Initial experience with CytoSorb therapy in patients receiving left ventricular assist devices.

BACKGROUND: The use of left ventricular assist devices (LVAD) in patients with advance heart failure is still associated with an important risk of immune dysregulation and infections. The aim of this study was to determine whether extracorporeal blood purification using the CytoSorb device benefits patients after LVAD implantation in terms of complications and overall survival. MATERIALS AND METHODS: Between August 2010 and January 2020, 207 consecutive patients underwent LVAD implantation, of whom 72 underwent CytoSorb therapy and 135 did not. Overall survival, major adverse events, and laboratory parameters were compared between 112 propensity score-matched patients (CytoSorb: 72 patients; non-CytoSorb: 40 patients). RESULTS: WBC (p = .033), CRP (p = .001), and IL-6 (p < .001), significantly increased with LVAD implantation, while CytoSorb did not influence this response. In-hospital mortality and overall survival during follow-up were similar with CytoSorb. However, patients treated with CytoSorb were more likely to develop respiratory failure (54.2% vs. 30.0%, p = .024), need mechanical ventilation for longer than 6 days post-implant (50.0% vs. 27.5%, p = .035), and require tracheostomy during hospitalization (31.9% vs. 12.5%, p = .040). No other significant differences were observed with regard to major adverse events during follow-up. CONCLUSIONS: Overall, our results showed that CytoSorb might not convey a significant morbidity or mortality benefit for patients undergoing LVAD implantation.

Utility of sleep nasendoscopy versus microlaryngotracheobronchoscopy in the diagnosis of paediatric upper airway obstruction.

OBJECTIVE: To describe the utility of sleep nasendoscopy in determining the level of upper airway obstruction compared to microlaryngotracheobronchoscopy. METHODS: A retrospective observational study was conducted at a tertiary level paediatric hospital. Patients clinically diagnosed with upper airway obstruction warranting surgical intervention (i.e. with obstructive sleep apnoea or laryngomalacia) were included. These patients underwent sleep nasendoscopy in the anaesthetic room; microlaryngotracheobronchoscopy was subsequently performed and findings were compared. RESULTS: Twenty-seven patients were included in the study. Sleep nasendoscopy was able to induce stridor or stertor, and to detect obstruction at the level of palate and pharynx, including tongue base collapse, that was not observed with microlaryngotracheobronchoscopy. Only 47 per cent of patients who had prolapse or indrawing of arytenoids on sleep nasendoscopy had similar findings on microlaryngotracheobronchoscopy. However, microlaryngotracheobronchoscopy was better in diagnosing shortened aryepiglottic folds. CONCLUSION: This study demonstrates the utility of sleep nasendoscopy in determining the level and severity of obstruction by mimicking physiological sleep dynamics of the upper airway.

Long-term Outcomes of Juvenile Onset Recurrent Respiratory Papillomatosis with Pulmonary Involvement.

OBJECTIVE: To investigate the clinical characteristics and long-term outcomes of juvenile onset recurrent respiratory papillomatosis (JORRP) with or without pulmonary involvement. METHODS: A group of patients with JORRP who had clinical course over an extended period of time (at least 5 years) in the Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital were included in this retrospective study. Lung/bronchus involvement was revealed by lung imaging. Data on mortality rate, frequency of surgical interventions, and age of disease onset were collected and analyzed. RESULTS: The 192 patients (107 male and 85 female) included had a median [quartiles] age of JORRP onset of 2 [1, 4] years, and median follow-up duration of 10 [7, 13] years; 17 patients (8.9%) had papilloma with bronchial and pulmonary involvement 7.0 [4.0, 12.5] years after the onset of the disease. Compared to patients without lung involvement, patients with lung involvement had a younger age of disease onset (P = .001), higher frequency of surgical interventions (P < .001), higher mortality rate (OR = 94.909), and an increased risk of tracheotomy that could not be decannulated (P < .001). They also had a younger age of disease onset, and a higher frequency of surgical interventions and mortality compared to patients with tracheotomy but free from lung involvement (P < .001). CONCLUSIONS: Children with JORRP and with pulmonary involvement have a higher average number of operations per year than those without pulmonary involvement, and pulmonary involvement indicates a higher incidence of tracheotomy that cannot be decannulated. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2277-E2283, 2021.

