Apnoeic oxygenation with high flow nasal oxygen for interventional surgery of the larynx and pharynx.

BACKGROUND: Highflow nasal cannula oxygen (HFNO) is known to be used for noninvasive oxygenation in intensive care patients but it has rarely been used in airway management for elective surgery of the upper aerodigestive tract. OBJECTIVES: HFNO offers opportunities of a tubeless oxygenation system which is easy to handle and not limited only on surgery of the endolarynx. METHODS: We evaluated this method for oxygenation during brief interventional procedures of the larynx and pharynx in 92 adult patients for safety and intraoperative complications. The need of secondary endotracheal intubation and limiting comorbidities as pulmonal and cardiac diseases were documented. RESULTS: HFNO showed a good safety profile concerning saturation and hypercapnia. Oxygen desaturation below 90% occurred only in 5 patients, mask ventilation led to quick recovery except in one patient who was secondary intubated. A significant influence of the body mass index on the minimal O2 saturation was shown (p < 0,001) so that a possible limitation of the method exists here. Comorbidities were grouped into the ASA classification. There was a significant difference between ASA I/II and ASA III patients in terms of minimum O2saturation. CONCLUSION: We conclude that HFNO may hold great promise for changing ventilator technique in general anesthesia, particularly in short elective laryngeal and pharyngeal surgery. Safety and feasibility were proven in this study.

Sex-specific aspects in patients with oropharyngeal squamous cell carcinoma: a bicentric cohort study.

BACKGROUND: Oropharyngeal squamous cell carcinoma (OPSCC) is the only subgroup of head neck cancer that presents with an increased incidence. Gender-specific studies in other cancer entities have revealed differences in treatment response and prognosis. However, only limited data in OPSCC according to gender and human papillomavirus (HPV) status exist. Therefore, we aimed to investigate sex-specific differences in OPSCC and how these may be distributed in relation to HPV and other risk factors. METHODS: This retrospective, bicentric study included 1629 patients with OPSCC diagnosed between 1992 and 2020. We formed subgroups based on TNM status, American Joint Cancer Committee 8th edition (AJCC8), HPV status, treatment modality (surgery (± radio(chemo)therapy (RCT) vs. definitive RCT) and patient-related risk factors and investigated gender differences and their impact on patients survival via descriptive-,uni- and multivariate analysis. RESULTS: With the exception of alcohol abuse, no significant differences were found in risk factors between men and women. Females presented with better OS than males in the subgroup T1-2, N + , independent of risk factors (p = 0.008). Males demonstrated significant stratification through all AJCC8 stages (all p < 0.050). In contrast, women were lacking significance between stage II and III (p = 0.992). With regard to therapy (surgery (± R(C)T) - vs. definitive RCT) women treated with surgery had better OS than men in the whole cohort (p = 0.008). Similar results were detected in the HPV-negative OPSCC sub-cohort (p = 0.042) and in high-risk groups (AJCC8 stage III and IV with M0, p = 0.003). CONCLUSION: Sex-specific differences in OPSCC represent a health disparity, particularly according to staging and treatment, which need to be addressed in future studies.

Factors associated with an increased risk of SARS-CoV-2 infection in healthcare workers in aerosol-generating disciplines.

BACKGROUND: Healthcare workers (HCWs) are at a high risk of SARS-CoV-2 infection due to exposure to potentially infectious material, especially during aerosol-generating procedures (AGP). We aimed to investigate risk factors for SARS-CoV-2 infection among HCWs in medical disciplines with AGP. METHODS: A nationwide questionnaire-based study in private practices and hospital settings was conducted between 12/16/2020 and 01/24/2021. Data on SARS-CoV-2 infections among HCWs and potential risk factors of infection were investigated. RESULTS: 2070 healthcare facilities with 25113 employees were included in the study. The overall infection rate among HCWs was 4.7%. Multivariate analysis showed that regions with higher incidence rates had a significantly increased risk of infection. Furthermore, hospital setting and HCWs in gastrointestinal endoscopy (GIE) had more than double the risk of infection (OR 2.63; 95% CI 2.50-2.82, p<0.01 and OR 2.35; 95% CI 2.25-2.50, p<0.01). For medical facilities who treated confirmed SARS-CoV-2 cases, there was a tendency towards higher risk of infection (OR 1.39; 95% CI 1.11-1.63, p=0.068). CONCLUSION: Both factors within and outside medical facilities appear to be associated with an increased risk of infection among HCWs. Therefore, GIE and healthcare delivery setting were related to increased infection rates. Regions with higher SARS-CoV-2 incidence rates were also significantly associated with increased risk of infection.

