Revision Tracheotomy Complicated by History of Follicular B-Cell Lymphoma.

This case report presents a 65-year-old woman with multiple complications during a revision tracheotomy including subcutaneous emphysema and a pneumothorax. Management of her airway was complicated by a history of recurrent follicular B-cell lymphoma associated with extensive cervical lymphadenopathy. We detail the importance of heightened clinical awareness and the use of intraoperative safety adjuncts when performing revision tracheostomies.

Gaps in Training: Misunderstandings of Airway Management in Medical Students and Internal Medicine Residents.

OBJECTIVES: (1) Evaluate baseline airway knowledge of medical students (MSs) and internal medicine (IM) residents. (2) Improve MS and IM resident understanding of airway anatomy, general tracheostomy and laryngectomy care, and management of airway emergencies. METHODS: A before-and-after survey study was carried out over a single academic year. MS and IM resident knowledge was evaluated before and after an educational, grand rounds-style lecture reviewing airway anatomy, tracheostomy tube components, tracheostomy and laryngectomy care, and clinical vignettes. The primary outcome measure was change in pre- and postlecture survey scores. RESULTS: Prelecture surveys were completed by 90 participants, and 83 completed a postlecture assessment. Postlecture scores were statistically improved for all questions on the assessment (P < .001). Level of training did not confer an improved pre- or postlecture survey score. DISCUSSION: While the majority of participants in our study had previously cared for patients with a tracheostomy or laryngectomy, less than half were able to correctly address basic airway emergencies. Senior IM residents were no more proficient than MSs in addressing airway emergencies. The lack of formal airway training places patients at risk with routine care and in emergencies, demonstrating the need for formal airway education for early medical trainees. IMPLICATIONS FOR PRACTICE: Our data demonstrate a serious gap in MS and IM resident knowledge with respect to emergent airway care in patients with tracheostomies and laryngectomies. An interdepartmental collaborative curriculum offers a realistic and potentially life-saving solution for medical trainees.

Readmission and reoperation after laryngeal dilation in children: NSQIP-P analysis.

OBJECTIVE: To identify specific comorbidities and their relationship to complications in children who underwent laryngeal dilation, specifically comparing children with tracheostomy versus no tracheostomy as well as differences in outcomes between age groups. METHODS: Retrospective study analyzing data collected in the American College of Surgeons National Surgical Improvement - Pediatric Database (2015-2018). Patients were selected using Current Procedural Terminology code 31528. Variables analyzed include demographics, comorbidities, readmission, reoperation, reintubation and total length of stay. RESULTS: 982 cases were identified. Comorbidities significantly higher (p < .001) in age group 1 (Age ≤ 1 year, N = 245) versus age groups 2 (Age >1 but ≤ 3 years, N = 151) and 3 (Age > 3 years, N = 270) include premature birth, ventilator dependent, oxygen support, cardiac risk factors, steroid use, nutritional support, and hematologic disorders. Comorbidities significantly higher (p < .001) in children without a tracheostomy include premature birth, history of asthma, bronchopulmonary dysplasia/chronic lung disease, oxygen support, structural pulmonary/airway abnormality, esophageal/gastric/intestinal disease, history of previous cardiac surgery, developmental delay/impaired cognitive status, cerebral palsy, neuromuscular disorder, steroid use, and nutritional support. Younger children were significantly more likely (p < .001) to require reintubation and remain in the hospital longer. Children without a tracheostomy were significantly more likely (p < .001) to return to the operating room and remain in the hospital longer. CONCLUSION: Younger children and those without a tracheostomy are more likely to have adverse outcomes after laryngeal dilation. Awareness of these associations and outcomes is helpful in establishing benchmarks for outcomes in this group.

Proposed ultrasound algorithm to differentiate thyroglossal duct and dermoid cysts.

