Intraoral Hirudotherapy for Venous Congestion following Free Flap Head and Neck Reconstruction: Novel Intraoral Technique.

Intraoral hirudotherapy is traditionally used for venous congestion following head and neck free flap reconstruction. Many institutions and healthcare teams have been reluctant to use intraoral leech therapy due to risks such as migration into the airway, increased infection from intraoral manipulation, and patient discomfort. Several protocols recommend blocking the path to the oropharynx via gauze or leaving a tracheotomy in place to protect the airway. This report pre-sents a novel technique for intraoral hirudotherapy that is safe and simple for treatment of free flap venous congestion. The base of a clear cup or a plastic lid is utilized, and the leech is attached onto the inside of the lid with 2 sutures near each end. Several cups with leeches attached are made at a time to reduce delay and difficulty of application by less experienced clinical staff. The leech is then applied onto the compromised flap and then simply removed once it has unlatched from the flap. This method allows the leech to be applied with ease by multiple members of the healthcare team, decreases the need for intraoral manipulation, and reduces the risk of migration into the aerodigestive tract. Future prospective studies are warranted to assess the efficacy of this technique.

Outcomes of free flap reconstructions with near-infrared spectroscopy (NIRS) monitoring: A systematic review.

BACKGROUND: Free flap failure or vascular compromise remains a dreadful complication of microvascular free tissue transfer. Near-infrared spectroscopy (NIRS) is a novel technique for free flap monitoring that has the propensity for early detection of vascular compromise when compared to the current gold standard, clinical monitoring (CM). The objective of this review is to evaluate the efficacy of a NIRS system in the postoperative monitoring of free flaps and its effect on flap salvage. METHODS: A comprehensive literature review was performed including English-language articles evaluating the use of NIRS in free flap monitoring. MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), OVID, and Web of Science were searched upto December 2017. RESULTS: A total of 590 articles were identified, and 10 articles were included for analysis. Overall, flaps with vascular compromise monitored with NIRS had a significantly higher salvage rate of 89% compared with a salvage rate of 50% in the flaps monitored by CM alone (p < .01). Partial loss occurred in 15% of the successful salvages in the NIRS group versus 80% with CM alone (p < .01). Detection of vascular compromise by NIRS preceded clinical signs on average by 82 ± 49 min. NIRS was accurate in detecting compromised flaps with a low false-positive and false-negative rate. CONCLUSION: Despite lack of robust data, NIRS has the potential to be an objective, accurate, and continuous postoperative free flap monitoring technique with a greater flap salvage rate than CM alone.

Revisiting the gastric pull-up for pharyngoesophageal reconstruction: A systematic review and meta-analysis of mortality and morbidity.

Gastric pull-up (GPU) is among the oldest techniques for reconstructing the pharyngoesophageal junction following cancer resection. This review examines morbidity and mortality rates following GPU pharyngoesophageal junction reconstruction from 1959 until present: 77 studies, 2,705 patients. The odds of mortality, anastomotic complications, and other complications decreased by 37.2% (95%CI = 28.0-45.3%; P < 0.0001), 8.0% (95%CI = -2.1 to 17.1%; P = 0.12), 21.0% (95%CI 3.5-35.2%; P = 0.021) per decade respectively. J. Surg. Oncol. 2016;114:907-914. © 2016 Wiley Periodicals, Inc.

The timing of drain removal in parotidectomies: outcomes of removal at 4 h post-operatively and a Canadian survey of practice patterns.

BACKGROUND: The post-operative management of parotidectomies is highly provider dependent. No guidelines are currently available for timing of parotid drain removal. This study aimed to assess: (1) outcomes and complications after early drain removal (< 4 h, post-operative day [POD] 0) versus late drain removal (POD ≥ 1); (2) current Canadian provider practices. METHODS: A single surgeons ten-year parotidectomy practice was reviewed, spanning his practice change from routine POD ≥ 1 drain removal to POD 0 removal, with extraction of patient demographic, disease, and complication variables. An anonymous, cross-sectional survey on parotid drain practices was distributed to Canadian Society of Otolaryngology-Head and Neck Surgery members. Descriptive statistics, Wilcoxon Rank Sum, and unpaired student's t-tests were calculated. RESULTS: In total, 526 patients were included and 44.7% (235/526) had drains removed POD 0. There was no significant difference in hematoma or seroma rates between the POD 0 and POD ≥ 1 drain removal cohorts. The national survey on parotid drain management had 176 responses. The majority (67.9%) reported routinely using drains after parotidectomy and 62.8% reported using a drain output based criteria for removal. The most common cut-off output was 30 ml in 24 h (range 5-70 ml). CONCLUSION: There was no difference in hematoma or seroma rates for patients with parotid drains removed on POD 0 versus POD ≥ 1. Our national survey found significant variation in Canadian parotidectomy drain removal practices, which may be an area that can be further assessed to minimize hospital resources and improve patient care.