[Management of blunt and penetrating laryngeal trauma]. / Management von stumpfen und scharfen Kehlkopfverletzungen.

Patients presenting with laryngotracheal trauma can be in a life-threatening situation. Early recognition of the severity of the injury and, if necessary, surgical intervention within the first 24-48 h increases the chance of achieving a good functional late result. Preservation or restoration of voice and swallowing function is the long-term therapeutic goal. Precise assessment of the extent of the injury can be achieved using a combination of computed tomography and flexible laryngotracheoscopy. Symptoms often do not reflect the extent of the injury, which can vary from endolaryngeal hemorrhage to complete laryngotracheal separation. Conservative treatment consists of observation with symptomatic therapy. On the other hand, surgery may include endolaryngeal repair and/or transcervical reconstruction; securing the airways is of utmost importance.

[Salivary gland carcinomas - Monocentric experience on subtypes and their incidences over 42 years]. / Speicheldrüsenkarzinome ­ Monozentrische Erfahrung zu Subtypen und deren Inzidenz über 42 Jahre.

OBJECTIVE: Salivary gland carcinomas are rare and heterogeneous. More than 20 subtypes are recognized and risk factors are diverse. The aim of this work was to evaluate the subtype and other risk factors in a monocentric population from more than four decades. MATERIAL AND METHODS: 205 cases (diagnosis period 1972-2014) were retrospectively collected and analyzed with regard to the distribution of risk factors and their influence on overall survival (OS). RESULTS: 19/24 (79.2%) of the subtypes listed in the WHO classification occurred rarely in the cohort (< 5%). 10/24 (41.7%) of all subtypes were never diagnosed. With a total of 145/205 cases (70.7%), squamous cell carcinoma (PEC), adenocarcinoma (AdenoCa), acinar cell carcinoma (AcinarCa), mucoepidermoid carcinoma (MEC), and adenoid cystic carcinoma (ACC) were by far the most common subtypes. Risk factors are significantly different in these groups (e.g., lymphogenic metastasis and degree of differentiation in AdenoCa and age, T and UICC stage in PEC). The 5-year overall survival of all patients was 66.9% and differed significantly within the most common subtypes. An independent impact on overall survival was detectable for patient age (p<0.001), and T- (p=0.003) and N-stage (p=0.046) in multivariate analysis. CONCLUSIONS: Most subtypes occurred markedly rarely or not at all within decades. The most common diagnoses differ with respect to risk factors as well as OS and 3 risk groups can be defined based on histology. In conclusion, considering TNM alone is insufficient for prognosis estimation in salivary gland carcinoma.

Editor's Choice - Association Between Peri-OPerative Aspirin ResisTance and CardioVascular Outcome (POPART-CVO): a Prospective Non-Interventional Cohort Study.