OBJECTIVE: 1) To assess reproducibility of the previously established SIST score. 2) To determine inter-observer agreement in using ultrasound (US) characteristics to differentiate thyroglossal duct cyst (TGDC) from dermoid cysts (DC) 3) Improve the method used to pre-operatively differentiate TGDC from DC. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care pediatric hospital. SUBJECTS AND METHODS: An electronic medical record was queried to identify children with midline neck masses who underwent pre-operative neck US and had a histopathologic diagnosis of either TGDC or DC. Two pediatric radiologists, blinded to the pathologic diagnosis, evaluated the US images and documented the presence of pre-determined characteristics of each mass. Potential differentiating factors were analyzed for their predictive power. The SIST (septations, irregular walls, solid components = TGDC) score was determined as well as inter-observer agreement. Using the characteristics that had significant predictive power, we used the data to develop an algorithm to improve predicting cyst type. RESULTS: Pathologically, there were 47 TGDC and 25 DC. The inter-observer agreement about the pathologic diagnosis between the two radiologists was substantial, K = 0.66. Overall, the SIST score predicted the correct diagnosis 67% of the time. Radiologist 1 and radiologist 2 were more accurate than the SIST score alone, making the correct diagnosis 96% and 86% of the time, respectively. In our study, we found that the most important US characteristics in differentiating TGDC and DC are: internal Septations, depth relative to Strap muscles, Shape and Solid parts (4 S algorithm). The SIST score criteria were individually shown to be significant and sensitive in recognizing DC, however, they were not specific and often misclassified TGDC as DC. We developed a new sequential filtering algorithm that more accurately differentiates cysts. This new algorithm uses step-wise filtering of characteristics, first for Septations, then for depth to Straps, then Shape of the cyst and lastly Solid parts (4 S algorithm). This algorithm correctly categorized cyst type in 100% of patients in our study. CONCLUSIONS: Pre-operatively differentiating TGDC and DC continues to be a challenge. Using our 4 S algorithm, we can more definitively differentiate TGDC from DC compared to the SIST score. All SIST score characteristics were significant and sensitive in detecting dermoid cysts, however, not very specific. The radiologists' judgment and accuracy was better than the SIST score. The 4 S algorithm uses sequential filtering of important characteristics: Septations, depth to Straps, Shape of cyst and lastly Solid parts to improve diagnostic accuracy.

Presurgical induction chemotherapy for squamous cell carcinoma of the tonsil.

OBJECTIVES/HYPOTHESIS: The indications for and efficacy of induction chemotherapy in the management of squamous cell carcinoma of the head and neck is controversial. With the advent of human papillomavirus (HPV)-related cancers, survival has improved significantly. Here we present a group of patients with tonsil cancer treated with induction chemotherapy followed by surgery. STUDY DESIGN: Retrospective cohort study. METHODS: Thirty-eight patients with tonsil cancer were treated with induction chemotherapy, consisting of cisplatin and docetaxel, followed by neck dissection and radical tonsillectomy. Twenty-six patients were HPV+, 28 were nonsmokers or long-term former smokers, and 28 were T1/T2. Fourteen patients required postoperative chemoradiotherapy (CRT). Median follow-up time was 4.1 years. RESULTS: A complete response to induction chemotherapy was achieved in 45% (17) of patients. In total, 76% (29/38) of patients were successfully treated: 53% (20/38) with chemotherapy and surgery alone, and 24% (9/38) required postoperative CRT. Almost 90% (23/26) of HPV+ and half (6/12) of HPV- patients are no evidence of disease (NED). HPV status is a significant prognostic factor (P = .02). Only 38% (5/13) of current smokers were NED compared to 96% (24/25) of nonsmokers (P = .0002). All HPV+ nonsmokers (20/20) were NED at last follow-up. CONCLUSIONS: In this study, the primary driver of prognosis was smoking status. HPV status and T stage were also important. The prognosis for HPV+ nonsmokers is extremely good; most likely regardless of treatment. Treatment failures have a poor chance of salvage, irrespective of treatment type. With the major exception of HPV- smokers, induction chemotherapy followed by surgery with selective CRT is a viable treatment option for tonsil cancer. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1206-1211, 2020.

Infrared imaging of trauma patients for detection of acute compartment syndrome of the leg.

