Tracheostomy clinical practices and patient outcomes in three tertiary metropolitan hospitals in Australia.

BACKGROUND: There is a paucity of literature in Australia on patient-focused tracheostomy outcomes and process outcomes. Exploration of processes of care enables teams to identify and address existing barriers that may prevent earlier therapeutic interventions that could improve patient outcomes following critical care survival. OBJECTIVES: The objectives of this study were to examine and provide baseline data and associations between tracheostomy clinical practices and patient outcomes across three large metropolitan hospitals. METHODS: We performed a retrospective multisite observational study in three tertiary metropolitan Australian health services who are members of the Global Tracheostomy Collaborative. Deidentified data were entered into the Global Tracheostomy Collaborative database from Jan 2016 to Dec 2019. Descriptive statistics were used for the reported outcomes of length of stay, mortality, tracheostomy-related adverse events and complications, tracheostomy insertion, airway, mechanical ventilation, communication, swallowing, nutrition, length of cannulation, and decannulation. Pearson's correlation coefficient and one-way analyses of variance were performed to examine associations between variables. RESULTS: The total cohort was 380 patients. The in-hospital mortality of the study cohort was 13%. Overall median hospital length of stay was 46 days (interquartile range: 31-74). Length of cannulation was shorter in patients who did not experience any tracheostomy-related adverse events (p= 0.036) and who utilised nonverbal communication methods (p = 0.041). Few patients (8%) utilised verbal communication methods while mechanically ventilated, compared with 80% who utilised a one-way speaking valve while off the ventilator. Oral intake was commenced in 20% of patients prior to decannulation. Patient nutritional intake varied prior to and at the time of decannulation. Decannulation occurred in 83% of patients. CONCLUSIONS: This study provides baseline data for tracheostomy outcomes across three large metropolitan Australian hospitals. Most outcomes were comparable with previous international and local studies. Future research is warranted to explore the impact of earlier nonverbal communication and interventions targeting the reduction in tracheostomy-related adverse events.

A randomised clinical trial of single or extended dosing ciprofloxacin versus no intervention for prevention of ventilation tube otorrhoea and obstruction (PreVenTO2).

OBJECTIVES: To determine the effectiveness of ciprofloxacin .3% antibiotic eardrops in preventing clinically significant postoperative otorrhoea and tube obstruction following grommet insertion in children. DESIGN: Three-arm parallel assessor-blinded randomised controlled trial. Randomisation in 1: 1: 1 ratio to single intraoperative application of ciprofloxacin drops, extended 5 day postoperative application and no drops. Patients were assessed by blinded assessors at 6 weeks postoperatively. SETTING: The study was conducted in a large tertiary health network in Melbourne, Australia. PARTICIPANTS: All children, 17 years and under, undergoing bilateral middle ear ventilation tube surgery with or without concurrent upper airway surgery for recurrent acute otitis media and chronic otitis media with effusion were approached. MAIN OUTCOME MEASURES: Presence of postoperative otorrhoea and ventilation tube obstruction at 6 weeks postoperatively. RESULTS: Two-hundred and fifty-six paediatric patients completed the study with a median age of 4.02 years. One-hundred and fifty-three participants were male. Ear analysis (n = 512) showed intraoperative antibiotics were more effective than no drops in preventing otorrhoea (RR = .341, 95% CI .158-.738, NNT =11.25, p = .006). Postoperative antibiotics were more effective than no drops in preventing ventilation tube obstruction (RR = .424, 95% CI .193 to .930, NNT =14.7, p = .032). CONCLUSION: Intraoperative topical ciprofloxacin was effective at preventing early postoperative otorrhoea, and a prolonged course was effective at preventing ventilation tube obstruction. Future studies on this topic should seek to clarify whether particular subgroups of patients benefit more from prophylactic topical antibiotics and model for cost-effectiveness.

What is the optimal diagnostic pathway in tuberculous lymphadenitis in the face of increasing resistance: Cytology or histology?

BACKGROUND: The London Borough of Newham has the highest rates of tuberculosis (TB) within Europe (116 per 100,000). There is a lack of guidance in lymph node (LN) TB on how to best obtain a positive culture, which is the gold standard in the face of increasing mycobacterial resistance. METHODS: An individual cohort study was carried out via a prospective local TB database capturing 90 cases of cervical LN TB over 34 months. We compared the diagnostic efficacy of fine needle aspiration (FNA) and excision biopsy of LN. RESULTS: FNA cytology revealed granulomata in 49%, acid-fast bacilli (AFB) in 8.6% and a positive culture in 40%. LN excision showed granulomata in 97.6%, AFB in 17.1% and a positive culture in 70.1%. There was an 18% resistance to first-line antimicrobials. CONCLUSIONS: We describe our experience and suggest an algorithm for the culture of TB organisms to avoid a lengthy diagnostic process.

