Effects of coronavirus disease-2019 on voice: our experience of laryngeal complications following mechanical ventilation in severe coronavirus disease-2019 pneumonitis and review of current literature.

PURPOSE OF REVIEW: Dysphonia has been described as a major symptom of coronavirus disease-2019 (COVID-19). A literature review examining this topic was undertaken and is presented here, combined with insights from our experience in managing patients with laryngeal complications following mechanical ventilation for severe COVID-19 pneumonitis. RECENT FINDINGS: Naunheim et al. reported that patients who are most at risk of needing intubation with COVID-19 disease are those with patient-specific risk factors and these are at an increased risk for subsequent laryngotracheal injury following intubation (1). In our cohort of 105 patients referred with laryngological symptoms postintubation for COVID-19 pneumonitis, 40% presented as urgent reviews, of which almost half had severe postintubation complications requiring surgery. Perceptual voice ratings and patient-reported voice ratings varied widely, but there was no significant change in voice scores postoperatively. The reflux symptom index (RSI) scores did improve significantly (p = 0.0266). The need for surgery was associated with the presence of comorbidities for instance hypertension, diabetes and obesity in our cohort. This is in support of reported association of comorbidity as a risk factor for intubation and subsequent development of postintubation airway complications. SUMMARY: Dysphonia following COVID-19 infection may have multiple causes. Literature reports demonstrate intubation injury, sensory neuropathy, and postviral neuropathy are associated with voice changes. Our personal experience has confirmed postintubation injury markedly affects glottic function with resultant dysphonia attributable to scar formation, posterior glottic stenosis, granulation and subglottic stenosis. Frequent surgical intervention is required for airway patency and may have short-term further deleterious effects on phonation, although in our cohort this is not statistically significant analysing Grade, Roughness, Breathiness, Asthenia, Strain, Voice Handicap Index-10 or Airway, Voice, Swallow scores. Maximal antireflux medications and advice statistically improved RSI scores postoperatively.

Virtual voice clinics in the COVID-19 era: have they been helpful?

PURPOSE: In response to the coronavirus pandemic, a tertiary combined Laryngology-Speech Therapy voice clinic was converted to a wholly virtual clinic, with consultations carried out via telephone or video. The aim of our mixed method study was to assess (a) how effective are virtual clinics vs face-to-face clinics in progressing patients' care and (b) what is patient satisfaction with virtual consultation methods. METHODS: Analysis of clinic data from patient databases for both virtual and face-to-face clinics was carried out. A patient satisfaction survey was carried out by 75 of the patients who had attended virtual clinics. RESULTS: There was statistically a significant difference (p value < 0.01) in the proportion of patients prescribed medical therapy, referred for Speech and Language Therapy (SALT) or listed for surgery in the virtual clinic by comparison to the face-to-face clinic. 75 patients completed the questionnaire. 98% of patients were satisfied overall with the virtual method of consultation. 84% believed they would still benefit from face-to-face review. 83% would like the option of a virtual type of clinic in the future. CONCLUSION: Our data clearly demonstrates that face-to-face clinics are superior to virtual clinics, with almost no patients progressed to surgery in virtual consultations. Despite this, virtual methods are still valuable, and many patients have meaningful progression of care. In current circumstances, patients have very high satisfaction with virtual consultations and certain groups have been identified as particularly benefiting. Going forward, an ideal clinic may be a hybrid of face-to-face and virtual appointments as clinically indicated.

Applications of Office-Based 445 nm Blue Laser Transnasal Flexible Laser Surgery: A Case Series and Review of Practice.

BACKGROUND: The recent introduction of 445 nm blue laser to office-based laryngology presents potential advantages. These include a desirable combination of cutting and photoangiolytic qualities and a lightweight, shock-resistant design. Despite its increasing use, current evidence is limited to experimental data and case reports. OBJECTIVES: The authors present a case series and overview of office blue laser transnasal flexible laser surgery (TNFLS), considering indications, patient selection, safety, technique, and surgical outcomes. We also review the safety and relevance of TNFLS to the ongoing coronavirus pandemic. METHODS: Retrospective case series and narrative review. Our primary outcome measure was preoperative and postoperative Voice Handicap Index (VHI-10) score. Complications were documented by nature and severity. RESULTS: Thirty-six cases of office blue laser TNFLS were performed. A statistically significant improvement in VHI-10 score was demonstrated in cases of recurrent respiratory papillomatosis (RRP) and benign laryngeal lesions causing dysphonia (P < 0.01 and 0.045). Blue laser also proved effective in assisting office biopsy procedures. A minor and self-limiting complication was reported. CONCLUSIONS: Office blue laser TNFLS is safe and effective in the treatment of RRP and a range of benign laryngeal lesions. Future research should compare the efficacy and safety of blue laser with potassium titanyl phosphate laser in office-based treatment of these conditions. Further assessment of the cutting qualities of blue laser, initially in the theater environment, is necessary to refine our understanding of future applications.

Tracheostomy care and decannulation during the COVID-19 pandemic. A multidisciplinary clinical practice guideline.

PURPOSE: Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient. METHODS: This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients. RESULTS: Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise. CONCLUSION: COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit.