Dr. Damrose noted, have identified 55 Gy as an important target dose.
Explore This IssueMarch 2016
It’s also important to minimize iatrogenic endotracheal and tracheostomy tube injuries, he said. Here, education of colleagues will be crucial. “The bottom line is, base tube size selection on height, not weight, and ensure tubes are adequately advanced, especially in taller patients,” Dr. Damrose said.
Voice and Swallow Rehabilitation
Michael Johns III, MD, director of the University of Southern California Voice Center in Los Angeles, said that when physicians are pondering the course of treatment for voice difficulties, “we’re listening and we’re looking.” Visually, the keys are the size of the gap between the vocal folds and the stiffness of the folds. When listening to a patient, he listens for breathiness. “The breathier the patient is, the more likely we’re going to be able to help them,” he said. Vocal stiffness is hard to manage, he said, but surgeons are able to close glottal gaps, which can improve vocal function significantly.
“Roughness is hard to manage,” he added. “Vocal fold stiffness—we don’t really have a lot of tools for improving that.” So, when a patient’s voice is rough and not very breathy, he is more likely to avoid surgery.
When it comes to trouble swallowing, including loss of sensation, loss of tongue base volume and strength, or reduced pharyngeal squeeze, there are not many good surgical options. Surgery can be more helpful with glottal insufficiency and cricopharyngeal or esophageal stenosis, he added. In cases of dysphagia, Dr. Johns usually will emphasize behavior modification. If things are not very severe, he advised strongly considering the risks and benefits of surgery. If, on a modified barium swallow, you don’t see hyolaryngeal excursion, he said, then dilation probably won’t help.
When assessing an airway patient for surgery, Dr. Johns recommended getting a sense of how easy it would be to obtain operative direct laryngeal exposure in the office, and whether a tracheotomy would be needed. “If those two features are unfavorable, then try to avoid surgery,” he said.
Stenosis Following Radiation
Tools for treating stenosis that occurs after radiation of the larynx include the CO2 laser, bougies and balloons, steroid injections, and the chemotherapy drug mitomycin, said Lucian Sulica, MD, director of the Sean Parker Institute for the Voice at Weill Cornell Medical College in New York City. “I’m sorry to say that none of these things is a game-changer,” he said.