Endoscopic Chemocauterization with Trichloroacetic Acid for Congenital or Recurrent Tracheoesophageal Fistula in Children with Esophageal Atresia: Experience from a Tertiary Center.

BACKGROUND: Recurrent tracheoesophageal fistula (rTEF) is a well-known complication after surgery of EA, occurring in roughly 3-10% of the patients. Recent studies have highlighted safety and efficacy of endoscopic management of recurrent TEF. The aim of this study was to evaluate the efficacy of chemocauterization with trichloroacetic acid (TCA) in rTEF and congenital tracheoesophageal fistula (cTEF). METHODS: Retrospective chart review of consecutive patients with recurrent or congenital TEF who underwent endoscopic chemo-cauterization between 2018 and 2022 at a tertiary center. Children diagnosed with TEF who underwent primary or secondary endoscopic treatment were included. Median follow up time was 19 months for rTEF and 33 months for cTEF. RESULTS: During the study period, 18 patients were treated endoscopically by chemocatuerization with TCA at our institution. Treatment of recurrent TEF was successful in 13 of 14 patients (93%) Treatment of congenital TEF was successful in 2 of 4 patients (50%). In 14 patients, closure was seen after 1-2 treatments. There were no serious adverse reactions or complications to the endoscopic treatment of TEF. CONCLUSION: Endoscopic chemocauterization is a minimal invasive technique with low morbidity and high success rate and may be considered as primary treatment for recurrent TEF. LEVEL OF EVIDENCE: III.

Wideband tympanometry in ears with superior canal dehiscence before and after surgical correction.

OBJECTIVES: Wideband tympanometry (WBT) has been shown to be sensitive to mechanical changes in the ear. This study investigated the effect of surgical correction of superior canal dehiscence (SCD) on WBT (i.e. absorbance and middle ear resonance frequency) compared to those on common surgical outcomes such as symptom resolution, vestibular evoked myogenic potentials (VEMP), and hearing thresholds. STUDY SAMPLE AND STUDY DESIGN: Seven patients (eight ears with SCD) who underwent surgical correction of SCD underwent WBT in addition to pure-tone audiometry and VEMP assessment. RESULTS: Postoperatively, all ears showed normalised/decreased absorbance at low frequencies and slightly enhanced absorbance in the middle frequency range (7/8 ears). The middle ear resonance frequency, which was initially lower than normal in most patients, increased in 6/8 operated ears, and decreased in two ears with no/partial symptom relief. In comparison, complete symptom control was observed in 6/8 operated ears, VEMP amplitudes reduced or normalised in all ears, and hearing thresholds remained stable or improved in 6/8 ears and worsened in two ears. CONCLUSIONS: Surgery seems to change the response to WBT in patients with SCD. The results of WBT may represent mechanical changes induced by SCD, and should be considered when evaluating surgical outcomes.

Sclerotherapy of ranulas with OK-432 - a prospective, randomized, double-blinded placebo-controlled study.

BACKGROUND: Ranula is a rare benign cystic lesion in the floor of the mouth, which can herniate through the mylohyoid muscle and become a plunging ranula. Treatment for ranulas is currently surgical excision of the sublingual gland. Sclerotherapy with OK-432 is a well-established treatment of lymphatic malformations, but not yet thoroughly evaluated on ranulas. Objectives: To evaluate sclerotherapy of ranulas with OK-432 in a randomized double-blinded trial. MATERIALS AND METHODS: 20 patients with plunging or intraoral ranula were randomized to two double-blinded injections with OK-432 or saline. Effect on the ranula and evaluation of symptoms and QOL were investigated. RESULTS: Treatment response differed significantly between OK-432 and placebo, p = .041(student's T-test). All patients with intraoral ranulas had a complete response, but only 1/4 of the patients with plunging ranula. The inflammatory reaction after injection with OK-432 caused a mild to moderate impact on QOL. No serious complications were observed. CONCLUSION: This study suggests that sclerotherapy with OK-432 in ranula is a very effective treatment for intraoral ranulas, but possibly less useful in plunging ranulas. SIGNIFICANCE: This is a limited study, but we believe that sclerotherapy with OK-432 should be recommended as primary treatment at least for intraoral ranulas.

[EXIT: Experiences from Karolinska University Hopsital]. / EXIT ­ säkraste förlossningsmetod för foster med livshotande luftvägshinder - Samlade erfarenheter från Karolinska universitetssjukhuset.

The main, but not sole, indication for an Ex-utero Intrapartum Treatment (EXIT) delivery is an airway obstruction due to either laryngeal atresia or tumors in the head and neck region. Here we present our Institution's experience with eleven cases: three teratomas, four lymphatic malformations, two laryngeal atresias and two dermoid cysts. The EXIT procedure was used to secure the fetal airway while maintaining uteroplacental gas exchange and fetal hemodynamic stability through the umbilical circulation. Five fetuses required tracheostomy. Only one fetal death occurred due to extensive growth of a teratoma preventing us from establishing an airway. No other fetal or major maternal complication occurred. The EXIT procedure is a complex procedure and these rare cases should be referred to a center with a dedicated and experienced multidisciplinary team.

[Advances in fetal surgery]. / Fosterkirurgi är en växande multidisciplinär subspecialitet - Etablerad behandling vid ryggmärgsbråck ­ i framtiden skymtar artificiell placenta och stamcellsterapi.

Advances in fetal surgery Fetal surgery is a subspeciality that is evolving rapidly with focus on improving the natural history of congenital malformations and conditions that are either life threatening or cause severe disability. Fetal surgery for myelomeningocele has been shown to improve neurologic outcome, motor function and to reduce the need of ventriculo-peritoneal shunting after birth compared to postnatal care. However, it conveys an increased risk of preterm birth and maternal morbidity. The role of prenatal intervention with endoscopic tracheal occlusion in congenital diaphragmatic hernia is currently the focus of an ongoing multicenter randomized controlled trial. The trial is comparing the effect of fetal surgery as an alternative to standard postnatal management. The main, but not sole, indication for an Ex-utero intrapartum treatment (EXIT) is airway obstruction due to laryngeal atresia and tumors in the head and neck region. It is a complex procedure that should be performed only in experienced centers with a multidisciplinary team.

Taste disturbance after stapes surgery: an evaluation of frequency, severity, duration, and quality-of-life.

CONCLUSION: The incidence of taste disturbance after stapes surgery is high (61.9%), whereas the majority (94.8%) recovers within 1 year. More severe surgical nerve trauma caused more disturbance, implying that the nerve should be handled carefully during surgery. OBJECTIVES: Patients operated on for otosclerosis seem more often to complain about post-operative taste disturbance than those operated on for chronic otitis media, although the chorda tympani nerve more seldom becomes maltreated in stapedotomy. These observations seem paradoxical. It is unclear to what extent a post-operative taste disturbance affects the quality-of-life. This study aims to shed light on the occurrence of post-operative taste disturbances, on possible prognostic factors, and to what extent post-operative taste disturbance impairs the quality-of-life. METHODS: One hundred and thirty-four adults undergoing primary stapedotomy were included. Questionnaires on taste disturbance and quality-of-life (SF-36) were answered before and after surgery, until 1 year post-operatively. RESULTS: Eighty-three (61.9%) study persons reported post-operative taste disturbance. Seven (5.2%) reported persisting disturbance at 1 year. Surgically more traumatized chorda tympani nerves correlated with more severe taste disturbance post-operatively than less traumatized. Taste disturbance at 1 year post-operatively correlate with a decrease of the physical function domain in the SF-36.

High-frequency hearing, tinnitus, and patient satisfaction with stapedotomy: A randomized prospective study.

