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Rough vocal effects, extreme, or extended vocal techniques to sound intentionally hoarse or rough are an integral part of many genres and styles, and research has recently demonstrated the involvement of supraglottic narrowing and vibrations to produce such sounds. The vocal health of singing with rough vocal effects is poorly documented, especially in a longitudinal manner, while much vocal pedagogy continuously treats the sounds as harming to or dangerous for the vocal mechanism.To longitudinally investigate the vocal health of professional singers who perform the five rough-sounding vocal effects Distortion, Growl, Grunt, Rattle, and Creaking as part of their singing and teaching.Twenty singers underwent nasoendoscopic examination, filled in SVHI questionnaires, and were assessed by GRBAS with a 14-year interval in a retrospective longitudinal study (from 2007 to 2021). Endoscopic materials were assessed by Reflux Finding Score and a hybrid version of the Stroboscopy Rating Scale.Singers presented at initiation of study with an average SVHI of 9.2 (±9), which decreased at time of follow up 14 years later to an average of 5.12 (±6). Laryngeal assessments (RFS and SRS) revealed low averages at initiation of study as well as at conclusion of the study with only small fluctuations in averages, with findings mainly relating to arytenoid asymmetry.The participating singers perform and teach rough vocal effects continually and present with healthy laryngeal mechanisms and within-normal SVHI and GRBAS scores. The findings suggest that controlled supraglottic narrowing and techniques to allow for supraglottic structures to engage in vibration as an additional noise source can be performed sustainable and in a healthy manner if performed with correct vocal technique.

Purpose To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe. Methods Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion. Results Twenty-four sections on HNC-specific OD topics. Conclusion This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Introduction: The novel Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, may need intensive care unit (ICU) admission in up to 12% of all positive cases for massive interstitial pneumonia, with possible long-term endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common airway-related complications of such ICU maneuvers are laryngotracheal granulomas, webs, stenosis, malacia and, less commonly, tracheal necrosis with tracheo-esophageal or tracheo-arterial fistulae. Materials and methods: This paper gathers the opinions of experts of the Laryngotracheal Stenosis Committee of the European Laryngological Society, with the aim of alerting the medical community about the possible rise in number of COVID-19-related laryngotracheal stenosis (LTS), and the aspiration of paving the way to a more rationale concentration of these cases within referral specialist airway centers. Results: A range of prevention strategies, diagnostic work-up, and therapeutic approaches are reported and framed within the COVID-19 pandemic context. Conclusions: One of the most important roles of otolaryngologists when encountering airway-related signs and symptoms in patients with previous ICU hospitalization for COVID-19 is to maintain a high level of suspicion for LTS development, and share it with colleagues and other health care professionals. Such a condition requires specific expertise and should be comprehensively managed in tertiary referral centers.

OBJECTIVES Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology. DESIGN A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite. MAIN OUTCOME MEASURES Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival. RESULTS Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43 ± 50 days for control patients to 115 ± 140 days for ICR patients (P

IntroductionTo self-monitor asthma symptoms, existing methods (e.g. peak flow metre, smart spirometer) require special equipment and are not always used by the patients. Voice recording has the potential to generate surrogate measures of lung function and this study aims to apply machine learning approaches to predict lung function and severity of abnormal lung function from recorded voice for asthma patients.MethodsA threshold-based mechanism was designed to separate speech and breathing from 323 recordings. Features extracted from these were combined with biological factors to predict lung function. Three predictive models were developed using Random Forest (RF), Support Vector Machine (SVM), and linear regression algorithms: (a) regression models to predict lung function, (b) multi-class classification models to predict severity of lung function abnormality, and (c) binary classification models to predict lung function abnormality. Training and test samples were separated (70%:30%, using balanced portioning), features were normalised, 10-fold cross-validation was used and model performances were evaluated on the test samples.ResultsThe RF-based regression model performed better with the lowest root mean square error of 10·86. To predict severity of lung function impairment, the SVM-based model performed best in multi-class classification (accuracy = 73.20%), whereas the RF-based model performed best in binary classification models for predicting abnormal lung function (accuracy = 85%).ConclusionOur machine learning approaches can predict lung function, from recorded voice files, better than published approaches. This technique could be used to develop future telehealth solutions including smartphone-based applications which have potential to aid decision making and self-monitoring in asthma.

Objectives: The aim of this study was to assess the outcome of treating glottic dysplasia and early squamous cell carcinoma (SCC) with potassium titanyl phosphate (KTP) photoangiolytic laser ablation. Methods: Patient demographics, comorbidities, and tumor characteristics were recorded. Perceptual, patient-reported, and objective voice outcomes were assessed. Use of treatment modalities in addition to the KTP laser, development of locoregional or metastatic SCC, and overall survival were recorded. Results: There were 23 patients with glottic dysplasia and 18 patients with glottic SCC. Mean age at treatment was 69 years. Most patients (95%) were male. Posttreatment fundamental frequency fell from 132 ± 35 to 116 ± 24 Hz ( P = .03). Overall, 61% of patients achieved a normal voice. There was a learning-curve, and most treatment failures occurred in the first half of the series. Five-year KTP-only disease-control rates were 87.1% and 53.5% for dysplasia and malignancy, respectively. Five-year overall survival was 56%, with no laryngectomies or deaths due to SCC. Conclusions: Ablating dysplasia and early glottic cancer using a KTP laser is a viable treatment option. It has a learning curve and a failure rate but, in this series, no ultimate loss of oncologic control. Its introduction into clinical practice should be managed carefully in the context of multidisciplinary cancer care. Level of Evidence: 4.

