Isolated Hyoid Fracture Associated with Blunt Trauma

Trauma-related hyoid fractures are rare entities. These fractures represent only 0.002% of head and neck region fractures. Victims of hanging and strangling constitute the great majority of cases. Fractures associated with trauma are extremely rare. These fractures are difficult to diagnose and can easily be overlooked during physical examination. However, they are also important traumas since airway safety is endangered in these rare cases. We describe a case of a young male presenting with isolated neck injury associated with hitting an electric cable while riding a motorbike. Tenderness was present in the anterior neck region at physical examination, but movement was not restricted and no respiratory difficulty was determined. Isolated hyoid fracture was detected at tomography of the neck performed in the emergency department. Hyoid bone fractures should not be forgotten in patients with pain and tenderness in the anterior neck region following blunt trauma to the neck.©Copyright 2020 by Emergency Physicians Association of Turkey - Available online at www.jemcr.com.

Left Vocal Cord Palsy Immediately After COVID-19 Despite No Tracheal Intubation.

The cases of coronavirus disease 2019 (COVID-19) typically present with pulmonary and upper respiratory tract symptoms, but may also present with neurologic complications. Because severe cases are often intubated or ventilated, there are some reports of vocal cord palsy associated with intubation; however, there are few reports of recurrent nerve palsy without intubation management. We experienced a case of left vocal cord palsy following COVID-19 in a healthy young male patient with no previous medical history. The patient became aware of hoarseness symptoms three days after he was found to be COVID-19 positive, and an endoscopic examination of the larynx revealed left vocal cord palsy. Since the patient had no previous medical history and there were no lesions that could cause recurrent nerve palsy on neck-thorax imaging, it was considered likely that the patient had unilateral recurrent nerve palsy due to acute inflammation caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Medication was started and his hoarseness became relieved. In vocal cord palsy occurring after COVID-19 illness, it is necessary to consider the presence of both vocal cord palsy related to tracheal intubation and recurrent nerve palsy associated with SARS-CoV-2 infection.

Effect of COVID-19 on the incidence of postintubation laryngeal lesions.

Background: Critically ill patients intubated in the intensive care unit experience prolonged intubation leading to increased frequency of laryngeal injuries. This study aimed to demonstrate a suspected increase in vocal fold injury in patients who were intubated with COVID-19 as compared with patients intubated for other reasons. Methods: A retrospective review of medical records was performed to identify patients examined using flexible endoscopic evaluation of swallowing exams. The study included 25 patients with COVID-19 and 27 without COVID-19 at Baylor Scott & White Medical Center in Temple, Texas. Various injuries were evaluated, ranging from granulation tissue to vocal cord paralysis. Severe lesions were those causing clinically significant airway obstruction or requiring operative intervention. The incidence of laryngeal injury in patients intubated for COVID-19 was then compared with that of patients intubated for other reasons. Results: The increased presence of severe injury in COVID-positive patients appeared clinically significant but was not statistically significant (P = 0.06). Interestingly, patients who received pronation therapy had 4.6 times the odds of more severe injury compared with patients who did not (P = 0.009). Conclusion: Lower thresholds for performing flexible laryngoscopy on postintubated patients who are proned may allow for earlier intervention and reduce morbidity in an already at-risk population.

Dysfunctional breathing induces vocal cord dysfunction following COVID-19 infection

Introduction/Aim: SARS-CoV-2 (COVID-19) has affected over 60 million people world-wide. In most cases symptoms are mild, however some people have ongoing symptoms lasting longer known as 'long COVID'. Exertional breathlessness is a common complaint in these patients. Dysfunctional breathing (DB) and vocal cord dysfunction (VCD) are two underappreciated causes of breathlessness. We hypothesized that in individuals who had experienced COVID-19, dysfunctional breathing could give rise to VCD. Method(s): Nine convenience-sampled participants with confirmed COVID-19 infection were included following resolution of the acute illness. Vocal cords movements were visualised via continuous laryngoscopy. Hyperventilation was employed as a surrogate for DB, using a standard protocol of 40 breathes per minute (bpm). Participants breathed through a flow sensor with concomitant laryngoscopy, and we monitored hyperventilation, gas exchange measurements and laryngeal movements. After 12-weeks patients returned for repeat hyperventilation testing. Result(s): The nine participants consisted of five females and four males, age range 24-66 years. Three of the nine participants developed classic inspiratory VCD during hyperventilation. Patients with VCD were female, younger (<45), reported significantly reduced exercise tolerance post infection and had been physically very active prior to COVID infection. In two participants VCD associated with hyperventilation had resolved on laryngoscopy at 12-weeks. In these two participants who had VCD, breathlessness and reduced exercise tolerance resolved at 12-weeks following laryngeal retraining. In one person evidence of VCD and reduced exercise tolerance persisted post 12-weeks review. Conclusion(s): This study provides the first evidence that COVID-19 may facilitate VCD via DB, causing unexplained breathlessness. Our findings suggest that this disease process may be implicated in 'long COVID' and provide a rationale for therapies such as breathing and laryngeal retraining.

