty consenting patients with body mass index ranging from 30 to 70 were evaluated. These patients, from a bariatric clinic, underwent ultrasound (US) of the neck in predetermined sitting, supine, and neck-extended positions (as for tracheostomy). US was performed by a qualified radiologist. Standard anthropometric measurements of weight, height, arm, hip, waist, and neck sizes were performed. Multiple regression analysis was used to determine which anthropometric measurements best correlated with TTSSTT. RESULTS: The TTSSTT, as measured by US in the supine position, ranged from 0.65 to 3.53 cm. Although the anthropometric measurement most predictive of TTSSTT was waist circumference, a combination of the more practical arm and neck circumferences resulted in an equivalent correlation (r = 0.82). The average root mean squared error was 0.4 cm. From the fitted regression equation, a table predicting TTSSTT from neck and arm circumference was prepared. CONCLUSION: TTSSTT can be closely predicted using simple anthropometric tape measures. The predicted TTSSTT can be used to select appropriate tracheostomy tube size in obese patients. Use of this simple tool is expected to significantly reduce the incidence of accidental decannulation in obese patients.

Angiotensin-converting enzyme inhibitor-induced unilateral tongue angioedema

Angioedema, also known as angioneurotic edema or Quincke’s disease, is a localized transient swelling of sudden onset that can occur in the face, lips, tongue, hands, feet, and gastrointestinal system. Angiotensin-converting enzyme (ACE) inhibitors have been implicated in multiple cases of angioedema, with the oral region being the most common site of presentation. 1,2 Tongue edema has been reported to be one of the risk factors leading to airway compromise. 3 In this article we present a case of unilateral tongue angioedema induced by Vasotec (enalapril) and review the literature pertaining to this disease. To our knowledge, there are no reported cases in the English literature describing this unilateral form of tongue edema. CASE REPORT

Mucosal wave asymmetries in the clinical voice laboratory.

OBJECTIVE Anecdotally, it has been observed that in some healthy middle-aged men, who have neither vocal complaints nor known vocal pathology, asymmetries of the mucosal wave exist when examined videostroboscopically. This may cause concern on the part of the otolaryngologist, who might consider mucosal wave asymmetries to be a forewarning of subclinical pathology and subject the patient to unnecessary, expensive, and anxiety-provoking investigations or interventions. The purpose of this study is to establish the presence of mucosal wave asymmetries in a healthy, asymptomatic subpopulation. Acoustic spectral analysis is also used to determine if the presence of subharmonics might be associated. STUDY DESIGN A prospective, cohort study design was used. The population was randomly selected, healthy, asymptomatic, nonsmoking men aged 35 to 50 years. Each subject completed acoustic spectral analysis and a medical questionnaire, followed by videostroboscopic laryngeal examination. RESULTS Thirty-seven percent of the subjects exhibited mucosal wave variations at stroboscopy, characterized as periodic lateral phase asymmetries. There was no association with the acoustic spectral parameters chosen. CONCLUSION Mucosal wave asymmetries may be a variance of normal. The 37% found here is expected to be very significant. Mucosal wave asymmetries are likely to be far more common in the general population than previously believed. There have been few normative data published for variations of the mucosal wave specifically for epidemiologic purposes. These results establish a starting point and justification for the normative population studies under way at our institution. Clinically, in the absence of such data, otolaryngologists may overinterpret videostroboscopic findings, leading to unnecessary investigations or interventions.