Outcomes After Tracheostomy for Patients With Respiratory Failure due to COVID-19.

OBJECTIVE: To evaluate the utility and safety of tracheostomy for patients with respiratory failure from COIVD-19 and describe patient clinical characteristics and process of management. METHODS: Case series of the first 24 COVID-19 patients who underwent tracheostomy at our institution, a single-center tertiary care community hospital intensive care/ventilator weaning unit. The patients all had respiratory failure from COVID-19 and required endotracheal intubation and mechanical ventilation. Outcomes reviewed include mortality, percent discharged, percent liberated from mechanical ventilation, percent decannulated, time from tracheostomy to ventilator liberation and discharge, and number of staff infected with COVID-19 during tracheostomy and management. RESULTS: Of the 24 patients who underwent tracheostomy, 21 (88%) of 24 survived. Twenty (83%) were liberated from mechanical ventilation, and 19 (79%) were discharged. Fourteen (74%) of the discharged had been decannulated. The average (± SD) time from tracheostomy to ventilator liberation was 9 ± 4.3 days and from tracheostomy to discharge 21 ± 9 days. All discharged patients had been liberated from mechanical ventilation. No health care workers became infected with COVID-19 during the procedure or subsequent patient management. CONCLUSION: Patients with respiratory failure from COVID-19 who underwent tracheostomy had a high likelihood of being liberated from mechanical ventilation and discharged. Tracheostomy and subsequent ventilator weaning management can be performed safely. Tracheostomy allowed for decompression of higher acuity medical units in a safe and effective manner.

Oto-tricho-tussia: An Unexpected Cause of Cough.

Chronic cough is a frequently encountered condition with multiple etiologies. In patients with neurogenic chronic cough, peripheral laryngopharyngeal hypersensitivity of the vagus nerve stimulates the cough reflex. We present three cases of "Oto-tricho-tussia," describing hair within the ear canal stimulating Arnold's branch of the vagus nerve and triggering the urge-to-cough. All three patients experienced significant improvement or complete resolution of their cough symptoms after removal of the hair resting on their tympanic membrane and external auditory canal. We encourage ear canal examination and promotion of proper ear cleaning habits as this is an easily treatable consideration for the cause of chronic cough.

From Tracheal Stenosis to Tracheostomy Displacement: A Case Report on a Seemingly Never-Ending Difficult Airway.

We report a case of undiagnosed tracheal stenosis that culminated in acute respiratory failure in an inpatient unit. After failed intubation attempts, the placement of a supraglottic airway resulted in successful ventilation and was followed by a tracheostomy in the operating room. Postoperatively, the tracheostomy tube became accidentally dislodged necessitating emergency measures with eventual reinsertion of a longer tracheostomy tube. We present this case to highlight life-saving airway strategies that may be considered in such emergency situations and propose 2 simple algorithms to guide anesthesiologists in managing similar airway emergencies.

Trigger Reduction Prior to Systemic Drugs for Neurogenic Chronic Cough.

OBJECTIVE/HYPOTHESIS: Neurogenic chronic cough typically presents as a postviral chronic cough, often with paroxysms of coughing preceded by a tickle sensation with multiple triggers and often recalcitrant to multiple treatments for reflux disease, sinus disease, and asthma. Current treatment uses neuromodulating agents with moderate success. Post nasal drainage and laryngopharyngeal reflux can be triggers in the setting of laryngopharyngeal hypersensitivity. Treatment will focus on trigger reduction using nasal toilet and a dietary regimen for laryngopharyngeal reflux. STUDY DESIGN: Systematic review of retrospective cohort studies METHODS: One-year retrospective review of new patients with cough (R05.0) excluding asthma, proton pump inhibitor response, and sinus or pulmonary disease. Cough severity index (CSI) and reflux symptom index (RSI) were evaluated initially and 6 weeks after trigger-reduction treatment using nasal saline irrigation, nasal steroids, nasal antihistamines, and a plant-based diet with alkaline water. RESULTS: Of 119 patients, 29 met the criteria. Using the six-point reduction (improvement) in RSI as an accepted response, 20 of 29 patients (68.9%, P = .0014) experienced a clinical response. Using reduction in RSI and CSI as a continuous variable to assess response, patients experienced a 10 (95% confidence interval [CI]: 6.75-13.2) and 10.9 (95% CI: 7.4-14.3) mean point reduction, respectively. The mean percent reduction in RSI following 6 weeks of treatment was 54.7% (95% CI: 41.5-68.0; P = .0001). These patients experienced a 59.8% (95% CI: 43.4-76.2; P = .0001) reduction in CSI. CONCLUSIONS: A trigger-reduction approach using nasal toilet and a plant-based diet in patients with neurogenic chronic cough prior to the initiation of systemic neuromodulating medications should be considered. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:198-202, 2019.