OBJECTIVE: Early compartment syndrome is difficult to diagnose, and a delay in the diagnosis can result in amputation or death. Our objective was to explore the potential of infrared imaging, a portable and noninvasive technology, for detecting compartment syndrome in the legs of patients with multiple trauma. We hypothesized that development of compartment syndrome is associated with a reduction in surface temperature in the involved leg and that the temperature reduction can be detected by infrared imaging. DESIGN: Observational clinical study. SETTING: Level I trauma center between July 2006 and July 2007. PATIENTS: Trauma patients presenting to the emergency department. INTERVENTIONS: Average temperature of the anterior surface of the proximal and distal region of each leg was measured in the emergency department with a radiometrically calibrated, 320 x 240, uncooled microbolometer infrared camera. MEASUREMENTS AND MAIN RESULTS: The difference in surface temperature between the thigh and foot regions (thigh-foot index) of the legs in trauma patients was determined by investigators blinded to injury pattern using thermographic image analysis software. The diagnosis of compartment syndrome was made intraoperatively. Thermographic images from 164 patients were analyzed. Eleven patients developed compartment syndrome, and four of those patients had bilateral compartment syndrome. Legs that developed compartment syndrome had a greater difference in proximal vs. distal surface temperature (8.80 +/- 2.05 degrees C) vs. legs without compartment syndrome (1.22 +/- 0.88 degrees C) (analysis of variance p < .01). Patients who developed unilateral compartment syndrome had a greater proximal vs. distal temperature difference in the leg with (8.57 +/- 2.37 degrees C) vs. the contralateral leg without (1.80 +/- 1.60 degrees C) development of compartment syndrome (analysis of variance p < .01). CONCLUSIONS: Infrared imaging detected a difference in surface temperature between the proximal and distal leg of patients who developed compartment syndrome. This technology holds promise as a supportive tool for the early detection of acute compartment syndrome in trauma patients.

Application of infrared-based molecular imaging to a mouse model with head and neck cancer.

BACKGROUND: This study investigated whether near infrared (NIR) or visible fluorescent molecular imaging produced a better representation of a mouse model with head and neck squamous cell carcinoma (HNSCC). Additionally, the study explored whether epidermal growth factor receptor (EGFR)-targeted probes could play an important role in the diagnosis of HNSCC. METHODS: An orthotopic mouse model of HNSCC labeled with the NIR fluorophore, infrared fluorescent protein (iRFP), was developed and monitored noninvasively in real time. The tumors were further evaluated using tumor-specific EGFR-targeted probes conjugated with an NIR dye (IRDye800), or a visible fluorescent protein. RESULTS: The iRFP cell line produced better results than cells emitting visible light when studying local, distant, and deep tumors in the mouse model. The EGFR-targeted probe conjugated with IRDye800 accurately detected tumor perimeters. CONCLUSION: This model has great potential as a unique tool in the study of HNSCC tumor development. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1351-E1357, 2016.

Independence of brain and trunk temperature during hypothermic preconditioning in rats.

UNLABELLED: Hypothermic preconditioning is rapid cooling and warming to induce tolerance to ischemia. The purpose of the study was to examine differences in brain and trunk temperature during hypothermic preconditioning. METHODS: Rats (n=18) were implanted with telemetric probes for simultaneous measure of brain and trunk temperature. Hypothermic preconditioning was produced by exposing rats to cool and warm environments that produced rapid cooling to 30 degrees C and warming to 35 degrees C. RESULTS: Brain temperature was warmer (37.56+/-0.45 degrees C) than trunk (37.17+/-0.29 degrees C) temperature in unanesthetized, free roaming rats at room temperature (t-test p=0.04). The brain cooled (0.59+/-0.1 degrees C/min) quicker than the trunk (0.44+/-0.19 degrees C/min) during cooling cycles of hypothermic preconditioning and the brain (0.28+/-0.04 degrees C/min) warmed quicker than the trunk (0.18+/-0.07 degrees C/min) during the warming cycle of hypothermic preconditioning (t-test p<0.0001). When the trunk temperature probe was designated to reach the target temperature of 35 degrees C during warming, the brain temperature (38.1+/-0.44 degrees C) was warmer than trunk temperature (34.95+/-0.16 degrees C) during the peak of warming (t-test p<0.0001). CONCLUSION: The brain cools and warms quicker than the trunk during hypothermic preconditioning. Failure to anticipate these differences could lead to unrecognized brain hyperthermia during warming. Appreciation of differences in rates of change between brain and trunk temperature may be important when designing hypothermic preconditioning experiments.