Otosclerosis is a common disorder that leads to conductive hearing loss. Most patients with otosclerosis also have tinnitus, and surgical treatment is known to improve hearing as well as tinnitus. Some patients however experience worsening of tinnitus after the operation, but there are no known factors that allow surgeons to predict who will be at risk. In this prospective observational study on 133 patients undergoing stapedotomy, we show that postoperative air conduction thresholds at very high stimulus frequencies predict improvement of tinnitus, as assessed with proportional odds logistic regression models. Young patients were significantly more likely to experience reduction of tinnitus and patients whose tinnitus became better were also more satisfied with the outcome of the operation. These findings have practical importance for patients and their surgeons. Young patients can be advised that surgery is likely to be beneficial for their tinnitus, but a less positive message should be conveyed to older patients.

A randomised, double blind trial of N-Acetylcysteine for hearing protection during stapes surgery.

BACKGROUND: Otosclerosis is a disorder that impairs middle ear function, leading to conductive hearing loss. Surgical treatment results in large improvement of hearing at low sound frequencies, but high-frequency hearing often suffers. A likely reason for this is that inner ear sensory cells are damaged by surgical trauma and loud sounds generated during the operation. Animal studies have shown that antioxidants such as N-Acetylcysteine can protect the inner ear from noise, surgical trauma, and some ototoxic substances, but it is not known if this works in humans. This trial was performed to determine whether antioxidants improve surgical results at high frequencies. METHODS: We performed a randomized, double-blind and placebo-controlled parallel group clinical trial at three Swedish university clinics. Using block-stratified randomization, 156 adult patients undergoing stapedotomy were assigned to intravenous N-Acetylcysteine (150 mg/kg body weight) or matching placebo (1:1 ratio), starting one hour before surgery. The primary outcome was the hearing threshold at 6 and 8 kHz; secondary outcomes included the severity of tinnitus and vertigo. FINDINGS: One year after surgery, high-frequency hearing had improved 2.7 ± 3.8 dB in the placebo group (67 patients analysed) and 2.4 ± 3.7 dB in the treated group (72 patients; means ± 95% confidence interval, p = 0.54; linear mixed model). Surgery improved tinnitus, but there was no significant intergroup difference. Post-operative balance disturbance was common but improved during the first year, without significant difference between groups. Four patients receiving N-Acetylcysteine experienced mild side effects such as nausea and vomiting. CONCLUSIONS: N-Acetylcysteine has no effect on hearing thresholds, tinnitus, or balance disturbance after stapedotomy. TRIAL REGISTRATION: ClinicalTrials.gov NCT00525551.

Planning human upper airway surgery using computational fluid dynamics.

The study advances the idea of using computational fluid dynamics in the process of planning surgical treatment modalities for patients with obstructive airway disorders. It is hypothesized that the a priori knowledge of the functional outcome of surgical intervention on the flow and airway resistance can guide the surgeon in choosing an effective surgical strategy. Computed tomography images spanning the respiratory tract of an adult patient with a combined glottic and subglottic stenosis are used to reconstruct three-dimensional geometrical models of the airway. Computational fluid dynamics is used to obtain airway flow patterns during inspiration and expiration in these models. Numerical predictions about flow velocity, pressure distribution on the airway lumen, wall shear stress, and airway resistance are obtained so that the relevance of each individual stenotic level is quantified. Four different virtual surgeries in different combinations are assessed in order to remedy the constricted airway. The virtual surgery based airway models are evaluated by comparisons with the pre-treatment flow modeling results. The predicted numerical data revealed that the removal of the constriction at the level of the vocal folds will have the most significant effect on the airway resistance. The flow simulations offer a quantitative method of evaluating the airway resistance in patients with combined glottic and subglottic stenoses. Predictions of airway resistances and other numerical calculations from different virtual surgeries give additional inputs for the surgeon, in deciding the most appropriate surgery on a case-by-case basis.

The use of radiology in middle ear and temporal bone surgery.