Esophageal perforation as a complication of the Heimlich maneuver in a pediatric patient: A case report.

We report a case of cervical esophageal perforation caused by the Heimlich maneuver in a healthy 16-year-old boy. The patient reported a short coughing episode while eating rice, and his mother performed the Heimlich maneuver on him. Five days later, he presented to the emergency department with throat pain, odynophagia, secretion intolerance, muffled voice, and neck stiffness. He was admitted to the pediatric intensive care unit for conservative management. The next day he underwent transcervical incision and drainage of purulence, but the esophageal perforation could not be visualized at that time. The perforation was identified several days later and successfully repaired surgically. Esophageal perforation as a complication of the Heimlich maneuver is exceedingly rare, but the clinician should be aware of this entity in the differential diagnosis, as it is associated with a high mortality rate and warrants multidisciplinary care, including timely surgical intervention.

Indications for Surgical Repair of Type 1 Laryngeal Cleft.

OBJECTIVES: Type 1 laryngeal cleft (T1LC) is a congenital deficiency in the posterior glottis, resulting in a communication between the hypopharynx and glottis. No consensus treatment paradigm exists for timing and criteria for patient selection for surgical repair. Our goal is to assess whether patient characteristics can help predict improvement after surgery. METHODS: After Institutional Review Board exemption, a retrospective chart review was performed for patients undergoing surgery to diagnose a T1LC. Charts were examined for age, presenting symptoms, comorbidities, pre/postoperative videoflouroscopic swallow study reports, and outcomes. RESULTS: Ninety-seven patients with clinical suspicion for T1LC underwent direct laryngoscopy and bronchoscopy, and 63 (64%) were diagnosed with a T1LC. Twenty-two patients (63%) undergoing surgery achieved clinical or radiographic improvement. There was no difference in average age, aspiration, or penetration between clinical improvement and no improvement groups. Of 13 patients with comorbidities that increase their risk of aspiration, 12 were significantly improved. There were 5 complications, which were managed conservatively. CONCLUSIONS: Our experience supports the repair of T1LC repair at time of diagnostic laryngoscopy if satisfactory improvement is not noted with conservative treatment. This should be performed without segregation for age, comorbidities, or degree of dysphagia. Our technique is performed with minimal complications and achieves satisfactory results.

Palatopharyngoplasty for treatment of nasopharyngeal stenosis secondary to extra-laryngeal tuberculosis.

Nasopharyngeal stenosis is a rare sequela of extra-laryngeal tuberculosis that can adversely impact the quality of life of afflicted patients. Relying solely on the oropharyngeal airway, patients often complain of inspiratory dryness and decreased sensation of airflow as the nasal mucosa and turbinate complex is entirely excluded from the breathing mechanism. Often times, the oropharyngeal inlet can be narrowed as well, limiting the air flow through the oropharyngeal airway. In those circumstances, patients often require tracheostomy for establishment of a reliable airway. We present the unique case of a previously tracheotomized patient with nasopharyngeal stenosis secondary to tuberculosis successfully treated with a modified palatopharyngoplasty to reestablish a patent naso-oropharyngeal airway. During the follow-up period, the patient was decannulated and highly satisfied with his respiratory status. Although rare and more commonly used in the treatment of sleep apnea, palatopharyngoplasty can be a viable option for the treatment of naso-oropharyngeal stenosis and should be kept in the armamentarium of reconstructive craniofacial surgeons.