Tracheotomy Outcomes in 64 Ventilated COVID-19 Patients at a High-Volume Center in Bronx, NY.

OBJECTIVES/HYPOTHESIS: The COVID-19 pandemic has resulted in a dramatic increase in the number of patients requiring prolonged mechanical ventilation. Few studies have reported COVID-19 specific tracheotomy outcomes, and the optimal timing and patient selection criteria for tracheotomy remains undetermined. We delineate our outcomes for tracheotomies performed on COVID-19 patients during the peak of the pandemic at a major epicenter in the United States. METHODS: This is a retrospective observational cohort study. Mortality, ventilation liberation rate, complication rate, and decannulation rate were analyzed. RESULTS: Sixty-four patients with COVID-19 underwent tracheotomy between April 1, 2020 and May 19, 2020 at two tertiary care hospitals in Bronx, New York. The average duration of intubation prior to tracheotomy was 20 days ((interquartile range [IQR] 16.5-26.0). The mortality rate was 33% (n = 21), the ventilation liberation rate was 47% (n = 30), the decannulation rate was 28% (n = 18), and the complication rate was 19% (n = 12). Tracheotomies performed by Otolaryngology were associated with significantly improved survival (P < .05) with 60% of patients alive at the conclusion of the study compared to 9%, 12%, and 19% of patients undergoing tracheotomy performed by Critical Care, General Surgery, and Pulmonology, respectively. CONCLUSIONS: So far, this is the second largest study describing tracheotomy outcomes in COVID-19 patients in the United States. Our early outcomes demonstrate successful ventilation liberation and decannulation in COVID-19 patients. Further inquiry is necessary to determine the optimal timing and identification of patient risk factors predictive of improved survival in COVID-19 patients undergoing tracheotomy. LEVEL OF EVIDENCE: 4-retrospective cohort study Laryngoscope, 131:E1797-E1804, 2021.

Predictive Nomogram for the Necessity of Tracheotomy During Oral and Oropharyngeal Cancer Surgery.

OBJECTIVES/HYPOTHESIS: The individualized risk of airway obstruction after head and neck cancer surgery is unclear, especially oral and oropharyngeal cancer. The study aimed to establish an individualized predictive model for the necessity of temporary tracheotomy in these patients. METHODS: Patients who underwent oral and oropharyngeal cancer surgery from 1999 to 2019 were retrospectively reviewed. A nomogram was developed and validated in patients treated from 1999 to 2009 and 2010 to 2019, respectively. RESULTS: In total, 1551 patients were included. Oropharyngeal cancer, large tumor, midline crossing, preoperative radiation, mandibulectomy, flap reconstruction, and neck dissection were independent risk factors of postoperative airway obstruction in the training group (n = 707). A nomogram incorporating these factors had a C-index of 0.931 and was validated in the testing group (n = 844) (C-index, 0.918). Good calibration curves were observed in both groups. CONCLUSIONS: The nomogram successfully predicted the individual risk of postoperative airway obstruction for patients with oral and oropharyngeal cancer. LEVEL OF EVIDENCE: 4. Laryngoscope, 131:E1489-E1495, 2021.

National questionnaire on skills and techniques in pediatric tracheotomy surgery in Turkey.

