Optimization of Subglottic View During Flexible Laryngoscopy With Patient Positioning.

OBJECTIVE: Determine the ideal head position to optimize visualization of the subglottis using flexible laryngoscopy. STUDY DESIGN: Prospective cohort study. SETTING: Outpatient multidisciplinary airway clinic at a tertiary care center. METHODS: Patients presenting to a multidisciplinary airway clinic undergoing nasoendoscopic airway examination were enrolled. Three head positions were utilized to examine the subglottis during laryngoscopy: "sniffing," chin tuck, and stooping positions. In-office reviewers and blinded clinician participants evaluated views of the airway based on Cormack-Lehane (CL) scale, airway grade (AG), and visual analog scale (VAS). Demographic data were obtained. Statistical analysis compared head positions and demographic data using Student's t test, analysis of variance, and Tukey's post hoc analysis. RESULTS: One hundred patients participated. No statistical differences existed among in-clinic or blinded reviewers for the CL score in any head position (p = .35, .5, respectively). For both AG and VAS, flexed and stooping positions were rated higher than the sniffing positions by both in-clinic and blinded reviewers (p < .01 for all analyses), but there was no statistical difference between these two positions (p = .28, .18, respectively). There was an inverse correlation between age and scores for AG and VAS in the flexed position for both sets of reviewers (p = .02, <.01 respectively), and a higher body mass index was significantly associated with the need to perform tracheoscopy for full airway evaluation (p < .01). CONCLUSION: Both flexion and stoop postures can be implemented by an experienced endoscopist in awake, transnasal flexible laryngoscopy to enhance visualization of the subglottic airway.

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.

Impact of social deprivation on the outcome of major head and neck cancer surgery in England: A national analysis.

BACKGROUND: Socioeconomic status plays an important role in the incidence and prognosis of many cancers. We examined the relationship between social deprivation and clinical outcomes in patients undergoing major surgery for head and neck cancer. METHODS: A retrospective population-based observational study was performed. Patients undergoing head and neck surgical procedures in England between 2002 and 2012 were identified. This totaled 5051 patients in the less socially deprived (LSD) and 7282 in the more socially deprived (MSD) group. RESULTS: MSD patients were younger (61 vs 63) and were more likely to present with hypopharyngeal-laryngeal cancers (41% vs 30%). They had higher burdens of morbidity and more frequently required emergency surgery (odds ratio [OR] 1.74 [95% CI 1.52-1.99]). Following surgery, MSD patients had higher lengths of inpatient stay (OR 1.72 [95% CI 1.57-1.88]) and higher proportions of both inpatient (OR 1.47 [95% CI 1.19-1.82]) and overall mortality (OR 1.34 [95% CI 1.24-1.45]). CONCLUSION: Increasing socioeconomic deprivation is associated with poor health outcomes in patients with head and neck cancer.

Aortopexy for the treatment of tracheobronchomalacia in 100 children: a 10-year single-centre experience.

OBJECTIVES: Our study describes and analyses the results from aortopexy for the treatment of airway malacia in children. METHODS: Demographic data, characteristics and preoperative, operative and outcome details, including the need for reintervention, were collected for children undergoing aortopexy between 2006 and 2016. RESULTS: One hundred patients [median age 8.2 months, interquartile range (IQR) 3.3-26.0 months] underwent aortopexy. Sixty-four (64%) patients had tracheomalacia (TM) only, 24 (24%) patients had TM extending into their bronchus (tracheobronchomalacia) and 11 (11%) patients had bronchomalacia. Forty-one (41%) children had gastro-oesophageal reflux disease, of which 17 (41%) children underwent a Nissen fundoplication. Twenty-eight (28%) children underwent a tracheo-oesophageal fistula repair prior to aortopexy (median 5.7 months, IQR 2.9-17.6 months). The median duration of follow-up was 5.3 years (IQR 2.9-7.5 years). Thirty-five (35%) patients were on mechanical ventilatory support before aortopexy. Twenty-seven (77%) patients could be safely weaned from ventilator support during the same admission after aortopexy (median 2 days, IQR 0-3 days). Fourteen patients required reintervention. Overall mortality was 16%. Multivariable analysis revealed preoperative ventilation (P = 0.004) and bronchial involvement (P = 0.004) to be adverse predictors of survival. Only bronchial involvement was a predictor for reintervention (P = 0.012). CONCLUSIONS: Aortopexy appears to be an effective procedure in the treatment of children with severe airway malacia. Bronchial involvement is associated with adverse outcome, and other procedures could be more suitable. For the treatment of severe airway malacia with isolated airway compression, we currently recommend aortopexy to be considered.

The influence of stents on microbial colonization of the airway in children after slide tracheoplasty: a 14-year single-center experience.

