Flexible Nasal Endoscopic Procedures in Family Medicine: Indications and Effectiveness

Background and Objectives: Most literature about flexible nasolaryngoscopy comes from specialty clinics, making it unclear if these indications can be effectively managed without referral. This study evaluated effectiveness of diagnosis and management of upper airway complaints, utilizing flexible nasal endoscopic procedures, in a family medicine center. Methods: We performed retrospective chart review for all patients who had nasal endoscopy, nasopharyngoscopy, and nasolaryngoscopy performed at the University of Florida Family Medicine Center over 3 years (n=89) with 5 additional years of follow up. We used descriptive statistics to evaluate indications, diagnoses, effectiveness of management by family medicine, and referral rate. Results: The most common primary indications were hoarseness (n=33, 37%), chronic cough (n=20, 22%), nasal obstruction (n=9, 10%), and unilateral ear dysfunction (n=6, 7%). The most common primary diagnoses found were allergic rhinitis/postnasal drip (n=41, 46%), laryngopharyngeal reflux (LPR)/gastroesophageal reflux disease (GERD; n=24, 27%), masses concerning for malignancy (n=4, 4.5%), true vocal cord (TVC) polyp (n=3, 3%), TVC nodules (n=3, 3%), and epistaxis (n=3, 3%). Of the four concerning masses, two were confirmed cancers (2%). In addition, there was one case (1%) of erythroleukoplakia with dysplasia of the TVC. Most patients had documented improvement with family medicine management (n=57, 64%) and another six (7%) had follow up without documentation of status and no need for referral. Thus, a total of 71% (n=64) did not require referral and 20% (n=18) needed specialist referral. Conclusions: Flexible nasal endoscopic procedures are effective in the care of patients in a family medicine residency center and can be safely performed and taught to residents.

Use of Supraclavicular Flap by End to Side Technique in Pharyngeal SCC: A Case Report and Review of Literature

Objectives. In recent years, conservation laryngeal surgeries, including partial pharyngectomy, have been introduced as an alternative procedure for selected cases of hypopharyngeal squamous cell carcinoma (HSCC). Reconstruction of these defects presents a considerable challenge for the surgeon after partial pharyngectomy due to its circumferential nature. In this case report, we represent the innovative “End to side” technique to reconstruct hypopharyngeal defect using the rolled supraclavicular flap after laryngeal-preserving partial pharyngectomy. Methods and Results. A 70-year-old female presented with a history of progressive dysphagia and odynophagia. The evaluations revealed a T3N0M0 SCC of pyriform sinus. The mass was successfully resected through partial pharyngectomy, and the hypopharyngeal defect reconstruction was achieved using the rolled supraclavicular flap via the “End to side” technique. The patient was discharged after decannulation on day 10. The 3-week barium swallow was performed with no evidence of anastomotic leakage, and the oral feeding was started after NG tube removal. At week 5, complete movement of the true vocal cord on the one side and good phonation and deglutition was observed. There was no evidence of recurrence after 1 year. Conclusions. Laryngeal-preserving partial pharyngectomy and hypopharyngeal reconstruction with the rolled supraclavicular flap via the “End to side” technique could lead to good oncological and functional outcomes in selected cases of pyriform sinus.

Stereotactic body radiotherapy for T1 glottic cancer: dosimetric data in 27 consecutive patients

Aim: Because the clinical feasibility of stereotactic body radiotherapy (SBRT) for early glottic cancer (T1) is controversial, we report dosimetric results in 27 consecutive patients from a prospective phase I and II study that started in 2017. Methods: In our approach, only the parts of the true vocal cord containing cancer and those immediately adjacent are planned to be treated to 36 Gy and 30 Gy, respectively, in 3 fractions. Several dosimetric metrics for both target volumes and organs at risk were extracted from individual plans and results were compared to those achieved by other authors in a similar setting. Results: Proper coverage was reached at planning in 2/3 of planning treatment volume 30 Gy, but only 4 planning treatment volume 36 Gy; conversely, the maximum dose objective was met for most of the patients on either arytenoid cartilage, but this was not the case for 51.9% and 96.3% of cricoid and thyroid cartilages, respectively. Our dosimetric results are similar to if not better than those achieved by others. Conclusion: SBRT in 3 fractions for T1 glottic lesions is dosimetrically challenging. Clinical validation is awaited.

A Case Report of Lipoid Proteinosis with Brain and Laryngeal Presentation

: Lipoid proteinosis (LP) is a rare autosomal recessive genodermatosis. Genetic mutation leads to deposition of abnormal amounts of hyaline like material in the skin and viscera, which is the cause of clinical manifestations. It mostly involves the skin, intracranium, and the larynx. In this case report, we present a case with a long history of hoarseness. Imaging findings include bilateral true vocal cord (TVC) mucosal irregularity with hyperdense depositions, bilateral medial temporal amygdala parallel bean shape calcification (pathognomonic sign), and bilateral striatal (caudate and putamen) hypoattenuation. The patient also had multiple warty papules on the hands. Biopsy of the right TVC showed submucosal deposition of periodic acid-Schiff (PAS)-positive amorphous hyaline material and confirmed the diagnosis of lipoid proteinosis. Typical imaging findings especially in the brain could be very helpful in interpretation of laryngeal imaging findings in cases of lipoid proteinosis who manifest with long term voice changes and hoarseness.

Unilateral hypoglossal nerve and recurrent laryngeal nerve weakness following endotracheal intubation

Endotracheal intubation with cuffed tube is a safe procedure associated with few complications in majority of patients. Immediate complications are primarily associated with problems dring intubation and extubation while early and late complications represent the short- and long-term effets of epithelial trauma. True vocal cord paralysis may follow endotracheal intubation and be the result of peripheral nerve damage. This damage can occur as the result of compressing the nerve between an inflated endotracheal tube cuff and the overlying thyroid cartilage.1 The hypoglossal nerve (12th cranial nerve) is motor nerve. It supplys the tongue muscle and help in speech, Food manipulation, and swallowing. Hypoglossal nerve injury following endotracheal intubation under general anesthesia is a rare complication and can cause symptoms, such as dysarthria and dysphagia.2

Arytenoid Fixation in Laryngeal Cancer: Radiological Pictures and Clinical Correlations with Respect to Conservative Treatments

Background: The aim of this retrospective study was to identify different radiological features in intermediate–advanced laryngeal cancer (LC) associated with arytenoid fixation, in order to differentiate cases still safely amenable to conservative treatment by partial laryngectomy or chemoradiotherapy. Methods: 29 consecutive patients who underwent open partial horizontal laryngectomies (OPHLs), induction chemotherapy followed by radiotherapy in the case of >50% response (IC + RT) or total laryngectomy were classified as: pattern I (supraglottic LC fixing the arytenoid due to weight effect), pattern II (glottic LC involving the posterior paraglottic space and spreading toward the crico-arytenoid joint and infraglottic extension <10 mm), pattern III (glottic—infraglottic LC involving the crico-arytenoid joint and infraglottic extension >10 mm) and pattern IV (transglottic and infraglottic LC with massive crico-arytenoid unit involvement, reaching the hypopharyngeal submucosa). All glottic cancers treated with surgery were studied by a cross sectional approach. Results: A substantial agreement between the work-up and the pathology results has been obtained in each of the subcategories. Three-year disease-free survivals, local control and freedom from laryngectomy were significantly better in pattern II compared to pattern III–IV. Conclusions: LC showing fixed arytenoid due to weight effect or posterior paraglottic space involvement with infraglottic extension <10 mm assessed at the true vocal cord midline are still safely manageable by OPHL or IC + RT.