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Background: Primary fit tracheoesophageal puncture (TEP) is widely preferred for individuals who have not undergone prior radiation. However, there is no consensus on the relative utility of primary‐fit TEP in the setting of salvage laryngectomy. Methods: A retrospective, single‐center review was conducted of individuals undergoing laryngectomy with primary fit TEP between 2012 and 2018. Multivariable analysis was conducted to compare short‐term and long‐term complications, as well as speech and swallowing outcomes, of those who underwent primary versus salvage laryngectomy. Results: In this study, 134 patients underwent total laryngectomy with primary fit TEP. Aside from a higher rate of peristomal dehiscence (13.1% vs. 1.4%) found in the salvage group, there was no difference in incidence of all other complications, including pharyngocutaneous fistula formation. The groups had comparable speech and swallow outcomes. Conclusion: Primary fit TEP is a safe and effective surgical choice for individuals undergoing salvage laryngectomy who desire a voice prosthesis. [ABSTRACT FROM AUTHOR]

Background: The loss of laryngeal function affects breathing, swallowing, and voice, thus severely compromises quality of life. Laryngeal transplantation has long been suggested as a solution for selected highly affected patients with complete laryngeal function loss. Objective: To obtain insights regarding the advantages, weaknesses, and limitations of this procedure and facilitate future advances, we collected uniform data from all known laryngeal transplants reported internationally. Methodology: A case series. Patients were enrolled retrospectively by each institutional hospital or clinic. Eleven patients with complete loss of laryngeal function undergoing total laryngeal transplantation between 1998 and 2018 were recruited. Results: After a minimum of 24 months follow‐up, three patients had died (27%), and there were two graft explants in survivors, one total and one partial, due to chronic rejection. In the remaining cases, voice was functional in 62.5% and 50% achieved decannulation. Swallowing was initially restricted, but only one patient was gastrostomy‐dependent by 6 months and all had normal or near‐normal swallowing by the end of year two after transplantation. Median follow‐up was 73 months. Functional (voice, swallowing, airway) recovery peaked between 12 and 24 months. Conclusions: Laryngeal transplantation is a complex procedure with significant morbidity. Significant improvements in quality of life are possible for highly selected individuals with end‐stage laryngeal disorders, including laryngeal neoplasia, but further technical and pharmacological developments are required if the technique is to be more widely applicable. An international registry should be created to provide better quality pooled data for analysis of outcomes of any future laryngeal transplants. Level of Evidence: 4 Laryngoscope, 134:4313–4320, 2024 [ABSTRACT FROM AUTHOR]

Background: Evaluate whether extranodal extension (ENE) extent impacts outcomes in patients with oral cavity squamous cell carcinoma (OCSCC). Methods: From an institutional database, patients with OCSCC and pathologic ENE who received adjuvant treatment were included. Surgical slides were reviewed to confirm ENE extent. Multivariable Cox regression was used to relate patient/treatment characteristics with disease‐free survival (DFS) and overall survival (OS). ENE was analyzed as both a dichotomous and continuous variable. Results: A total of 113 patients were identified. Between major (>2 mm) versus minor ENE (≤2 mm), there was no significant difference in DFS (HR 1.18, 95%CI 0.72–1.92, p = 0.51) or OS (HR 1.17, 95%CI 0.70–1.96, p = 0.55). There was no significant association between ENE as a continuous variable and DFS (HR 0.97 per mm, 95%CI 0.87–1.4, p = 0.96) or OS (HR 0.96 per mm, 95%CI 0.83–1.11, p = 0.58). Conclusion: No significant relationship was seen between ENE extent and DFS or OS in individuals with OCSCC. [ABSTRACT FROM AUTHOR]

