The Beneficial Role of Endotracheal Lidocaine in Mitigating Hemodynamic Responses During Elective Surgical Tracheostomy in Head and Neck Cancer Patients.

BACKGROUND: The effectiveness of endotracheal lidocaine administration to reduce sympathetic stimulus after tracheostomy is still uncertain. PURPOSE: This study aimed to compare the hemodynamic responses of patients undergoing tracheostomy with and without pre-tracheostomy administration of endotracheal lidocaine. STUDY DESIGN, SETTING AND SAMPLE: A prospective cohort study was conducted at a tertiary care cancer center in the United Kingdom. Patients who underwent tracheostomy as part of their head and neck cancer surgery were included. Exclusion criteria comprised tracheostomies involving special requirements and subjects with documented cardiac history or taking specific medications. PREDICTOR VARIABLE: The predictor variable was pre-tracheostomy anesthetic management defined as the administration of endotracheal 4 ml 4% lidocaine before tracheostomy coded as lidocaine used or not used. OUTCOME VARIABLE: The primary outcome measures in this study were the observed hemodynamic responses after tracheostomy, including heart rate, systolic blood pressure, and diastolic blood pressure. The secondary outcome measure in the two groups was the time it took for subjects to return to their pre-tracheostomy baseline hemodynamic parameters, measured in minutes. ANALYSES: Data analyses included χ2, t-test, analysis of variance, and multivariable regression models. P values < .05 were considered statistically significant. COVARIATES: The patients' age, sex, body mass index, smoking status, tracheostomy tube size, and tumor stage were evaluated. RESULTS: The sample included 50 consecutive patients, the majority of whom were male (55%) with a mean age of 62 years (standard deviation[SD] 12) and a mean body mass index of 28 (SD 4). Most patients had stage III or IV oral cancers (59%). Following surgical tracheostomy, the group that received endotracheal lidocaine demonstrated significantly less hemodynamic variability when compared with the control group. The case group exhibiting lower systolic blood pressure (117 [SD 10] vs 136 [SD 18]), diastolic blood pressure (62 [SD 4] vs 68 [SD 4]), and heart rate (72 [SD 4] vs 78 [SD 4]), with statistical significance (P < .05). However, there was no significant difference in the time taken for the two groups to return to their pre-tracheostomy baseline hemodynamic parameters. CONCLUSIONS AND RELEVANCE: This study demonstrates an association between the preadministration of 4% endotracheal lidocaine with an observed attenuation in hemodynamic response following surgical tracheostomy in head and neck cancer patients.

Bio-Degradable Stents: Primary Experience in a Tertiary Hepatopancreaticobiliary Center in the United Kingdom.

BACKGROUND: Management of benign biliary strictures (BBS) post bilioenteric anastomoses requires a multidisciplinary approach including surgical, radiological, and/or endoscopic input. Patients often need multiple hospital visits for treatment with the long-term possibility of restenosis. Conventionally BBS have been treated with serial percutaneous transhepatic biliary dilatations necessitating repeat procedures for drain exchange or removal. Surgery may become necessary in refractory strictures. In the last decade, there have been increasing reports of the use of biodegradable stents (BDS) in treating biliary strictures mainly to address the need for repeated procedures for drain exchange. AIM:  This study aimed to report the early outcomes in patients with BBS treated with BDS. METHODS: Retrospective analysis of prospectively collected data was performed in patients who had a bilioenteric anastomosis presenting with an anastomotic stricture and were intended to be treated with BDS. The primary endpoints reported were technical success (defined as a successful resolution of stricture on repeat cholangiogram) and clinical success (defined as the absence of repeated cholangitis). Clavien-Dindo (CD) grade of complication was reported. RESULTS: Twelve patients presented with BBS and nine patients had BDS. Three patients were not considered suitable for BDS due to a non-traversable stricture and had surgery. The male-female ratio was 1:2. There was 100% technical and clinical success with one patient having stent migration not needing intervention. The procedure took an average of 45 min. In seven (77.7%) patients, it was safely performed under local anesthesia with sedation. Two patients preferred general anesthesia. There was no restenosis noted at a median follow-up of 11 months. CONCLUSION: The use of BDS in the treatment of BBS is a safe and effective procedure. Longer-term follow-up with multi-institutional reporting on a national database is needed to assess its long-term benefits.

