Objective The COVID-19 pandemic has led to unprecedented demands on healthcare with many requiring intubation. Tracheostomy insertion has often been delayed and the enduring effects of this on voice, swallow, and airway outcomes in COVID-19 tracheostomy patients are unknown. The aim of this study was to prospectively assess these outcomes in this patient cohort following hospital discharge. Methods All COVID-19 patients who had undergone tracheostomy insertion, and were subsequently decannulated, were identified at our institution and followed up 2 months post-discharge. Patient-reported (PROMS) and clinician-reported outcome measures, endoscopic examination, and spirometry were used to assess voice, swallow, and airway outcomes. Results Forty-one patients were included in the study with a mean age of 56 years and male:female ratio of 28:13. Average duration of endotracheal intubation was 24 days and 63.4% of tracheostomies were performed at day 21 to 35 of intubation. 53.7% had an abnormal GRBAS score and 30% reported abnormal swallow on EAT-10 questionnaire. 81.1% had normal endoscopic examination of the larynx, however, positive endoscopic findings correlated with the patient self-reported VHI-10 (P = .036) and EAT-10 scores (P = .027). 22.5% had spirometric evidence of fixed upper airway obstruction using the Expiratory-Disproportion Index (EDI) and Spearman correlation analysis showed a positive trend between abnormal endoscopic findings and EDI scores over 50 (P Conclusion The preliminary results of this study reveal a high incidence of laryngeal injury among patients who underwent intubation and tracheostomy insertion during the COVID-19 pandemic. As these patients continue to be followed up, the evolution of these complications will be studied. Level of evidence Level 3. Laryngoscope, 2020.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/lary.29346

A Prospective Study of Voice, Swallow, and Airway Outcomes Following Tracheostomy for COVID-19.

In vivo regeneration of rat laryngeal cartilage with mesenchymal stem cells derived from human induced pluripotent stem cells via neural crest cells.

Large volume, low pressure endotracheal tube cuffs are claimed to have less deleterious effect on tracheal mucosa than high pressure, low volume cuffs. Low pressure cuffs, however, may easily be overinflated to yield pressures that will exceed capillary perfusion pressure. Various large volume cuffed endotracheal tubes were studied, including Portex Profile, Searle Sensiv, Mallinkrodt Hi-Lo, and Lanz. Tracheal mucosal blood flow in 40 patients undergoing surgery was assessed using an endoscopic photographic technique while varying the cuff inflation pressure. It was found that these cuffs when overpressurised impaired mucosal blood flow. This impairment of tracheal mucosal blood flow is an important factor in tracheal morbidity associated with intubation. Hence it is recommended that a cuff inflation pressure of 30 cm H2O (22 mm Hg) should not be exceeded.

Endotracheal Cuff Pressure and Tracheal Mucosal Blood Flow: Endoscopic Study of Effects of Four Large Volume Cuffs

Management of tracheal complications due to endotracheal intubation in patients with coronavirus disease-2019 (COVID-19) is an important concern. This study aimed to present the results of patients who had undergone tracheal resection and reconstruction due to COVID-19-related complex post-intubation tracheal stenosis (PITS). We evaluated 15 patients who underwent tracheal resection and reconstruction due to complex PITS between March 2020 and April 2021 in a single center. Seven patients (46.6%) who underwent endotracheal intubation due to the COVID-19 constituted the COVID-19 group, and the remaining 8 patients (53.4%) constituted the non-COVID-19 group. We analyzed the patients’ presenting symptoms, time to onset of symptoms, radiological and bronchoscopic features of stenosis, bronchoscopic intervention history, length of the resected tracheal segment, postoperative complications, length of hospital stay, and duration of follow-up. Six of the patients (40%) were female, and 9 (60%) were male. Mean age was 43.3 ± 20.5. We found no statistically significant difference between the COVID-19 and non-COVID-19 PITS groups in terms of presenting symptoms, time to onset of symptoms, stenosis location, stenosis severity, length of the stenotic segment, number of bronchoscopic dilatation sessions, dilatation time intervals, length of the resected tracheal segment, postoperative complications, and length of postoperative hospital stay. Endotracheal intubation duration was longer in the COVID-19 group than non-COVID-19 group (mean ± SD: 21.0 ± 4.04, 12.0 ± 1.15 days, respectively). Tracheal resection and reconstruction can be performed safely and successfully in COVID-19 patients with complex PITS. Comprehensive preoperative examination, appropriate selection of surgery technique, and close postoperative follow-up have favorable results. 

/pdf/complex-post-intubation-tracheal-stenosis-in-covid-19-1orezu50.pdf

Complex Post-intubation Tracheal Stenosis in Covid-19 Patients

Postintubation tracheal stenosis: A devastating complication!