Objective: Endoscopic management of subglottic stenosis (SGS) includes a wide range of techniques. This 17‐year review compares treatment outcomes between carbon dioxide (CO2) laser and cold steel. Study Design: Retrospective chart review. Setting: Single tertiary care center. Methods: A chart review was performed for all patients undergoing endoscopic treatment of SGS at Cleveland Clinic between July 12, 2000 and September 1, 2017. Data collected included demographics, stenosis etiology, stenosis severity, comorbidities, treatment modality, and airway procedure history. The primary endpoint was repeated treatment‐free survival (RTFS) within 2 years using a Kaplan‐Meier analysis and Cox proportional hazard model. Results: A total of 139 patients (median [interquartile range] aged 48.7 [37.8, 57.0] years; 83.4% female) were included in the analysis, with etiologies including idiopathic (56.8%), granulomatosis with polyangiitis (25.2%), and intubation (16.5%). All patients underwent either cold steel (107 patients) or CO2 laser (32 patients) lysis of stenosis with concurrent dilation. RTFS within 2 years was 50.2% for CO2 laser and 31.9% for cold steel (hazard ratio [HR] and 95% confidence interval [CI]: 1.69, 0.96‐2.97, P =.07). In patients with no prior airway procedures, there was no difference in RTFS between laser and cold knife (P =.41). However, in patients with prior airway procedures, RTFS was significantly greater in the laser group, even after adjusting for age, smoking history, and stenosis etiology (50.0% vs 16.8%, adjusted HR and CI: 2.82, 1.14‐6.98, P =.025). Conclusion: Endoscopic lysis of SGS with CO2 laser should be considered in revision cases. [ABSTRACT FROM AUTHOR]

Objectives: Post intubation phonatory insufficiency (PIPI) or posterior glottic diastasis describes posterior glottic insufficiency (PGI) caused by prolonged intubation causing medial arytenoid ulceration, mucosal scarring, and incomplete cricoarytenoid joint adduction. The purpose of this review is to showcase diagnostic findings, surgical rehabilitation, and gaps in our treatment algorithm of PIPI. Data Sources: Embase, PubMed, Scopus, Web of Science. Review Methods: Two independent reviewers completed a systematic search of the literature studying PIPI. Reported intubation history, laryngeal defect, clinical symptoms, surgical intervention, and outcomes were gathered from included studies. Results: Nine studies met our inclusion criteria for full review, (45 patients) all of which were case reports/series. All patients had posterior glottic defects, most commonly loss of medial arytenoid tissue, causing varying degrees of PGI. Eleven patients had vocal fold (VF) immobility or hypomobility. Treatment interventions were observation (1), speech therapy (2), VF or posterior glottic injection augmentation (15), medialization laryngoplasty (4), arytenoid repositioning (6), endoscopic (19) or open (3) posterior cricoid reduction, local mucosal rotation flap (11), or free mucosal graft (2) to fill the glottic defect. Observation, voice therapy, and augmentation or type 1 laryngoplasty failed to improve symptoms. Other surgical techniques improved symptoms with varying outcomes. Conclusion: PIPI is a difficult injury to diagnosis and treat. Conservative measures and augmentation/laryngoplasty often fail to fix the PGI. Our review supports symptom improvement with reconstruction of the posterior glottic defect with cricoid reduction or mucosal grafts. Future investigation is needed to better define the diagnosis and successful treatment algorithm. Laryngoscope, 134:2048–2058, 2024 [ABSTRACT FROM AUTHOR]