Optimal Tracheostomy Timing Through Modeling Based on Severity of Vocal Cord Injury.

BACKGROUND: Endotracheal intubation is a routinely performed procedure in the ICU. Whereas it is recognized that endotracheal intubation can result in laryngeal and tracheal injury, this study evaluated factors that may affect the incidence of posterior vocal cord ulcers (PVCUs). METHODS: One thousand three hundred fifty-five patients were retrospectively screened from 2002-2018 that received a tracheostomy with routine bronchoscopy at a single institution. Post tracheostomy operative notes were reviewed and included only if proper visualization of the vocal cords was documented. Primary outcome measures included presence of PVCU, length of time on a ventilator until a tracheostomy, hospital length of stay, and mortality. Stratification of the data focused on the severity of the ulcer (mild, moderate, and severe) and was analyzed using analysis of variance, multivariate analysis, and Kaplan-Meier modeling of PVCU incidence over time. RESULTS: We enrolled 192 subjects with documentation of vocal cord visualization. Thirty-nine subjects did not have a PVCU, whereas 153 subjects did. A median duration of 9 (interquartile range [IQR] 5-13) d was associated with developing a mild PVCU, whereas individuals intubated for a median of 6 (IQR 4-7) d were ulcer free. Statistical difference between length of time on a ventilator before tracheostomy and the severity of the PVCU seen was significant (P < .001). The Kaplan-Meier model showed that beyond 2 weeks of endotracheal intubation subjects will have > 80% chance of developing a moderate vocal cord ulcer. Whereas by day 7, there is only a 20% chance of developing a moderate ulcer. CONCLUSIONS: Earlier tracheostomy placement was associated with reduced severity of vocal cord ulcer formation. The Kaplan-Meier model suggests that waiting for 14 d is likely too long and earlier placement of a tracheostomy, within a week, may decrease the morbidity of posterior vocal cord injury.

The Role of Ultrasonography in Evaluating the Function of the Vocal Cords, Post-Thyroidectomy

Objective: Although there are several methods to assess vocal cord (VC) paralysis, direct flexible laryngoscopy (DFL) is used as a main diagnostic modality. In recent years, transcutaneous laryngeal ultrasonography (TLUS) has emerged as an alternative method to evaluate VCs. The objective of this study was to investigate the efficiency of TLUS in the evaluation of VCs, post-thyroidectomy. Materials and Methods: The study included 93 patients who had undergone thyroid surgery. All patients were examined using DFL, 1 to 3 days before surgery, to evaluate their VC functions. Patients were examined using DFL and TLUS on postoperative day 7. Patients' age, sex, diagnosis, type of surgery, preoperative DFL findings, postoperative DFL, and TLUS findings were recorded. Results: Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPVs) were 75% (6/8), 98.66% (74/75), 85.71% (6/7), and 97.36% (74/76), respectively. The diagnostic accuracy of TLUS was 97.96%. The area under the receiver operator characteristic (ROC) curve was 0.869, P value <.0001 (95% confidence inteval, 0.75–1.00), which indicated that TLUS was a good tool for identification of VC palsy in this cohort of post-thyroidectomy patients. Conclusion: This cohort study demonstrated that TLUS was a reliable diagnostic tool to evaluate VC functions in patients after thyroidectomy. It may be used as a safer alternative during the ongoing COVID-19 pandemic due to the lack of human-originated aerosols. © The Author(s) 2023.

