A Novel Approach to the Challenging Injection Laryngoplasty.

INTRODUCTION: Injection laryngoplasty (IL) is typically performed either awake or under general anesthesia with paralysis. There is a subgroup of patients, however, for whom neither of these is a good option. For such patients, we report a hybrid technique that allows for a percutaneous injection without paralysis but with sedation to increase patient tolerance. Supraglottic airway laryngotracheal intervention (SALTI) brings the benefits of injection laryngoplasty to a group of patients previously underserved. METHODS: Injection laryngoplasty cases using SALTI technique from July 1, 2013, to October 21, 2014, were reviewed. Data were collected regarding the indication, success of injection, comorbidities, and outcomes. RESULTS: Seventeen subjects were reviewed. All were successfully injected without complications. Follow-up data were available for 15 subjects. The majority of patients experienced improved symptoms of dysphonia and/or dysphagia after the procedure. DISCUSSION AND CONCLUSIONS: This study demonstrates the feasibility of the SALTI technique for IL. The technique may also be useful for other procedures. Advantages include maintenance of spontaneous ventilation without paralysis, no neck extension, improved patient tolerance, and accommodation of difficult anatomy. Disadvantages are increased time and cost related to the operating room and the need for an assistant. Overall, SALTI permits IL in previously ineligible patients.

Prevention of pressure ulcers after pediatric tracheotomy using a Mepilex Ag dressing.

OBJECTIVES/HYPOTHESIS: Skin irritation and ulceration beneath the tracheostomy tube or ties secondary to pressure and shearing forces on the skin frequently complicate pediatric tracheotomy in the immediate postoperative period. The aim of this study is to determine the effectiveness of Mepilex Ag dressings in reducing posttracheotomy wound complications. STUDY DESIGN: Retrospective study. METHODS: We identified 134 pediatric tracheotomies performed between June 2005 and June 2011 at a tertiary care academic pediatric hospital. Peristomal skin breakdown was documented at the time of the first tracheostomy tube change. Starting in February 2010, the application of Mepilex Ag, a silver-impregnated foam dressing, underneath the tracheostomy tube and twill ties became standard practice. The rates of wound breakdown before and after the introduction of Mepilex Ag were compared. Age, indication for tracheotomy, comorbidities, and severity of wound breakdown were also compared. RESULTS: Patients undergoing tracheotomies prior to February 2010 had no dressing applied under the tracheotomy at the end of the procedure (n = 93). Beginning in February 2010, Mepilex Ag barrier was applied beneath the tracheostomy and ties in all subjects undergoing tracheotomy (n = 41). In the cohort without Mepilex Ag, 11.8% developed skin breakdown by the time of first tracheostomy tube change. When Mepilex Ag was used to pad the tracheotomy site, no peristomal skin breakdown occurred (P = 0.02). No comorbidities were associated with postoperative ulcer formation in either cohort. CONCLUSIONS: The use of Mepilex Ag after pediatric tracheotomy reduces the occurrence of postoperative peristomal pressure ulcers.

Ultrasound gel causes fine needle aspiration artifact? A clear choice.

OBJECTIVES: Ultrasound-guided fine needle aspiration (FNA) is a commonly employed tool in cytopathologic practice. Artifacts resulting in misinterpretation of specimens have been noted with various ultrasound gel media. Our purpose was to perform a prospective human cadaveric study of this phenomenon to identify a low-cost solution that eliminates the artifact. STUDY DESIGN: Three separate ultrasound-guided FNAs were performed on the thyroid and parotid glands in situ of a fresh human cadaver using three different types of ultrasound gel media. Slides were prepared in standard fashion (Quik-Diff and Papanicolaou stains). Two cytopathologists subsequently analyzed the slides for the presence of any artifact interfering with their ability to visualize and interpret the cellular aspirate material. RESULTS: Two of the three gel media revealed significant artifacts mimicking apoptosis, necrosis or colloid, making it difficult to visualize the cellular components and differentiate the artifact from the thyroid colloid. One gel medium did not show any significant artifact, and there was no discernable difference in its quality with regard to the ultrasound image during FNA procedures. CONCLUSIONS: Ultrasound gels can be associated with a significant artifact in FNA specimens. To eliminate this artifact, which may alter the adequacy, diagnosis or cytologic appearance, we confirm a specific gel type that is useful for ultrasound-guided FNAs.

Office-based laser surgery of the larynx: cost-effective treatment at the office's expense.

OBJECTIVE: While office-based laser surgery (OBLS) for benign laryngeal disease is cost-effective for the patient, the financial impact on the office offering the service has not been characterized. We hypothesize that OBLS offers savings to the patient that are not widely realized because of the financial liability the technology poses. STUDY DESIGN: A 2-part financial analysis. SETTING: (1) Hospital operating room and (2) non-facility-based office. SUBJECTS AND METHODS: First, the average cost and reimbursements for 50 patients undergoing OBLS were compared with those of 50 patients undergoing operative direct laryngoscopy with laser (DLL). Second, a detailed financial comparison was performed on a self-paired series of patients who had each undergone both OBLS and DLL for benign laryngeal disease. RESULTS: When compared with DLL, OBLS provides more than a $5000 per-case cost savings for the third-party payer. Average DLL reimbursement was $6453.44 per case, including hospital, anesthesiologist, and surgeon reimbursements of $5150, $745.66, and $357.78, respectively. Based on the calculated hospital cost of $2069.15 per case, the hospital profited more than $3000 per DLL. For OBLS in a non-facility office setting, the average reimbursement was $643.08 per case, with procedure and laser fiber reimbursements of $596.52 and $46.56, respectively. Based on office expenditures of $1388.06 per case, the office lost more than $500 per OBLS case. CONCLUSION: OBLS in a non-facility-based office setting leads to a net financial loss for the office, making OBLS-associated health care cost savings unlikely to be widely realized unless reimbursement patterns are changed.