Objective: There are several options for surgical management of subglottic stenosis, including endoscopic and open procedures. However, treatment algorithms, outcomes, and anesthetic management of subglottic stenosis during pregnancy are not well described. Data Sources: MEDLINE, EMBASE, and the Cochrane databases. Review Methods: A scoping review of management of subglottic stenosis during pregnancy was performed, and then reported in compliance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Inclusion criteria consisted of those with subglottic or tracheal stenosis aged greater than 18 years, those in whom management was performed during pregnancy, and those who reported delivery related outcomes. Results: After systematic review and detailed search of 330 identified articles, 15 articles met inclusion criteria and were included in the final analysis. All studies were case reports or case series (level 4 evidence). This study identified 27 patients. The median age was 29 and the median gestational age at intervention was 28 weeks. Left lateral positioning and fetal heart rate monitoring were used in nearly every case. The most common intervention performed was endoscopic balloon dilation. In many cases, jet ventilation or transnasal humidified rapid insufflation ventilatory exchange was satisfactory for maintenance of the airway. Three women ultimately required tracheostomy prior to labor and delivery. There was no fetal death or complications reported in these studies, and all but one woman proceeded to deliver at term. Conclusion: Endoscopic balloon dilation during pregnancy is safe and effective, resulting in optimized respiratory outcomes for the mother and safe delivery of the fetus. The third trimester appears to be safe for airway intervention. Laryngoscope, 134:1014–1022, 2024 [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study is to characterize Medicare reimbursement trends for laryngology procedures over the last two decades. Methods: This analysis used CMS' Physician Fee Schedule (PFS) Look‐Up Tool to determine the reimbursement rate of 48 common laryngology procedures, which were divided into four groups based on their practice setting and clinical use: office‐based, airway, voice disorders, and dysphagia. The PFS reports the physician service reimbursement for "facilities" and global reimbursement for "non‐facilities". The annual reimbursement rate for each procedure was averaged across all localities and adjusted for inflation. The compound annual growth rate (CAGR) of each procedure's reimbursement was determined, and a weighted average of the CAGR for each group of procedures was calculated using each procedure's 2020 Medicare Part B utilization. Results: Reimbursement for laryngology procedure (CPT) codes has declined over the last two decades. In facilities, the weighted average CAGR for office‐based procedures was −2.0%, for airway procedures was −2.2%, for voice disorders procedures was −1.4%, and for dysphagia procedures was −1.7%. In non‐facilities, the weighted average CAGR for office‐based procedures was −0.9%. The procedures in the other procedure groups did not have a corresponding non‐facility reimbursement rate. Conclusion: Like other otolaryngology subspecialties, inflation‐adjusted reimbursements for common laryngology procedures have decreased substantially over the past two decades. Because of the large number of physician participants and patient enrollees in the Medicare programs, increased awareness and further research into the implications of these trends on patient care is necessary to ensure quality in the delivery of laryngology care. Level of Evidence: NA Laryngoscope, 134:247–256, 2024 [ABSTRACT FROM AUTHOR]

Objective: Organ preservation (OP) treatment for advanced laryngeal cancer has increased compared to primary total laryngectomy. Our study compares oncologic and functional outcomes between these approaches. Study Design: Retrospective cohort study. Setting: Single tertiary care institution. Methods: Retrospective review of patients receiving primary total laryngectomy or OP for laryngeal cancer between 1/1/2000 and 12/31/2018. Results: A total of 118 patients received primary total laryngectomy and 119 received OP. Overall survival was similar between total laryngectomy and OP. When stratified by T stage, disease‐free survival was worse among T3 patients receiving OP versus total laryngectomy. In T3 patients, 28 OP patients experienced local recurrence (28.9%) compared to 3 total laryngectomy patients (7.1%; p < 0.01). In total, 20 OP patients with local recurrence received salvage surgery. These patients had similar overall survival to patients who underwent initial total laryngectomy (TL). About 14 OP patients with local recurrence did not receive salvage surgery. About 89 (75.4%) TL patients achieved normal diet as compared to 64 (53.8%) OP patients (p < 0.001). In TL patients, 106 (89.8%) received primary or secondary tracheoesophageal‐prosthesis, 82 (77.4%) of whom achieved completely understandable speech. Conclusions: There was no difference in survival by treatment in T4 patients, possibly because of strict patient selection. However, disease‐free survival was worse in T3 patients receiving OP, likely due to a high local recurrence rate. Approximately 40% of patients with local recurrence were not eligible for salvage laryngectomy. TL patients had comparable swallowing and speech outcomes with OP patients. Level of Evidence: 3 Laryngoscope, 133:1122–1131, 2023 [ABSTRACT FROM AUTHOR]