Role of real-time colour-flow Doppler in perforator free flap head and neck reconstruction.

We discuss the use of real-time colour-flow Doppler ultrasound to optimally evaluate the vascular anatomy of patients receiving free perforator flap head and neck reconstruction. We explore the advantages of the technique and its role as a valuable adjunct for the planning and harvesting of perforator flaps.

Iatrogenic chylous collection post laparoscopic nephrectomy.

With the increasing number of laparoscopic nephrectomies, trauma to lymphatic channels has become an increasingly recognised complication. Early diagnosis and prompt management are key to avoid highly morbid sequelae including severe malnutrition and immunodeficiency. This case reviews the important complication of a retroperitoneal chylous collection following laparoscopic radical nephrectomy.

Head and neck ablative and microvascular reconstructive surgery in the UK: current operating team composition.

We sought to explore the current landscape of team composition in the provision of major head and neck ablative and reconstructive surgery in the UK. We conducted a survey of maxillofacial surgery units and compiled data on the operating model adopted at each institution. Our survey confirmed 54 active maxillofacial units undertaking microvascular free flap reconstructive surgery, with 44 (82%) hospitals adopting a two-team operative approach. We found no significant association between hospital type and volume of free flaps undertaken and prevailing operating team model. Our study provides an interesting snapshot of the current head and neck microvascular reconstructive practice in the UK.

Analysis of facial morphology of UK and US general election candidates: Does the 'power face' exist?

AIMS: To determine the frequency of recognised morphologic facial phenotypes among the UK and US election candidates and to assess whether there is a relationship between facial morphology and success in general elections. METHODS: Facial morphology analysis of prime ministerial and presidential candidates in the UK and US elections was performed. Direct facial measurements were made from frontal images and facial morphological indices calculated for all candidates. Anthropometric facial phenotype was determined and comparisons made between the elected leaders and unelected runner-up candidates. Paired candidates who had different facial types were analysed as a subgroup, with the probabilities of electoral success calculated. RESULTS: Data were available for 45 subjects: 22 election winners and 23 unelected runner-ups. Our data showed some variation in facial morphology between the groups. The predominant facial phenotype in both groups was leptoprosopic (long and/or narrow face), accounting for 40% (n = 18). Mesoprosopic (average dimension) and euryprosopic (short and/or broad) facial type represented 31% (n = 14) and 18% (n = 8), respectively. A majority of the sample (n = 36) demonstrated a malar width to mandibular angle width ratio consistent with the modern 'power face' proportion. Subgroup analysis showed a significant association with success in an election when leptoprosopic candidates were paired against candidates of another facial phenotype (p < 0.05). CONCLUSION: Leptoprosopic (long and/or narrow) facial phenotype with a wide mandibular angle width is predominant in the UK and US election candidates. Moreover, this facial phenotype appears to be associated with greater electoral success, supporting the concept of a modern political 'power face'.

Primary signet-ring cell adenocarcinoma of the head and neck: a case study and brief review.

We present a patient who had an aggressive primary signet-ring cell adenocarcinoma in the oral cavity that spread rapidly and led to his death. Most reports describe an indolent clinical course, but further reports are needed to better evaluate the particular clinical characteristics and course of this uncommon and biologically variable condition.

Head and neck cancer surgery provision in England: A current analysis of contributing specialties caseloads.

To ascertain the current provision for surgery for head and neck cancer in England with respect to the operative caseloads of oral and maxillofacial, ear nose and throat (ENT) and plastic surgeons, we analysed data from the 2013 report of the National Head and Neck Audit (DAHNO). Clinicians were grouped by specialty of affiliation and assigned surgical caseloads were compared. There was a wide disparity in the extent of surgical activity between the specialties (p<0.001), and the percentage of those active in head and neck oncology within each specialty similarly varied (p<0.001).

Assault-related facial injuries during the season of goodwill.

