Long-term results using LigaSure™ 5 mm instrument for treatment of Zenker's diverticulum.

The purpose of the present study was to evaluate the long-term results and patient's satisfaction of a new approach using the LigaSure™ 5 mm instrument for treatment of Zenker's diverticulum (ZD) and to compare with other long-term results using traditional treatment modalities. Between December 2011 and August 2013, a total of 23 patients with ZD underwent endoscopic surgery using the LigaSure™ technique in our department. A retrospective evaluation of the surgery was based on medical records and additionally a long-term follow-up was performed using a standardized questionnaire that was send to all patients. The questions dealt with complaints according to a visual analog scale (VAS) and were sent a minimum of one year after the surgery (mean time 22 months, range 12-32 month). The overall response rate was 91%. The mean age of the patients was 69 years (range 37-89 years). The patients reported nine for overall satisfaction on the VAS (range 0-10: 10 being very content and 0 very uncontent, 25 and 75% quartiles: 7 and 10) regarding the final outcome of their surgery, although several of the patients had continuous symptoms within the first postoperative year. Eight patients (38%) reported no symptoms at all. Our results suggest that endoscopic management of ZD with the LigaSure™ 5 mm instrument is a minimally invasive, fast and safe method with solid long-term outcome with relief of symptoms and patient satisfaction. This new operative instrument was not found inferior to traditional endoscopic techniques and is now the standard treatment method for ZD in our departments.

Primary transoral robotic surgery with concurrent neck dissection for early stage oropharyngeal squamous cell carcinoma implemented at a Danish head and neck cancer center: a phase II trial on feasibility and tumour margin status.

There is an increasing incidence of oropharyngeal squamous cell carcinoma (OPSCC) in the western world due to human papillomavirus (HPV). According to the Danish Head and Neck Cancer Group guidelines, the current recommended treatment of patients with OPSCC in Denmark is primary radiation therapy (RT) with or without concomitant chemotherapy. This is the first study in Scandinavia from a head and neck cancer centre that aims to demonstrate the feasibility of performing primary transoral robotic surgery (TORS) and concurrent neck dissection for patients with early stage OPSCC. Between September 2014 and January 2016, 30 consecutive patients with clinical T1-T2, N0-N1 OPSCC underwent primary TORS and concurrent neck dissection. The patients were offered postoperative adjuvant therapy according to pathological risk parameters: pT >2, T-site margin <2 mm, pN >1 or extracapsular extension (ECE). Concomitant chemotherapy was offered to patients with the presence of ECE or involved margins. Twenty-nine patients had negative margins on T-site after primary resection. Only one patient had a close margin of 1 mm. Unilateral neck dissection was performed in 21 patients while nine patients underwent bilateral neck dissection. Due to an upstaging following surgery, 13 patients were referred to adjuvant therapy. Four of these patients received RT and two patients received concomitant chemo-radiation (CCR) therapy. Seven patients declined the recommended adjuvant therapy one of whom later developed an N-site recurrence and received salvage surgery with postoperative RT. In summary, 43% of the patients were referred to adjuvant therapy following primary surgery which was mainly due to N-site stage migration and ECE. Primary TORS and concurrent neck dissection is a safe and feasible procedure that may be an alternative to primary RT and CCR in a selected group of patients with early stage OPSCC.

Transoral robotic surgery for the management of head and neck squamous cell carcinoma of unknown primary.

CONCLUSION: The addition of transoral robotic surgery (TORS) in the diagnostic management of patients classified with head and neck squamous cell carcinoma of unknown primary (SCCUP) is promising and appears to improve detection rates of the primary tumour. The approach presented in this first Scandinavian study could potentially minimize the radiation field to the pharyngeal axis in patients with identified primary tumours. OBJECTIVES: The aim of the study was to investigate whether bilateral lingual tonsillectomy performed with TORS is feasible, and whether it could improve the detection rates of primary tumours in patients diagnosed and classified as having SCCUP. METHODS: The study was retrospective and included 13 patients with SCCUP who were referred to TORS between October 2013 and January 2015. All 13 patients had previously undergone a full investigation programme following the national guidelines including whole-body PET/CT, examination in general anaesthesia, including random biopsies of the base of the tongue and bilateral palatine tonsillectomy without identification of the primary tumour. RESULTS: The primary tumour was identified by TORS in seven of the 13 patients (54%) at the lingual tonsils. Human papillomavirus DNA and p16 were positive in all identified primary tumour specimens and in the corresponding lymph node metastases.