OBJECTIVE: New onset aspirin resistance during surgery, known as peri-operative aspirin resistance, is observed in up to 30% of vascular surgery patients and is associated with post-operative myocardial damage; questioning aspirin effectiveness towards peri-operative cardiovascular events. The objective of this study was to prospectively evaluate whether peri-operative aspirin resistance in vascular surgery is associated with an adverse cardiovascular outcome. METHODS: Based on a sample size calculation, 194 adult elective vascular or endovascular surgery patients receiving aspirin were analysed in this prospective, single centred, non-interventional cohort study. Platelet function was measured before surgery, one hour after incision, four hours post-operatively, and on the morning of the first and second post-operative days using the Multiplate analyser. The primary outcome was myocardial injury after non-cardiac surgery (MINS). Secondary outcomes included major bleeding, admission to intensive care unit, length of hospital stay, and major adverse cardiac and cerebrovascular events. Subgroup analyses were performed for patients with different cardiovascular risk and for patients who underwent endovascular surgery. RESULTS: Peri-operative aspirin resistance was observed in 27.8% of patients but was not associated with MINS (27.8% vs. 32.1%, aspirin resistance vs. no aspirin resistance, OR 0.812, 95% CI 0.406 - 1.624, p = .56) or with any of the secondary endpoints (all p > .050). In nine of the 10 subgroup analyses, aspirin resistance was not associated with a difference in MINS rate. However, in patients with a low cardiovascular risk profile (RCRI 0-2), MINS occurred more frequently in patients without aspirin resistance (p = .049). CONCLUSION: This study confirmed previous reports demonstrating that peri-operative aspirin resistance is common in patients undergoing vascular or endovascular surgery. However, in patients who continue aspirin throughout the peri-operative period, aspirin resistance is a phenomenon, which does not appear to be related to MINS. Measuring peri-operative platelet function using the Multiplate analyser with the intention to identify and potentially prevent or treat peri-operative aspirin resistance seems to be dispensable.

18F-FDG PET cannot predict expression of clinically relevant histopathological biomarkers in head and neck squamous cell carcinoma: a meta-analysis.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) is a common cancer. Positron emission tomography (PET) with 18F-fluorodeoxyglucose (18F-FDG) is a widely used imaging modality in HNSCC. PURPOSE: To provide evident data about associations between 18F-FDG PET and histopathology in HNSCC. MATERIAL AND METHODS: The MEDLINE database was screened for associations between maximum standard uptake values (SUVmax) derived from 18F-FDG PET and histopathological features in HNSCC up to May 2020. Only papers containing correlation coefficients between SUVmax and histopathology were acquired. Overall, 23 publications were collected. RESULTS: The following correlations were calculated: KI 67: 12 studies (345 patients), pooled correlation coefficient (PCC): 0.23 (95% confidence interval [CI] 0.06-0.40); hypoxia-inducible factor-1α: eight studies (240 patients), PCC: 0.24 (95% CI 0.06-0.42); microvessel density: three studies (64 patients), PCC: 0.33 (95% CI 0.02-0.65); vascular endothelial growth factor: two studies (59 cases), PCC: 0.27 (95% CI 0.02-0.51); tumor suppressor protein p53: four studies (159 patients), PCC: 0.05 (95% CI -0.41 to 0.51); epidermal growth factor receptor: two studies (124 patients), PCC: 0.21 (95% CI 0.05-0.37); tumor cell count: three studies (67 patients), PCC: 0.18 (95% CI -0.06 to 0.42); tumor cell apoptosis: two studies (40 patients), PCC: 0.07 (95% CI = -0.85 to 0.99); B-cell lymphoma-2 protein: two studies (118 patients); PCC: 0.04 (95% CI -0.65 to 0.74); glucose-transporter 1: 10 studies (317 patients), PCC: 0.20 (95% CI 0.10-0.30). CONCLUSION: SUVmax derived from 18F-FDG PET cannot reflect relevant histopathological features in HNSCC.

[Sonographic diagnostics in the head and neck area, part 2 - transcervical sonography]. / Sonografische Diagnostik im Kopf-Hals-Bereich ­ Teil 2: Transzervikale Sonografie.

Transcervical sonography has become an integral part of the diagnostic spectrum of otorhinolaryngology, as evidenced by its firm inclusion in continuing education catalogs and guidelines. For these reasons, the user should be aware of a basic understanding of ultrasound physics and of technical innovations. A standardized examination scheme with structured reporting and documentation is an elementary prerequisite to meet the daily clinical challenges and to be able to answer specific questions. In this educational article, we span from an introduction to structured examination techniques to a clinical update on sonography of the cephalic glands and cervical lymph nodes.