Development of the rat larynx: a histological study.

OBJECTIVES/HYPOTHESIS: To evaluate and describe the cartilaginous and muscular development of the rat larynx. STUDY DESIGN: Histologic evaluation. METHODS: The larynges of Sprague Dawley rats of embryonic day (E) 13, 15, 17, 19, 21, postnatal day 0, 14, and adult of 250 gm were collected. Four larynges of each age were harvested, cut into 15-µm serial sections, stained with hematoxylin and eosin, and evaluated under light microscopy. Representative digital images were recorded and evaluated at the preglottic (supraglottic in humans), glottic, and postglottic (subglottic in humans) levels. RESULTS: Brachial arches were observed at E13. At E17, immature structures of the larynx, including skeletal muscle, cartilage, and the lumen were identifiable. Chondrification and muscle formation were clearly seen by E19. The muscular and cartilagenous components of the larynx were well established by E21. During the span between birth and adult maturation, the size of the larynx increased from a height of 1.10 mm to 2.90 mm, and from a width of 1.80 mm to 5.40 mm, and from a length of 1.38 mm to 4.77 mm in the stained section. Although developed at E21, the laryngeal structures continued to grow by approximately 30%. CONCLUSION: Rat laryngeal development parallels that in mice and humans. In the rat, at E17 immature structures of the larynx are identifiable, they are well developed at birth and grow by approximately 30% into adulthood. Understanding the chronology and morphology of the embryogenesis of the rat laryngeal musculature is essential and will allow for further evaluation of the embryologic innervation of these muscles.

Recurrent laryngeal nerve transection and anastomosis: rat laryngeal motoneuron survival and effect of the anastomosis site.

OBJECTIVES: We investigated the quantity of recurrent laryngeal nerve motoneurons (RLNMs) that survive after transection and anastomosis of the rat recurrent laryngeal nerve (RLN), as well as the impact of the anastomosis site on RLN regeneration. METHODS: Ten rats underwent right RLN transection and anastomosis. After 16 weeks, Fluoro-Ruby (FR) was applied to the RLN that was transected proximal or distal to the anastomosis site. The brain stems were harvested, and the nucleus ambiguus was evaluated for labeled RLNMs. The RLNM counts were compared to each other and to those from 3 control rats in which FR was applied to an acutely transected RLN. RESULTS: The number of RLNMs that were stained after RLN transection, anastomosis, and regeneration was consistent with the total number of RLNMs in the nucleus ambiguus of control rats. This finding confirms that most RLNMs survived after RLN transection and anastomosis. The quantity of labeled RLNMs was statistically similar whether the FR was applied proximal or distal to the anastomosis, implying that most of the viable axons that were present proximal to the anastomosis crossed into the distal nerve. CONCLUSIONS: Rat RLNMs survive nerve transection, anastomosis, and regeneration. The anastomosis site does not significantly impede axonal regeneration, and most of the axons traverse the anastomosis into the distal nerve.

Embryologic innervation of the rat laryngeal musculature--a model for investigation of recurrent laryngeal nerve reinnervation.