Tetracycline and macrolide co-resistance in Streptococcus pyogenes: co-selection as a reason for increase in macrolide-resistant S. pyogenes?

In Denmark, tetracycline resistance in Streptococcus pyogenes is frequent (>30%) whereas macrolide resistance is low (<5%). The aim of this study was to investigate the genetic background of tetracycline- and macrolide resistance in macrolide-resistant S. pyogenes (MRSP) and to investigate the correlation between the use of macrolide and tetracycline and macrolide resistance using international data. A total of 133 MRSP isolates were received at Statens Serum Institut from nine Danish clinical microbiology laboratories between. November 2000, and November 2002. The macrolide-resistance genes, erm(B), erm(A), and mef(A) were detected in 46%, 18%, and 32% of the tested MRSP isolates, respectively. In 4% of MRSP isolates, none of the MR genes were detected. Tetracycline resistance was found in 52% of MRSP. Tetracycline resistance was encoded by either tet(M) or tet(O). erm(B) and mef(A) were associated with tet(M). Sixteen different T types were detected among the 133 MRSP. Analysis of the importance of antibiotic use for development of macrolide resistance in S. pyogenes showed no correlation with macrolide use alone (p = 0.15) but a significant correlation (p = 0.03) for the combination of macrolide and tetracycline use. The frequency of macrolide resistance in Danish S. pyogenes was low and mainly due to erm genes. A high frequency of macrolide-tetracycline coresistance in S. pyogenes is found in many countries including Denmark, hence tetracycline use must be considered as a co-factor in selection of MRSP.

Nasopharyngeal pathogens in children with acute otitis media in a low-antibiotic use country.

OBJECTIVE: Acute otitis media (AOM) is one of the most common diseases of childhood. Knowledge, of which bacteria are the most common pathogens in AOM and their susceptibilities towards antibiotics, is essential for the reasonable empiric treatment. With rapidly increasing frequencies of antibiotic resistance surveillance of the common etiologic pathogens has become pertinent. The purpose of this paper is to present the bacteriological findings and antibiotic susceptibilities, in cultures from nasopharyngeal swabs, in Danish children with AOM. METHODS: Children aged up to 10 years who had AOM diagnosed in general practice in Denmark were swabbed in nasopharynx, cultures were incubated and susceptibility testing was performed as tablet diffusion and minimal inhibitory concentrations (MICs) were determined by E-test. RESULTS: We included 331 patients, in 257 bacteria were found, which could be classified as commonly ear pathogenic. The most frequent bacteria found was Streptococcus pneumoniae followed by Haemophilus influenzae and Moraxella catarrhalis. Ninety-six percent of the tested S. pneumoniae were susceptible towards penicillin and 99% towards erythromycin. Eighty-nine percent of the H. influenzae were susceptible to ampicillin and all tested M. catarrhalis were susceptible towards erythromycin. In more than 30% of H. influenzae MIC of phenoxymethylpenicillin were above the level that could be achieved in middle ear fluid. CONCLUSION: Antimicrobial resistance is still infrequent in pathogens that might cause AOM in children in Denmark; this is probably due to minimal use of antibiotics as well as the use of phenoxymethylpenicillin as primary drug for treatment of AOM. Phenoxymethylpenicillin and azithromycin are not efficient for treating the majority of infections due to H. influenzae.