BACKGROUND Tracheostomy and endotracheal intubation can result in subglottic tracheal stenosis, and predisposition to keloid scar formation can increase stenosis risk after tracheal injury. This study aims to compare the incidence and severity of subglottic tracheal stenosis in keloid and non-keloid patients following iatrogenic tracheal injury, in particular tracheostomy. METHODS From 2012 to 2017, 218 573 patients were intubated for surgery; 2276 patients received tracheostomy in People's Hospital of Zhengzhou University, China. Among these patients, 133 patients, who developed tracheal stenosis after intubation and/or tracheostomy, were divided into keloid or non-keloid groups; their Myer and Cotton grading of tracheal stenosis, time-to-onset of airway stenosis, and treatment outcome were assessed and compared. RESULTS The percentages of high grade (Myer and Cotton grading III/IV) tracheal stenosis were higher among keloid patients than non-keloid patients (intubation: 83.3% vs 25.7%; tracheostomy: 77.7% vs 33.3%). Time-to-onset of airway stenosis following intubation (tracheostomy) was 27 ± 5 (38 ± 13) and 41 ± 7 (82 ± 14) days for keloid and non-keloid patients, respectively (P < 0.01). The incidence of tracheal stenosis is higher in keloid than non-keloid subjects (19.4% vs 1.82%, P < 0.001). Keloid patients also required more frequent treatment (P < 0.01) of longer duration, yet cure rate was significantly lower (P < 0.01). CONCLUSIONS Our study suggests that tracheostomized patients with keloid phenotype are more susceptibility to develop iatrogenic tracheal stenosis of greater severity and with poorer treatment outcome. Greater cautions may be required when performing tracheostomy in keloid subjects. More substantive analysis is warranted to establish keloid phenotype as a risk factor for tracheal stenosis.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/aas.13371

Iatrogenic subglottic tracheal stenosis after tracheostomy and endotracheal intubation: A cohort observational study of more severity in keloid phenotype.

Comparison of the Accuracy of Maxillary Repositioning Between Using Splints and Templates in 2-Jaw Orthognathic Surgery.

Background This study aims to investigate whether a systematic digital training system can improve the learning efficiency of residents in the first-year orthognathic surgery training course and evaluate its effectiveness in teaching orthognathic surgery. Methods A digital training system was applied, and a comparative research approach was adopted. 24 first-year orthognathic surgery residents participated in the experiment as part of their professional skill training. The Experimental group was required to use a digital training system, and the Control group was trained in lectures without digital technologies. Three indicators, including theoretical knowledge and clinical operation, were assessed in tests, and evaluations from instructors were analyzed to evaluate learning efficiency. Results The results showed that the scores in theoretical tests, practical operations, and teacher evaluations, the Experimental groups were all higher than the Control group (P = 0.002 for anatomy, P = 0.000 for operation theory) after using digital technology, except for the understanding of complications (P = 0.771). In addition, the questionnaire survey results showed that the study interest (P = 0.001), self-confidence (P = 0.001), satisfaction (P = 0.002), and academic performance (P = 0.001) of the residents of the Experimental group were higher than those of the Control group. Conclusions The outcomes indicated that the digital training system could benefit orthognathic residents’ learning efficiency, and learning interest and teaching satisfaction will also improve.

Digital technology for orthognathic surgery training promotion: a randomized comparative study

The aim of this study is to investigate the effect of bimaxillary orthognathic surgery on orofacial myofunctional changes in skeletal class III patients. 35 patients who received Le Fort I maxillary advancement osteotomy and mandibular SSRO setback were included in this study. Facial expression function was analyzed by "placid" or "smile" expressions using chL-chR, ∠chRnchL, and ls-li. Occlusal force and balance were analyzed using a T-scan III digital occlusal analysis system. Maximum mouth opening (MMO) was measured prior to surgery and 2/14/28/42/90/180/360 days after surgery. After surgery, patients recovered facial expressions in no less than 3 months for both the "placid" or "smile" facial expression. Patients obtained significantly improved 'smile' expressions 3 months after the operation compared to preoperative "smiles", and this improvement remained stable 12 months after the operation. Occlusal force was significantly decreased with the balance of occlusion lost immediately after surgery. These conditions gradually recovered, and patients finally obtained a more balanced and stronger occlusion [occlusion balance: 6.7 ± 2.7 mm vs. 4.1 ± 3.0 mm (day -7 vs. day 42); occlusion force: 19.6 ± 7.0 kg vs. 24.2 ± 9.3 kg (day -7 vs. day 180)]. However, patients had smaller postoperative mouth opening compared to preoperation opening during our follow-up. Our results confirmed that orthognathic surgery obstructs orofacial myofunctions of skeletal class III patients in the short-term. In the long-term, orthognathic surgery results in more stable and balanced orofacial myofunctions. By understanding the process of functional recovery of orofacial muscles after orthognathic surgery, we hope to accelerate patient's recovery from surgery. 

Wenli Zhao

Papers

Iatrogenic subglottic tracheal stenosis after tracheostomy and endotracheal intubation: A cohort observational study of more severity in keloid phenotype.

Comparison of the Accuracy of Maxillary Repositioning Between Using Splints and Templates in 2-Jaw Orthognathic Surgery.

Digital technology for orthognathic surgery training promotion: a randomized comparative study

Orofacial myofunctional changes in skeletal Class III patients after bimaxillary orthognathic surgery.