Background Emergency medical centers are globally one of the most important pillars of pre-hospital care. The most important purpose of this system is to provide satisfactory services in the shortest possible time and in accordance with the modern scientific standards of the world. The present study aimed to compare the effect of virtual and face-to-face training methods on the quality of service provided by Kermanshah pre-hospital emergency personnel, Iran. Methods This was a randomized educational intervention trial performed among the staff of Kermanshah Emergency Medical Center. Individuals were randomly divided into two training groups of virtual and face-to-face. Participants in the face-to-face group received slides, lectures, and practical work with moulage for 6 h a day. Subjects were taught the four skills of intubation, laryngeal mask airway (LMA), cardiopulmonary resuscitation (CPR) and attenuated electrical device (AED). Participants in the virtual group received the same content in the form of a training video on CD with a full explanation of the project's objectives. Pre- and post-test scores of participants were compared within and between the groups by Stata 14.0 software. Results Eighty-seven individuals were participated in the study, 43 of whom were assigned to the face-to-face training group and 44 to the virtual training group. There was no significant difference between the two groups in terms of work experience and educational level (P > 0.05). Post-training scores in both groups were significantly higher than pre-training in the four skills (P ≤ 0.005). After adjusting for educational level and work experience, however, the quality of CPR, intubation, and AED was higher in the face-to-face training group than in the virtual group. However, the increase in the mean score of LMA in the virtual training was not significantly different than that of the face-to-face training group. Conclusion The results of our study showed the same efficacy of both face-to-face and virtual methods in improving the performance of personnel in tracheal intubation, LMA, CPR and AED shock skills. E-learning methods can be used as a complement to face-to-face methods in education.

OBJECTIVES Our study describes and analyses the results from aortopexy for the treatment of airway malacia in children. METHODS Demographic data, characteristics and preoperative, operative and outcome details, including the need for reintervention, were collected for children undergoing aortopexy between 2006 and 2016. RESULTS One hundred patients [median age 8.2 months, interquartile range (IQR) 3.3-26.0 months] underwent aortopexy. Sixty-four (64%) patients had tracheomalacia (TM) only, 24 (24%) patients had TM extending into their bronchus (tracheobronchomalacia) and 11 (11%) patients had bronchomalacia. Forty-one (41%) children had gastro-oesophageal reflux disease, of which 17 (41%) children underwent a Nissen fundoplication. Twenty-eight (28%) children underwent a tracheo-oesophageal fistula repair prior to aortopexy (median 5.7 months, IQR 2.9-17.6 months). The median duration of follow-up was 5.3 years (IQR 2.9-7.5 years). Thirty-five (35%) patients were on mechanical ventilatory support before aortopexy. Twenty-seven (77%) patients could be safely weaned from ventilator support during the same admission after aortopexy (median 2 days, IQR 0-3 days). Fourteen patients required reintervention. Overall mortality was 16%. Multivariable analysis revealed preoperative ventilation (P = 0.004) and bronchial involvement (P = 0.004) to be adverse predictors of survival. Only bronchial involvement was a predictor for reintervention (P = 0.012). CONCLUSIONS Aortopexy appears to be an effective procedure in the treatment of children with severe airway malacia. Bronchial involvement is associated with adverse outcome, and other procedures could be more suitable. For the treatment of severe airway malacia with isolated airway compression, we currently recommend aortopexy to be considered.

To present the current state of knowledge concerning different laryngeal reinnervation procedures for unilateral and bilateral vocal palsy.Recent reports show positive outcomes on both unilateral and bilateral reinnervations. The phrenic nerve is the most commonly used donor for bilateral vocal palsy, but use of the superior laryngeal nerve has also been suggested.Reinnervation of the larynx is a complex undertaking that can be performed by ENT surgeons with skills in microsurgery. Advances in this this field represent a paradigm shift in laryngeal rehabilitation and a prerequisite for laryngeal transplantation. Advances in basic understanding of nerve regeneration and in particular the need to surgically manage competitive reinnervation make the results of laryngeal reinnervation more predictable.

Summary Objectives This study describes the microbial colonization profile of the airway in children after slide tracheoplasty (STP) with and without stents, and compares colonization to children undergoing cardiothoracic surgical procedures without airway related disease. Methods A 14-year retrospective single case note review was performed on patients undergoing STP and stent insertion. Nose and throat (NT) and bronchoalveolar lavage (BAL) specimens were analyzed for microbial profile and expressed as cumulative mean microorganisms per patient (MMP). Results Forty-three patients (median age ± SD 15.02 ± 31.76 months) underwent STP and 141 patients underwent cardiothoracic but no airway surgery (median age ± SD 31.7 ± 47.2 months). Sixteen patients required a stent after STP. One-hundred seventy-two positive microbial specimens were identified. The predominant 6 microorganisms were (1) Staphylococcus aureus; (2) Pseudomonas aeruginosa; (3) Haemophilus influenzae not type B; (4) Coliforms; (5) Streptococcus pneumoniae; and (6) Candida Albicans, and accounted for 128 (74%) of all positive specimens found. Children with stents had more MMP compared to children without stents after STP [4.06 ± 2.38 and 2.04 ± 2.24 MMP (P