OBJECTIVE: The aim of the study was to determine the differences in surgical preferences of ENT Surgeons in Turkey with regard to pediatric tracheotomy. DESIGN: Questionnaire study. PARTICIPANTS: ENT Surgeons. MATERIALS AND METHODS: The national multiple-choice questionnaire study included a total of 16 questions about physicians technical preferences, different methods and complications in pediatric tracheotomy surgery. It was planned and implemented with the support of a professional survey company (www.surveymonkey.com). RESULTS: The questionnaire was answered by 591 ENT Surgeons; the percentage of the physicians performing pediatric tracheotomies in the previous year was 59.6%. Forty point four percent (40.4%) of the physicians had not performed tracheotomies in the pediatric age group and 57.9% had not performed tracheotomies in patients under one year old. Seventy point six percent (70.6%) of the physicians who had performed tracheotomies had made vertical skin incisions, 69.5% of them had removed subcutaneous adipose tissue, 81.4% of them had retraction the thyroid isthmus area from their field of view; 83.9% of them had made a vertical incision to the trachea, 82.5% of them had applied a stay suture to the trachea and 4.7% of them had used additional techniques for stoma maturation. The intraoperative mortality, early complication, late complication, and total complication rates were 3.9%, 32.7%, 21.2% and 53.9 respectively. CONCLUSIONS: This is the first large-scale questionnaire study with data on pediatric tracheotomy techniques and the practices of ENT Surgeons at a national level. Common approaches were observed among the.

Laryngo-tracheal resections in the Nordic countries: an option for further centralization?

PURPOSE: We aimed to obtain information on the number of Nordic centers performing tracheal resections, crico-tracheal resections, and laryngo-tracheal reconstructions, as well as the patient volume and the standard regimens associated with these procedures. METHODS: Consultants at all Departments of Otorhinolaryngology-Head and Neck Surgery (ORL-HNS, n = 22) and Thoracic Surgery (n = 21) in the five Nordic countries were invited (April 2018-January 2019) to participate in an online survey. RESULTS: All 43 departments responded to the survey. Twenty departments declared to perform one or more of the three types of tracheal resections. At five hospitals, departments of ORL-HNS and Thoracic Surgery perform these operations in collaboration. Hence, one or more of the tracheal operations in question are carried out at 15 centers. The median annual number of tracheal operations per center is five (range 1-20). Great variations were found regarding contraindications (relative and absolute) for surgery, the use of guardian sterno-mental sutures (all patients, 33%; selected cases, 40% of centers), prophylactic antibiotic therapy (cefuroxime +/- metronidazole, penicillin +/- metronidazole, clindamycin, imipenem, or none), post-operative follow-up time (range: children: 3-120 months; adults: 0-60 months), and the performance of post-operative bronchoscopy. CONCLUSIONS: Fifteen centers each perform a low number of annual operations with significant variations in the selection of patients and the clinical setup, which raises the question if a higher degree of collaboration and centralization would be warranted. We encourage Nordic transnational collaboration, pursuing alignment on central management issues, and establishment of a common prospective database for future tracheal resection surgery.

Otorhinolaryngology surgery analysis in Japan and Thailand: Comparing Nihon University School of Medicine with Thammasat University Faculty of Medicine.

BACKGROUND/OBJECTIVE: We compared the surgery data of the department of otorhinolaryngology of the university hospitals in Japan and Thailand to make each feature and the differences of both otorhinolaryngology surgeries clear. There are some medical meetings and congresses between Japan and Thailand, but so far it has not reported about the comparison of surgery data. METHODS: Retrospectively, we analyzed the surgical statistics of department of otorhinolaryngology of Nihon University Itabashi Hospital (Japan) and Thammasat University Hospital (Thailand) between 2013 and 2014. RESULTS: In Japan, there were many surgeries involving the middle ear and paranasal sinuses whereas in Thailand, tracheotomy and tonsillectomy were more frequently performed. Statistical analysis of the surgical data revealed specific tendencies in the nature of the operations performed at each university. CONCLUSION: This study revealed that there are rather differences between two hospitals' surgeries features. It was thought that it would be beneficial to both institutions to gain a deeper understanding of the areas of expertise of each university in order to foster an environment conducive to increasing future international collaborations.

Management and outcomes of pediatric vocal cord paresis in Chiari malformation.