Transjugular Approach for Recurrent Intracranial Glomus Vagale Tumors: An Ideal Approach to Preserve Hearing and Facial Nerve Function

Lateral skull base paragangliomas (glomus tumors) are rare skull base tumors arising from neuroendocrine cells. These benign tumors can be locally aggressive with potential for intracranial extension and significant morbidity as they compromise cranial nerve structures. Treatment is highly patient dependent. Herein, we present a case of recurrent glomus vagale paraganglioma requiring a multidisciplinary transjugular and transcervical approach for complete resection. A 64-year-old male was referred to the neurotology clinic in 2019 for a left skull base tumor causing progressive dysphonia and dysphagia. Exam revealed left true vocal fold weakness and no other abnormalities. Hearing was normal on the left. Magnetic resonance imaging (MRI) revealed a large hyperintense lesion of the left jugular foramen with intracranial cerebellopontine angle extension and normal flow through the sigmoid sinus and jugular vein. The patient elected for surgical removal and near-total resection was achieved via retrosigmoid craniotomy. A small portion was intentionally left in the jugular foramen to preserve the intact eleventh cranial nerve, internal jugular vein, and sigmoid sinus. Surgical pathology confirmed glomus paraganglioma. Postoperative radiation was strongly recommended, but the patient was lost to follow-up due to the COVID-19 pandemic. The patient re-presented in late 2021 with worsened dysphonia and dysphagia. Exam confirmed left true vocal fold immobility consistent with vagal nerve paralysis and a new finding of left tongue weakness consistent with hypoglossal nerve injury. MRI revealed recurrence of the lesion to dimensions larger than original presentation and complete occlusion of the sigmoid-jugular system. Hearing and facial nerve function remained fully intact, thus a transjugular approach with hearing preservation and complete surgical resection was utilized. After combined retrosigmoid and transcervical incision, the transjugular approach was utilized to resect the sigmoid sinus, the tumor of the jugular foramen, and the intracranial extension. The ear canal and facial nerve canal were preserved. The sigmoid sinus was ligated with surgical clips and the jugular vein was ligated with suture thread. Intracranially, the hypoglossal nerve was identified and preserved, and the vagus nerve was seen eroded by tumor. Pathology confirmed recurrent paraganglioma. Postoperatively, the patient recovered well but continues to endorse persistent dysphonia. His treatment plan includes radiation and thyroplasty. Multiple surgical approaches for the treatment of skull base paragangliomas have been reported including infratemporal types A to D, among others. This report identifies a rare case of recurrent paraganglioma which necessitated removal via transjugular approach. While uncommon in skull base surgery, this approach allowed identification and preservation of important neck and skull base structures (e.g., facial nerve, ear canal, spinal accessory nerve) while achieving complete gross resection. Radiation techniques have become popular alternatives for treatment of glomus tumors of the skull base due to high levels of surgery-related adverse events. Thus, skull base surgeons should be aware of the utility of the transjugular surgical technique for patients with intact hearing and facial nerve function who seek removal of intracranial jugular foramen tumors.

[A CASE OF INDUCIBLE LARYNGEAL OBSTRUCTION UNSUCCESSFULLY TREATED AS SEVERE ASTHMA WAS WELL CONTROLLED AFTER APPROPRIATE DIAGNOSIS AND INSTRUCTION OF THERAPEUTIC BREATHING MANEUVERS].

BACKGROUND: Inducible laryngeal obstruction (ILO) refers to respiratory disorders caused by airflow limitation in the larynx, including vocal cord dysfunction, and may sometimes be misdiagnosed as bronchial asthma (BA). Here, we report the case of an 11-year-old boy diagnosed with BA in infancy. He was referred to our Allergy Center and was taking a high dose of inhaled corticosteroids (ICS) due to frequent coughing from the age of 10 years and persistent coughing following COVID-19 infection at the age of 11. However, the patient continued to experience frequent coughing attacks and repeated visits to the emergency department after inhalation of ß2-stimulants failed to improve his cough. We admitted him to the allergy center for examinations to assess the BA severity. In the airway hypersensitiveness test, saline inhalation performed prior to methacholine inhalation caused expiratory stridor and respiratory distress in the larynx, which worsened with ß2-stimulant inhalation. Based on these results, we ruled out BA and diagnosed ILO. We instructed him on breathing maneuvers, and he was able to respond appropriately when symptoms appeared. We then started reducing his ICS dose.