OBJECTIVE: The aim of this study was to assess if the "season of goodwill," over the 12 days of Christmas, manifests in a reduction in the rate of maxillofacial injuries secondary to interpersonal violence. STUDY DESIGN: We performed a retrospective analysis at a teaching hospital in the United Kingdom. We identified consecutive patients presenting at our institution with facial injuries secondary to assault during the Christmas season, together with corresponding Easter time and control periods. Data for 4 consecutive years starting from 2010 were collected. We compared the rates of presentation of facial injuries over the Christmas season with those occurring during Easter and control periods. Our outcome measures included frequency distributions of facial injuries secondary to assault as well as maxillofacial injury patterns. RESULTS: For the study, 440 patients met the inclusion criteria, with 194 presentations occurring during the Christmas season, 132 presentations over Easter, and 114 over the control period (P = .006). There was a statistically significant difference in the mean rates of presentation between the Christmas and Easter seasons (P = .03) and also between the Christmas and control periods (P = .02). We noted an increasing annual trend during the study period in the frequency of assault-related facial injuries during Christmas. CONCLUSIONS: Our data suggest that the rate of assault-related facial trauma during Christmas is significantly greater compared with that for both the Easter holiday period and the baseline presentation rate. The "season of goodwill," therefore, does not appear to manifest in a reduction in the rate of assault-related facial injuries. This increased trauma workload requires strategic planning to ensure adequate clinical cover for these anticipated busy periods.

Does a patient's Mallampati score predict outcome after maxillomandibular advancement for obstructive sleep apnoea?

The Mallampati airway classification has been used to estimate the success of uvulopalatopharyngoplasty in patients with obstructive sleep apnoea (OSA) but its predictive value in maxillomandibular advancement has not been proved. We aimed to explore the association between preoperative Mallampati scores and surgical outcome after bimaxillary advancement for OSA. We retrospectively analysed data on 50 patients who had maxillofacial operations for OSA at our hospital and stratified them into two groups based on Mallampati scores: high (class III/IV) and low (class I/II). We compared pre- and postoperative apnoea/hypopnoea indices (AHIs), Epworth sleepiness scores, and lowest recorded oxygen saturation in both groups. The postoperative values for all three outcome measures were not significantly different when patients were stratified according to the Mallampati classification (mean (SD) AHI was 41(19) before and 7 (6) after operation in the low group, and 42 (15) before and 9 (7) after in the high group). Success rates (AHI less than 15 postoperatively) were similar in both low and high score groups (p>0.05). Maxillomandibular advancement alleviates obstruction at multiple levels and our study has shown comparable surgical outcomes in both groups. The Mallampati score can be used to optimise patient selection for surgeons considering single-level procedures for OSA. Our study suggests that the Mallampati classification is less useful for the prediction of surgical outcome after maxillomandibular advancement surgery.

Effects of maxillomandibular advancement on systemic blood pressure in patients with obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) is associated with resistant hypertension. We investigated to what extent maxillomandibular advancement affected a patient's blood pressure postoperatively. We retrospectively analysed consecutive patients who had Bimaxillary advancement for OSA at our hospital following referral from the local sleep clinic. We collected relevant data on clinical characteristics and explored the changes in systolic and diastolic blood pressures, as well as mean arterial pressure (MAP) preoperatively, with those taken 6 months following surgery. We identified 51 patients with a mean (SD) age of 44 (8) years and a mean (SD) body mass index of 29 (3.4). Preoperative and postoperative data on blood pressure were available for analysis in 45. The mean (SD) systolic blood pressure was significantly reduced in our sample following surgery (from 131(12.6) to 127 (12.5)mmHg, p<0.001). The mean (SD) reduction in postoperative MAP values in the overall group, approached statistical significance (recorded MAP 96.6(10) to 93.1(8)mmHg, p=0.06). In a subgroup of 10 patients who had established hypertension the reduction in values postoperatively (mean reduction: systolic blood pressure 6 mmHg, diastolic blood pressure 10 mmHg, mean arterial pressure 9 mmHg) was greater than that observed in the overall group. Our results have shown an improvement in systemic blood pressure after maxillomandibular advancement for OSA, particularly in those with established hypertension. The data suggest that in addition to being a highly effective treatment for OSA, this surgery may more effectively lower systemic blood pressure than other treatment modalities.

Innovative use of anterior subapical setback combined with bilateral sagittal split osteotomy in patients with obstructive sleep apnoea.