INTRODUCTION: Pediatric vocal cord paresis (VCP) has a variety of etiologies, including congenital neurologic disease. Arnold-Chiari Malformation (ACM) is one such disease with known VCP association. However, the natural history, need for tracheostomy, and rate of decannulation in this patient population is not well characterized. OBJECTIVE: To provide prognostic information on infants with ACM and VCP. METHODS: A retrospective chart review was conducted of patients with both ACM and VCP at a single institution. Clinical outcomes and disease progression were determined using flexible laryngoscopy, serial clinical exams, and operative reports from otolaryngology and neurosurgery services. RESULTS: Eighteen patients were included in this study, four with ACM Type I and 14 with ACM Type II. These groups were analyzed separately. For ACM I, the average age at diagnosis was 25 months and two (50%) required tracheostomy. Three subjects (75%) achieved VCP resolution, with two doing so after neurosurgical decompression. For ACM II, the average age at diagnosis was eight months and 12 patients (86%) underwent tracheostomy. Four subjects with tracheostomy (33%) achieved decannulation, with three of these demonstrating VCP resolution. In total, six ACM II patients had complete and one had partial VCP resolution, all of whom underwent decompression. Two patients initially had normal endoscopic exams despite stridor and VCP was only noted on serial exams. DISCUSSION: This study represents the largest series of pediatric patients with VCP and ACM. The majority needed decompression (80%) and tracheotomy (78%). Tracheostomy decannulation typically occurred only after decompression and resolution of VCP. No children diagnosed at age <1 month were decannulated. Early decompression was associated with successful avoidance of tracheostomy in majority of Chiari I but not Chiari II patients. Serial endoscopies were required to confirm VCP in some patients. This information could potentially aid in management and counseling parents of children with VCP and CM.

Outcome after long-segment tracheal resection: study of 52 cases.

OBJECTIVES: Resection of long-segment trachea is challenging, and although 50% of adult trachea can be removed, anastomotic complications arise proportionally. Different release manoeuvres have been described to gain length and reduce tension at the suture line. The aim of the study was to evaluate the outcome when different release manoeuvres have been utilized during resection and reconstruction of the trachea. METHODS: From January 2005 to December 2015, 52 patients with long segments of trachea ≥40 mm requiring resection and reconstruction were treated at our institute. Demographic, operative and postoperative data were retrospectively analysed. RESULTS: Fifty-two patients with long-segment tracheal disorders ≥40 mm were analysed in this stud. Transient swallowing and phonation dysfunction occurred in 17 (32.2%) patients, exclusively in patients who underwent laryngeal release. Swallowing dysfunction was Grade I in all patients, except 2 who suffered Grade II dysphagia and were relieved in the early postoperative period. Forty-five (86.5%) patients were symptom free, and 7 (13.4%) patients were symptomatic (dyspnoea on exertion and/or stridor) and required reintervention. Four (7.6%) patients responded to 1 or 2 sessions of bronchoscopic dilatation, and 3 patients were left with permanent tracheostomies. Patients with neoplastic pathology were followed up without any neoplastic recurrence. CONCLUSIONS: Long-segment resection and reconstruction of the trachea utilizing one or more release manoeuvres can be safely done, with low complication rates. Although swallowing and phonation dysfunction after laryngeal release were commonly encountered (almost one-third of patients), they were mild, transient, self-limited and recovered within 2-3 weeks of the early postoperative period.

National changes in pediatric tracheotomy epidemiology during 36 years.

