Nausheen Jamal

Effects of asymmetric superior laryngeal nerve stimulation on glottic posture, acoustics, vibration

Evaluate the effects of asymmetric superior laryngeal nerve stimulation on the vibratory phase, laryngeal posture, and acoustics.

Airway Management and Endoscopic Treatment of Subglottic and Tracheal Stenosis The Laryngeal Mask Airway Technique

Objectives: The objective is to present clinical outcomes of subglottic and tracheal stenosis treated by flexible bronchoscopic delivery of carbon dioxide (CO2) laser via laryngeal mask airway (LMA). Methods: All consecutive, nontracheotomy dependent cases of subglottic and tracheal stenosis treated endoscopically over a 4-year period were retrospectively reviewed. The surgical approach consisted of radial incisions using a flexible fiber-based CO2 laser, balloon dilation, and topical application of mitomycin C. Ventilation during the procedure occurred through the LMA, and the CO2 laser fiber was delivered through the working channel of a flexible bronchoscope passed through the LMA. Number of dilations, period between dilations, and operative times were reviewed. Results: Eleven patients who underwent airway intervention during the study period were identified. Average follow-up was 28 months. Etiologies of airway stenosis included intubation injury (6), idiopathic (4), or autoimmune disease (1), requiring an average of 1.3, 1.5, and 3 dilations, respectively. Average operative time was 67 minutes. Autoimmune etiology correlated with more frequent dilations. Conclusion: LMA is an effective way to manage ventilation while simultaneously allowing unencumbered flexible bronchoscopic access for laser surgery, balloon dilation, and mitomycin C application for airway stenosis. Long-term success in treating stenosis is achievable using this technique.

Percutaneous injection laryngoplasty.

NA Laryngoscope, 124:742–745, 2014

Treatment of Chronic Cough Single-Institution Experience Utilizing Behavioral Therapy

Objective Chronic cough remains a challenging condition, especially in cases where it persists despite comprehensive medical management. For these particular patients, there appears to be an emerging role for behavior modification therapy. We report a series of patients with refractory chronic cough to assess if there is any benefit of adding behavioral therapy to their treatment regimen. Study Design A case series with planned chart review of patients treated for chronic cough. Setting The review was performed with an outpatient electronic health record system at a tertiary care center. Subjects and Methods The charts of all patients treated for chronic cough by a single laryngologist over a 30-month period were analyzed. Patients’ response to treatment and rate of cough improvement were assessed for those with refractory chronic cough who underwent behavior modification therapy. Results Thirty-eight patients with chronic cough were initially treated empirically for the most common causes of cough, of which 32% experienced improvement. Nineteen patients who did not significantly improve with medical management underwent behavior modification therapy with a speech-language pathologist. Of these patients, 84% experienced resolution or marked improvement of their symptoms. Conclusion Behavioral therapy may be underutilized in practice and could lead to improvement of otherwise recalcitrant cough.

Office-based tracheoesophageal puncture: updates in techniques and outcomes.

PURPOSE Tracheoesophageal puncture (TEP) is an effective rehabilitation method for postlaryngectomy speech and has already been described as a procedure that is safely performed in the office. We review our long-term experience with office-based TEP over the past 7 years in the largest cohort published to date. MATERIALS AND METHODS A retrospective chart review was performed of all patients who underwent TEP by a single surgeon from 2005 through 2012, including office-based and operating room procedures. Indications for the chosen technique (office versus operating room) and surgical outcomes were evaluated. RESULTS Fifty-nine patients underwent 72 TEP procedures, with 55 performed in the outpatient setting and 17 performed in the operating room, all without complication. The indications for performing TEPs in the operating room included 2 primary TEPs, 14 due to concomitant procedures requiring general anesthesia, and 1 due to failed attempt at office-based TEP. Nineteen patients with prior rotational or free flap reconstruction successfully underwent office-based TEP. CONCLUSIONS TEP in an office-based setting with immediate voice prosthesis placement continues to be a safe method of voice rehabilitation for postlaryngectomy patients, including those who have previously undergone free flap or rotational flap reconstruction. Office-based TEP is now our primary approach for postlaryngectomy voice rehabilitation.

Partial Epiglottoplasty for Pharyngeal Dysphagia due to Cervical Spine Pathology

Objective To examine the role of epiglottoplasty in patients with pharyngeal dysphagia due to pharyngeal crowding from cervical spine pathology and to assess swallowing outcomes following epiglottoplasty. Study Design Retrospective case series. Setting Academic tertiary care medical center. Subjects and Methods Dysphagia can occur in patients with cervical spine pathology because of hypopharyngeal crowding. Swallowing studies, such as modified barium swallow study and fiberoptic endoscopic evaluation of swallowing, may demonstrate a nonretroflexing epiglottis owing to cervical spine osteophytes or hardware, thus impeding pharyngeal bolus transit. We performed partial epiglottoplasties in a series of these patients. A retrospective review of swallowing outcomes was performed to assess the efficacy of this surgery in this patient population. Results Epiglottic dysfunction causing dysphagia due to cervical spine pathology was diagnosed by modified barium swallow study and/or fiberoptic endoscopic evaluation of swallowing in 12 patients. Findings included hypopharyngeal crowding because of cervical osteophytes (n = 8) or cervical hardware (n = 4) associated with absent epiglottic retroflexion and retained vallecular residue. Partial epiglottoplasty resulted in significant reduction of vallecular residue and a significant increase in functional swallow outcomes without an increase in swallow morbidity. Conclusion There is a role for partial epiglottoplasty in patients with dysphagia attributed to hypopharyngeal crowding from cervical spine pathology. Surgery enables reduced vallecular residue and improved functional swallowing outcomes.