Multimodal control of neck muscles for vestibular mediated head oscillation damping during walking: a pilot study.

PURPOSE: It is still in question whether head oscillation damping during walking forms a part of the vestibular function. The anatomical pathway from the vestibular system to the neck muscles via the medial vestibulospinal tract (MVST) is well known but there is a lack of knowledge of the exact influence and modulation of each other in daily life activities. METHODS: (I) We fixed a head-neck unit of a human cadaver specimen in a steal frame to determine the required pitch-torque for a horizontal head position. The mean value of the acquired pitch-torque was 0.54 Nm. (II) On a motorized treadmill we acquired kinematic data of the head, the sternum and both feet by wireless 3D IMUs for seven asymptomatic volunteers. Subsequently three randomized task conditions were performed. Condition 1 was walking without any irritation. Condition 2 imitated a sacculus irritation using a standardized cVEMP signal. The third condition used an electric neck muscle-irritation (TENS). The data were analyzed by the simulation environment software OpenSim 4.0. RESULTS: 8 neck muscle pairs were identified. By performing three different conditions we observed some highly significant deviations of the neck muscle peak torques. Analysing Euler angles, we found during walking a LARP and RALP head pendulum, which also was strongly perturbated. CONCLUSION: Particularly the pitch-down head oscillation damping is the most challenging one for neck muscles, especially under biomechanical concerns. Mainly via MVST motor activity of neck muscles  might be modulated by vestibular motor signals. Two simultaneous proprioceptor effects might optimize head oscillation damping. One might be a proprioceptive feedback loop to the vestibular nucleus. Another might trigger the cervicocollic reflex (CCR).

European white paper: oropharyngeal dysphagia in head and neck cancer.

PURPOSE: To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe. METHODS: Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion. RESULTS: Twenty-four sections on HNC-specific OD topics. CONCLUSION: This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Deep Convolution Neural Network for Laryngeal Cancer Classification on Contact Endoscopy-Narrow Band Imaging.

(1) Background: Contact Endoscopy (CE) and Narrow Band Imaging (NBI) are optical imaging modalities that can provide enhanced and magnified visualization of the superficial vascular networks in the laryngeal mucosa. The similarity of vascular structures between benign and malignant lesions causes a challenge in the visual assessment of CE-NBI images. The main objective of this study is to use Deep Convolutional Neural Networks (DCNN) for the automatic classification of CE-NBI images into benign and malignant groups with minimal human intervention. (2) Methods: A pretrained Res-Net50 model combined with the cut-off-layer technique was selected as the DCNN architecture. A dataset of 8181 CE-NBI images was used during the fine-tuning process in three experiments where several models were generated and validated. The accuracy, sensitivity, and specificity were calculated as the performance metrics in each validation and testing scenario. (3) Results: Out of a total of 72 trained and tested models in all experiments, Model 5 showed high performance. This model is considerably smaller than the full ResNet50 architecture and achieved the testing accuracy of 0.835 on the unseen data during the last experiment. (4) Conclusion: The proposed fine-tuned ResNet50 model showed a high performance to classify CE-NBI images into the benign and malignant groups and has the potential to be part of an assisted system for automatic laryngeal cancer detection.

[Sonography of the head and neck area - Part 1: Endosonography]. / Sonografische Diagnostik im Kopf-Hals-Bereich ­ Teil 1: Endosonografie.

Sonography of the head and neck area plays a major role in both outpatient and inpatient ear, nose and throat medicine. Transcervical ultrasound is an important imaging method, especially in lymph node and tumor diagnostics. Its advantage is the ubiquitous availability and the excellent combinability with endoscopy and palpation. Despite decades of experience with sonography in the head and neck area, in contrast to the transcutaneous application, the transoral or endosonographic approach has so far not been widely used. Here it is often not due to the technical capabilities of the examiner, but rather to the unusual approach within the scope of the investigation. In this context, endosonography may be used primarily in tumor diagnostics in order to establish a complete sonographic examination from in- and outside.

