Transoral endoscopic vestibular approach Sistrunk procedure (TEVAS)-case report and scoping review.

Background: Thyroglossal duct cyst (TGDC) is the most common congenital neck mass among the pediatric population. Less than 10% of the cases occur in adults. The standard of care for TGDC is surgical treatment with the Sistrunk procedure via a traditional transverse cervicotomy. This technique involves the resection of the cyst with its tract and the central portion of the hyoid bone body to avoid recurrence. The transoral vestibular approach has gained popularity as an alternative approach to open neck surgery in order to eliminate the transcervical scar associated with these procedures. Methods: We describe a case of an endoscopic Sistrunk procedure performed by the transoral vestibular approach. A scoping review of the transoral endoscopic vestibular approach Sistrunk procedure (TEVAS) was performed. The PubMed, Medline, Cochrane, Lilacs, Scielo, Mary Ann Libert and Scopus databases were systematically searched by using a Medical Subject Heading (MeSH)-optimized search strategy. The selection of papers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines after setting inclusion and exclusion criteria. Results: The case was successful and without complications. Five studies were included in the final analysis for this review. Conclusions: This novel approach to the Sistrunk procedure is an effective alternative way to treat TGDC in selected patients who are motivated to avoid a visible neck scar.

Transoral thyroid and parathyroid surgery in Brazil: where are we?

INTRODUCTION: thyroid surgery through the transoral vestibular approach is a reality in many countries. While several competing remote access techniques have been developed in the last 20 years, many were not reproducible. Transoral Endoscopic Neck Surgery (TNS) has been shown to be reproducible in different centers around the world, and approximately five years after its description it has been adopted relatively quickly for various reasons. To date, there are at least 7 Brazilian studies published, including a series of more than 400 cases. The aim of this work is to study the progression of Transoral Neck Surgery in Brazil and describe the profile of surgeons involved in this new approach. METHODS: this is a retrospective study with descriptive statistics. A REDCap based survey about transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach (TOETVA/TOEPVA) was done with 66 Brazilian surgeons regarding surgeon profile, numbers of cases performed by geographic region, what kind of training was necessary prior to the first case and behavior of the surgeon proposing these new approaches. RESULTS: response rate of this survey was 53%. To date, 1275 TOETVA/TOEPVA cases had been performed in Brazil, 1229 thyroidectomies (96.4%), 42 parathyroidectomies (3.3%) and 4 combined procedures (0.3%). Most of the cases were done in the southeast region (821, 64.4%), 538 (42.2%) cases in the State of São Paulo and 283 (22.2%) cases in the State of Rio de Janeiro. CONCLUSIONS: TOETVA is becoming popular in Brazil. Younger surgeons, especially those between 30 and 50 years old were more likely to adopt this approach.

Transoral thyroid and parathyroid surgery in Brazil: where are we? / Cirurgia transoral de tireóide e paratireóide no Brasil: onde estamos?

ABSTRACT Introduction: thyroid surgery through the transoral vestibular approach is a reality in many countries. While several competing remote access techniques have been developed in the last 20 years, many were not reproducible. Transoral Endoscopic Neck Surgery (TNS) has been shown to be reproducible in different centers around the world, and approximately five years after its description it has been adopted relatively quickly for various reasons. To date, there are at least 7 Brazilian studies published, including a series of more than 400 cases. The aim of this work is to study the progression of Transoral Neck Surgery in Brazil and describe the profile of surgeons involved in this new approach. Methods: this is a retrospective study with descriptive statistics. A REDCap based survey about transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach (TOETVA/TOEPVA) was done with 66 Brazilian surgeons regarding surgeon profile, numbers of cases performed by geographic region, what kind of training was necessary prior to the first case and behavior of the surgeon proposing these new approaches. Results: response rate of this survey was 53%. To date, 1275 TOETVA/TOEPVA cases had been performed in Brazil, 1229 thyroidectomies (96.4%), 42 parathyroidectomies (3.3%) and 4 combined procedures (0.3%). Most of the cases were done in the southeast region (821, 64.4%), 538 (42.2%) cases in the State of São Paulo and 283 (22.2%) cases in the State of Rio de Janeiro. Conclusions: TOETVA is becoming popular in Brazil. Younger surgeons, especially those between 30 and 50 years old were more likely to adopt this approach.