We describe the use of anterior mandibular subapical setback osteotomy combined with bilateral sagittal split osteotomy in the treatment of selected patients with obstructive sleep apnoea (OSA). The technique enables maximal mandibular advancement, it alleviates pharyngeal narrowing, and minimises the alteration to the mid facial profile that is associated with traditional maxillomandibular advancement.

How often does the operating list follow the planned order? An analysis of elective maxillofacial operating lists.

OBJECTIVES: The authors explored consistency of the observed running order in operating sequence compared with prior scheduled listing. We analysed potential variables felt to be predictive in the chances of a patient having their procedure as previously scheduled. METHODS: Data were retrospectively collected for a consecutive group of patients who underwent elective maxillofacial procedures over a four week period. The consistency of scheduled and observed running order was documented. We considered four independent variables (original list position, day of week, morning or afternoon list, seniority of surgeon) and analysed their relationship to the probability of a patient undergoing their operation as per listing. Logistic regression analysis was used to determine significant associations between predictor variables with an altered list order. RESULTS: Data were available for 35 lists (n = 133). 49% of lists were found to run according to prior given order, the remainder subject to some alteration. Logistic regression analysis showed a statistically significant association between original scheduled position and day of week, with list position consistency. Patients listed first were twelve times more likely to have their operation as listed compared to those placed fourth (OR 12.7, 95% CI 3.7-43, p < 0.05). Operating lists at the start of a week were subject to less alteration (p < 0.05). There was no demonstrated relationship between the grade of surgeon operating and alteration in operating sequence. CONCLUSION: Approximately half of lists showed some alteration to the previously printed order. It appears that being first on an elective list offers the greatest guarantee that a patient will have their operation as per prior schedule. It may be reasonable for clinicians to be mindful of potential operating list alterations when preparing their patients for elective surgery.

Effect of preoperative continuous positive airway pressure duration on outcomes after maxillofacial surgery for obstructive sleep apnoea.

Continuous positive airway pressure (CPAP) remains the first-line treatment for obstructive sleep apnoea (OSA), and is known to result in various physiological changes. The objective of this study was to evaluate the association between duration of preoperative CPAP therapy and outcome after maxillomandibular advancement (MMA) for OSA. We retrospectively analysed consecutive patients treated at our institution, and divided them into 2 groups based on duration of treatment with CPAP: short-term (up to 12 months) and long-term use (12 months or more). We controlled for baseline demographic and clinical characteristics. We compared postoperative scores for the apnoea/hypopnoea index (AHI) and the Epworth sleepiness scale (ESS), and lowest recorded oxygen saturation between groups. In 43 patients data were available on the preoperative use of CPAP, and in 37 of them preoperative and postoperative polysomnographic data were also available for inclusion. Most had bimaxillary advancement with genioplasty. Differences between the groups in mean reduction in the AHI and lowest oxygen saturation were not significant, and operative success rates were comparable. After operation, the reduction in ESS scores was significantly greater in the long-term group than in the short-term group (mean (SD) 8(3) compared with 2 (2), respectively, p<0.001). Our results suggest that the duration of use of CPAP preoperatively does not significantly influence objective outcome measures. The reduction in AHI scores after MMA was equivalent in both groups. The long-term group seemed to fare better than the short-term group on subjective outcome measures.

Subjective assessment of facial aesthetics after maxillofacial orthognathic surgery for obstructive sleep apnoea.

We aimed to evaluate the subjective perception of facial appearance by patients after maxillofacial surgery for obstructive sleep apnoea (OSA), and explored the possible correlation between satisfaction and surgical outcome. A total of 26 patients, 24 men and 2 women (mean (SD) age 45 (7) years), subjectively assessed their facial appearance before and after operation using a visual analogue scale (VAS). To investigate a possible association between postoperative facial appearance and surgical outcome, we analysed postoperative scores for the apnoea/hypopnoea index (AHI) and Epworth sleepiness scale (ESS). Postoperatively, 14 (54%) indicated that their facial appearance had improved, 4 (15%) recorded a neutral score, and 8 (31%) a lower score. The rating of facial appearance did not correlate with changes in the AHI or ESS following surgery. This study supports the view that most patients are satisfied with their appearance after maxillofacial orthognathic surgery for OSA. The subjective perception of facial aesthetics was independent of the surgical outcome.