Vocal Cord Dysfunction During the COVID-19 Pandemic.

BACKGROUND: Vocal cord dysfunction is an upper-airway disorder characterized by exaggerated and transient glottic constriction causing respiratory and laryngeal symptoms. Common presentation is with inspiratory stridor often in the context of emotional stress and anxiety. Other symptoms include wheezing (which may be on inspiration), frequent cough, choking sensation, or throat and chest tightness. This is seen commonly in teenagers, particularly in adolescent females. The COVID-19 pandemic has been a trigger for anxiety and stress with an increase in psychosomatic illness. Our objective was to find out if the incidence of vocal cord dysfunction increased during COVID-19 pandemic. METHODS: We performed a retrospective chart review of all the subjects with a new diagnosis of vocal cord dysfunction who were seen at the out-patient pulmonary practice at our children's hospital between January 2019-December 2020. RESULTS: The incidence of vocal cord dysfunction in 2019 was found to be 5.2%, (41/786 subjects seen) compared to 10.3% (47/457 subjects seen) in 2020, which is a nearly 100% increase in incidence (P < .001). CONCLUSIONS: It is important to recognize that vocal cord dysfunction has increased during the COVID-19 pandemic. In particular, physicians treating pediatric patients, as well as respiratory therapists, should be aware of this diagnosis. It is imperative to avoid unnecessary intubations and treatments with bronchodilators and corticosteroids as opposed to behavioral and speech training to learn effective voluntary control over the muscles of inspiration and the vocal cords.

Vocal Cord Dysfunction: Do Infections Drive Disease?

Rationale: Vocal cord dysfunction (VCD) is often under-recognized and/or misdiagnosed as asthma. Although post-viral syndrome has been suggested as a contributing factor in VCD, there is little data on infectious-associated VCD and no information with COVID-19. The purpose of this ongoing, prospective registry study is to characterize risk factors contributing to VCD. Methods: Subjects age ≥ 12 years referred for VCD assessment at the time of provocation challenge-rhinolaryngoscopy were eligible to participate. Enrollment initiated September, 2021. An investigator designed questionnaire of potential risk factors for VCD including COVID-19 infection was administered with data chart collection. Results: Of 31 subjects currently enrolled, 52% (N=16) reported VCD symptoms either 1) onset following respiratory infection (N=9, 29%) or 2) worsened following COVID-19 infection (N=7, 23%). Those reporting infectious-associated VCD symptoms were more likely to report gastroesophageal reflux disease (p=0.017) with approaching significance for symptoms of throat clearing (p=0.097), chronic sinus infections (p=0.095), and age > 40 years (p=0.097) when compared to subjects who denied infectious-associated VCD symptoms. Additionally, the noninfectious-associated VCD group was approaching significance for reporting increasing number of triggers over time (p=0.051) versus infectious-associated VCD. There was no difference (p>0.05) between groups in Pittsburgh VCD Index scores, BMI, sex, co-morbid asthma, smoking status, environmental allergy history, or symptoms of shortness of breath, cough, wheezing, or throat tightness. Conclusions: Our early results suggest an important role for infectious etiologies, including COVID-19, in triggering and/or worsening VCD. Clinical awareness of these associations is warranted to rapidly address and provide appropriate therapeutic care.

Isolated tracheobronchial mucormycosis: Report of a case and systematic review of literature

Background: Isolated tracheobronchial mucormycosis (ITBM) is an uncommonly reported entity. Herein, we report a case of ITBM following coronavirus disease 2019 (COVID-19) and perform a systematic review of the literature. Case description and systematic review: A 45-year-old gentleman with poorly controlled diabetes mellitus presented with cough, streaky haemoptysis, and hoarseness of voice 2 weeks after mild COVID-19 illness. Computed tomography and flexible bronchoscopy suggested the presence of a tracheal mass, which was spontaneously expectorated. Histopathological examination of the mass confirmed invasive ITBM. The patient had complete clinical and radiological resolution with glycaemic control, posaconazole, and inhaled amphotericin B (8 weeks). Our systematic review of the literature identified 25 additional cases of isolated airway invasive mucormycosis. The median age of the 26 subjects (58.3% men) was 46 years. Diabetes mellitus (79.2%) was the most common risk factor. Uncommon conditions such as anastomosis site mucormycosis (in two lung transplant recipients), post-viral illness (post-COVID-19 [n = 3], and influenza [n = 1]), and post-intubation mucormycosis (n = 1) were noted in a few. Three patients died before treatment initiation. Systemic antifungals were used in most patients (commonly amphotericin B). Inhalation (5/26;19.2%) or bronchoscopic instillation (1/26;3.8%) of amphotericin B and surgery (6/26;23.1%) were performed in some patients. The case-fatality rate was 50%, primarily attributed to massive haemoptysis. Conclusion: Isolated tracheobronchial mucormycosis is a rare disease. Bronchoscopy helps in early diagnosis. Management with antifungals and control of risk factors is required since surgery may not be feasible. © 2022 Wiley-VCH GmbH.