Preoperative neutrophil to lymphocyte ratio and platelet to lymphocyte ratio are associated with major adverse cardiovascular and cerebrovascular events in coronary heart disease patients undergoing non-cardiac surgery.

BACKGROUND: Preoperative risk prediction in patients at elevated cardiovascular risk shows limited accuracy. Platelet to lymphocyte ratio (PLR) and neutrophil to lymphocyte ratio (NLR) indicate systemic inflammation. Both have been investigated for outcome prediction in the field of oncology and cardiovascular medicine, as well as risk prediction of adverse cardiovascular events in non-surgical patients at increased cardiovascular risk. METHODS: For this post-hoc analysis, we included all 38 coronary heart disease patients from the Leukocytes and Cardiovascular Perioperative Events cohort-1 study scheduled for elective non-cardiac surgery. We evaluated preoperative differential blood counts for association with major adverse cardiovascular and cerebrovascular events (MACCE) defined as the composite endpoint of death, myocardial ischemia, myocardial infarction, myocardial injury after non-cardiac surgery, or embolic or thrombotic stroke within 30 days after surgery. We used Youden's index to calculate cut-off values for PLR and NLR. Additive risk-predictive values were assessed using receiver operating characteristic curve and net reclassification (NRI) improvement analyses. RESULTS: Patients with the composite endpoint MACCE had higher PLR and NLR (309 [206; 380] vs. 160 [132; 203], p = 0.001; 4.9 [3.5; 8.1] vs. 2.6 [2.2; 3.4]), p = 0.001). Calculated cut-offs for PLR > 204.4 and NLR > 3.1 were associated with increased risk of 30-day MACCE (OR 7, 95% CI [1.2; 44.7], p = 0.034; OR 36, 95% CI [1.8; 686.6], p = 0.001). Furthermore, NLR improved risk prediction in coronary heart disease patients undergoing non-cardiac surgery when combined with hs-cTnT or NT-proBNP (NRI total = 0.23, p = 0.008, NRI total = 0.26, p = 0.005). CONCLUSIONS: Both PLR and NLR were associated with perioperative cardiovascular adverse events in coronary heart disease patients. NLR proved to be of additional value for preoperative risk stratification. Both PLR and NLR could be used as inexpensive and broadly available tools for perioperative risk assessment. TRIAL REGISTRATION: NCT02874508, August 22, 2016.

Presepsin for pre-operative prediction of major adverse cardiovascular events in coronary heart disease patients undergoing noncardiac surgery: Post hoc analysis of the Leukocytes and Cardiovascular Peri-operative Events-2 (LeukoCAPE-2) Study.