BACKGROUND: Information on the incidence, indications and morbidity of pediatric tracheotomy from a nationwide setting is sparse. METHODS: From the nationwide Danish National Patient Registry, we identified all cases: 0-15-year-old children registered with a first-time tracheotomy from 1979 to 2014. We extracted the date of surgery, admission, discharge, age, gender, hospital, department, hospitalization length, hospital contacts, and diagnosis-code related to the surgery. We estimated age-adjusted incidence rates (AAIR) and annual (APC) and average annual percentage change (AAPC) of tracheotomy incidence. RESULTS: A total of 510 children (328 boys, 63%) underwent tracheotomy. The median age at surgery was 8 years. The AAIR was 1.4/100,000 person-years (range 1.0-1.8) from 1980 to 2014. During 1979-2014, the AAPC decreased - 0.9% (95% confidential interval - 2.4; 0.8, p < 0.3). From 1979 to 2003 the APC decreased - 4.1% (95% CI - 5.4; - 2.8, p < 0.001) and from 2003 to 2014 the APC increased 6.6% (95% CI 2.0; 11.5, p < 0.001). Infants had the highest incidence (4.0/100,000 years) compared with the 12-15-year-olds (AAIR: 0.4/100,000 years). From 1979 to 2014 the most common indication for tracheotomy among children aged 0-2 years was congenital malformations (n = 48, 30%) and among children aged 3-11 and 12-15 years the most common indication was trauma (respectively n = 67, 36% and n = 85, 52%). During 2006-2014 the most common indications for all ages was neurological impairment (n = 25, 21%) and neoplasms (n = 20, 17%). CONCLUSIONS: Pediatric tracheotomy was a rare surgical procedure with decreasing incidence rates from 1980-89 to 1990-99 and increasing incidence rates from 2000-2009 to 2010-2014. Indications and postoperative morbidity have changed adjunct to the treatment of chronic disorders.

Development of a prediction model for long-term quality of life in critically ill patients.

PURPOSE: We developed a prediction model for quality of life (QOL) 1 year after intensive care unit (ICU) discharge based upon data available at the first ICU day to improve decision-making. METHODS: The database of a 1-year prospective study concerning long-term outcome and QOL (assessed by EuroQol-5D) in critically ill adult patients consecutively admitted to the ICU of a university hospital was used. Cases with missing data were excluded. Utility indices at baseline (UIb) and at 1 year (UI1y) were surrogates for QOL. For 1-year non-survivors UI1y was set at zero. The grouped lasso technique selected the most important variables in the prediction model. R2 and adjusted R2 were calculated. RESULTS: 1831 of 1953 cases (93.8%) were complete. UI1y depended significantly on: UIb (P<0.001); solid tumor (P<0.001); age (P<0.001); activity of daily living (P<0.001); imaging (P<0.001); APACHE II-score (P=0.001); ≥80 years (P=0.001); mechanical ventilation (P=0.006); hematological patient (P=0.007); SOFA-score (P=0.008); tracheotomy (P=0.018); admission diagnosis surgical P<0.001 (versus medical); and comorbidity (P=0.049). Only baseline health status and surgical patients were positively associated with UI1y. R2 was 0.3875 and adjusted R2 0.3807. CONCLUSION: Although only 40% of variability in long-term QOL could be explained, this prediction model can be helpful in decision-making.

Risk Factors of Stomal Recurrence After Laryngectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: We wished to investigate the risk factors for stoma recurrence following laryngectomy. METHODS: PubMed, Cochrane Library, and Embase were searched to identify primary research studies published between January 1, 1967, and October 31, 2016. We only included observational epidemiological studies and used risk ratios (RRs) and 95% confidence intervals (CI) to summarize the primary risk factors associated with recurrence following laryngectomy. RESULTS: A total of 44 articles, including 11 928 patients, were included in the current meta-analysis. The pooled estimates of the stomal recurrence rate and the local recurrence rate following laryngectomy were 6.60% (95% CI, 5.40-7.90) and 19.40% (95% CI, 14.00%-24.80%), respectively. For stomal recurrence, we confirmed a series of earlier identified factors, including tumor site, prior tracheotomy, tracheotomy timing, T-classification, lymph node metastases, postoperative pharyngoperistomal fistula, and a positive surgical margin. For local recurrence, postoperative radiotherapy, overexpression of p53, and overexpression of p21 were significant, while preoperative tracheostomy and postoperative pharyngoperistomal fistula had an unexpectedly low impact on risk. CONCLUSION: This study has confirmed a series of earlier identified factors for stomal recurrence and local recurrence following laryngectomy. Our results will provide important insights for clinical practice.

Nasotracheal prolonged safe extubation in acute respiratory failure post-thyroidectomy: An efficacious technique to avoid tracheotomy? A retrospective analysis of a large case series.