Society of Critical Care Medicine 52nd Critical Care Congress

472 HOSPITAL-ACQUIRED ACHROMOBACTER DENITRIFICANS BACTEREMIA: CASE REPORT AND REVIEW OF LITERATURE 473 MULTISYSTEM INFLAMMATORY SYNDROME IN ADULTS (MIS-A) AFTER COVID-19 INFECTION 474 RISK FACTORS FOR EARLY-ONSET MDRO INFECTIONS IN CRITICALLY ILL PATIENTS 475 DESCENDING NECROTIZING MEDIASTINITIS FROM PERITONSILLAR ABSCESS PRESENTING AS A STEMI 476 OUTCOMES OF PATIENTS AGED 85 YEARS OR OLDER ADMITTED WITH COVID-19 477 BABESIOSIS AND RED BLOOD CELL EXCHANGE TRANSFUSION: CONSIDER IT EARLY 478 REFRACTORY TOXIC SHOCK SYNDROME: IV IMMUNOGLOBULIN TO THE RESCUE! 390 IMPACT OF VACCINATION ON COST AND COURSE OF HOSPITALIZATION ASSOCIATED WITH COVID-19 INFECTION Research Snapshot Theater: Infection III PUBLISHING NUMBER 391 THE PROGNOSTIC VALUE OF ICHIKADO SCORES AND CCI FOR HOSPITALIZED PATIENTS WITH COVID-19 PNEUMONIA 392 PROGNOSTIC MARKERS OF GERIATRIC PATIENTS IN THE ICU WITH RESPIRATORY FAILURE SECONDARY TO COVID-19 393 SEVERE SUPPURATIVE SIALADENITIS IN A COVID-19-POSITIVE PATIENT 394 A CASE OF EXTENSIVE NECROTIZING FASCIITIS DUE TO STRING TEST-NEGATIVE KLEBSIELLA PNEUMONIAE 395 IMPACT OF BMI ON MORTALITY, MECHANICAL VENTILATION, AND LENGTH OF STAY IN COVID-19 PATIENTS 396 IMPACT OF OBESITY ON CLINICAL OUTCOMES IN PATIENTS RECEIVING ACYCLOVIR FOR HSV ENCEPHALITIS 397 DEGREE OF THROMBOCYTOPENIA IN HOSPITALIZED COVID-19 PATIENTS WITH EBV AND CMV COINFECTION 398 ICU MANAGEMENT OF SEVERE BABESIOSIS IN AN IMMUNOCOMPROMISED ASPLENIC PATIENT Research Snapshot Theater: Infection IV PUBLISHING NUMBER 399 A CASE OF SEVERE BABESIOSIS REQUIRING EXCHANGE TRANSFUSION 400 BLOOD RNA BIOMARKERS DISTINGUISH IMMUNE RESPONSES TO COVID-19 VIREMIA VERSUS COMORBID INFECTIONS 401 HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A HIDDEN SURPRISE UNDER THE GARB OF DENGUE FEVER?. [Extracted from the article]

Bilateral vocal cords paralysis requiring urgent tracheostomy on COVID-19 patient: a case report.