Discharge destination following elective and emergency surgical tracheostomies in head and neck cancer patients.

OBJECTIVES: Tracheostomy in the setting of head and neck cancer may be performed either electively for prophylactic airway protection in an ablative procedure, or as an emergency due to impending airway obstruction in the setting of an obstructing upper aerodigestive tract malignancy. Tracheostomy care has biopsychosocial implications, which may require a higher level of care from carers, post-acute care, or placement into care facilities. Existing database studies have largely excluded patients with a history of head and neck cancer. This study aims to examine and compare discharge destinations for head and neck cancer patients requiring either elective or emergency surgical tracheostomies. METHODS: Retrospective cohort study (January 2010-December 2019) of adult head and neck cancer patients undergoing surgical tracheostomy in a tertiary Australian hospital network. Primary outcome was discharge destination. Secondary outcomes were mortality, morbidity, and decannulation timing. RESULTS: Of 188 patients (47 emergency, 141 elective), 83.0 % returned to their pre-morbid accommodation, either directly home (54.6 %), or with additional community-based services (27.7 %). There was a significant difference in post-discharge destination (p = 0.012). Emergency patients were less likely to return home compared to elective patients (OR 0.76, 95 % CI 0.32-1.79), and more likely to require additional supports on discharge(67.6 %) compared to elective(41.9 %) patients. However, these outcomes did not demonstrate statistical significance. Emergency tracheostomy patients were at higher risk of permanent tracheostomy, unplanned readmission within 30 days, and longer time to successful decannulation. CONCLUSION: Emergency tracheostomy patients are likely to return to their pre-morbid place of residence but may require additional support.

Treatment outcomes of standard (high dose) cisplatin and non-standard chemotherapy for locally advanced head and neck cancer.

INTRODUCTION: Concurrent chemoradiotherapy with high-dose (HD) cisplatin is the standard treatment for locally advanced head and neck squamous cell carcinoma (LA-HNSCC). Due to the higher treatment-related adverse effects with standard therapy, alternative regimens (non-standard therapy), namely, lower dose weekly cisplatin, carboplatin/paclitaxel, or cetuximab are considered. There is, however, no consensus on non-standard regimens. We aimed to investigate the efficacy and safety profile of these regimens. METHODS: This single centre retrospective cohort study included all consecutive adult patients with newly diagnosed LA-HNSCC treated with either standard or non-standard regimens between January 2016 and April 2021. The primary outcome was 2-year failure-free survival (FFS). The secondary outcomes included acute toxicities, hospitalisation rates, dose modifications, treatment failure rates (TFR), and overall survival. RESULTS: About 235 patients were included in the final analysis; median age was 61 years (IQR 55-67), and 87% were male. Most had oropharyngeal tumours (85.5%) and p16-positivity was frequent (80%). About 56% received non-standard regimens: weekly cisplatin = 79 and non-cisplatin = 48. These patients had higher Charlson Comorbidity Index (CCI; p < .001) and lower European Cooperative Oncology Group (ECOG)-0 (p = .003). There was no difference in 2-year FFS (hazard ratio [HR] = 1.16; 95% confidence interval - [CI] 0.65-2.05), hospitalisation and grade-3 toxicity rates between the two regimens. Nausea and vomiting were lower in the non-standard regimen (3.0% vs. 16%, p < .001). Dose reductions, adjusted for age, sex, and CCI, were less likely in the non-standard regimen (OR = 2.36; 95%-CI: 1.01-5.49, p = .007). CONCLUSIONS: We demonstrated similar efficacy of lower dose weekly cisplatin and carboplatin/paclitaxel regimens and better safety profile of weekly cisplatin compared to standard HD cisplatin regimens for LA-HNSCC. Multicenter randomised control trials are required in HD cisplatin-ineligible patients.

Self-dilatation of benign oesophageal strictures: a literature review.

BACKGROUND: Benign oesophageal strictures can have several aetiologies and often require serial endoscopic dilatation. The aim of this study was to review the existing literature regarding the efficacy of self-dilatation for benign oesophageal strictures. METHODS: This study presents the results of a systematic review that was performed on the available literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text articles from Medline, PubMed and Embase were used, as well as associated reference lists. This study systematically reviews the literature to present the efficacy and different outcome measurements associated with self-dilatation of benign oesophageal strictures. RESULTS: This study identified 13 articles with 274 participants. CONCLUSION: Self-dilatation for refractory benign oesophageal strictures is effective regardless of aetiology. It is well tolerated, safe and leads to lasting symptom resolution in the majority of patients.

Predictors of postoperative complications in paediatric patients receiving grommets - A retrospective analysis.