A nationwide survey was performed in Sweden regarding the way that practicing otosurgeons utilize radiological imaging before and after performing surgery of the middle ear and temporal bone. Sixty-six surgeons from 30 different otorhinolaryngology departments participated in the study. These represented all hospitals in Sweden where ear surgery is performed to some degree. A questionnaire was designed consisting of 18 questions that were assigned to 4 different groups. Questions in group 1 assessed the general conditions regarding imaging services in the local hospital. Questions in group 2 illuminated the level of tuition and competence development when it comes to judging radiological examinations. Group 3 questions mirrored the clinical routines when ordering various specific investigations. In group 4, the questions were aimed at describing which type of information the surgeons wanted to obtain from the imaging investigations. The answers gave a good picture of how Swedish otosurgeons use the services offered by their local radiological departments. One of the conclusions is that, although there is consensus regarding certain types of examinations in specific conditions, there is a great variation in how surgeons utilize radiological imaging in many of the most common clinical conditions. It is obvious that the routines regarding the use of radiology in conjunction with ear surgery vary from place to place and also between different surgeons. Whether a consensus can be reached in the future regarding this issue remains to be seen.

Popliteal pterygium syndrome (PPS) with intra-alveolar syngnathia: a discussion of anesthetic and surgical considerations.

Popliteal pterygium syndrome (PPS) is a rare genetic disorder that involves the association of a popliteal web with a combination of craniofacial, genitourinary and extremity malformations. In this article, we describe a patient with PPS complicated with multiple intra-alveolar syngnathia. We discuss the anesthetic and the surgical management of this case and review the literature regarding PPS and intra-alveolar syngnathia.

IgE-positive plasma cells are present in adenoids of atopic children.

CONCLUSIONS: We demonstrated the presence of IgE(+) plasma cells in the adenoids of atopic children. Our data suggest that adenoids are capable of local production of IgE and support the role of adenoids as an inductive site for allergic reactions. OBJECTIVE: We have previously demonstrated increased numbers of IgE(+) cells in the adenoids of atopic children and also found support for an IL-4-induced class switch to IgE production in adenoids. In search of further evidence of adenoids being involved in IgE-mediated sensitization, we investigated the distribution of plasma cells and macrophages positive for IgE in adenoids. MATERIAL AND METHODS: Adenoid tissue from atopic and non-atopic children was examined using immunohistochemical markers for IgE, plasma cells (CD138) and macrophages (CD68). The distribution of positive cells was determined in the extrafollicular area and in the follicles of adenoids. Co-localization of IgE and CD138(+) plasma cells and CD68(+) macrophages was examined using immunohistochemical double-staining methods. RESULTS: Non-atopic adenoids contained no or very few IgE(+) cells. In contrast, IgE(+) cells were found in high numbers in atopic adenoids, mainly in the extrafollicular area. Higher numbers of IgE(+) plasma cells and IgE(+) macrophages were also found in the adenoids of atopic children.

Increased levels of IL-2 and IL-4 in stimulated adenoidal lymphocytes of atopic children.

BACKGROUND: The adenoid is involved in the defence against airway pathogens and its surface is also exposed to airborne allergens. The knowledge about reactions taking place in the lymphatic tissue of this organ is, however, limited. To elucidate the influence of atopy we investigated the cellular and cytokine profile of in vitro-stimulated adenoid lymphocytes. METHODS: Adenoid tissue cells from 13 atopic and 8 non-atopic children were cultured and stimulated with ionomycin and 4beta-phorbol 12-myristate 13-acetate. Supernatants were collected after 4 and 20 h of stimulation and interleukin-2 (IL-2), IL-4 and interferon-gamma (IFN-gamma) were analysed by ELISA. Flow cytometry was used to quantify the leukocyte markers CD3, CD19, CD25 and HLA-DR. RESULTS: Increased levels of IL-2 and IL-4 but not IFN-gamma were detected in the supernatants of adenoid cell cultures from atopic children after 20 h of stimulation (p < 0.05) and a significant correlation with a positive regression between IL-2 and IL-4 was found. Atopy was also associated with a greater increase in the percentage of CD19-positive B cells after stimulation (p < 0.05). CONCLUSIONS: A difference in the reactivity of adenoidal lymphoid cells in children was observed between atopic and non-atopic subjects. Atopy was associated with an increased production of IL-2 and IL-4 as well as a more pronounced increase of B cells.