OBJECTIVES/HYPOTHESIS: Optimal management of vocal fold paralysis would entail recurrent laryngeal nerve (RLN) reinnervation resulting in normal vocal fold motion. Unfortunately, RLN reinnervation currently results in a nonfunctional vocal fold due to synkinetic reinnervation. Therapeutic interventions that guide regenerating axons back to the appropriate muscle would prevent synkinesis and restore vocal fold and glottal function. The initial step toward developing these therapies is the elucidation of the embryologic innervation of the larynx. This study aimed to identify the age of occurrence, timing, and pattern of embryologic innervation of the rat larynx, hypothesizing that differences in these parameters exist between distinct laryngeal muscles. STUDY DESIGN: Descriptive anatomic study. METHODS: The larynx of rats aged embryologic day (E) 15, 16, 17, 19, and 21 were harvested and then sectioned. Two rats were used for each age. Sections were colabeled with neuronal class III ß-tubulin polyclonal antibody to identify the presence of axons and alexa 488 conjugate α-bungarotoxin to identify the presence of motor endplates. The age at which axons and motor endplates were first present was noted. The position and pattern of the axons and motor endplates was recorded in relation to each other as well as the musculoskeletal anatomy of the larynx. The time at which axons appeared to innervate the medial thyroarytenoid (MTA) muscle, lateral thyroarytenoid (LTA) muscle, and the posterior cricoarytenoid (PCA) muscle was documented. RESULTS: Findings in the rat suggest the RLN reaches the larynx and begins branching by E15. Axons branch dorsally first and reach the PCA muscle before the other muscles. Branching toward the MTA muscle occurs only after axons have reached the LTA muscle. By E19, RLN axons have been guided to and selected their respective muscles with formation of neuromuscular junctions (NMJs) in the PCA, LTA and MTA muscles, though the formation of NMJs in the MTA muscle was comparatively delayed. CONCLUSIONS: This study describes the embryologic innervation of the rat larynx and suggests that there are distinct differences in the age of occurrence, timing, and pattern of innervation of the PCA, LTA, and MTA muscles of the rat. These findings lay the foundation for studies investigating the role of guidance cues in RLN axon guidance and the utility of these cues in the treatment of RLN injury via the stimulation of functional, nonsynkinetic reinnervation.

Variability of postoperative esophagrams after endoscopic cricopharyngeal myotomy: technique dependence.

OBJECTIVES: We illustrate the dependence of postoperative day (POD) 1 esophagram findings on the closure technique used after endoscopic cricopharyngeal myotomy (ECPM). METHODS: We performed a retrospective chart review of POD 1 fluoroscopic examinations of the cervical esophagus utilizing contrast dye after ECPM to assess radiologic findings associated with three different techniques of addressing the exposed buccopharyngeal fascia (BPF). RESULTS: Each technique resulted in specific and different findings on the POD 1 esophagram. When the BPF was untreated, the esophagram demonstrated a pseudodiverticulum with free flow of contrast dye. When a fibrin glue seal was used, the esophagram demonstrated a curvilinear focus of contrast dye projected over the retropharyngeal soft tissue persisting after the swallow, similar to a leak. When fibrin glue application was combined with single-suture reapproximation of the mucosal incision, the pattern was similar to esophagrams performed 6 weeks after myotomy. CONCLUSIONS: Different techniques used to address the exposed BPF following ECPM result in specific findings on the POD 1 esophagram. Recognition of these imaging differences and open communication with the fluoroscopist will avoid a misdiagnosis of a pharyngeal leak, which might cause an unnecessary delay of oral feeding and hospital discharge.

Evaluation of functional recovery of recurrent laryngeal nerve using transoral laryngeal bipolar electromyography: a rat model.

OBJECTIVES: We developed a standardized method of minimally invasive transoral laryngeal (ToL) bipolar electromyography (EMG) for evaluation of recurrent laryngeal nerve (RLN) recovery after a controlled crush injury in a rat model. METHODS: Ten 200- to 250-g Sprague-Dawley rats underwent a controlled crush injury to the left RLN performed with 60 seconds of use of a calibrated aneurysm clamp with a closing force of 0.61 N. Serial ToL bipolar EMG was performed on adductor muscles and the posterior criocoarytenoid muscle during spontaneous vocal fold motion under anesthesia. Each animal underwent ToL EMG immediately after surgery and 1, 3, and 6 weeks after surgery. RESULTS: The EMG signals showed normal motor unit potentials and recruitment patterns 3 weeks after crush injury. Endoscopic evaluation of vocal fold mobility yielded consistently normal findings 6 weeks after crush injury. CONCLUSIONS: We have developed a standardized method of crush injury to the rat RLN model and a minimally invasive transoral bipolar spontaneous EMG technique to serially evaluate and follow nerve injury and recovery in rats. This model is intended to simulate intraoperative RLN injury, to elucidate the electrophysiological events that occur during nerve recovery, and to form the basis for studying agents to enhance such recovery.