BACKGROUND: Insertion of middle ear ventilation tubes (MEVT), tympanostomy tubes or grommets is one of the most common paediatric surgical procedures performed by ENT surgeons worldwide. Outcomes may be complicated by postoperative otorrhoea and ventilation tube blockage. OBJECTIVE: To identify risk factors associated with early postoperative complications of MEVT insertion. METHOD: In a case-control study, set in a tertiary hospital in Melbourne, Australia, 590 paediatric patients undergoing grommet insertion between February 2017 and February 2018, 311 patients (205 males & 106 females; median age of 3.86 years) met the inclusion criteria and had identical middle ear status bilaterally. INTERVENTION: Tympanostomy tube insertion and postoperative topical otic antibiotic drops. MAIN OUTCOME AND MEASURES: Patient age, gender, weight/BMI percentile, intraoperative middle ear status, number of previous grommets, type of surgery, season of surgery, diagnosis and time to first medical review were examined. The duration of topical otic antibiotic drops used and tube patency and presence of otorrhoea at 6-week postoperative review were also recorded. RESULTS: At the first medical review, 8.7% of patients (n = 27) developed otorrhoea from one or both ears, 6.4% of patients (n = 20) had an obstructed MEVT in one or both ears. Exposure to intraoperative [IO] and postoperative [PO] antibiotic drops were significantly less associated with developing postoperative otorrhoea compared to non-exposure (IO: Odds Ratio [OR] = 0.15, 95%CI 0.04 to 0.57, p = 0.005; PO: OR = 0.21, 95%CI 0.58 to 0.76, p = 0.017). There were no statistically significant associations between antibiotic drop exposure and grommet blockage (p > 0.05). There was a significant association between developing postoperative otorrhoea and patients receiving surgery during the colder months of Winter/Autumn (OR = 3.17, 95%CI 1.14 to 8.84, p = 0.028), as well as patients aged less than 3 years (OR = 2.66, 95%CI 1.01 to 7.03, p = 0.049). There was a statistically significant association between serous effusions and grommet blockage compared to no effusion (OR = 4.03, 95%CI 1.03 to 15.7, p = 0.045). There were no statistically significant associations identified between otorrhoea and gender, weight/BMI percentile, intraoperative middle ear status, number of previous grommets, type of surgery, diagnosis and time to first medical review. There were no statistically significant associations between grommet blockage and age, gender, indication for surgery, concurrent surgery, season or number of previous grommets. CONCLUSIONS: 8.7% of patients developed otorrhoea within 6 weeks post-operatively. Undergoing the procedure during winter/autumn, age <3 years were associated with developing otorrhoea. Topical antibiotic exposure was inversely associated with developing postoperative otorrhoea. 6.4% of patients had grommet blockage. Presence of serous middle ear effusion intraoperatively was a statistically significant indicator for developing grommet blockage.

Synchronous p16+ nasopharyngeal and oropharyngeal squamous cell carcinoma: a case report and review.

We report a case of synchronous p16+ SCC involving both the nasopharynx and base of tongue treated with definitive chemo-radiotherapy with concurrent high dose cisplatin. The nasopharyngeal lesion was detected incidentally on PET/CT imaging. Head and neck clinicians treating p16+ SCC should consider the possibility of synchronous lesions, including lesions which may be located in the lymphoid tissue of the nasopharynx.

The History of Myringotomy and Grommets.

The first recorded myringotomy was in 1649. Astley Cooper presented 2 papers to the Royal Society in 1801, based on his observations that myringotomy could improve hearing. Widespread inappropriate use of the procedure followed, with no benefit to patients; this led to it falling from favor for many decades. Hermann Schwartze reintroduced myringotomy later in the 19th century. It had been realized earlier that the tympanic membrane heals spontaneously, and much experimentation took place in attempting to keep the perforation open. The first described grommet was made of gold foil. Other materials were tried, including Politzer's attempts with rubber. Armstrong's vinyl tube effectively reintroduced grommets into current practice last century. There have been many eponymous variants, but the underlying principle of creating a perforation and maintaining it with a ventilation tube has remained unchanged. Recent studies have cast doubt over the long-term benefits of grommet insertion; is this the end of the third era?

Elective neck dissection in metastatic cutaneous squamous cell carcinoma to the parotid gland: A systematic review and meta-analysis.

Current management of metastatic cutaneous squamous cell carcinoma (CSCC) to the parotid is surgical excision and postoperative radiotherapy. In the node-negative neck, there is debate about the role of elective neck dissection (END), irradiation or observation. This systematic review assesses the prevalence of occult cervical disease and the evidence for END. A literature search was performed using Medline and Embase. All papers describing management of the neck in metastatic CSCC to the parotid were assessed for inclusion. Eighty-nine papers were identified and 17 met inclusion criteria. A total of 874 ENDs were performed in 874 patients with metastatic CSCC to the parotid with no clinically evident cervical disease. The overall prevalence of occult disease in a random effects model was 22.5% (95% confidence intervals 18.9-26.0). The prevalence of occult cervical disease in metastatic CSCC to the parotid is high. END is recommended in this patient group.