RESUMO Introdução: a cirurgia de tireoide por via transoral vestibular é uma realidade em muitos países. Embora várias outras técnicas de acesso remoto tenham sido desenvolvidas nos últimos 20 anos, muitas não eram reprodutíveis. A cirurgia endoscópica cervical transoral (TNS - Transoral Neck Surgery) tem se mostrado reprodutível em diferentes centros ao redor do mundo sendo que, aproximadamente cinco anos após sua descrição, foi adotada de forma relativamente rápida por vários motivos. Até o momento, existem pelo menos 7 estudos brasileiros publicados, incluindo uma série de mais de 400 casos. O objetivo deste trabalho é estudar a evolução da Cirurgia Transoral do Pescoço (TNS) no Brasil e descrever o perfil dos cirurgiões envolvidos nesta nova abordagem. Métodos: trata-se de um estudo descritivo. Uma pesquisa online hospedada no REDCap sobre tireoidectomia e paratireoidectomia endoscópica transoral por abordagem vestibular (TOETVA/TOEPVA) foi realizada com 66 cirurgiões brasileiros. Foram levantados dados sobre o perfil do cirurgião, número de casos realizados por região geográfica, que tipo de treinamento foi necessário antes do primeiro caso e comportamento do cirurgião durante o relacionamento com o paciente ao abordar essas novas técnicas. Resultados: a taxa de resposta desta pesquisa foi de 53%. Até o momento, 1.275 casos de TOETVA/TOEPVA foram realizados no Brasil, sendo 1.229 tireoidectomias (96,4%), 42 paratireoidectomias (3,3%) e 4 procedimentos combinados (0,3%). A maioria dos casos foi realizada na região sudeste (821, 64,4%), 538 (42,2%) casos no estado de São Paulo e 283 (22,2%) casos no estado do Rio de Janeiro. Conclusões: a TOETVA está se popularizando no Brasil. Cirurgiões mais jovens, especialmente aqueles entre 30 e 50 anos, são mais propensos a adotar essa abordagem.

Analysis of the status of treatment of benign thyroid diseases - a public health problem aggravated in the COVID-19 pandemic era / Análise da situação do tratamento das doenças benignas da tireoide - Um problema de saúde pública agravado pela pandemia de Covid-19

Abstract Objective: Goiters and benign nodules detected in the thyroid are growing lesions and the COVID-19 pandemic have negatively impacted on their surgical treatment. The appropriate selection of patients to treatment will improve the overall health status. This article review will focus on the impact of the COVID-19 pandemic on treatment of benign conditions of the thyroid gland and their implications. Methods: This review pointed out the status of the health system in developing country and the problems to treat benign surgical diseases of thyroid. Aspects of epidemiology, incidence, clinical presentation and surgical treatment of goiters, economic and health status impact were cited. Results: All surgical treatment of goiter and other benign conditions were postponed, forced to redirect, and reschedule all benign surgeries, situation aggravated by poor public management and closure of hospital beds. These conditions have caused deterioration in patients' physical (decompensated thyroid disease) and mental health status, increasing work disabilities and burdening society by increasing the social and health cost. The overall situation could be catastrophic in emergent countries where this increased disease-related social expenditure on surgical treatment may increase the risk of national impoverishment as increase the treatment cost. Brazilian Society Head and Neck Surgery related some recommendations and new suggestions were made to safely treat these high potential hazard surgical conditions. Conclusions: Surgeries for goiter and benign thyroid conditions can be performed during the COVID-19 pandemic, following strict safety protocols for the patient and the medical team, reducing the negative economic and on patient health impact.