The objective of the study is to increase awareness and understanding of the techniques and safety measures to minimise complications and improve patient outcomes. Literature review using MedLine and keywords snoring; obstructive sleep apnoea; radiofrequency ablation; electrosurgery; palate; tongue base was conducted. There is no accepted gold standard technique for radiofrequency ablation; to date, there is no published literature regarding common tips and pitfalls in radiofrequency application specifically for superficial applications and second-stage surgery. Surgery for snoring and obstructive sleep apnoea is typically multilevel. Pre-operative patient assessment and selection are critical to ensure good outcomes. Radiofrequency is generally safe and efficacious in this subset of patients. However, as with all surgery, it is operator-dependent. In particular, we emphasise the methodology for second-stage surgery, optimising visualisation and avoiding ulceration/fistulation of the soft palate, which are previously undescribed in the literature.

Objectives/Hypothesis To evaluate the efficacy of endoscopic resection tracheoplasty (ERT) for treating post-tracheotomy stomal stenosis caused by inward collapse of tracheal ring remnants. Study design Prospective observational study. Methods Between 2007 and 2012, we treated 40 patients with “lambdoid” tracheal deformity with a two-staged minimally invasive procedure undertaken using suspension microtracheoscopy and high-frequency jet ventilation. The first procedure entailed CO2 laser photoablation of collapsed tracheal rings and dilatation. The second procedure, performed 6 to 8 weeks later, involved ablation of residual structural obstruction, removal of granulation tissue, and intralesional corticosteroid injection. Perioperative patient and lesion characteristics and results of treatment were assessed. Results There were 22 males and 18 females, and mean age at first treatment was 59 years. There were 17 cases of scarring at the postero-lateral tracheal groove (trachealis blunting), and 22 patients had age-adjusted Charlson comorbidity scores greater than 4. All patients without trachealis blunting were successfully managed endoscopically, with only one patient requiring one additional endoscopic treatment. Seven patients with trachealis blunting needed additional treatment, and four patients had tracheal resection (P = 0.013). All patients were decannulated, and 75% of patients achieved good dyspnea outcomes. Patients with low morbidities were significantly more likely to achieve good dyspnea outcomes (P < 0.027). There were no treatment-related worsenings of voice or swallowing. Conclusions ERT is an effective minimally invasive treatment for intubation-related lambdoid tracheal stenosis. It achieves a successful outcome while avoiding the risks associated with open surgery. We recommend its more widespread use for treating patients with this condition. Level of Evidence 4. Laryngoscope, 2012

This review discusses the history of tracheal reconstruction; from early work to future challenges. The focus is primarily on prosthetic tracheal reconstruction in the form of intraluminal stents, patch repairs, circumferential repairs and replacement of the trachea. A historical perspective of materials used such as foreign materials, autografts, allografts, xenografts and techniques, along with their advantages and disadvantages, is provided.

Objective: To assess the impact of pre-procedural remote ischemic preconditioning on the incidence of myocardial complications following percutaneous coronary intervention. Background: Ischemic preconditioning of a remote vascular territory improves the subsequent ischemic tolerance of distant organs. Method: The Myocardial Event Reduction with Ischemic Preconditioning Therapy (MERIT) trial recruited 80 consecutive patients undergoing elective angioplasty with drug-eluting stents to receive two 5-min lower limb tourniquet occlusions or an un-inflated tourniquet (controls) 1 h before the procedure. The primary outcome was troponin T level at 24 h. Secondary outcomes were intra-procedural chest pain and ST-segment deviation. Results: 6 patients in the control group and 2 in the ischemic preconditioning group had pre-procedural raised troponin T ( p = 0.23). This increased to 16 (40%) in the control group and 5 (12.5%) in the study group at 24 h ( p = 0.01). Fewer patients in the study group experienced intra-procedural chest pain (1 vs. 7, p = 0.056). Mean ST-segment deviation time was 13 ± 35 s in the study group and 58 ± 118 s in the control group ( p = 0.02). At a mean follow-up of 11 months, the major adverse cardiac event rate did not differ significantly between the groups. Conclusion: These data suggest that ischemic preconditioning reduces the absolute risk of post-procedure cardiomyocyte necrosis by 27.5%, and reduces intra-procedural chest pain and ST-segment deviation in patients undergoing percutaneous coronary interventions. We suggest its routine use in percutaneous coronary intervention, although the long-term prognostic impact in this patient group warrants further investigation.

The complexity of facial fractures has changed considerably in recent years together with more commonly observed high velocity trauma. Traditional classification systems describe fractures in an isolated manner but fail to recognise those that affect more than one region. We applied four conceptual scoring systems for craniofacial trauma to a cohort of patients in east London. We exposed the limitations of the systems and developed a new scoring system that encompasses elements of all of the models and is capable of overcoming previous limitations.