BACKGROUND: SARS-CoV-2 infection has many manifestations, including otolaryngological symptoms. CASE PRESENTATION: A 60-year-old man with severe dyspnea underwent endotracheal intubation followed by 68 h of mechanical ventilation. After extubation, he left the ICU without any significant complications. Four days after the extubation, he developed dyspnea, which deteriorated the next 2 days, and stridor became evident. A fiberoptic laryngoscope revealed bilateral vocal cord edema and paralysis, which required an emergency airway. We decided to perform an awake tracheostomy under local anesthesia while considering protection for airborne infection to healthcare providers. The tracheostomy was closed when the edema and paralysis of the vocal cords were ameliorated. CONCLUSIONS: A COVID-19 patient who underwent injurious ventilation developed vocal cord paralysis and edema 6 days after extubation, leading to an emergency tracheostomy. Close attention to the upper airway of COVID-19 patients is essential since the pathophysiology of the present incident may be specific to the viral infection.

Laryngeal complications after endotracheal intubation and prone positioning in patients with coronavirus disease 2019.

Objectives: Laryngeal complications have been reported after endotracheal intubation and prone positioning in patients with critical coronavirus disease 2019 (COVID-19), but their association is unclear. In this study, we investigated the rate of laryngeal complications in patients with COVID-19 compared to an alternative condition (control group). Methods: We retrospectively analyzed the data of 40 patients who underwent endotracheal intubation for either COVID-19 or an alternative condition (control group). Data on age, sex, body mass index (BMI), cardiovascular disease (CVD) risk factors, use of prone therapy, duration of endotracheal intubation, and duration from extubation/tracheostomy to laryngeal evaluation were collected from medical records. Results: There were no significant differences in BMI, frequency of CVD risk factors, duration of endotracheal intubation, or duration from extubation/tracheostomy to laryngeal evaluation between the two groups. In the COVID-19 group, all patients adopted the prone position. In comparison, only one patient in the control group adopted the prone position. Significant differences were observed between the two groups regarding the incidence of vocal fold immobility and laryngeal granuloma. Conclusion: Laryngeal complications were more common in the COVID-19 group than in the control group. Prone positioning may be a risk factor for these complications. Level of Evidence: 4.

Epiglottic Abscess in a Healthy but Unvaccinated Patient With COVID: Predilection for the Upper Airway?

Introduction: With new SARS-CoV-2 variants emerging such as Delta and Omicron, it is important to reevaluate patterns of presentation and affected patient characteristics. SARS-CoV-2 infection may be shifting from a primary insult of the lower airway to one primarily affecting the upper airway. Method(s): This is a report of a novel case of SARS-CoV-2 infection causing an epiglottic abscess during the peak of the Omicron wave. A literature review showed no previous reports of this specific entity. Result(s): An otherwise healthy, unvaccinated 25-year-old man presented with 3 days of throat pain and mild cough. He had no subjective or objective fevers, malaise, voice changes, or difficulty breathing. White blood cell count was normal. A computed tomography neck with intravenous (IV) contrast revealed edema and gas formation of the epiglottis with a small developing abscess. Flexible fiber-optic laryngoscopy showed an edematous epiglottis with prolapse posteriorly to the pharyngeal wall and mild arytenoid edema without involvement of the vocal folds. He was intubated in the operating room, and incision and drainage of the epiglottic abscess was performed. He was given steroids and broad-spectrum IV antibiotics and extubated without difficulty on postoperative day 2. Intraoperative cultures unfortunately did not speciate to guide antibiotic therapy. He continued to improve clinically and was discharged home on postoperative day 3 with a course of amoxicillin/clavulanate. Conclusion(s): This case highlights a unique presentation of COVID in a young, unvaccinated patient that was successfully managed with operative drainage. He was without any medical comorbidities or immunodeficiency. It is possible that current COVID variants have a predilection for the upper airway as evidenced by this case.

