Scott Rickert

Laryngeal electromyography for prognosis of vocal fold palsy: A Meta-Analysis

To analyze existing evidence regarding utility of laryngeal electromyography (LEMG) for prognosis in cases of vocal fold palsy (VFP).

Lymphatic Malformations of the Airway

Objectives/Hypothesis To characterize the anatomic distribution of lymphatic malformations of the upper airway. Study Design Case series with chart review. Setting Tertiary care referral center specializing in the diagnosis and treatment of vascular anomalies. Methods A 7-year (2004-2011) retrospective chart review of patients with lymphatic malformations was performed at a tertiary care referral center. Patients with airway lymphatic malformations were identified. The anatomic distribution of lymphatic malformations within the airway was reviewed. Results A total of 141 patients with lymphatic malformations of the upper aerodigestive tract (UADT) were studied. Of these, 15 (11%) had laryngeal (supraglottic) involvement. In all of these patients, the disease was above the true vocal folds. Seventy-four (52%) patients had involvement of 1 anatomic zone (most common was the oral cavity), and 67 (48%) had involvement of multiple zones. With regard to each zone, 105 (75%) patients had involvement of the oral cavity, 50 (36%) the oropharynx, 8 (6%) the hypopharynx, 42 (30%) the parapharynx, and 12 (9%) had retropharygeal disease (some patients had multiple zones involved). No patients were identified with glottic, subglottic, or tracheal involvement. Conclusions Based on our large series, airway involvement in head and neck lymphatic malformations may occur at multiple sites above the glottis. A high percentage of these patients have involvement of the oral cavity (75%) and oropharynx (35%). None involve the glottis, subglottis, or trachea.

Practice patterns, safety, and rationale for tracheostomy tube changes : A survey of otolaryngology training programs

Introduction: Tracheotomy for long‐term ventilation is a common surgical procedure in the hospital setting. Although the postoperative care is often perceived as routine, complications associated with tracheostomy changes may result in loss of airway and death. In addition, the practice patterns, rationale, and complications related to tube changes have been poorly described.

Patient Perceptions of Factors Leading to Spasmodic Dysphonia: A Combined Clinical Experience of 350 Patients

Spasmodic dysphonia (SD) is an idiopathic voice disorder that is characterized by either a strained, strangled voice quality or a breathy voice with aphonic segments of connected speech. It has been suggested that environmental factors play a role in triggering the onset. Clinical observation suggests that some patients associate onset with specific events or factors while others do not. The purpose of this study was to examine a large database of SD patients to determine if specific triggers are associated with the onset of SD.

Laryngeal Manifestations of Relapsing Polychondritis and a Novel Treatment Option

OBJECTIVES Laryngotracheal involvement in relapsing polychondritis (RP) is rare. However, it is one of the most common causes of death in this patient population. We present three patients who primarily presented with laryngeal manifestations of RP and a novel treatment option for bamboo nodules. STUDY DESIGN Retrospective chart review and comprehensive review of the literature. RESULTS Two patients first presented to an otolaryngologist because of hoarseness and chronic cough that eventually progressed to dyspnea upon exertion. Laryngeal examination revealed subglottic stenoses. Upon rheumatologic workup both were diagnosed with RP. After treatment with steroids and immunosuppressive drugs, one of the patients laryngeal symptoms improved, whereas the other required dilation procedures. Neither patient had classic auricular or nasal symptoms upon initial presentation. The third patient was being treated for spasmodic dysphonia and was noted to have bamboo nodules with accompanying dysphonia. Rheumatologic workup revealed RP and systemic treatment ensued. Unfortunately, her symptoms of hoarseness persisted despite systemic treatment. A pulsed-potassium-titanyl-phosphate (KTP) laser was applied to the bilateral bamboo nodules, which eventually caused resolution of her vocal fold lesions and dysphonia. CONCLUSIONS We present three patients with RP, all of whom sought health care by an otolaryngologist primarily. Awareness of this disease entity and the possibility for early laryngeal involvement is crucial for proper care of those with this life-threatening disease.

A Complication of Tracheobronchopathia Osteochondroplastica Presenting as Acute Hypercapnic Respiratory Failure

Patient: Male, 27 Final Diagnosis: Tracheobronchopathia osteochondroplastica Symptoms: Shortness of breath • stridor Medication: — Clinical Procedure: Neck computer tomography • pulmonary function test • neck surgical exploration • tracheostomy placement Specialty: Critical Care Medicine Objective: Unusual clinical course Background: Tracheobronchopathia osteochondroplastica is a rare benign and often indolent disease. We report the first case of tracheobronchopathia osteochondroplastica (TBO) presenting as acute hypercarbic respiratory failure due to superimposed subglottic submucosal abscess. Case Report: A 27-year-old man presented to the emergency department in respiratory distress that required mechanical ventilation for acute hypercarbic respiratory failure. Upon extubation the next day, stridor was elicited with ambulation. Spirometry revealed fixed upper airway obstruction. Neck imaging showed a 2.8×2.0×4.0 cm partially calcified subglottic mass with cystic and solid component obstructing 75% of the airway. Surgical exploration revealed purulent drainage upon elevation of the thyroid isthmus and an anterolateral cricoid wall defect in communication with a subglottic submucosal cavity. Microbiology was negative for bacteria or fungi. Pathology showed chondro-osseous metaplasia compatible with tracheobronchopathia osteochondroplastica (TBO). The patient received a course of antibiotics and prophylactic tracheostomy. Since tracheostomy removal 3 days later, the patient remains asymptomatic. Conclusions: Tracheobronchopathia osteochondroplastica is a rare disease with usually benign clinical course and incidental diagnosis. It may present as acute hypercarbic respiratory failure when subglottic infection is superimposed.

Nasal Septal Anatomy in Skeletally Mature Patients With Cleft Lip and Palate.

IMPORTANCE Septal deviation commonly occurs in patients with cleft lip and palate (CLP); however, the contribution of the cartilaginous and bony septum to airway obstruction in skeletally mature patients is poorly understood. OBJECTIVES To describe the internal nasal airway anatomy of skeletally mature patients with CLP and to determine the contributors to airway obstruction. DESIGN, SETTING, AND PARTICIPANTS This single-center retrospective review included patients undergoing cone-beam computed tomography (CBCT) from November 1, 2011, to July 6, 2015, at the cleft lip and palate division of a major academic tertiary referral center. Patients met inclusion criteria for the study if they were at least 15 years old at the time of CBCT, and images were used only if they were obtained before Le Fort I osteotomy and/or formal septorhinoplasty. Twenty-four skeletally mature patients with CLP and 16 age-matched control individuals were identified for the study. MAIN OUTCOMES AND MEASURES Septal deviation and airway stenosis were measured in the following 3 coronal sections: at the cartilaginous septum (anterior nasal spine), bony septum (posterior nasal spine), and midpoint between the anterior and posterior nasal spine. The perpendicular plate of the ethmoid bone and vomer displacement were measured as angles from the vertical plane at the coronal section of maximal septal deviation. The site of maximal septal deviation was identified. RESULTS Among the 40 study participants, 26 were male. The mean (SD) age was 21 (5) and 23 (6) years for patients with CLP and controls, respectively. Septal deviation in patients with CLP was significantly worse than that of controls at the anterior nasal spine (2.1 [0.5] vs 0.8 [0.2] mm; P < .05) and posterior nasal spine (2.9 [0.5] vs 1.0 [0.3] mm; P < .01) and most severe at the midpoint (mean [SD], 4.4 [0.6] vs 2.1 [0.3] mm; P < .01). The point of maximal septal deviation occurred in the bony posterior half of the nasal airway in 27 of 40 patients (68%). The CLP bony angular deviation from the vertical plane was significant in the CLP group compared with the control group (perpendicular plate of the ethmoid bone, 14° [2°] vs 8° [1°]; vomer, 34° [5°] vs 13° [2°]; P < .05 for both), and vomer deviation was significantly associated with anterior nasal airway stenosis (r = -0.61; P < .01). CONCLUSIONS AND RELEVANCE Skeletally mature patients with CLP have significant septal deviation involving bone and cartilage. Resection of the bony and cartilaginous septum should be considered at the time of definitive cleft rhinoplasty. LEVEL OF EVIDENCE NA.

