Robert Eller

Flexible Laryngoscopy: A Comparison of Fiber Optic and Distal Chip Technologies. Part 1: Vocal Fold Masses

This study was designed to evaluate the usefulness of fiber optic (FO) and distal chip (DC) flexible imaging platforms in the diagnosis of true vocal fold pathology when compared to the gold standard rigid transoral laryngeal telescopic examination. The recorded strobovideolaryngoscopic examinations of 34 consecutive patients were evaluated retrospectively by five raters. All stroboscopy segments were evaluated by two laryngologists, an otolaryngologist, a laryngology fellow, and an otolaryngology resident. Seventeen patients were examined with a high-quality, large-diameter, FO flexible laryngoscope (FO group) and 17 random patients were examined with a DC flexible laryngoscope (DC group). Each patient was also examined using rigid laryngeal videostroboscopy at the same sitting. Examinations of three patients from each group were presented twice to monitor internal consistency. Diagnoses of intrinsic vocal fold pathology made with the flexible laryngoscopes were compared for accuracy to the diagnoses provided using the rigid laryngeal telescope. The ability to make clinical diagnoses via stroboscopy was statistically equivalent with FO technology and DC technology. Rigid examination provided more information than the flexible examination in 27% of the FO examinations and in 32% of the DC examinations. DC technology did not add diagnostic information to the examination when compared to a high-quality, large-diameter, FO endoscope. Rigid endoscopy provides superior images of the true vocal folds and is necessary for precise diagnosis in patients with true vocal fold pathology. Thus, the most cost-effective means of evaluation of voice disorders remains FO flexible endoscopy for dynamic voice assessment and the neurolaryngologic examination followed by rigid stroboscopy for evaluation of the vocal fold edge and mucosal wave. Strobovideolaryngoscopy using high-quality FO or DC flexible equipment should be reserved for patients who cannot tolerate transoral rigid examination, such as children and those with a very strong gag reflex.

Traumatic Airway Management in Operation Iraqi Freedom

Objectives. To examine the role of head and neck surgeons in traumatic airway management in Operation Iraqi Freedom and to understand the lessons learned in traumatic airway management to include a simple airway triage classification that will guide surgical management. Study Design. Case series with chart review. Setting. Air Force Theater Hospital at Balad Air Base, Iraq. Subjects and Methods. The traumatic airway experience of 6 otolaryngologists/head and neck surgeons deployed over a 30-month period in Iraq was retrospectively reviewed. Results. One hundred and ninety-six patients presented with airway compromise necessitating either intubation or placement of a surgical airway over the 30-month timeframe. Penetrating face trauma (46%) and penetrating neck trauma (31%) were the most common mechanisms of injury necessitating airway control. The traumatic airways performed include 183 tracheotomies, 3 cricothyroidotomies, 9 complicated intubations, and 1 stoma placement. Red or emergent airways were performed in 10% of patients, yellow or delayed airways in 58% of patients, and green or elective airways in 32% of patients. Lastly, surgical repair of the laryngotracheal complex was performed in 25 patients with 16 thyroid cartilage repairs, 4 cricoid repairs, and 8 tracheal repairs. Conclusions. The role of the deployed otolaryngologist in traumatic airway management was crucial. Potentially lifesaving airways (red/yellow airways) were placed in 68% of the patients. The authors’ recommended treatment classification should optimize future traumatic airway management by stratifying traumatic airways into red (airway less than 5 minutes), yellow (airway less than 12 hours), or green categories (airway greater than 12 hours).

Diagnosing Aerodynamic Supraglottic Collapse With Rest and Exercise Flexible Laryngoscopy

OBJECTIVE Laryngomalacia is best known as a self-resolving infantile disorder characterized by inspiratory stridor with occlusion of the larynx by collapse of arytenoid tissues due to Bernoulli forces. Adult laryngomalacia has been sporadically described in the literature. We identified a series of patients with aerodynamic supraglottic collapse mimicking laryngomalacia in our Otolaryngology clinic. STUDY DESIGN Case series. METHODS/PATIENTS A series of five patients from our Otolaryngology clinic with aerodynamic supraglottic collapse presented with complaints ranging from noisy breathing to dyspnea with exertion. Diagnosis was made using rest and exercise flexible laryngoscopy. RESULTS Symptoms resolved in all patients who underwent traditional or modified supraglottoplasty. CONCLUSIONS These patients, all with abnormal corniculate/cuneiform motion occluding the airway during forceful inspiration, reinforce the diagnostic role of rest and exercise flexible laryngoscopy in patients with dyspnea and stridor. These results may suggest that aerodynamic supraglottic collapse is an underdiagnosed clinical entity.

Reduction of anterior frontal sinus fracture involving the frontal outflow tract using balloon sinuplasty.

Balloon catheter dilation of paranasal sinus ostia is a new technique with preliminary data that suggest it is safe and feasible. We report its novel use in the internal reduction of an anterior frontal sinus fracture. A 22-year-old patient who sustained a right anterior table frontal sinus fracture involving the frontal sinus outflow tract after being struck by a thrown rock. The patient initially presented to an outside hospital where a 3-cm right lower brow/upper nasal sidewall laceration was closed. There was neither a bony depression nor a step-off. A preoperative maxillofacial CT scan was obtained which revealed the fracture without posterior table involvement or intracranial injury (Fig 1). Under general anesthesia, the Acclarent Balloon Sinuplasty system (Acclarent, Inc., Menlo Park, CA) was utilized to internally reduce the fracture. Using endoscopic guidance, a Relieva sinus guide catheter (Acclarent, Inc., Menlo Park, CA) was placed in the right nasofrontal recess. The Relieva sinus guidewire was then passed into the right nasofrontal tract into the frontal sinus under fluoroscopic guidance. The Relieva sinus balloon catheter was deployed over the wire, positioned at the superior extent of the internally displaced fracture fragment, and was inflated to 14 atm. The balloon was deflated and, after repositioning it more proximally in the nasofrontal outflow tract, was once again inflated to a pressure of 14 atm. Fluoroscopy suggested that the largest fracture fragment was reduced and that the frontal sinus outflow tract was enlarged. After deflation, the balloon catheter was removed. A syringe of MeroGel Injectable (Medtronic Xomed, Jacksonville, FL) was then attached to the sinus guide catheter and injected into the frontal sinus outflow tract. The total surgery time was 53 minutes. The patient was admitted for 23-hour observation. A postoperative maxillofacial CT was obtained on the first postoperative day and revealed reduction of the largest of the comminuted, internally displaced bony fragments of the anterior table. Frontal sinus outflow tract patency was reestablished. Broad-spectrum antibiotics were given for four weeks postoperatively. Follow-up at seven months