Effect of COVID-19 on the Incidence of Postintubation Laryngeal Lesions

Introduction: Critically ill patients intubated in the intensive care unit experience prolonged intubation leading to increased frequency of laryngeal injuries, and there is an increasing need for intubation and mechanical ventilation currently due to the COVID-19 pandemic. It is important to fill the literature gaps regarding the incidence of laryngeal injury following prolonged intubation due to COVID-19. Method(s): This study is a retrospective review of patients with swallowing, voice, or airway concerns identified by their primary physician or speech-language pathologist who were evaluated using flexible laryngoscopy from August 14, 2020, to August 18, 2021. A total of 25 patients with COVID-19 and 27 patients without COVID-19 were included. Specific injuries evaluated for were edema/erythema, granulation tissue/ ulceration, posterior glottic stenosis, subglottic stenosis, vocal cord immobility, and vocal cord paralysis. Severe lesions were those that caused significant airway obstruction or required operative treatment or tracheostomy dependence. Result(s): Within the COVID-19 group, 80% of patients had laryngeal injury, with 45% of these in the severe category. In the non-COVID-19 group, 62.9% of patients had a laryngeal injury, with 23.5% being severe. Mild injuries were seen in 44% of COVID-19 patients and 48% of non-COVID-19 patients. The most common injury category seen was granulation tissue/ulceration. Patients with severe injuries were intubated for 6 to 39 days (mean 14.8), those with mild injuries were intubated for 0 to 31 days (mean 10.4), and patients with no injuries were intubated for 0 to 34 days (mean 9.53). Conclusion(s): Patients who were intubated for COVID-19 were more likely to have severe clinically significant laryngeal injuries than non-COVID-19 patients, even when they were intubated for similar amounts of time. Interestingly, the incidence of mild injuries was similar between the 2 groups. Based on these results, it may be beneficial to have a lower threshold for performing flexible laryngoscopy on postintubated COVID-19 patients to evaluate for laryngeal injury. This would allow for earlier intervention and, it is hoped, reduction of morbidity.

Anesthetic Considerations for Chiari I Malformation in a BMI 62 Patient

Patients with Chiari I malformations present with tonsillar herniation below the foramen magnum causing abnormal spinal anatomy. Anesthesia challenges in this population include difficult airway management, monitoring intraoperative autonomic dysfunction, avoiding increased intracranial pressure, and accommodating sensitivity to neuromuscular blockade. We present a case with an additional airway management challenge due to morbid obesity with a BMI of 62. A 23 year old female with a history of Covid pneumonia and morbid obesity who presented with syringomyelia and Chiari I malformation. She initially presented with bilateral numbness, tingling, weakness, and pain in her hands. Imaging with MRI at the time showed downward displacement of the cerebellar tonsils with the tips reaching the lower portion of C1 and overall 10-12 mm displacement below the level of the foramen magnum. Syrinx was also visualized from the level of C1-C2 extending down to the level of T5-T6. Repeat MRI a year later showed no significant changes. However, she has worsening symptoms of pain in her right arm preventing her from working. She is agreeable to surgical decompression of the posterior fossa through a suboccipital craniotomy with resection of the posterior arch of C1 with duraplasty. Significant findings on the physical exam include Mallampati III, shorter thyromental distance, and limited range of motion of her cervical spine due to pain in her arms. We chose awake fiberoptic intubation due to difficult airway from morbid obesity and limited cervical spine range of motion and the consideration of hypercapnia induced from brief apnea the patient may not tolerate. She was premedicated with versed, glycopyrrolate, and dexmedetomidine, and given a 5% lidocaine paste lollipop to topicalize oropharynx. She was also started on a low dose remifentanil infusion for sedation during the awake fiberoptic approach. Blood pressure, heart rate, respiratory rate with continuous end-tidal capnography, and pulse oximetry were monitored during the awake fiberoptic intubation. A 7.0 endotracheal tube was lubricated with viscous lidocaine and placed over a fiberoptic scope. Once there was visualization of the vocal cords, additional 2% lidocaine was administered directly at the vocal cords. She was intubated smoothly on the first attempt. She was then immediately induced to general anesthesia with propofol and non-depolarizing muscle relaxant to avoid using succinylcholine due to the possible hypersensitivity caused by denervation. Intraoperatively, a conventional air warmer was used to prevent hypothermia. Invasive arterial blood pressure monitoring was applied. Normotensive blood pressure and normocapnia were maintained throughout the surgery. Muscular blockade was reversed with sugammadex at the end of surgery to ensure adequate ventilation especially with the patient's body habitus. Upon extubation, the patient had acute hypertension which was managed by nicardipine infusion and hydralazine boluses. Patient was taken to a neurosurgical intensive unit and monitored for two days. She was discharged home without any complication. In conclusion, anesthetic considerations for patients with Chiari I malformation include airway management, monitoring for autonomic dysfunction, avoiding increase in ICP, and optimizing postoperative neurological status with balanced anesthetic management.