BACKGROUND: Accurate pre-operative evaluation of cardiovascular risk is vital to identify patients at risk for major adverse cardiovascular and cerebrovascular events (MACCE) after noncardiac surgery. Elevated presepsin (sCD14-ST) is associated with peri-operative MACCE in coronary artery disease (CAD) patients after noncardiac surgery. OBJECTIVES: Validating the prognostic utility of presepsin for MACCE after noncardiac surgery. DESIGN: Prospective patient enrolment and blood sampling, followed by post hoc evaluation of pre-operative presepsin for prediction of MACCE. SETTING: Single university centre. PATIENTS: A total of 222 CAD patients undergoing elective, inpatient noncardiac surgery. INTERVENTION: Pre-operative presepsin measurement. MAIN OUTCOME MEASURES: MACCE (cardiovascular death, myocardial infarction, myocardial ischaemia and stroke) at 30 days postsurgery. RESULTS: MACCE was diagnosed in 23 (10%) patients. MACCE patients presented with increased pre-operative presepsin (median [IQR]; 212 [163 to 358] vs. 156 [102 to 273] pgml, P = 0.023). Presepsin exceeding the previously derived threshold of 184 pg ml was associated with increased 30-day MACCE rate. After adjustment for confounders, presepsin more than 184 pg ml [OR = 2.8 (95% confidence interval 1.1 to 7.3), P = 0.03] remained an independent predictor of peri-operative MACCE. Predictive accuracy of presepsin was moderate [area under the curve (AUC) = 0.65 (0.54 to 0.75), P = 0.023]. While the basic risk model of revised cardiac risk index, high-sensitive cardiac troponin T and N-terminal fragment of pro-brain natriuretic peptide resulted in an AUC = 0.62 (0.48 to 0.75), P = 0.072, addition of presepsin to the model led to an AUC = 0.67 (0.56 to 0.78), P = 0.009 and (ΔAUC = 0.05, P = 0.438). Additive risk predictive value of presepsin was demonstrated by integrated discrimination improvement analysis (integrated discrimination improvement = 0.023, P = 0.022). Net reclassification improvement revealed that the additional strength of presepsin was attributed to the reclassification of no-MACCE patients into a lower risk group. CONCLUSION: Increased pre-operative presepsin independently predicted 30-day MACCE in CAD patients undergoing major noncardiac surgery. Complementing cardiovascular risk prediction by inflammatory biomarkers, such as presepsin, offers potential to improve peri-operative care. However, as prediction accuracy of presepsin was only moderate, further validation studies are needed. TRIAL REGISTRATION: Clinicaltrials.gov: NCT03105427.

Interrater variation of vascular classifications used in enhanced laryngeal contact endoscopy.

PURPOSE: Combined use of contact endoscopy (CE) and Narrow Band Imaging (NBI, Olympus®) is suggested for the visualization of specific vascular changes indicative of glottic neoplasia. We investigated the interrater reliability and agreement in 3 recognized classification systems of vascular changes applied to images from CE + NBI in patients suspected for glottic neoplasia. METHODS: Six experienced head and neck surgeons familiar with NBI rated 120 images obtained by CE + NBI by 3 classification systems of vascular changes as suggested by Ni et al. (N-C), Puxeddu et al. (P-C), and the European Laryngological Society (ELS-C). Three raters were experienced in CE, and three raters had only limited experience with CE. Crude agreement and Fleiss' kappa with 95% confidence interval were estimated for all 6 raters, and for the 2 levels of expertise for each original classification system and for dichotomized versions of the N-C and the P-C based on suggested neoplastic potential. RESULTS: The interrater crude agreement and the corresponding kappa values for the ELS-C were good and significantly higher than those for the N-C and P-C for all raters, irrespective of the level of experience with CE (p < 0.0001). There were no significant differences between the N-C and the P-C (p = 0.16). Kappa was considerably improved for both the N-C and the P-C to a level not different from the ELS-C (p = 0.21-0.71) when their 5 original categories were pooled into dichotomized classifications. CONCLUSION: Difficulties in reliably classifying vascular changes in CE + NBI are evident. Two-tier classification systems are the most reliable.

Laryngeal Lesion Classification Based on Vascular Patterns in Contact Endoscopy and Narrow Band Imaging: Manual Versus Automatic Approach.

Longitudinal and perpendicular changes in the vocal fold's blood vessels are associated with the development of benign and malignant laryngeal lesions. The combination of Contact Endoscopy (CE) and Narrow Band Imaging (NBI) can provide intraoperative real-time visualization of the vascular changes in the laryngeal mucosa. However, the visual evaluation of vascular patterns in CE-NBI images is challenging and highly depends on the clinicians' experience. The current study aims to evaluate and compare the performance of a manual and an automatic approach for laryngeal lesion's classification based on vascular patterns in CE-NBI images. In the manual approach, six observers visually evaluated a series of CE+NBI images that belong to a patient and then classified the patient as benign or malignant. For the automatic classification, an algorithm based on characterizing the level of the vessel's disorder in combination with four supervised classifiers was used to classify CE-NBI images. The results showed that the manual approach's subjective evaluation could be reduced by using a computer-based approach. Moreover, the automatic approach showed the potential to work as an assistant system in case of disagreements among clinicians and to reduce the manual approach's misclassification issue.

