L. Arick Forrest

Review of Percutaneous Tracheostomy

The purpose of this study is to assess the safety and efficacy of the four known methods of percutaneous tracheostomy. Perioperative, postoperative, and late complication rates were generated for each method after a complete literature review identified 1684 percutaneous tracheostomy patients reported in 40 series. Two methods, the Toye and the guide wire dilator forceps (GWDF) methods, have been the subject of few investigations. Two other methods have been extensively studied. A high perioperative complication rate was calculated for the Rapitrac™ method, whereas percutaneous dilational tracheostomy (PDT) has complication rates similar to those reported for standard operative tracheostomy. A retrospective review of 22 patients who underwent PDT at a local community hospital confirmed a “learning curve” for this technique that had been previously suggested. Review of the literature suggests that PDT can be safe and cost‐effective for selected patients, but a learning curve for this technique exists that dictates caution, experience, and preparation on the part of any surgeon who wishes to add percutaneous tracheostomy to his or her repertoire.

Quantification of the Learning Curve for Percutaneous Dilatational Tracheotomy

Objectives/Hypothesis: Although numerous investigators have reported a bedside percutaneous dilatational tracheotomy (PDT) complication incidence similar to that of standard operative tracheostomy, others have proposed a “learning curve” for PDT resulting in increased complications early in individual or institutional experience with this procedure. The objective of this investigation is to characterize and quantify the proposed learning curve for PDT.

Paradoxical vocal cord motion: Classification and treatment

Paradoxical vocal cord motion (PVCM), or vocal cord dysfunction, is a descriptive term for inappropriate adduction of the vocal folds during respiration. The laryngeal mistiming leads to breathing difficulty and is often misdiagnosed as refractory asthma. The etiology of PVCM has been unclear but has long been hypothesized to be psychological. The present thesis is a prospective study of 170 patients older than 18 years being evaluated for PVCM, with 117 of the 170 (68.8%) identified as having PVCM by video laryngoscopy. Laryngeal edema (P = .021) and reflux (P = .026) were increased in patients with PVCM. A flat inspiratory arm of the flow volume loop during spirometry testing was a predictor of PVCM (P = .034). A subgroup of 47 newly diagnosed patients with PVCM underwent psychological analysis. The psychological profiles were elucidated using the Minnesota Multiphasic Personality Inventory and the Life Experiences Survey to evaluate stress. Compared to established normative data, PVCM demonstrated a conversion disorder pattern (P < .01) but not an anxiety disorder or a correlation with stress. A subgroup, 11 of the 47 (23.4%), had normal psychological outcomes, and two of the 47 (4.3%) were identified as malingering. Previous studies have suggested that PVCM is strictly a psychological disorder. It is proposed that PVCM is a descriptive term that is multifactorial and the etiology should direct treatment. A classification scheme divides PVCM into primary, or psychological, and secondary. The secondary form consists of medical disorders divided into irritable larynx syndrome and neurologic disorders. Laryngoscope, 2012

Formal Psychological Testing in Patients With Paradoxical Vocal Fold Dysfunction

Objective: The etiology of paradoxical vocal fold dysfunction (PVFD) has been unclear, but it has long been hypothesized that there is a significant psychological component. The purpose of this study was to elucidate the psychological profiles of patients newly diagnosed with PVFD using psychometrically‐sound psychological assessment instruments.

Endoscopic and stroboscopic description of adults with paradoxical vocal fold dysfunction

The purpose of this study was to determine if endoscopic and stroboscopic parameters of voice were normal between attacks of paradoxical vocal fold dysfunction (PVFD). Fifty adults (38 females, 12 males) and 54 adult controls (40 females, 14 males) were examined via endoscopy with and without stroboscopy. Endoscopy indicated paradoxical adduction of the folds during the respiratory cycle of all 50 participants with PVFD, although they were asymptomatic. Atypical laryngeal configurations were observed including abnormality of the anterior-posterior dimension and ventricular fold medialization in both groups of subjects. Stroboscopy demonstrated abnormalities including unstable zero phase, decreased amplitude of vibration, decreased mucosal waves, and phase asymmetry primarily for the PVFD subjects alone. Results indicate that persons with PVFD demonstrate subtle laryngeal abnormality endoscopically and stroboscopically when dyspnea is not reported. This supports the hypothesis that PVFD is not episodic but exists as a continuum of laryngeal instability that may, due to various precipitating factors, be exacerbated to breathing attacks.