BACKGROUND: Acute respiratory failure is a rare life threatening complication following thyroid surgery and its incidence is reported as high as 0.9%. Clinical presentation of severe acute respiratory failure is characterized by dyspnea, inspiratory airways distress, hypoxia and its standard current management is the orotracheal intubation and safe extubation. In case of persistent distress, tracheotomy is mandatory. The Authors, analysing a large acute respiratory failure clinical series, describe an innovative treatment of this severe condition: the nasotracheal prolonged safe extubation. METHODS: Patients treated at our Intensive Care Unit for acute respiratory failure following thyroid surgery from January 2004 to December 2013, were reviewed. Demographic data including gender, age, clinical presentation, laryngoscopic findings, management and outcome during a 24-months follow-up after treatment were collected and evaluated. Moreover, the strategy for prolonged nasotracheal safe extubation was carefully described. RESULTS: Nineteen out of the 2853 patients scheduled for thyroid surgery (0.66%) at our University Hospital, developed post-operative acute respiratory failure. All of them were treated by nasotracheal prolonged safe extubation. The success rate in avoiding highly invasive treatment was of 84.2%, since only 3 patients needed definitive tracheotomy (15.7%). CONCLUSIONS: In our series, the prolonged safe extubation reduced the almost totality of expected tracheotomies in patients with acute respiratory failure following thyroid surgery (84.2%), demonstrating its feasibility and efficacy. It was a well tolerated and minimal invasive procedure that allowed a good respiratory ability and a fast clinical resolution of the laryngeal functional impairment.

Development of a nomogram for predicting the probability of postoperative delirium in patients undergoing free flap reconstruction for head and neck cancer.

PURPOSE: To develop nomogram for prediction of postoperative delirium (POD) in patients undergoing ablative and reconstruction surgery for head and neck cancer. METHODS: Total 341 patients were retrospectively analyzed, and clinical variables in preoperative, intraoperative and postoperative periods were compared between delirium group (n = 89) and non-delirium group (n = 252). Multivariate logistic regression, receiver operating characteristics curve, and area under the curve (AUC) were used to generate and test a nomogram, which performance was evaluated by 10-fold cross validation (CV) procedure. RESULTS: In univariate and multivariate analysis, age, history of psychiatric disorder, marital status, preoperative numeric rating scale for pain, ASA classification, and ICU stay period were identified as significant risk factors. Using these factors, nomogram for predicting the POD was developed and it showed sensitivity of 61.8%, specificity of 75.4%, PPV of 47.0%, and NPV of 84.8% (Youden's index of 0.372). In 10-fold cross validation set, corresponding values were 44.9%, 84.1%, 50.0% and 81.2% (Youden's index of 0.337). AUC was comparable between two sets (0.7407 and 0.6898). CONCLUSIONS: Proposed nomogram showed fair discriminative power for POD risk in head and neck cancer patients undergoing major surgery.

Traqueostomía percutánea por anestesiólogos: descripción de técnica con control fibrobroncoscópico directo y resultados en unidad de cuidados intensivos y grandes quemados / Percutaneous tracheostomy by anaesthesiologists: description of direct fiberoptic technic and results in an intensive care and burn unit

Introduction: The anesthesiologist often leaves the walls of the operating room to perform procedures in other departments, an activity inherent to his expert airway and critical patient’s management. Prolonged mechanical ventilation is one of the factors that increase Intensive Care Unit (ICU) stay, which is associated with increased mortality and an increase in healthcare-associated pneumonia. Percutaneous tracheostomy has reduced the length of stay in the ICU and indirectly, morbidity and mortality. Objectives: To describe the experience and results of percutaneous tracheostomy by Anesthesiologists in the ICU of the Mutual de Seguridad Clinical Hospital between 2013 and 2016. Methods: Case Series Study of percutaneous tracheostomies (TQT), performed by anesthesiologists in the ICU...