Total airway reconstruction

We present a case of obstructive sleep apnea (OSA) that required multilevel surgical correction of the airway and literature review and discuss the role supraglottic laryngeal collapse can have in OSA. A 34‐year‐old man presented to a tertiary otolaryngology clinic for treatment of OSA. He previously had nasal and palate surgeries and a Repose tongue suspension. His residual apnea hypopnea index (AHI) was 67. He had a dysphonia associated with a true vocal cord paralysis following resection of a benign neck mass in childhood. He also complained of inspiratory stridor with exercise and intolerance to continuous positive airway pressure. Physical examination revealed craniofacial hypoplasia, full base of tongue, and residual nasal airway obstruction. On laryngoscopy, the paretic aryepiglottic fold arytenoid complex prolapsed into the laryngeal inlet with each breath. This was more pronounced with greater respiratory effort. Surgical correction required a series of operations including awake tracheostomy, supraglottoplasty, midline glossectomy, genial tubercle advancement, maxillomandibular advancement, and reconstructive rhinoplasty. His final AHI was 1.9. Our patients supraglottic laryngeal collapse constituted an area of obstruction not typically evaluated in OSA surgery. In conjunction with treating nasal, palatal, and hypopharyngeal subsites, our patients supraglottoplasty represented a key component of his success. This case illustrates the need to evaluate the entire upper airway in a complicated case of OSA. Laryngoscope, 2012

P182: Balloon Sinuplasty Reduction of Frontal Sinus Fracture

were analyzed. RESULTS: Mean volume of maxillary sinuses was 23.96 4.13 cm3 in the normal group, and 21.68 4.54 cm3 in the sinusitis group, which was statistically significant (p 0.04). However, no correlation was found between disease periods and maxillary sinus volume (r -0.07, p 0.69). Mean thicknesses of bony walls were 1.17 0.4mm (maxillary sinus), 1.12 0.3mm (ethmoid sinus), and 2.15 0.6mm (middle turbinate) in CRS group, and 0.92 0.3 (maxillary sinus), 0.80 0.2 (ethmoid sinus), and 1.65 0.3mm in the control group, respectively, which showed significant differences between the two groups (p 0.01). CONCLUSIONS: The volume of maxillary sinuses was decreased and increased bony thickness of paranasal sinuses was found in longstanding pediatric CRS, which might encourage more active surgical treatment for pediatric CRS.

Laryngocardiac Reflex: A Case Report and Review of the Literature

INTRODUCTION The vagus nerve has sensory and motor function in the larynx, as well as parasympathetic function in the thorax and abdomen. Stimulation of the superior laryngeal nerve can cause reflexive bradycardia. CASE We describe a case of a 45-year-old man with pre-syncopal symptoms while exercising, and bradycardia found during cardiology workup. Radiography and flexible laryngoscopy showed evidence of a right-sided, vascular laryngeal mass. Exercise testing before and after superior laryngeal nerve block showed reversal of the symptoms with the block. Subsequent resection of the lymphovascular malformation with CO2 laser eliminated the patients symptoms. DISCUSSION This is the first case reported of the laryngocardiac reflex producing symptomatic bradycardia as a result of exercise-induced engorgement of a supraglottic lymphovascular malformation, which was then cured by surgical excision. We discuss this case and the literature regarding lymphovascular malformations in the airway and the neural pathways of the laryngocardiac reflex.

Geniotubercle Advancement Effect on Swallow Function

Objective: 1) Evaluate swallowing characteristics before and after geniotubercle advancement (GTA). 2) Determine if GTA’s effects on tongue-base position could be useful for patients who have dysphagia without OSA. Method: Patients with AHI greater than 10 scheduled for GTA were enrolled consecutively. Video fluoroscopic swallow study (VFSS) was performed preoperatively and 4 months postoperatively. Imagej64 software (National Institutes of Health, Bethesda, Maryland) was used to measure hyolaryngeal elevation and displacement. Video recordings assessed valecular pooling, aspiration, and bolus movement. Studies were reviewed by a speech pathologist and an otolaryngologist. Results: Preoperative demographics AHI range was 12.4 to 72 with a mean of 51.4 and a median of 65. Postoperatively AHI was 3.8 to 22.4 with a mean of 11.6 and a median of 11.2. There was no reported pre- or postoperative dysphagia or aspiration. There was no radiographic evidence of silent aspiration. Hyolaryngeal superior elevation was 0.40, 0.39 (P = .85), anterior displacement changes were 0.27, 0.17 (P = .23), and total motion was 0.50, 0.43 (P = .13). Conclusion: While geniotubercle advancement surgery was effective at reducing the AHI in all patients in this series, the procedure did not significantly affect the swallowing function of patients. It also did not appear to significantly alter the hyolaryngeal movement, making it unlikely to assist with patients suffering from dysphagia.