OBJECTIVES: This study describes the microbial colonization profile of the airway in children after slide tracheoplasty (STP) with and without stents, and compares colonization to children undergoing cardiothoracic surgical procedures without airway related disease. METHODS: A 14-year retrospective single case note review was performed on patients undergoing STP and stent insertion. Nose and throat (NT) and bronchoalveolar lavage (BAL) specimens were analyzed for microbial profile and expressed as cumulative mean microorganisms per patient (MMP). RESULTS: Forty-three patients (median age ± SD 15.02 ± 31.76 months) underwent STP and 141 patients underwent cardiothoracic but no airway surgery (median age ± SD 31.7 ± 47.2 months). Sixteen patients required a stent after STP. One-hundred seventy-two positive microbial specimens were identified. The predominant 6 microorganisms were (1) Staphylococcus aureus; (2) Pseudomonas aeruginosa; (3) Haemophilus influenzae not type B; (4) Coliforms; (5) Streptococcus pneumoniae; and (6) Candida Albicans, and accounted for 128 (74%) of all positive specimens found. Children with stents had more MMP compared to children without stents after STP [4.06 ± 2.38 and 2.04 ± 2.24 MMP (P < 0.001), respectively]. Both groups of children after STP had more MMP compared to the control group (P < 0.001). Children with stents had more microbial colonization of their lower respiratory tract compared to their upper respiratory tract (3.36 ± 2.02 and 1.36 ± 0.93 MMP (P < 0.01) respectively). Staphylococcus aureus colonization of the lower respiratory tract was significantly higher in children with stents compared to children without stents after STP [0.5 and 0.15 MMP (P < 0.05) respectively]. CONCLUSIONS: This study indicates airway surgery and the subsequent use of stents to be a significant risk factor for microbial colonization of the airway in children. More specifically airway stents appear to increase colonization in the distal airway, which appears unrelated to that of the upper respiratory tract.

Multilevel radiofrequency ablation to the soft palate and tongue base: tips and pitfalls.

The objective of the study is to increase awareness and understanding of the techniques and safety measures to minimise complications and improve patient outcomes. Literature review using MedLine and keywords snoring; obstructive sleep apnoea; radiofrequency ablation; electrosurgery; palate; tongue base was conducted. There is no accepted gold standard technique for radiofrequency ablation; to date, there is no published literature regarding common tips and pitfalls in radiofrequency application specifically for superficial applications and second-stage surgery. Surgery for snoring and obstructive sleep apnoea is typically multilevel. Pre-operative patient assessment and selection are critical to ensure good outcomes. Radiofrequency is generally safe and efficacious in this subset of patients. However, as with all surgery, it is operator-dependent. In particular, we emphasise the methodology for second-stage surgery, optimising visualisation and avoiding ulceration/fistulation of the soft palate, which are previously undescribed in the literature.

Towards a classification system for complex craniofacial fractures.

The complexity of facial fractures has changed considerably in recent years together with more commonly observed high velocity trauma. Traditional classification systems describe fractures in an isolated manner but fail to recognise those that affect more than one region. We applied four conceptual scoring systems for craniofacial trauma to a cohort of patients in east London. We exposed the limitations of the systems and developed a new scoring system that encompasses elements of all of the models and is capable of overcoming previous limitations.

Otogenic cranial base osteomyelitis: a proposed prognosis-based system for disease classification.

OBJECTIVES: To review the presentation, microbiology, and long-term results of treating otogenic cranial base osteomyelitis to develop a prognosis-based disease classification system. PATIENTS AND METHODS: Thirty-eight patients with otogenic cranial base osteomyelitis treated between 1989 and 2002 were studied. Patient demographics, presentation, pathogens, details of therapy, and disease-specific survival were recorded. Patients were stratified using Technetium-99 single-photon emission computerized tomography (SPECT) at presentation into 4 grades: I, mild uptake; II, focal mastoid/temporal bone uptake not reaching midline; III, petrous temporal bone uptake reaching midline; and IV, uptake crossing midline, involving the contralateral temporal bone. Actuarial analysis was used to identify prognostic factors. RESULTS: There were 27 men. The average age at presentation was 65 +/- 16 years (range, 19-95 yr). The median age-adjusted Charlson comorbidity score was 5, and 63% of patients were diabetic. The most common presenting symptoms were pain and otorrhea, and 8 patients had cranial nerve neuropathy. Pseudomonas aeruginosa was the most common bacterial pathogen (n = 28; 74%), and 9 patients had fungal or mixed infections. On average, antibiotics were administered for 161 days, and 6 patients had concomitant surgery. The average follow-up was 33 months, and 3-year disease-specific survival was 76%. Univariate predictors of survival were the SPECT grade, fungal/mixed infections, Charlson score, immune compromise, and cranial nerve neuropathy. The only independent predictor of survival on multivariate Cox regression was the SPECT stage at presentation. CONCLUSION: Cranial base osteomyelitis is associated with significant morbidity and mortality and requires prolonged treatment. Long-term outcome can be predicted from the initial SPECT scan.