To determine the feasibility, safety, and efficacy of treating benign bronchial stenosis with laryngoscopy, jet ventilation, intralesional corticosteroids, and cutting-balloon bronchoplasty.Case series with planned data collection.National airway unit.Ten adult patients with bronchial stenosis caused by Wegener's granulomatosis (n = 6), tuberculosis (n = 2), intubation (n = 1), and photodynamic therapy (n = 1) who underwent bronchoplasty using cutting-balloon dilation via suspension laryngoscopy in 2009. Information about patient demography, etiology, lesion characteristics, and details of the interventions were recorded. Patients underwent spirometry before surgery and at last follow-up. Chest infection rate in the 6 months before bronchoplasty and from bronchoplasty to the last follow-up was ascertained.There were 3 men and 7 women. Mean age at bronchoplasty was 46 ± 20 years. Length of stay was 1 day in all cases, and no treatment-related complications occurred. One patient required a second bronchoplasty at 55 days. Mean follow-up was 7 ± 2.3 months. Forced expiratory volume in 1 second increased from a prebronchoplasty mean of 1.6 ± 0.6 to 2.2 ± 0.5 at last follow-up (P.0001; paired Student t test). Forced vital capacity rose from 2.7 ± 0.6 to 3.1 ± 0.6 (P = .02), and peak expiratory flow rate increased from 3.7 ± 0.8 to 5.0 ± 0.8 (P.0001). Chest infection rate fell from an average of 0.7 ± 0.3 infections per month to 0.2 ± 0.2 (P.003; paired Student t test).Cutting-balloon bronchoplasty via suspension laryngoscopy is an effective treatment for benign bronchial stenosis. It is safer than airway stenting and is less invasive than thoracotomy. The authors propose its use as first-line treatment for this condition.

Obstructive sleep apnea in children with syndromic craniosynostosis is a well-documented entity, and airway management in these group of children is difficult, with well-documented cardiorespiratory and neurodevelopment consequences. Numerous well-documented techniques are available for airway management in this group of children. In our center, the nasopharyngeal airway (NPA) is the first-line treatment. This study aimed to evaluate the improvement in health-related quality of life in this group of children using the Glasgow Children's Benefit Inventory. We conducted a retrospective postal study of 24 patients with craniofacial disorders who had an NPA inserted as part of their airway management. A 79.2% (n = 19) response rate was obtained. Mean (SD) age was 5.8 (4.1) years. Patients were classified into 3 main groups: Crouzon (n = 11), Apert (n = 6), and Pfeiffer (n = 2) syndromes. There was improvement in 3 of the 4 domains, namely, learning (P = 0.006), vitality (P = 0.003), physical (range, -3 to 8; mean, 2; P = 0.005). There was significant improvement in the sleep study parameters; however, no correlation was found between this and the Glasgow Children's Benefit Inventory findings. Parents also preferred an NPA as opposed to a tracheostomy when given a choice. Our study shows that NPA confers significant improvement not only in health-related quality of life but also in severity of obstructive sleep apnea as judged by sleep study parameters. The NPA is also well tolerated by patients and is much preferred by parents for airway management for their children as opposed to having a tracheostomy. We think that this should be considered in other centers as first-line management in children with syndromic craniosynostosis.

To determine the impact of rhinoplasty on the objective measurement and subjective appreciation of facial symmetry and to investigate whether perceptual shifts are correlated with objective changes in facial proportions.Frontal view photographs were used to measure bilateral symmetry ratios of the medial and lateral canthi, tragus, ala, and oral commissure in 100 patients before and 6 months after rhinoplasty. Gestalt dichotomous impressions of facial symmetry were also obtained in all cases. Paired t tests and chi(2) tests were used to compare facial proportions and the proportion of faces perceived as symmetrical, respectively, before and after surgery. The receiver operating characteristic and analysis of variance were used to assess whether perceptual shifts in symmetry could be correlated with objectively measurable changes in facial proportion.The number of faces perceived as symmetrical increased from 42 to 62 after rhinoplasty (P.001, chi(2) test). Objectively, midline-to-ala symmetry increased from an average of 91.1% (5.5%) (mean [SD]) to 93.8% (4.5%) after rhinoplasty (P.001, paired t test). Other facial proportions did not change significantly (P.10). The degree of change in midline-to-ala symmetry was the only objective measure that was significantly associated with the subjective perception of the face as symmetrical or asymmetrical (P.01, 1-way analysis of variance). Most positive perceptual shifts were associated with an objective improvement in nasal symmetry that was greater than 2%. Conversely, most negative perceptual shifts were associated with minimal postoperative improvement or loss of nasal symmetry.Rhinoplasty leads to objectively measurable changes in nasal symmetry that correspond with psychophysical modifications in the perception of a face as symmetrical or asymmetrical.