Setting the stage: Contemporary staging of non-melanomatous skin cancer and implementation of the new American Joint Committee on cancer eighth edition staging manual.

Non-melanomatous skin cancer (NMSC) generally refers to basal cell and squamous cell carcinoma of the skin. The majority of patients are curatively treated with simple excision. Only few present with locally advanced disease or have evidence of high-risk features, placing them at an elevated risk of relapse. In such cases, further investigations may guide the multidisciplinary management plan. There are no universally agreed on indications for recommending additional staging investigations, due to a lack of prospective data reporting their impact on patient outcomes. Some generally agreed upon indications are discussed in this review article. Most commonly, computed tomography (CT) and magnetic resonance imaging (MR) are used in cases of locally advanced NMSC for staging purposes and surgical planning. While Positron Emission Tomography (PET)/CT and sentinel lymph node biopsy have shown utility, data is lacking to establish their roles in the staging algorithm. An updated NMSC system was included in The American Joint Committee for Cancer eighth edition staging manual (AJCC8). Under AJCC8 the majority of patients with regional disease are upstaged by the presence of extranodal extension, however, this updated system appears to provide limited prognostic discrimination between the nodal categories and the overall TNM stages. This review article will explore the contemporary role of staging investigations, including evolving technologies, and review the changes implemented in AJCC8. It will also discuss the implications of the AJCC8 decision to assign patients with p16-positive cervical nodal SCC with an unknown primary to the oropharyngeal staging system, with particular relevance to clinicians working in areas of high NMSC incidence.

Safety and effectiveness of endovascular embolization or stent-graft reconstruction for treatment of acute carotid blowout syndrome in patients with head and neck cancer: Case series and systematic review of observational studies.

BACKGROUND: Indications for treatment and outcomes after endovascular management of carotid blowout syndrome for patients with head and neck cancer are not well defined. We investigated the safety and effectiveness of endovascular embolization and stent-graft reconstruction. METHODS: A literature review was performed for studies published between 2001 and 2015 with relevance to treatment outcomes. Our institutional database was examined to identify patients treated with endovascular techniques. RESULTS: A total of 266 patients were included. Rates of procedural stroke were higher after embolization of internal carotid artery (ICA)/common carotid artery (CCA) compared to stent graft (embolization 10.3%; stent graft 2.5%; P < .02). Stent graft of ICA/CCA was associated with higher rates of recurrent bleeding (embolization 9.1%; stent graft 31.9%; P < .01). CONCLUSION: Both embolization and stent grafts are safe therapeutic options for acute carotid blowout syndrome. Embolization for ICA/CCA carotid blowout syndrome was associated with higher risks of procedural stroke and lower recurrent bleeding compared to stent grafts.

Prophylactic dissection of level V in primary mucosal SCC in the clinically N positive neck: A systematic review.

OBJECTIVE: To review the evidence for level V dissection in the management of previously untreated mucosal squamous cell carcinoma (SCC) of the head and neck presenting with nodal metastasis when level V is clinically uninvolved. DATA SOURCE: The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) were used to conduct a systematic review of the current literature, including all English language articles published after 1990. A literature search was performed on November 29, 2015, of Medline, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library. REVIEW METHODS: The search yielded a total of 270 papers. Strict inclusion and exclusion criteria were applied, leaving 20 eligible papers. Overall prevalence was calculated using random effect meta-analysis. RESULTS: The overall prevalence of level V occult disease in the node (N)-positive neck, irrespective of subsite, was 2.56% (95% confidence interval 1.29-3.84) (2,368 patients and 2,533 necks). The prevalence of occult level V metastasis was up to 7.7% for oral cavity and 8.3% for oropharyngeal tumors. Five studies reported regional recurrence rates over variable time periods. There is exceedingly limited data on outcomes, such as spinal accessory nerve function, quality of life, and perioperative complications. CONCLUSION: Mucosal head and neck SCC presenting with nodal metastasis but with level V clinically uninvolved has a low prevalence of occult level V disease. Routine dissection of level V does not appear to be warranted; however, a definitive conclusion is unable to be drawn due to limited data on morbidity and oncological outcomes. Laryngoscope, 127:2074-2080, 2017.

WITHDRAWN: Association of Surgeons in Training Conference - Sheffield 2011.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, doi:10.1016/j.ijsu.2011.09.003. The duplicate article has therefore been withdrawn.