A systematic approach to the recurrent laryngeal nerve dissection at the cricothyroid junction.

BACKGROUND: To describe and evaluate a four step systematic approach to dissecting the recurrent laryngeal nerve (RLN) starting at the cricothyroid junction during thyroid surgery (subsequently referred to as the retrograde medial approach). METHODS: All thyroidectomies completed by the senior author between August 2014 and January 2016 were retrospectively reviewed. Patients were excluded if concurrent lateral or central neck dissection was performed. A follow up period of 1 year was included. RESULTS: Surgical photographs and illustrations demonstrate the four steps in the retrograde medial approach to dissection of the RLN in thyroid surgery. Three hundred forty-two consecutive thyroid surgeries were performed in 17 months, including 213 hemithyroidectomies, 91 total thyroidectomies, and 38 completion thyroidectomies. The rate of temporary and permanent hypocalcemia was 13% (95% confidence interval [CI]: 8-20%) and 3% (95% CI: 1-8%) respectively. The rate of temporary and permanent vocal cord palsy was 9% (95% CI: 6-12%) and 0.3% (95%CI: 0.01-2%) respectively. The median surgical times for hemithyroidectomy, total thyroidectomy, and completion thyroidectomy were 39 min (Interquartile range [IQR]: 33-47 min), 48 min (IQR: 40-60 min), and 40 min (IQR: 35-51 min) respectively. 1% of cases required conversion to an alternative surgical approach. CONCLUSION: In a tertiary endocrine head and neck practice, the routine use of the retrograde medial approach to RLN dissection is safe and results in a short operative time, and a low conversion rate to other RLN dissection approaches.

Upper airway obstruction due to a change in altitude: first report in fifty years.

BACKGROUND: Air travel mostly causes minor ear, nose and throat complaints. We describe a second report in literature of airway obstruction caused by a drop in atmospheric pressure during a routine commercial flight. CASE PRESENTATION: A 54-year-old male was referred to a head and neck surgeon with a 2 cm left submandibular mass that would enlarge during commercial flights. As the plane gained elevation, the mass would grow and cause him to become stridorous and short of breath. The shortness of breath and stridor would only resolve upon landing of the plane. A CT scan showed a large air sac extending from the larynx at the level of the true vocal cords up to the angle of the mandible. Based on the history and the CT findings a diagnosis of a laryngocele was made. The laryngocele was excised using an external approach, resolving the patient's difficulty with flying. CONCLUSION: This article reports a rare case of upper airway obstruction caused by atmospheric pressure changes during air travel. The reported case is of significance as only a few uncomplicated laryngoceles have been reported to cause airway distress in the literature. This report highlights the epidemiology, presentation, complication and management of laryngoceles.

Management algorithm for failed gastric pull up reconstruction of laryngopharyngectomy defects: case report and review of the literature.

BACKGROUND: Gastric pull up remains a popular reconstructive option for pharyngoesophagectomy defects extending to thoracic inlet. Gastric necrosis is a dreaded complication of gastric pull up reconstruction and few studies report on management of this complication. MEDLINE, EMBASE, and Web of Science™ databases were searched for publications in the last 25 years on gastric pull up reconstruction following pharyngoesophagectomy. The rates of complications related to gastropharyngeal anastomosis were extracted, and methods of managing gastric necrosis were noted. Forty seven case series were identified reporting on the use of gastric pull up for reconstruction of pharyngoesophageal defects. Mortality rate varied from 0 to 33 % with a weighted average of 8.6 %. In 39 % of patients, mortality was either caused or directly related to failure of the gastropharyngeal anastomosis. The reported rate of gastric necrosis ranged from 0 to 24 % resulting in a 28 % mortality. Options for managing gastric necrosis included: temporary cervical diversion, free jejunum flap, colonic interposition, tubed radial forearm flap, deltopectoralis and pectoralis myocutaneous flaps. CASE PRESENTATION: We present the first case of an anterolateral thigh flap rescue of gastric necrosis after gastric pull up reconstruction. The case report is followed by a review of literature on management of gastric pull up failures. CONCLUSION: Based on the extracted information, we propose an algorithm for managing gastric pull up failure following pharyngoesophageal reconstruction.

Rinne test: does the tuning fork position affect the sound amplitude at the ear?