[Surgery of the Larynx - Part 2b: Transcervical Surgical Therapy of Malignant Lesions]. / Chirurgie des Larynx ­ Teil 2b: Transzervikale chirurgische Therapie maligner Läsionen.

Transoral endoscopic laryngeal surgery (TEC) is typically used as a cervical tissue-sparing and function-preserving surgical procedure. Transoral robotic surgery (TORS) in particular has been pushing the boundaries towards transoral resection in recent years. Nevertheless, there are still limitations to this approach. Transcervical surgery is then the therapy of choice. It is used in case of insufficient visibility of the entire larynx and especially the tumor-bearing region, cartilage infiltration, a lack of mobility of both arytenoid cartilages or a lack of patient compliance. Even with the transcervical approach, from an oncological point of view, the procedure must be as radical as necessary on the one hand and as function-preserving as possible on the other. In case of a transcervical appraoch, however, additional requirements, side effects and consequences must be considered during planning, implementation and follow-up treatment. In addition to our previous publications, this article is intended to provide an overview of transcervical surgery for malignancies of the larynx.

[Cervical lymphadenitis caused by non-tuberculous mycobacteria in children with different residence]. / Zervikale Lymphadenitis durch atypische Mykobakterien bei Kindern mit unterschiedlichem Wohnsitz.

OBJECTIVE: Atypical mycobacteria form a heterogeneous group. Although more than 140 species have been identified, only 25 of them are considered responsible for infection in humans. The most frequent manifestation of the disease in immunocompetent children is the cervical lymphadenitis. Aims of this study were to identify a correlation of the location of residence with patients' demographics and disease characteristics, to evaluate the ultrasonographic findings and the different operative treatments modalities and to develop an algorithm for the diagnosis and treatment. MATERIALS AND METHODS: Cases were identified by using the hospital's correspondence, microbiology and pathology databases. Demographic and clinical data were collected. A statistical analysis of the results was performed. RESULTS: 32 patients were included. Our data revealed no significant correlation between area of residence and disease characteristics. Hypoechoic lymph nodes with intraglandular necrosis and low vascularity were observed in the majority of patients. Surgical treatment included abscess incision with biopsy, lymphadenectomy, selective neck dissection and partial parotidectomy. A recurrent disease was significantly more frequent after abscess incision. CONCLUSIONS: Further studies with prospective design are required, in order to confidently identify the correlation between area of residence and disease characteristics. Similar ultrasonographic findings suggest a constant constellation of changes that facilitate diagnostic evaluation. Complete surgical excision offers an effective management option as it combines definitive treatment and histological confirmation with low risk of complications.

Elevated Presepsin Is Associated With Perioperative Major Adverse Cardiovascular and Cerebrovascular Complications in Elevated-Risk Patients Undergoing Noncardiac Surgery: The Leukocytes and Cardiovascular Perioperative Events Study.