Resumo Objetivo: Bócios e nódulos benignos detectados na tireoide são lesões em crescimento e a pandemia de Covid-19 impactou negativamente seu tratamento cirúrgico. A seleção adequada de pacientes para o tratamento vai melhorar o estado geral de saúde. Esta revisão de artigos se concentrará no impacto da pandemia de Covid-19 no tratamento de condições benignas da glândula tireoide e suas implicações. Método: Esta revisão evidenciou a situação do sistema de saúde em países em desenvolvimento e os problemas para tratar doenças cirúrgicas benignas da tireoide. Aspectos da epidemiologia, incidência, apresentação clínica e tratamento cirúrgico do bócio, impacto econômico e no estado de saúde foram relatados. Resultados: Todos os tratamentos cirúrgicos de bócio e outras condições benignas foram adiados, forçados a se redirecionar e a remarcar todas as cirurgias benignas, situação agravada pela má gestão pública e fechamento de leitos hospitalares. Essas condições têm causado deterioração do estado de saúde física (doença da tireoide descompensada) e mental dos pacientes, aumentam as incapacidades para o trabalho e sobrecarregando a sociedade e o custo social e de saúde. A situação geral pode ser catastrófica em países emergentes, onde esse aumento dos gastos sociais relacionados à doença sob tratamento cirúrgico pode aumentar o risco de empobrecimento nacional à medida que aumenta o custo do tratamento. A Sociedade Brasileira de Cirurgia de Cabeça e Pescoço forneceu algumas recomendações e novas sugestões foram feitas para tratar com segurança essas condições cirúrgicas de alto risco potencial. Conclusão: As cirurgias para bócio e condições benignas da tireoide podem ser feitas durante a pandemia de Covid-19, se forem seguidos rigorosos protocolos de segurança para o paciente e equipe médica, o que reduz o impacto negativo na economia e na saúde do paciente.

Comparative analysis of anal colposcopy with histology in the follow-up of patients under treatment for anal condyloma

Objectives: To compare morphological abnormalities on anal colposcopy against histology to determine anal high-grade squamous intraepithelial lesions (HSILs). Methods: This is a retrospective data assessment of HIV-negative and HIV-positive patients undergoing outpatient follow-up. The sample comprised 54 patients presenting acetowhite lesions on anal colposcopy. Acetowhite lesions were classified according to their morphology into punctation, verrucous, mosaic, ulcerated, or hypervascularized, and biopsies of these specimens were classified as anal HSIL, low-grade squamous intraepithelial lesion (LSIL), or normal. The data were analyzed using SPSS forWindows version 13.0 (SPSS Inc., Chicago, IL, USA). The results were analyzed using the nonparametric Mann-Whitney test, the Fisher exact test and the chi-squared parametric test. A 95% confidence interval (CI) was used and a level of significance <5% was adopted for all statistical tests. Results Fifty-four patients (50 males, 80% HIV+) with biopsied acetowhite lesions were assessed. There were 31 punctation lesions, 1 classified as HSIL (3.2%; 95%CI: 0- 40.0), 17 verrucous lesions, 3 HSIL (17.7%; 95%CI: 0-10.7), and 1 ulcerated, classified as HSIL (100%), and 4 mosaic and 1 atypical vessel lesion, all classified as LSIL. The results showed no association of presence of anal HSIL with positivity for HIV infection or with counts above or below 500/µl in HIV+patients. Statistical analysis was performed using the Mann-Whitney nonparametric test, the Fisher exact test, and the chi-squared parametric test. Conclusion: The comparison of morphological findings on anal colposcopy against histology revealed no morphological pattern suggesting anal HSIL. (AU)

Analysis of the status of treatment of benign thyroid diseases - a public health problem aggravated in the COVID-19 pandemic era.

OBJECTIVE: Goiters and benign nodules detected in the thyroid are growing lesions and the COVID-19 pandemic have negatively impacted on their surgical treatment. The appropriate selection of patients to treatment will improve the overall health status. This article review will focus on the impact of the COVID-19 pandemic on treatment of benign conditions of the thyroid gland and their implications. METHODS: This review pointed out the status of the health system in developing country and the problems to treat benign surgical diseases of thyroid. Aspects of epidemiology, incidence, clinical presentation and surgical treatment of goiters, economic and health status impact were cited. RESULTS: All surgical treatment of goiter and other benign conditions were postponed, forced to redirect, and reschedule all benign surgeries, situation aggravated by poor public management and closure of hospital beds. These conditions have caused deterioration in patients' physical (decompensated thyroid disease) and mental health status, increasing work disabilities and burdening society by increasing the social and health cost. The overall situation could be catastrophic in emergent countries where this increased disease-related social expenditure on surgical treatment may increase the risk of national impoverishment as increase the treatment cost. Brazilian Society Head and Neck Surgery related some recommendations and new suggestions were made to safely treat these high potential hazard surgical conditions. CONCLUSIONS: Surgeries for goiter and benign thyroid conditions can be performed during the COVID-19 pandemic, following strict safety protocols for the patient and the medical team, reducing the negative economic and on patient health impact.

Trans Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Brazil: Safety and complications during learning curve.