Objective/Hypothesis: To review the incidence of, and risk factors for myocardial injury after head and neck surgery to help optimize patient care and develop perioperative cardioprotective strategies. Study Design: Observational cohort study. Methods: Records of 65 patients surgically treated for upper aerodigestive tract squamous cell carcinoma between 2005 and 2006 were reviewed. Information about cardiovascular history, tumor characteristics, details of surgery, and postoperative complications were recorded. Patients had troponin assays on the third postoperative day. Logistic regression was used to identify risk factors for postoperative myocardial injury. Results: The average age at presentation was 62 ± 12 years. There were 46 (71%) males and 19 (29%) females. Troponin-positive and -negative groups were matched for age, sex, cardiovascular risks, comorbidity, site, tumor-node-metastasis status, and duration of the operations. Sixteen (25%) patients had postoperative myocardial injury including five clinical myocardial infarctions. Factors identified as independent predictors of postoperative myocardial injury were blood pressure level (odds ratio [OR] 1.17; 95% confidence interval [CI] 1.04–1.31; P < .02), intraoperative heart rate variability (OR 1.33; 95% CI 1.04–1.71; P < .02), and the degree of postoperative inflammatory response (OR 1.07; 95% CI 1.02–1.13; P < .001). Conclusions: Postoperative myocardial injury is a known independent predictor of cardiovascular prognosis. Its incidence in head and neck patients could potentially be reduced through stringent blood pressure management, tight intraoperative heart rate control, and dampening of the postoperative inflammatory response. Troponin testing is a valuable screening tool, and patients who have elevated levels postoperatively should be closely monitored and referred to a cardiologist for optimization of cardiovascular care.

Objectives/Hypothesis: A model of airway obstruction was developed to study the impact of changes in airway resistance on ventilatory mechanics. This was used to derive quantitative indices of airway obstruction to aid in the objective diagnosis and physiological monitoring of adult patients with laryngotracheal stenosis (LTS). Methods: Six airway resistors, the characteristics of which mirrored the selective impediment to inspiratory airflow that occurs in patients with LTS, were created and calibrated. Maximum-effort flow-volume loops were obtained from 15 volunteers with resistors placed in series with the spirometer. Diagnostic and monitoring performances of various flow-volume indices were assessed with receiver-operating characteristics (ROC) and analysis of variance (ANOVA), respectively. Promising indices were further evaluated in patients with LTS. Results: Experimentally, the ratio of expiratory and inspiratory flows at midvital capacity (MEF50/MIF50) and peak expiratory to inspiratory flow ratio (PEF/PIF) had diagnostic sensitivities of 87% and 89%, respectively. The best index, both experimentally and clinically, was the ratio of area under the expiratory and inspiratory curves (ratio of integrals), with experimental and clinical sensitivities of 97% and 100%, respectively. A clinical specificity of 95%, and area under the curve of 0.965 were achieved for this index. Both PEF/PIF and the ratio of integrals could identify step changes in airway resistance greater than 10 cmH2O · sec · L−1 (P < .05; ANOVA). Conclusions: Flow-volume testing is simple and noninvasive and can be used to quantify the diagnosis and physiological monitoring of patients with LTS. The ratio of areas under the expiratory and inspiratory curves appears to be the optimal index for this purpose.

eralgia paresthetica (MP) is a mono-neuropathy resulting from the compression of the lateral femoralcutaneous nerve (LFCN) as it crosses be-tween the anterior superior iliac spine (ASIS)and the inguinal ligament to enter the thigh(2). The nerve receives sensory input from theskin of the anterolateral thigh. Affectedpatients consequently experience a veryprominent painful dysesthesia and, less com-monly, vasomotor disturbance in the cuta-neous distribution of the nerve (5). This condi-tion can be confused with, and in a smallgroup of patients it can coexist with, lum-bosacral radicular pain. This can lead to diag-nostic difficulties in discerning the exact natureand cause of a patient’s symptoms which, inthe context of concurrent spinal stenosis, canlead to unnecessary spinal surgery being per-formed (10). Conversely, MP can arise de novoas a transient compression neuropathy result-ing from patient positioning for spinal surgery(6). The apparent persistence of lower limbsymptoms in the early postoperative periodafter spinal surgery can be misconstrued bythe patient and the physician as a suboptimalsurgical outcome. As soon as it is suspected,MP can be diagnosed or excluded by electro-physiological studies of the LFCN (7).However, to our knowledge, there are no satis-factory, easy-to-apply clinical tests at present tohelp distinguish it from lumbosacral radicularpain to help direct the diagnostic effort.Many patients can be managed conserva-tively with measures including avoidance oftightly fitting garments, analgesia, and physi-cal therapy (12). However, patients whosesymptoms persist despite maximal medicaltherapy require operative intervention. Atpresent, there is controversy regarding theoptimal treatment of this condition; two mainoperative approaches, primary nerve decom