Treatment considerations for early glottic carcinoma: lessons learned and a primer for the general otolaryngologist.

In this commentary, we review our experience with early glottic carcinomas in an attempt to identify points to consider when developing a treatment protocol and technical considerations in oncologic resection to maintain laryngeal function. We highlight several consistent themes: (1) difficult exposure is not always a contraindication to endoscopic resection; (2) depth of invasion may be apparent only intraoperatively; (3) radiation therapy should be offered for deeply invasive cancers requiring extensive cordectomy or for patients who cannot afford lengthy vocal downtime; however, (4) radiation therapy leads to acute dysphagia and collateral damage to the contralateral vocal fold that is avoided with surgery; (5) good voice can be obtained after healing if resection is limited to intramuscular cordectomy; (6) the key to optimal vocal results is adequate glottal closure; and (7) second look operations are occasionally necessary, and therefore preoperative counseling should include this possibility. Since both surgery and radiation therapy achieve excellent oncologic control, a patient-centered approach is preferred in management.

Maximizing Functional Outcomes in Head and Neck Cancer Survivors: Assessment and Rehabilitation

With increases in survivorship for patients with head and neck cancer, attention is turning to quality-of-life issues for survivors. Care for these patients is multifaceted. Dysphagia and issues of voice/speech, airway obstruction, neck and shoulder dysfunction, lymphedema, and pain control are important to address. Rehabilitation interventions are patient-specific and aim to prevent, restore, compensate, and palliate symptoms and sequelae of treatment for optimal functioning. Central to providing comprehensive interdisciplinary care are the head and neck surgeon, laryngologist, and speech-language pathologist. Routine functional assessment, long-term follow-up, and regular communication and coordination among these specialists helps maximize quality of life in this challenging patient population.

The Role of Occupational Voice Demand and Patient-Rated Impairment in Predicting Voice Therapy Adherence

OBJECTIVE Examine the relationship among the severity of patient-perceived voice impairment, perceptual dysphonia severity, occupational voice demand, and voice therapy adherence. Identify clinical predictors of increased risk for therapy nonadherence. METHODS A retrospective cohort study of patients presenting with a chief complaint of persistent dysphonia at an interdisciplinary voice center was done. The Voice Handicap Index-10 (VHI-10) and the Voice-Related Quality of Life (V-RQOL) survey scores, clinician rating of dysphonia severity using the Grade score from the Grade, Roughness Breathiness, Asthenia, and Strain scale, occupational voice demand, and patient demographics were tested for associations with therapy adherence, defined as completion of the treatment plan. Classification and Regression Tree (CART) analysis was performed to establish thresholds for nonadherence risk. RESULTS Of 166 patients evaluated, 111 were recommended for voice therapy. The therapy nonadherence rate was 56%. Occupational voice demand category, VHI-10, and V-RQOL scores were the only factors significantly correlated with therapy adherence (P < 0.0001, P = 0.018, and P = 0.008, respectively). CART analysis found that patients with low or no occupational voice demand are significantly more likely to be nonadherent with therapy than those with high occupational voice demand (P < 0.001). Furthermore, a VHI-10 score of ≤29 or a V-RQOL score of >40 is a significant cutoff point for predicting therapy nonadherence (P < 0.011 and P < 0.004, respectively). CONCLUSION Occupational voice demand and patient perception of impairment are significantly and independently correlated with therapy adherence. A VHI-10 score of ≤9 or a V-RQOL score of >40 is a significant cutoff point for predicting nonadherence risk.

Inpatient injection laryngoplasty for vocal fold immobility: When is it really necessary?☆

PURPOSE To compare pulmonary and swallow outcomes of injection laryngoplasty when performed in the acute versus subacute setting in head & neck and thoracic cancer patients presenting with new onset unilateral vocal fold immobility. MATERIALS AND METHODS Case series with chart review at an academic cancer center over a 2year period. Based on swallow evaluation, patients diagnosed with vocal fold immobility were grouped into an unsafe swallow group, injected as inpatients, and a safe swallow group, for whom injection laryngoplasty was delayed to the outpatient setting or not performed. Rates of pneumonia, diet recommendations, and swallow outcomes were compared between groups. RESULTS 24 patients with new-onset vocal fold immobility were evaluated. 7 underwent injection in the inpatient setting, 12 in the outpatient setting, and 5 did not undergo injection. There was no perceived difference in speech and swallow outcomes between the inpatient and outpatient injection groups. CONCLUSIONS Injection laryngoplasty shows promise as an effective intervention for reducing aspiration risk and improving diet normalcy in patients with dysphagia as a result of unilateral vocal fold immobility. In patients determined to have a safe swallow, delay of injection laryngoplasty is not detrimental to swallow outcomes.