OBJECTIVE: The aim of this study was to address the first cases of TOETVA done in Brazil, by TOETVA-Bra study group, regarding safety and complications. METHODS: Series of the first 93 TOETVAs cases in Brazil. All authors except LPK, AJG JOR and RPT received TOETVA training including cadaveric hands-on in Thailand or United States (Johns Hopkins Medicine) during 2017. After they came back to Brazil and started doing their first TOETVA cases in the cities of Rio de Janeiro, Sao Paulo and Chapecó they agreed to collaborate and gather data using an online spreadsheet. All patients were submitted to the technique described by Anuwong. RESULTS: A total of 93 patients underwent TOETVA. Most patients (58.1%) were submitted to total thyroidectomy and 59.1% had benign disease. Two patients (2.2%) needed conversion to open surgery. Five patients (9.3%) developed transient hypoparathyroidism and there were 3 (2.0%) temporary recurrent laryngeal nerve palsy. There was one (0.7%) permanent unilateral palsy. Twenty patients had some sort of complication, 16.1% were minor and 5.4% were major. A total of 73 patients (78.5%) had an uneventful recovery. CONCLUSION: The technique is reproducible with a low complication rate. While further studies are needed to confirm equivalency, early efforts suggest that TOETVA is not inferior to traditional open thyroidectomy in appropriately selected patients.

Trans Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Brazil: Safety and complications during learning curve

ABSTRACT Background: The aim of this study was to address the first cases of TOETVA done in Brazil, by TOETVA-Bra study group, regarding safety and complications. Materials and Methods: Series of the first 93 TOETVAs cases in Brazil. All authors except LPK, AJG JOR and RPT received TOETVA training including cadaveric hands-on in Thailand or United States (Johns Hopkins Medicine) during 2017. After they came back to Brazil and started doing their first TOETVA cases in the cities of Rio de Janeiro, Sao Paulo and Chapecó they agreed to collaborate and gather data using an online spreadsheet. All patients were submitted to the technique described by Anuwong. Results: A total of 93 patients underwent TOETVA. Most patients (58.1%) were submitted to total thyroidectomy and 59.1% had benign disease. Two patients (2.2%) needed conversion to open surgery. Five patients (9.3%) developed transient hypoparathyroidism and there were 3 (2.0%) temporary recurrent laryngeal nerve palsy. There was one (0.7%) permanent unilateral palsy. Twenty patients had some sort of complication, 16.1% were minor and 5.4% were major. A total of 73 patients (78.5%) had an uneventful recovery. Conclusion: The technique is reproducible with a low complication rate. While further studies are needed to confirm equivalency, early efforts suggest that TOETVA is not inferior to traditional open thyroidectomy in appropriately selected patients.

Quality of life after Supracricoid Partial Laryngectomy.

BACKGROUND: Supracricoid partial laryngectomy has good oncologic results in the treatment of advanced laryngeal cancer with the advantage of preserving larynx phonatory function when compared with total laryngectomy. However the rehabilitation could be a challenge, especially regarding swallowing function. Is supracricoid partial laryngectomy associated with better quality of life than total laryngectomy? METHODS: Survey study that included 33 patients (16 total laryngectomy and 17 supracricoid partial laryngectomy) with advanced larynx cancer surgically treated and fully rehabilitated. The quality of life were evaluated with EORTC QLQ C30 and H&N 35 instrument. RESULTS: Patients who underwent supracricoid partial laryngectomy obtained better scores in global health status-quality of life and general activities and had lower levels of sensory and speech-related symptoms. CONCLUSION: SPL was associated with better quality of life when compared with TL.

Leishmania (V.) braziliensis infection promotes macrophage autophagy by a LC3B-dependent and BECLIN1-independent mechanism.