ObjectiveTo assess the impact of carotid endarterectomy on blood pressure homeostasis and baroreflex function, with particular reference to the presence or absence of significant contralateral carotid artery disease, we conducted a prospective study in 80 patients with symptomatic extracranial carotid disease undergoing carotid endarterectomy in a regional teaching hospital over 2 years.MethodsPatients were divided into two groups: the control group (n = 37) had no significant contralateral carotid disease; patients in the diseased group (n = 23) had either >70% stenosis or occlusion of the contralateral carotid artery. Seventeen patients with abnormal heart rhythms, poor quality recordings, or with intermediate degrees of contralateral carotid stenosis were excluded. Three patients who had previously undergone contralateral carotid endarterectomy were separately evaluated. Atheromatous plaque was removed from carotid lumen and the baroreflex mechanism received direct intraoperative stimulation before and after carotid endarterectomy. The main outcome measures were (1) the hemodynamic response to the carotid endarterectomy, baroreflex sensitivity, and operating set point (the resting blood pressure, which the baroreflex mechanism maintains) before and after removal of the atheromatous plaque, and (2) the responsiveness of the ipsilateral baroreceptor mechanism to direct stimulation. The impact of the presence of contralateral carotid stenosis on these variables was also evaluated.ResultsPatients in the two groups were comparable for preoperative demographic, medication, and hemodynamic variables. Carotid endarterectomy led to a rise in mean arterial pressure from 81.3 ± 3.9 mm Hg to 103.5 ± 4.6 mm Hg (P < .00001) and from 87.6 ± 4.3 mm Hg to 94.0 ± 4.5 mm Hg (P < .003) in the diseased and control groups, respectively. The magnitude of blood pressure response was significantly greater in the diseased group than in the control group (P < .00001). This hypertensive shift was not accompanied by the expected fall in heart rate. Direct baroreflex stimulation prior to carotid endarterectomy caused a significantly greater response in the diseased group, suggesting sensitization of the ipsilateral carotid baroreceptor in the presence of contralateral carotid disease. Furthermore, the baroreflex response was obliterated after endarterectomy. There were significant reductions in baroreflex sensitivity and a hypertensive shift in the operating set point, the magnitude of which was significantly greater in patients with contralateral carotid disease.ConclusionsCarotid endarterectomy impairs blood pressure homeostasis through surgical destruction of the ipsilateral carotid baroreflex mechanism. Patients with contralateral carotid stenosis have a reduced baroreflex reserve and show greater baroreflex dysfunction and hemodynamic instability after endarterectomy. These patients are at greater risk of postendarterectomy complications and should be monitored closely.

Background Surgeons extensively rely on photographic communication for documenting surgical results, teaching and research, and obtaining informed consent from patients. With the advent of digital photography and widespread availability of sophisticated image manipulation software, the potential for committing digital fraud cannot be discounted. Methods Ten ‘before' and ‘after' plastic surgical photographs were selected, and a number of them were digitally enhanced using a standard desktop software by a non-expert in digital photography. A panel of 10 consultant plastic surgeons was asked to judge which, if any of the images had been digitally manipulated. Results Expert assessment had a sensitivity of only 12% in identifying digitally manipulated images. Furthermore, there was poor interobserver agreement with an Intraclass Correlation Coefficient of 0.39. Conclusion Digital fraud is easy to commit and difficult to detect. Furthermore, a number of inadvertent and simple image manipulation functions can also amount to misrepresentation. There may be scope for cooperation within editorial circles to set standards for the submission of digital photographs. Surgeons need also to be aware of the potential for misrepresentation of information through digital image manipulation and exercise caution in the communication of digital photographic information.

Laryngotracheal stenosis (LTS) is a rare condition that occurs most commonly as a result of instrumentation of the airway but may also occur as a result of inflammatory conditions or idiopathically. Here, we present the case of a patient who developed LTS as a complication of granulomatosis with polyangiitis (GPA), which was misdiagnosed as asthma for 6 years. After an admission with respiratory symptoms that worsened to the extent that she required intubation, a previously well 14-year-old girl was diagnosed with GPA. Following immunosuppressive therapy, she made a good recovery and was discharged after 22 days. Over subsequent years, she developed dyspnoea and “wheeze” and a diagnosis of asthma was made. When she became pregnant, she was admitted to hospital with worsening respiratory symptoms, whereupon her “wheeze” was correctly identified as “stridor,” and subsequent investigations revealed a significant subglottic stenosis. The delay in diagnosis precluded the use of minimally invasive therapies, with the result that intermittent laser resection and open laryngotracheal reconstructive surgery were the only available treatment options. There were numerous points at which the correct diagnosis might have been made, either by proper interpretation of flow-volume loops or by calculation of the Empey or Expiratory Disproportion Indices from spirometry data.

We present a system for classification of bilateral vocal fold mobility impairment. Type 1 obstructions are caused by bilateral laryngeal denervation, most commonly due to bilateral recurrent laryngeal nerve palsy. Type 2 obstructions are caused by crico-arytenoid joint ankylosis. Type 3 obstructions are due to inter-arytenoid granulation tissue. Type 4 lesions are caused by mature inter-arytenoid scar tissue and type 5 lesions are complex or total laryngeal stenoses.

We estimate the population incidence of adult unilateral vocal fold mobility impairment at 5.13 per 100,000 per year.

Objectives/Hypothesis Delivering evidence-based patient care is predicated on the availability of objective and validated outcome measures. We aimed to calculate physiology-based minimum clinically important difference (MCID) values for adult laryngotracheal stenosis (LTS). Study Design Prospective observational study. Methods Patient demographics, morbidities, and stenosis severity were assessed preoperatively. Flow-volume loops and Medical Research Council (MRC) dyspnea grades were measured in 21 males and 44 females before and 6 to 8 weeks after airway surgery, and before treating recurrent disease in 10 patients. Anchor and distribution-based methodologies were used to calculate MCIDs for treatment efficacy and disease recurrence respectively. Results The mean age at treatment was 46 ± 16 years. The most common etiology was idiopathic subglottic stenosis (38%). Most lesions (66%) obstructed >70% of the lumen. There were strong correlations between treatment-related changes in total peak flow (TPF) (ΔTPF) (peak expiratory flow + |peak inspiratory flow|) and the ratio of area under the flow-volume loop (AUC) to forced vital capacity (FVC) (ΔAUCTotal/FVC), and treatment-related changes in the MRC grade (ΔMRC) (r = −0.76 and r = −0.82, respectively). Both TPF and AUCTotal/FVC discriminated between effective (ΔMRC

