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• W3045227481 abstract "TO THE EDITOR: We thank Aggarwal et al for the letter on our article related to nasotracheal intubation in anterior cervical spine surgery (ACSS). The beginning paragraph provides the explanation for the longer surgical time in the nasotracheal intubation group. We compared the difference in the mean surgical time between the two intubation modes by using the independent t test. As comparison of two means can be partially influenced by the sample size and the distribution,1 we re-analyze the difference of median using Mann-Whitney U test and the P value is 0.068. Thus, the surgical time was not significantly different between the two groups. Finally, in the present study, there was no effect of surgical time on the improvement in dysphonia score after ACSSs, as previously demonstrated.2,3 Surgeon experience remains an important determinant of overall morbidity, and higher surgeon volume is associated with lower morbidity.4 Our patients were operated by the same surgeon (W-C.H.) and his team members, with a high surgeon volume. The team members with different levels of surgical experience were responsible for particular tasks in different stages of surgery. The main part of surgery was performed by Dr. Huang. Thus, factors related to the surgeon were controlled for in the study. Ever since Sperry et al5 revealed that the endotracheal tube cuff pressure (ETCP) increases significantly when surgical retractors are set up during ACSS, many studies have focused on the evaluation and adjustment of cuff pressure during surgery. Currently, many surgical teams, including our team, ensure the control of ETCP as the standard procedure of ACSS. In our study, the cause–effect relationship between tracheal tubes (ETT), tracheal tube cuff pressure, and post-ACSS dysphonia, or vocal cord palsy/paresis was based on evidence from Apfelbaum et al.6,7 First is the pressure from the endotracheal tube cuff. The splay of surgical retractors causes the extrusion of tissues (particularly the recurrent laryngeal nerve) between the tracheal tube cuff and the retractor blade.6 Second is the pressure from the tube. Compared with nasotracheal tube, the orotracheal tube is asymmetrically located in the thyroid cartilage and trachea due to fixation on one side of the mouth and causes uneven pressure on the vocal cord.7 The control of ETCP was performed as per our surgical procedure; thus, the complication may result from the tube per se. Another confounding factor affecting the outcome of nasotracheal intubation is the tube size. A small ETT is more often used during nasointubation than during orointubation. The use of a smaller ETT can alleviate a sore throat,8 but its effect on postoperative dysphonia or vocal cord palsy/paresis is yet being investigated. To verify study results, we replaced the reference group with the nasotracheal intubation group with an ETT size of >7. Patients in the orointubation group with an ETT size of >7 had higher dysphonia scores than did patients in the nasointubation group with an ETT size of >7 (estimated treatment effect = 1.22, P = 0.044), indicating less improvement (Table 1). Patients in the orointubation group with an ETT size of ≤7 also had higher dysphonia scores than did patients in the nasointubation group with an ETT size of >7 (estimated treatment effect = 2.49, P < 0.001). This means that orotracheal intubation, regardless of a larger or smaller tracheal tube, resulted in higher dysphonia scores and less improvement than nasotracheal intubation with an ETT size of >7. Based on the results, the tube size effect can be excluded in different tracheal intubation modes. Therefore, we can conclude that nasotracheal intubation has beneficial effects on voice recovery after ACSS, regardless of the tube size.TABLE 1: Mixed Effect Model of Improving Dysphonia Score After Anterior Cervical Spine SurgeryAt 30-day follow-up, 77 patients (71.3%) reported that they were satisfied with their voice recovery; 31 (28.7%) had varying degrees of dysphonia. Among dysphonic patients, six reported significant impact on their life, such as influence on a voice-dependent job, deprivation of singing habit, and, rarely but the worst, symptoms of choking or dyspnea. After consultation with ENT specialists, these patients were kept under observation for some time. The evidence of the effect of methylprednisolone on postoperative vocal cord palsy was weak9; therefore, it was not a routine medication for prophylaxis or treatment of post-ACSS dysphonia or vocal cord palsy in our patients. No patient received methylprednisolone perioperatively in the study." @default.
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• W3045227481 date "2020-08-15" @default.
• W3045227481 modified "2023-10-16" @default.
• W3045227481 title "Response: Effect of Tracheal Intubation Mode on Cuff Pressure During Retractor Splay and Dysphonia Recovery after Anterior Cervical Spine Surgery" @default.
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• W3045227481 doi "https://doi.org/10.1097/brs.0000000000003579" @default.
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