Objective: To describe technical aspects and surgical outcomes of endoscopic resection and mucosal reconstitution with epidermal grafting (ie, the Maddern procedure) in the treatment of idiopathic subglottic stenosis. Study Design: Medical record abstraction. Setting: Johns Hopkins Hospital. Methods: Retrospective series of 9 adults with idiopathic subglottic stenosis who underwent the Maddern procedure by a single surgeon over a 5-year period. Prespecified outcomes included (1) perioperative outcomes (Clavien-Dindo grade 4/5 complications, need for staged tracheostomy, hospital length of stay), (2) postoperative outcomes (peak expiratory flow rate [PEFR], need for subsequent airway surgery, tracheostomy at follow-up), and (3) patient-reported quality-of-life outcomes (Clinical COPD Questionnaire, Voice Handicap Index–10, Eating Assessment Tool–10, and 12-Item Short Form Version 2). Wilcoxon matched-pairs signed rank test and Kaplan-Meier analysis were performed. Results: There were no Clavien-Dindo grade 4/5 complications; 2 patients required unplanned staged tracheostomy; and the median length of stay was 3 days. Following endoscopic resection and stent removal, a median of 2 laser resurfacing procedures were required. Two patients developed recurrent stenosis requiring cricotracheal resection (CTR). There were significant improvements in PEFR, Clinical COPD Questionnaire, and Voice Handicap Index–10, without significant difference in Eating Assessment Tool–10. The 12-Item Short Form Version 2 approximated the population norm. Kaplan-Meier analysis demonstrated significant improvement in time to surgery after the final laser resurfacing. Conclusion: The Maddern procedure has a low complication rate and offers durable physiologic improvement in PEFR, limiting need for additional procedures. Risks included need for CTR salvage, temporary tracheostomy, phlegm accumulation, and laryngospasm. It is a surgical option for patients with short dilation intervals who prefer to avoid the risks of CTR. [ABSTRACT FROM AUTHOR]

Importance: Vagus nerve stimulation (VNS) devices have gained widespread acceptance for treatment of resistant epilepsy and depression. The increasing number of procedures has resulted in an increasing number of iatrogenic injuries to the vagus nerve, which can have a significant effect on vocalization and quality of life., Objective: To determine the relative frequency of laryngeal adverse effects reported to the US Food and Drug Administration (FDA) after VNS implantation and to analyze associated VNS device problems., Design, Setting, and Participants: This retrospective cross-sectional analysis queried the FDA Manufacturer and User Facility Device Experience database of adverse events in the US between 1996 and 2020., Main Outcomes and Measures: The primary outcome was the percent of adverse events reported to the FDA that included patients who received VNS with laryngeal adverse effects and the associated proportion of device problems after VNS surgery., Results: A total of 12 725 iatrogenic vagus nerve issues were documented after VNS implantation, with apnea (n = 395; 3.1%) being the most common patient problem. Overall, 187 reports of laryngeal adverse effects associated with VNS devices were identified and represented the eighth most common iatrogenic vagus nerve problem reported to the FDA. Laryngeal adverse effects included 78 reports of voice alteration and 57 reports of paresis/paralysis. The VNS device problems frequently associated with laryngeal adverse effects were high impedance (n = 15, 8.02%), incorrect frequency delivery (n = 10, 5.35%), and battery problems (n = 11, 5.88%). The number of laryngeal adverse effect reports per year peaked in 2012 with 43 cases., Conclusions and Relevance: This cross-sectional study found that although the literature demonstrates that vocal changes occur with nearly all VNS devices, the FDA receives adverse event reports of voice changes. Our results emphasize a potential need to improve patient counseling prior to VNS surgery to better set patient expectations regarding vocal changes and to prevent unnecessary patient concern. In addition, reports of vocal fold paresis/paralysis potentially suggest that patients may benefit from preoperative laryngeal assessment to differentiate preexisting vocal fold paralysis from that caused by VNS surgery.