Rapid analysis of mandibular margins

Evaluating surgical margins during composite resection of carcinoma is limited by analysis of the bone margins. The standard pathologic evaluation of bone is by decalcification. A method of analysis was devised based on histologically proven methods of cortical invasion and subsequent spread. Frozen section analysis (FSA) of the cancellous bone was investigated as a rapid method of evaluating adequacy of the mandibular resection. Subjects consisted of 29 patients undergoing full‐thickness mandibular resection, with 16 cases of histologically proven mandibular invasion qualifying for evaluation. Results of FSA were then compared to the permanent section analysis of the cancellous bone and to the decalcified specimen. Complete correlation was found between frozen and permanent section results. Frozen section analysis was able to correctly predict adequacy of resection in 32 (97%) of 33 margins.

Safety of ototopical antibiotics

A prospective randomized study analyzing the safety and efficacy of a single dose of ototopical antibiotics following human middle ear tympanostomy tube insertion was performed. Fifty children undergoing bilateral tympanostomy tube insertion were studied by the placement of 0.5 mL of Cortisporin Otic Suspension (COS; Burroughs Wellcome Co., Research Triangle Park, N.C.) to one middle ear space by random assignment. Preoperative and postoperative audiograms were obtained, and the presence of otorrhea was noted. In one patient sensorineural hearing loss of 6 dB developed bilaterally, which was symmetric in both the treated and the untreated ear. This preliminary study showed no statistical difference in hearing loss or postoperative otorrhea associated with a single application of Cortisporin to the middle ear space.

Update on intraoperative analysis of mandibular margins

PURPOSE Assessing the adequacy of the surgical resection during composite resection of carcinoma is limited by the ability to evaluate the bone margins. The standard pathologic evaluation of bone is by decalcification. PATIENTS AND METHODS A method of analysis was devised based on histologically proven methods of cortical invasion and subsequent spread. Frozen-section analysis of cancellous bone was investigated as a rapid method of evaluating adequacy of the mandibular resection. This report is an update of previously published results and includes an increase in the sample size as well as the analysis of additional pathology. Subjects consisted of 66 patients undergoing full thickness mandibular resection with 30 cases of histologically proven mandibular invasion qualifying for evaluation. Results on frozen section were then compared to the permanent section analysis on the cancellous bone and to the decalcified specimen. RESULTS Complete correlation was found between frozen and permanent section results. Frozen section analysis was able to correctly predict adequacy of resection in 60 of 61 margins. CONCLUSION Based on these results, the oncologic surgeon can evaluate bone margins at the time of the resection and adjust the amount of excision required to eradicate the disease.

Exercise-induced paradoxical vocal fold motion disorder: diagnosis and management.

To review our experience with the diagnosis and treatment of exercise‐induced paradoxical vocal fold motion disorder (EPVFMD).

Candida laryngitis appearing asleukoplakia and gerd

The symptoms and physical findings of reflux laryngopharyngitis are characteristic, but the mucosal alterations evident in the larynx are not exclusive to reflux. When conventional reflux management produces an equivocal response, other etiologic factors such as mycotic laryngitis, need consideration. The differential diagnosis of dysphonia in an immunocompromised patient always includes mycotic infections, but mycotic laryngitis can also occur in the immunocompetent host. Laryngeal candidiasis can produce physical findings, such as erythema and leukoplakia, that are similar to reflux laryngopharyngitis. Predisposing factors include previous radiation therapy, antibiotic therapy, corticosteroids, and any alteration in the mucosal barrier. Diagnosis is established by mucosal biopsy with special staining of the tissue to identify the characteristic hyphae. Treatment of mycoses can be difficult and long-term therapy is often required.