This study describes the microbial colonization profile of the airway in children after slide tracheoplasty (STP) with and without stents, and compares colonization to children undergoing cardiothoracic surgical procedures without airway related disease.A 14-year retrospective single case note review was performed on patients undergoing STP and stent insertion. Nose and throat (NT) and bronchoalveolar lavage (BAL) specimens were analyzed for microbial profile and expressed as cumulative mean microorganisms per patient (MMP).Forty-three patients (median age ± SD 15.02 ± 31.76 months) underwent STP and 141 patients underwent cardiothoracic but no airway surgery (median age ± SD 31.7 ± 47.2 months). Sixteen patients required a stent after STP. One-hundred seventy-two positive microbial specimens were identified. The predominant 6 microorganisms were (1) Staphylococcus aureus; (2) Pseudomonas aeruginosa; (3) Haemophilus influenzae not type B; (4) Coliforms; (5) Streptococcus pneumoniae; and (6) Candida Albicans, and accounted for 128 (74%) of all positive specimens found. Children with stents had more MMP compared to children without stents after STP [4.06 ± 2.38 and 2.04 ± 2.24 MMP (P 0.001), respectively]. Both groups of children after STP had more MMP compared to the control group (P 0.001). Children with stents had more microbial colonization of their lower respiratory tract compared to their upper respiratory tract (3.36 ± 2.02 and 1.36 ± 0.93 MMP (P 0.01) respectively). Staphylococcus aureus colonization of the lower respiratory tract was significantly higher in children with stents compared to children without stents after STP [0.5 and 0.15 MMP (P 0.05) respectively].This study indicates airway surgery and the subsequent use of stents to be a significant risk factor for microbial colonization of the airway in children. More specifically airway stents appear to increase colonization in the distal airway, which appears unrelated to that of the upper respiratory tract.

Objectives/Hypothesis To perform a national review of the incidence and treatment of primary tracheal cancer and to identify gaps in service provision and factors associated with survival. Study Design Retrospective analysis of Hospital Episode Statistics data for England between 1996 and 2011. Methods Information about age, sex, morbidity, provider trust, diagnostic delay, nature of hospital admission and treatment, and palliation-free survival were recorded. The relationship between variables and survival was explored with Cox regression. Results There were 874 patients, giving an incidence of 0.9 per million. Mean age at diagnosis was 66 ± 13, and there were 456 (52%) males. Mean presentation to diagnosis latency was 2.5 ± 8 months, and 40% of patients presented as emergency admissions. There were 19 cases of oesophageal involvement and 241 cases of bronchopulmonary involvement; and 188 patients developed distant metastases. There were 60 curative resections (6.9%), which was the most significant predictor of palliation-free survival (hazard ratio: 0.23; 95% confidence interval 0.13–0.38). Other prognostic variables included age, sex, emergency admission, interventional bronchoscopy, chemotherapy, oesophageal involvement, and distant metastases. Ten-year palliation-free survival was 60.8% with curative resection and 19.5% overall. Eighty-six percent of patients were treated in units that treated fewer than one patient per year. Conclusion Tracheal cancer is under-recognized and under-treated. Early diagnosis, access to interventional bronchoscopy, and surgical treatment in specialist units may improve the survival of patients with this condition. Level of Evidence 4. Laryngoscope, 124:145–150, 2014

The study's objective was to determine the utility of expiratory disproportion index (EDI), the ratio of forced expiratory volume in 1 second (FEV1) to peak expiratory flow rate (PEFR) (EDI = FEV1[L] /PEFR[L/s] × 100), in differentiating between laryngotracheal stenosis (LTS) and other respiratory diagnoses. LTS is an uncommon complication of mechanical ventilation or vasculitis or a manifestation of airway compression or malignancy. It frequently masquerades as asthma and evades timely diagnosis, causing prolonged morbidity and airway-related mortality.Observational study.We compared spirometry results of 9,357 healthy subjects and nonstenosis pulmonary patients with 217 cases of LTS. Bootstrap analysis, receiver-operating characteristic (ROC) statistics, and Pearson correlation were used to assess the diagnostic utility of the EDI and its correlation with stenosis severity.Mean EDI values were 36 ± 7 in nonstenosis cases, 76 ± 17 in benign stenoses, and 69 ± 23 in tracheal cancer (P.0001). A significant correlation existed between anatomic stenosis severity and EDI (P.0001; R = 0.61). Area under the ROC curve was 0.98, and at a threshold of50, EDI had a sensitivity of 95.9% and a specificity of 94.2% in differentiating between stenosis and nonstenosis cases.EDI can reliably diagnose LTS using routine lung function data. Its simplicity and clinical utility, first recognized by Duncan Empey, are underpinned by a unique physiology whereby PEFR, being determined by total tracheobronchial tree resistance, falls disproportionately compared with FEV1 , which is determined within small intrathoracic airways. EDI provides valuable information about the presence and extent of LTS particularly in nonspecialist clinical settings and its routine inclusion within standard lung function reports could prevent the prolonged morbidity and mortality that currently result from missed and delayed diagnoses.