Leishmania (Viannia) braziliensis is one of the main etiological agents of tegumentary leishmaniasis in Latin America. The establishment of a successful infection in host cells requires several key events including phagocytosis, phagolysosomal maturation impairment, and parasite replication. Autophagy is accountable for the physiological turnover of cellular organelles, degradation of macromolecular structures, and pathogen elimination. In many cases, autophagy control leads to a successful infection, both impairing pathogen elimination or providing nutrients. Here, we have investigated the relationship between autophagy and L. braziliensis infection. We observed that BECLIN1 expression was upregulated early on infection in both in vitro macrophage cultures and biopsies of cutaneous lesions from L. braziliensis infected patients. On the other hand, LC3B expression was downregulated in cutaneous lesions biopsies. A transient pattern of LC3+ cells was observed along L. braziliensis infection, but the number of LC3 puncta did not vary. Additionally, autophagy induction, with rapamycin treatment or through starvation, reduced infection. As expected, rapamycin increased the percentage of LC3+ cells and the number of puncta, but the presence of parasite restricted this effect, indicating LC3-associated autophagy impairment by L. braziliensis. Finally, silencing LC3B but not BECLIN1 promoted infection, confirming BECLIN1 independent and LC3B-related control by the parasite. Taken together, these data indicate macrophage autophagic machinery manipulation by L. braziliensis, resulting in successful establishment and survival into the host cell.

Predictive factors of lethality and complications of deep fascial space infections of the neck.

OBJECTIVE: to identify predictive factors for lethality and complications of deep fascial space infections of the neck (DFSIN), establishing an early and aggressive treatment in the neck before the progression to descending mediastinitis. METHODS: we retrospectively analyzed 133 cases of DFSIN treated at Discipline of Head and Neck Surgery of the Medicine School of Santa Casa de Misericórdia de São Paulo. We accessed demographic characteristics, associated diseases, clinical presentation, laboratorial tests, length of hospital stay, number of involved anatomic neck spaces, intra-operative and microbiology findings. We analyzed these data using logistic regression to predict DFSIN lethality and life threatening complications (mediastinitis, septic shock, pneumonia, pleural empyema, skin necrosis). RESULTS: lethality and complication ratios were 9% and 50.3%, respectively. The logistic regression model showed that patients with septic shock were more likely to have progression to death (p < 0.001) and, the presence of more than two involved neck spaces (p < 0.001) and older individuals (p = 0.017) were more likely to have complicated deep neck infections. Descending necrotizing mediatinitis increased the lethality ratio by 50%, and was associated to necrotizing fasciitis (p=0.012) and pleural empyema (p<0.001). CONCLUSION: septic shock is a lethal predictive factor and age as well as more than two involved neck spaces are the predictive factors for complications. Necrotizing fasciitis is an important factor for complications and death. Therefore, its surgical treatment must be more aggressive. Descending mediastinitis has a high lethal rate and the successful treatment is based on early diagnosis and aggressive surgical approach.

Zika Virus Infects Human Placental Mast Cells and the HMC-1 Cell Line, and Triggers Degranulation, Cytokine Release and Ultrastructural Changes.

Zika virus (ZIKV) is an emergent arthropod-borne virus whose outbreak in Brazil has brought major public health problems. Infected individuals have different symptoms, including rash and pruritus, which can be relieved by the administration of antiallergics. In the case of pregnant women, ZIKV can cross the placenta and infect the fetus leading to congenital defects. We have identified that mast cells in the placentae of patients who had Zika during pregnancy can be infected. This led to our investigation on the possible role of mast cells during a ZIKV infection, using the HMC-1 cell line. We analyzed their permissiveness to infection, release of mediators and ultrastructural changes. Flow cytometry detection of ZIKV-NS1 expression 24 h post infection in 45.3% of cells showed that HMC-1 cells are permissive to ZIKV infection. Following infection, ß-hexosaminidase was measured in the supernatant of the cells with a notable release at 30 min. In addition, an increase in TNF-α, IL-6, IL-10 and VEGF levels were measured at 6 h and 24 h post infection. Lastly, different intracellular changes were observed in an ultrastructural analysis of infected cells. Our findings suggest that mast cells may represent an important source of mediators that can activate other immune cell types during a ZIKV infection, which has the potential to be a major contributor in the spread of the virus in cases of vertical transmission.

Mycobacterium tuberculosis and M. bovis BCG Moreau Fumarate Reductase Operons Produce Different Polypeptides That May Be Related to Non-canonical Functions.