New technique using LigaSure for endoscopic mucomyotomy of Zenker's diverticulum: diverticulotomy made easier.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to present a new approach for treatment of Zenker's diverticulum using the LigaSure (Covidien, Mansfield, MA) technique. STUDY DESIGN: A consecutive study with follow-up of 15 patients with Zenker's diverticulum endoscopically treated using the LigaSure. METHODS: All patients underwent an endoscopic division of the bridge between the esophagus and the diverticulum through a rigid diverticuloscope using the LigaSure. Variables such as demographics, symptoms, surgical details, complications, and outcome were collected during admission, and all patients were followed up 5 to 14 months after discharge. RESULTS: The median age of patients was 76 years. The diverticula measured between 2 and 7 cm. The median time of surgery was 33 minutes. All patients but one resumed oral intake within 24 hours. One patient experienced prolonged coughing and vomiting immediately postoperatively and was hours later diagnosed with a perforation. The patient was successfully treated with antibiotics. At follow-up this patient was on a normal diet. At follow-up after 2 to 8 weeks, all patients were relieved of their preoperative symptoms. At follow-up after 5 to 14 months, all but three had relief of all symptoms. Two patients had relapse of the diverticulum and one had relapse of a stricture known from before the diverticulotomy. CONCLUSIONS: Our results show that treating Zenker's diverticulum using the LigaSure instrument safely improves the patients condition. As a new operative instrument, the LigaSure technique constitutes in our opinion a valid and easy alternative for treatment of Zenker's diverticulum compared to other endoscopic techniques.

[A Christmas straw goat astray]. / Julebuk på afveje.

A 22-year-old otherwise healthy man presented to our clinic with suspected acute epiglottitis. The patient had a 1-week history of pain in the throat and fever for the latest 24 hours. During the physical examination, the patient mentioned that he had been eating a Christmas straw goat at a party one week previously. Direct fiberoptic laryngoscopy showed a red and swollen lingual surface of the epiglottis, but no foreign bodies were identified. After inhalation of adrenalin, a 4 cm straw became visible in the epiglottic vallecula. Mimic of acute epiglottitis from a straw in the vallecula has to our knowledge never been described in the literature.

Necrotizing fasciitis in the head and neck region: an analysis of standard treatment effectiveness.

A standard treatment procedure for necrotizing fasciitis in the head and neck region was introduced in 1999 at Rigshospitalet (National Hospital of Denmark) Copenhagen. The new procedure introduced more drastic surgical debridement than before, combined with a set antibiotic regime and intravenous gamma globulin and adjunctive hyperbaric oxygen treatment (HBO). To evaluate the effect of this, a retrospective study was undertaken, involving 19 patients treated for NF at the ENT department from 1996-2004. Between 1996 and 1999 eight patients were treated (non-HBO) from 1999-2004 eleven patients were treated (HBO group). Length of antibiotic treatment was very similar in the two groups (mean 22.5 days) as was bacteriology. Aetiological focus differed marginally with the HBO group showing a clear tendency towards odontogen focus. The HBO group was found to undergo significantly more debridement procedures (3.36). The most drastic difference in the two groups however, was the reduction in mortality. The non-HBO group had a mortality of 75% and in the HBO group they all survived. This obviously resulted in a prolonged hospital stay for the HBO group (mean 30.8 days). The study concluded that the reduction in mortality was due to the combined effects of the different entities in the new treatment guidelines. It was not possible to isolate a specific factor responsible for the change.

Beta-hemolytic streptococcal bacteremia: a review of 241 cases.

Bacteremia with beta-hemolytic Streptococci groups A, B, C and G has a mortality rate of approximately 20%. In this study we analyzed the association of various patient risk factors with mortality. Records from 241 patients with beta-hemolytic streptococcal bacteremia were reviewed with particular attention to which predisposing factors were predictors of death. A logistic regression model found age, burns, immunosuppressive treatment and iatrogenic procedures prior to the infection to be significant predictors of death, with odds ratios of 1.7 (per decade), 19.7, 3.6 and 6.8, respectively. In bacteremic patients with erysipelas, mortality increased from 8% to 50% when bullae were observed. No HIV-positive patients or IVDUs died as a result of their bacteremic episode. Surprisingly, we found 49% resistance to tetracycline.

Emergence of invasive serotype VIII group B streptococcal infections in Denmark.

Serotype VIII group B streptococcus has only rarely been described outside Japan. The Streptococcus Unit, Statens Serum Institut, performed national surveillance of invasive group B streptococcal (GBS) diseases in Denmark in 1999 to 2002 and identified seven clinical GBS isolates of serotype VIII in blood from seven patients admitted to different hospitals.