BACKGROUND: Perioperative major adverse cardiovascular and cerebrovascular events (MACCEs) are incompletely understood, and risk prediction is imprecise. Atherogenic leukocytes are crucial in cardiovascular events. However, it is unclear if surgical interventions affect leukocyte counts or activation status. Therefore, we investigated whether noncardiac surgery in patients with elevated cardiovascular risk is associated with changes in atherogenic leukocyte subsets and if these changes are related to perioperative MACCEs. METHODS: We enrolled 40 patients in this single-center prospective observational cohort study. Total leukocytes and subpopulations, including classical, intermediate, and nonclassical monocytes and natural killer and regulatory T cells, were quantified before surgery, at 2 and 6 hours after skin incision, and at postoperative days 1 and 2 (POD1+2). The monocyte activation marker presepsin (sCD14-ST) was measured post hoc to determine differentiation of classical to nonclassical monocytes. We evaluated presepsin for prediction of the composite primary end point MACCE (cardiovascular death, myocardial infarction, myocardial ischemia, and stroke) at 30 days. Its additive value to risk assessment based on high-sensitive cardiac troponin T and N-terminal probrain natriuretic peptide (NT-proBNP) was analyzed. RESULTS: We evaluated 38 patients, of whom 5 (13%) reached MACCE. In the entire cohort, classical monocytes continuously increased and peaked at POD1 (0.35 [0.23-0.43] cells per nanoliter blood [nL] vs 0.45 [0.31-0.66] cells·nL, preoperative [pre-OP] vs POD1, P = .002). Intermediate monocytes doubled by POD1 (0.017 [0.013-0.021] vs 0.036 [0.022-0.043] cells·nL, pre-OP versus POD1, P = .0003). Nonclassical monocytes decreased (0.022 [0.012-0.032] vs 0.012 [0.005-0.023] cells·nL, pre-OP vs 6 hours, P = .003). In our patient population, we did not detect changes in any of the other predefined leukocyte subsets investigated. In patients experiencing a MACCE, classical monocyte expansion was reduced (0.081 [-0.16 to 0.081] cells·nL vs 0.179 [0.081 to 0.292] cells·nL, MACCE versus non-MACCE, P = .016). Patients in the event group presented with elevated pre-OP presepsin (1528 [406-1897] pg·mL vs 123 [82.2-174] pg·mL, MACCE versus non-MACCE, P = .0001). Presepsin was associated with MACCE (area under the curve = 0.964, [0.846-0.998], P = .001). Presepsin above the calculated threshold >184 pg·mL was superior to high-sensitive cardiac troponin T for improvement of NT-proBNP-based risk prediction (28 [74%] vs 22 [58%] correctly classified patients, P = .014). CONCLUSIONS: Noncardiac surgery was associated with an increase in atherogenic leukocyte subsets. In a post hoc analysis, elevated pre-OP presepsin was associated with MACCE and improved NT-proBNP-based risk assessment. After validation in an independent data set, a presepsin cutoff of 184 pg·mL might qualify to complement NT-proBNP-based risk prediction, thereby increasing the proportion of correctly identified high-risk patients.

Flexible transnasal endoscopy with white light or narrow band imaging for the diagnosis of laryngeal malignancy: diagnostic value, observer variability and influence of previous laryngeal surgery.

PURPOSE: Flexible transnasal endoscopy is a common examination technique for the evaluation of laryngeal lesions, while the use of narrow band imaging (NBI) has been reported to enhance the diagnostic value of white light endoscopy (WLE). The purpose of this study is to assess observer variability and diagnostic value of both modalities and investigate the possible influence of previous laryngeal surgery on the detection rates of laryngeal malignancy. METHODS: The study was based on the retrospective evaluation of 170 WLE and NBI images of laryngeal lesions by three observers in a random order. The histopathological diagnoses serve as the gold standard. RESULTS: In identifying laryngeal malignancy, the sensitivity of NBI proved to be higher than that of WLE (93.3% vs. 77.0%). NBI was also superior to WLE in terms of accuracy (96.3% vs. 92%) and diagnostic odds ratio (501.83 vs. 120.65). Both modalities had a specificity of 97.3%. The inter-observer agreement was substantial (kappa = 0.661) for WLE and almost perfect (kappa = 0.849) for NBI. Both WLE and NBI showed a high level of intra-observer agreement. The sensitivity was significantly lower in images with history of previous laryngeal surgery compared to those without. CONCLUSIONS: Flexible transnasal endoscopy has been proved to be a valuable tool in the diagnosis of laryngeal malignancy. The use of NBI can increase the sensitivity and observer reliability in that context and can also provide a diagnostic gain in cases with previous laryngeal surgery.