Tuberculosis is a world widespread disease, caused by Mycobacterium tuberculosis (M.tb). Although considered an obligate aerobe, this organism can resist life-limiting conditions such as microaerophily mainly due to its set of enzymes responsible for energy production and coenzyme restoration under these conditions. One of these enzymes is fumarate reductase, an heterotetrameric complex composed of a catalytic (FrdA), an iron-sulfur cluster (FrdB) and two transmembrane (FrdC and FrdD) subunits involved in anaerobic respiration and important for the maintenance of membrane potential. In this work, aiming to further characterize this enzyme function in mycobacteria, we analyzed the expression of FrdB-containing proteins in M.tb and Mycobacterium bovis Bacillus Calmette-Guérin (BCG) Moreau, the Brazilian vaccine strain against tuberculosis. We identified three isoforms in both mycobacteria, two of them corresponding to the predicted encoded polypeptides of M.tb (27 kDa) and BCG Moreau (40 kDa) frd sequences, as due to an insertion on the latter's operon a fused FrdBC protein is expected. The third 52 kDa band can be explained by a transcriptional slippage event, typically occurring when mutation arises in a repetitive region within a coding sequence, thought to reduce its impact allowing the production of both native and variant forms. Comparative modeling of the M.tb and BCG Moreau predicted protein complexes allowed the detection of subtle overall differences, showing a high degree of structure and maybe functional resemblance among them. Axenic growth and macrophage infection assays show that the frd locus is important for proper bacterial development in both scenarios, and that both M.tb's and BCG Moreau's alleles can partially revert the hampered phenotype of the knockout strain. Altogether, our results show that the frdABCD operon of Mycobacteria may have evolved to possess other yet non-described functions, such as those necessary during aerobic logarithmic growth and early stage steps of infection.

Predictors of difficulty in bedside percutaneous dilatational tracheostomy: pilot study / Preditores de dificuldade em traqueostomia percutânea à beira do leito: estudo piloto

ABSTRACT Introduction: percutaneous dilatational tracheostomy is currently one of the main procedures performed in an intensive care unit (ICU). However, there are no well-defined indicators of technical difficulty in performing the procedure. Objectives: to define predictors of difficulty in performing bedside percutaneous dilatational tracheostomy. Methodology: prospective cohort study encompassing 21 patients who underwent bedside percutaneous dilatational tracheostomy in the ICU at a single center. Results: Sternohyoid (SH) distance shorter than 7 cm is associated with a 50% increase in the risk of technical difficulty (OR 0.44 and p <0.03). Conclusion: the reduction in (SH) distance is related to an increased risk of difficulty in performing percutaneous dilatational tracheostomy in the ICU bed.

RESUMO Introdução: a traqueostomia percutânea é hoje um dos principais procedimentos realizados em unidade de terapia intensiva (UTI). Não há, contudo, indicadores bem definidos de dificuldade técnica na realização do procedimento. Objetivos: definir preditores de dificuldade para realização de traqueostomia percutânea. Metodologia: estudo de coorte prospectivo no qual foram incluídos 21 pacientes submetidos a traqueostomia percutânea à beira leito, na UTI, em um único centro. Resultados: distância EH menor que 7 cm está associada a aumento de 50% na chance de dificuldade técnica (OR 0,44 e p<0,03). Conclusão: a redução da distância EH está relacionada com aumento do risco de dificuldade em realizar a traqueostomia percutânea à beira do leito, em UTI.

Predictive factors of lethality and complications of deep fascial space infections of the neck / Fatores preditivos de letalidade e complicações das infecções dos espaços fasciais profundos do pescoço

ABSTRACT Objective: to identify predictive factors for lethality and complications of deep fascial space infections of the neck (DFSIN), establishing an early and aggressive treatment in the neck before the progression to descending mediastinitis. Methods: we retrospectively analyzed 133 cases of DFSIN treated at Discipline of Head and Neck Surgery of the Medicine School of Santa Casa de Misericórdia de São Paulo. We accessed demographic characteristics, associated diseases, clinical presentation, laboratorial tests, length of hospital stay, number of involved anatomic neck spaces, intra-operative and microbiology findings. We analyzed these data using logistic regression to predict DFSIN lethality and life threatening complications (mediastinitis, septic shock, pneumonia, pleural empyema, skin necrosis). Results: lethality and complication ratios were 9% and 50.3%, respectively. The logistic regression model showed that patients with septic shock were more likely to have progression to death (p < 0.001) and, the presence of more than two involved neck spaces (p < 0.001) and older individuals (p = 0.017) were more likely to have complicated deep neck infections. Descending necrotizing mediatinitis increased the lethality ratio by 50%, and was associated to necrotizing fasciitis (p=0.012) and pleural empyema (p<0.001). Conclusion: septic shock is a lethal predictive factor and age as well as more than two involved neck spaces are the predictive factors for complications. Necrotizing fasciitis is an important factor for complications and death. Therefore, its surgical treatment must be more aggressive. Descending mediastinitis has a high lethal rate and the successful treatment is based on early diagnosis and aggressive surgical approach.