Isolated congenital maxillomandibular synechiae

INTRODUCTION Congenital maxillomandibular syngnathia, or fusion of the jaws, is a rare condition that has a broad spectrum of presentations. The restricted mouth opening can lead to issues with feeding, swallowing, and respiration resulting in failure to thrive and temporomandibular joint ankylosis. Early recognition and treatment is necessary for proper growth and development. CASE REPORT We report a 1-day-old male with isolated bilateral soft tissue alveolar fibrous bands. He presented with difficulty feeding secondary to trismus. No bony or muscular involvement in the synechiae was noted and the remainder of the physical exam was unremarkable. The bilateral alveolar synechiae were divided under local anesthesia using surgical scissors. The patient immediately showed improvement in mouth opening and had resolution of his feeding problems. He is now gaining weight and developing appropriately. DISCUSSION The accompanying review of the literature demonstrates only 11 cases worldwide of isolated maxillomandibular fusion. Depending upon the composition of the synechiae, simple surgical division under local anesthesia can be curative.

Microbiology and antibiotic resistance of chronic rhinosinusitisin patients undergoing primary vs. revision endoscopic sinus surgery

INTRODUCTION Chronic Rhinosinusitis (CRS) is an inflammatory process associated with several different pathogenic aerobic and anaerobic organisms. The microbiology of CRS has been studied extensively. As a result, probability guided antibiotics have been used. Endoscopic cultures of the middle meatus and sinuses have assisted in directing the choice of antibiotics and overall treatment. Reports of cultured organisms in medically treated patients as well those treated surgically by functional endoscopic sinus surgery (FESS) have demonstrated differences in the isolates. (1-6) Many patients that undergo FESS, however, often have recurrent and persistent CRS that requires additional surgical intervention after appropriate medical treatment. Studying the endoscopically guided cultures intraoperatively may demonstrate those microorganisms that persist in the nasal cavity and sinuses despite aggressive treatment. In this article, we describe the microbiology of patients undergoing primary FESS and those requiring revision FESS.

Prevalence of Voice Disturbances in the Pediatric Craniofacial Patient Population

Objective To report on the prevalence of voice disturbances in the pediatric craniofacial population and to prove that the pediatric Voice Handicap Index (pVHI) is a useful questionnaire for this unique population. Study Design Case series with chart review. Setting Tertiary care center. Subjects Pediatric patients seen by a pediatric otolaryngologist in a craniofacial clinic. Methods Consecutive patients (N = 366) seen by a single pediatric otolaryngologist in a craniofacial clinic from July 2011 to September 2012 were included. Any patient specifically referred for airway problems or voice difficulties completed a pVHI questionnaire. Patients each underwent an evaluation including flexible fiberoptic laryngoscopy and videostroboscopy. Voice disturbance was further characterized into dysphonia, hypernasality, or hyponasality. Results Of all the patients evaluated, 280 (77%) were specifically referred for airway problems or voice disturbance. Of those referred, 39 (10.7%) were found to have an organic vocal fold pathology causing dysphonia, as seen on the videostroboscopic examination; 53.7% of these lesions were attributable to potential iatrogenic causes. Hypernasality and hyponasality were seen in 116 (31.7%) and 78 (21.3%) patients, respectively. The pVHI was 3.95, 26.3, 11.34, and 10.53 for those with no voice disturbance, dysphonia, hypernasality, and hyponasality, respectively. Conclusion Pediatric patients with craniofacial disorders have a higher prevalence of dysphonia than the general pediatric population. The majority of causes of dysphonia in these patients are possibly iatrogenic in origin. The pVHI serves as a useful questionnaire in this unique patient cohort to quantify the disability from not only dysphonia but also hypernasality and hyponasality.