BACKGROUND: Guidelines and text-book descriptions of the Rinne test advise orienting the tuning fork tines in parallel with the longitudinal axis of the external auditory canal (EAC), presumably to maximise the amplitude of the air conducted sound signal at the ear. Whether the orientation of the tuning fork tines affects the amplitude of the sound signal at the ear in clinical practice has not been previously reported. The present study had two goals: determine if (1) there is clinician variability in tuning fork placement when presenting the air-conduction stimulus during the Rinne test; (2) the orientation of the tuning fork tines, parallel versus perpendicular to the EAC, affects the sound amplitude at the ear. METHODS: To assess the variability in performing the Rinne test, the Canadian Society of Otolaryngology - Head and Neck Surgery members were surveyed. The amplitudes of the sound delivered to the tympanic membrane with the activated tuning fork tines held in parallel, and perpendicular to, the longitudinal axis of the EAC were measured using a Knowles Electronics Mannequin for Acoustic Research (KEMAR) with the microphone of a sound level meter inserted in the pinna insert. RESULTS: 47.4 and 44.8% of 116 survey responders reported placing the fork parallel and perpendicular to the EAC respectively. The sound intensity (sound-pressure level) recorded at the tympanic membrane with the 512 Hz tuning fork tines in parallel with as opposed to perpendicular to the EAC was louder by 2.5 dB (95% CI: 1.35, 3.65 dB; p < 0.0001) for the fundamental frequency (512 Hz), and by 4.94 dB (95% CI: 3.10, 6.78 dB; p < 0.0001) and 3.70 dB (95% CI: 1.62, 5.78 dB; p = .001) for the two harmonic (non-fundamental) frequencies (1 and 3.15 kHz), respectively. The 256 Hz tuning fork in parallel with the EAC as opposed to perpendicular to was louder by 0.83 dB (95% CI: -0.26, 1.93 dB; p = 0.14) for the fundamental frequency (256 Hz), and by 4.28 dB (95% CI: 2.65, 5.90 dB; p < 0.001) and 1.93 dB (95% CI: 0.26, 3.61 dB; p = .02) for the two harmonic frequencies (500 and 4 kHz) respectively. CONCLUSIONS: Clinicians vary in their orientation of the tuning fork tines in relation to the EAC when performing the Rinne test. Placement of the tuning fork tines in parallel as opposed to perpendicular to the EAC results in a higher sound amplitude at the level of the tympanic membrane.

Surgical Interventions for Pediatric Unilateral Vocal Cord Paralysis: A Systematic Review.

IMPORTANCE: The most widely used surgical interventions for pediatric unilateral vocal cord paralysis include injection laryngoplasty, thyroplasty, and laryngeal reinnervation. Despite increasing interest in surgical interventions for unilateral vocal cord paralysis in children, the surgical outcomes data in children are scarce. OBJECTIVE: To appraise and summarize the available evidence for pediatric unilateral vocal cord paralysis surgical strategies. EVIDENCE REVIEW: MEDLINE (1946-2014) and EMBASE (1980-2014) were searched for publications that described the results of laryngoplasty, thyroplasty, or laryngeal reinnervation for pediatric unilateral vocal cord paralysis. Further studies were identified from bibliographies of relevant studies, gray literature, and annual scientific assemblies. Two reviewers independently appraised the selected studies for quality, level of evidence, and risk of bias as well as extracted data, including unilateral vocal cord paralysis origin, voice outcomes, swallowing outcomes, and adverse events. FINDINGS: Of 366 identified studies, the inclusion criteria were met by 15 studies: 6 observational studies, 6 case series, and 3 case reports. All 36 children undergoing laryngeal reinnervation (8 studies) had improvement or resolution of dysphonia. Of 31 children receiving injection laryngoplasty (6 studies), most experienced improvement in voice quality, speech, swallowing, aspiration, and glottic closure. Of 12 children treated by thyroplasty (5 studies), 2 experienced resolution of dysphonia, 4 had some improvement, and 4 had no improvement (2 patients had undocumented outcomes). Thyroplasty resolved or improved aspiration in 7 of 8 patients. CONCLUSIONS AND RELEVANCE: Published studies suggest that reinnervation may be the most effective surgical intervention for children with dysphonia; however, long-term follow-up data are lacking. With the exception of polytetrafluoroethylene injections, injection laryngoplasty was reported to be a relatively safe, nonpermanent, and effective option for most children with dysphonia. Thyroplasty appears to have fallen out favor in recent years because of difficulty in performing this procedure in children under local anesthesia, but it continues to be a viable option for children with aspiration.

Electrothermal bipolar vessel sealing system (LigaSure) for hemostasis during thyroid surgery: a comprehensive review.

Conventional hemostatic technologies utilized in thyroid surgery include clamp-and-tie, clips and monopolar and bipolar diathermy. Over the last decade, there has been a major shift towards utilizing newer hemostatic technologies, most notably the electrothermal bipolar vessel sealing systems (EBVS) and the Harmonic Scalpel (Ethicon Endosurgery, OH, USA), for thyroid surgery. Since the first report of EBVS thyroidectomy in 2003, more than 50 studies have been published evaluating EBVS utilization for thyroid surgery. In addition to providing a historical perspective and exploring the principles of EBVS technology, this review aims to evaluate the current published data regarding EBVS utilization for thyroid surgery. In particular, a focus is given to LigaSure (Covidien, Dublin, Ireland) technology because it has been studied most thoroughly in the literature. This review will also evaluate studies comparing the EBVS with Harmonic Scalpel technology for thyroid surgery.