RESUMO Objetivo: identificar os fatores preditivos de letalidade e complicações associados às infecções dos espaços fasciais profundos do pescoço, com intuito de estabelecer tratamento mais precoce antes de evolução para a mediastinite. Métodos: estudo retrospectivo de 133 casos, tratados na Disciplina de Cirurgia de Cabeça e Pescoço da Faculdade de Ciências Médicas da Santa Casa de São Paulo. Por meio da análise de regressão logística, estes dados foram estudados para a predição de letalidade e complicações graves (mediastinite, choque séptico, empiema pleural, pneumonia e necrose de pele). Resultados: a taxa de letalidade identificada foi de 9% e, de complicações de 50,3%. Identificou-se como fator preditivo de letalidade, a presença de choque séptico (p<0,001) e, para o ocorrência de complicações, a idade (p=0,017) e o acometimento de mais de dois espaços anatômicos (p<0,001). A ocorrência de mediastinite descendente necrosante esteve associada à presença de fasciíte necrosante (p=0,012) e empiema pleural (p<0,001). Conclusão: o fator preditivo de letalidade foi a presença de choque séptico e, para ocorrência de complicações graves, a idade e/ou a presença de mais de dois espaços anatômicos acometidos pela infecção. A fasciíte necrosante é fator importante para ocorrência de complicações e morte. Nestes casos, a conduta cirúrgica deve ser mais agressiva. A mediastinite descendente apresenta taxa de letalidade alta e o sucesso no tratamento está no diagnóstico precoce e na intervenção cirúrgica agressiva.

Subphrenic abscess secondary to cervical abscess and fasciitis from dental focus: case report.

BACKGROUND: Cervical fasciitis is a group of severe infections with high morbimortality. Reports in the literature of patients with cases evolving with mediastinal dissemination of deep cervical abscess are common. However, cases of abdominal dissemination by contiguity are much rarer. CASE PRESENTATION: A 34-year-old Caucasian man presented to the emergency department with a 15-day history of left neck edema, local pain, and fever. Seventeen days prior to presentation, he had undergone odontogenic surgical treatment in a dental clinic. Laboratory examinations did not show meaningful changes. He underwent computed tomography of the neck, thorax, and abdomen, which showed evidence of left collection affecting the retromandibular, submandibular, parapharyngeal, vascular, and mediastinal spaces, bilateral pleural effusion, right subphrenic collection and a small amount of liquids between intestinal loops. A cervical, thoracic, and abdominal surgical approach at the same surgery was indicated for odontogenic cervical abscess, descending necrotizing mediastinitis, and subphrenic abscess. The patient remained in the intensive care unit for three days, and he was discharged on the 22nd day after surgery with no drains and no tracheostomy. His outpatient discharge occurred after 6 months with no sequelae. CONCLUSIONS: Aggressive surgical treatment associated with antibiotic therapy has been shown to be effective for improving the clinical course of cervical fasciitis. Despite the extension of the infection in our patient, a surgical approach of all infectious focus associated with a broad-spectrum antibiotic therapy led to a good clinical evolution and has significant implications for aggressive treatment.

Tobacco influence in heavy metals levels in head and neck cancer cases.

Heavy metals intoxication is known to be risk factors for various diseases, including cancer. These metals may be presented in food and soil as well as in leaf and tobacco smoke. The aim of this study was to correlate the exposure to heavy metals stemming from tobacco and head and neck squamous cell carcinoma carcinogenesis. Analysis of lead, copper, manganese, arsenic, chromium, and cadmium by atomic absorption spectrophotometry was performed in whole blood samples from 91 patients: 68 smokers with oral cavity, pharynx, or laryngeal cancer; 8 non-smokers with oral or larynx cancer; and 15 non-cancer smokers with tobacco-related diseases (control group). No differences were found in metals quantifications, except a significant difference was observed (p = 0.0223) with higher mean in copper levels for non-smokers with cancer. The present study concluded, for the groups evaluated, it was not possible to prove the relationship between the studied metals in the development of the neoplasm. On the other hand, the results of copper demonstrated a correlation with smokers with cancer and lower levels of circulating copper.