Objectives/Hypothesis: To assess the utility of intraoperative pressure-volume curves as an objective method of physiological disease stratification and outcomes assessment in adult laryngotracheal stenosis. Study Design: Prospective observational study. Methods: We prospectively studied 42 tracheotomy-free patients undergoing endoscopic laryngotracheoplasty over 18 months. Patient and lesion characteristics were obtained. Dyspnea severity was assessed using the Medical Research Council scale. Preoperative spirometry and intraoperative pulmonary compliance were recorded. Results: There were 19 male and 23 female patients, and the mean age at treatment was 44 6 16 years. There were 14 Myer-Cotton 1 lesions and 14 and 13 patients had grade 2 or 3 stenoses, respectively. Pulmonary compliance was strongly correlated with anatomical stenosis severity (r 5 0.8, P

BackgroundObesity is a growing problem in lower income countries particularly among women. There are few studies exploring individual socioeconomic status indicators in depth. This study examines the interaction of education and wealth in relation to obesity, hypothesising that education protects against the obesogenic effect of wealth.MethodsFour datasets of women of reproductive age from the Egyptian Demographic and Health Surveys spanning the period 1992-2008 are used to examine two distinct time periods: 1992/95 (N = 11097) and 2005/08 (N = 23178). The association in the two time periods between education level and household wealth in relation to the odds of being obese is examined, and the interaction between the two socioeconomic indicators investigated. Estimates are adjusted for age group and area of residence.ResultsAn interaction was found between the association of education and wealth with obesity in both time periods (P-value for interaction ConclusionIn the present study, wealth appears to be a risk factor for obesity in women with lower education levels, while women with higher education are protected. The findings also suggest that a reversal in the social distribution of obesity risk is occurring which can be explained by the large increase in obesity levels in lower socioeconomic groups between the two time periods.

BACKGROUND: Carotid endarterectomy (CEA) improves the cerebrovascular prognosis of patients with carotid stenosis but carries a risk of causing postoperative neurological deterioration. OBJECTIVE: We assessed hemisphere-specific changes in saccadic eye movements to determine the utility of saccadometry as a quantitative neurosurgical outcome measure. METHODS: Visually evoked saccades were recorded at the bedside before and 2 days after surgery from 30 patients undergoing CEA for symptomatic carotid stenosis. Hemisphere-specific latency distributions were compared using Kolmogorov-Smirnov statistics. Latency distributions were fitted using the Linear Approach to Threshold with Ergodic Rate model and compared with binomial logistic regression. RESULTS: There were 21 males and mean age at surgery was 71 ± 7 years. Following CEA, the distribution of saccades initiated by the cerebral hemisphere distal to the operated artery significantly changed in 25 patients. By contrast, there were 14 significant contralateral-hemisphere saccadic changes (P < .001). Significant contralateral saccadic changes always co-occurred with significant ipsilateral changes and 10 of 14 patients with contralateral saccadic change had contralateral carotid stenosis. There was a significantly greater postoperative reduction in early saccades generated by the ipsilateral hemisphere than by the contralateral hemisphere (P < .02) CONCLUSION: CEA leads to significant hemisphere-specific subclinical changes in saccadic performance and, in particular, differentially affects the proportion of early saccades, a measure of the ability of the frontal cortex to successfully inhibit lower centers, generated by the 2 hemispheres. Saccadometry, a bedside test, provides data that can be statistically compared for individual and groups of patients. It could allow the neurological outcome of carotid surgery to be objectively quantified.

To report the results of treating laryngeal sarcoidosis with intralesional steroids and minimally invasive laser surgery. Sarcoidosis is a rare multisystem inflammatory disorder of unknown cause. Laryngeal involvement is extremely rare, and its optimal management remains controversial.Retrospective medical chart review. Settings Tertiary care center/national referral airway reconstruction center.Ten consecutive patients treated for laryngeal sarcoidosis between 2004 and 2008.Demographic and clinical information including extralaryngeal manifestations obtained from patient records, laryngeal anatomic subsite manifestation of disease, intraoperative findings, and scores from the Medical Research Council (MRC) dyspnea outcome assessment instrument (which was administered preoperatively, at the first postoperative outpatient visit 4-6 weeks later, and at last follow-up).The patients included 9 women and 1 man, a total of 2.8% of the unit's adult surgical airway case mix (10 of 353). Mean (SD) age at presentation was 37 (17) years. All patients presented with dyspnea and dysphonia; 2 required emergency tracheostomy prior to treatment. Six patients presented with isolated laryngeal sarcoid. Supraglottis and arytenoids were affected in all patients. The median number of endoscopic treatments was 2 (range, 1-4). Significant improvement in MRC dyspnea grading was found postoperatively (P.05), and patients with tracheostomy were successfully decannulated. The mean (SD) follow-up time was 24 (18) months. There were no adverse effects of surgery. Nine patients had a substantial dose reduction or discontinuation of their systemic corticosteroid therapy following endoscopic treatment.Minimally invasive endoscopic surgery with intralesional corticosteroid injection and laser reduction is an effective method of controlling laryngeal sarcoid. It improves symptoms immediately with minimal morbidity and, most importantly, reduces the need for systemic steroid administration in most patients. This study supports early recognition and endoscopic intervention in the management of laryngeal sarcoidosis.