Introducción: El especialista en Anestesiología y Reanimación extiende sus competencias fuera del pabellón quirúrgico cada vez con más frecuencia para realizar procedimientos en otros servicios, actividad inherente a su pericia en el manejo de la vía aérea y pacientes críticos. La ventilación mecánica (VM) prolongada es uno de los factores que extienden la estadía en la Unidad de Cuidados Intensivos (UCI), la que está relacionada a aumento de mortalidad y de neumonías asociadas a atención de salud (IAAS). La traqueostomía (TQT) percutánea ha logrado reducir la estadía en UCI e indirectamente, la morbilidad y mortalidad en esta unidad. Objetivos: Describir experiencia y resultados de realización de la traqueostomía percutánea por Anestesiólogos en UCI del Hospital Clínico Mutual de Seguridad entre 2013 y 2016. Métodos: Estudio descriptivo. Serie de casos de TQT percutánea realizados por anestesiólogos capacitados en la técnica...

Vocal Fold Paralysis after Esophagectomy for Carcinoma.

OBJECTIVES: (1) To recognize factors that contribute to vocal fold paralysis (VFP) after esophagectomy. (2) To describe the morbidity associated with VFP after esophagectomy. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: The medical records of 91 patients undergoing esophagectomy for malignancy were reviewed (2008-2014). Twenty-two patients with postoperative VFP were compared with 69 patients without VFP with regard to preoperative variables, surgical approach (transcervical vs other), and postoperative outcomes. A subset analysis of cervical approaches was performed, including those where an otolaryngologist assisted. RESULTS: There were no significant differences in preoperative variables between patients with and without VFP. Cervical approaches were associated with increased VFP (P < .0001). Recurrent laryngeal nerve (RLN) identification was associated with increased VFP (P = .0001). RLN dissection by head and neck surgeons was associated with decreased VFP (P = .0223). Patients with VFP had longer lengths of stay (P = .0078), higher rates of tracheotomy (P = .0439), and required more outpatient swallow evaluations (P = .0017). Mean time to diagnosis of VFP was 45.6 days (median, 7.5 days). CONCLUSIONS: Cervical approaches are associated with increased VFP in patients undergoing esophagectomy for malignancy. When cervical approaches and mobilization are required, the inclusion of an experienced cervical surgeon to identify the RLN may improve the rate of postoperative VFP. Patients with VFP after esophagectomy experience significantly more morbidity. Due to the potential delay in diagnosis and treatment of postoperative VFP, routine assessment of inpatient vocal fold function may be beneficial.

[Development of tracheal resection technique - our experience]. / Vývoj techniky resekcí trachey - nase zkusenosti.

INTRODUCTION: Tracheal resections are very frequent interventions on the trachea in general. In borderline cases where the tracheal resection length is too high, the situation can be resolved by inserting a stent or Montgomerys T cannula. Tracheal stenoses are of benign origin in 94%, and malignant in 6% of cases. We present a summary of tracheal resection interventions for the last 21 years. METHOD: 235 tracheal resections were performed at the authors institution in 1993-2013. In total 221 benign stenosis cases (85 % developed after tracheostomy, 15% developed after intubation) and 14 malignant cases were treated. The patients were divided into two groups: A resection in years 19932002 and B - resection in years 20032013. The comparison of these two time periods is presented with focus on surgical procedures development and recommendations based on experienced complications. RESULTS: Restenosis (early or late) is the most common complication during the process of tracheal resection treatment. Tiny fistulas in the suture can be diagnosed easily by minor air leaking and are treated conservatively without intervention. Fortunately, suture insufficiency is relatively rare. In some cases the restenoses can be resected or treated by stent application or by Montgomerys T-cannula application. Complications were observed in 2% of the treated patients, which is a number presented also by international studies. CONCLUSION: Tracheal resection is definitely an optimal solution for patients suffering from tracheal stenosis. As presented in our study, in the hands of experienced thoracic surgeons tracheal resections is a safe and final solution of tracheal stenosis. KEY WORDS: trachea - stenosis resection.

Difficult Intubation Factors in Prehospital Rapid Sequence Intubation by an Australian Helicopter Emergency Medical Service.

OBJECTIVE: Prehospital rapid sequence intubation (RSI) of critically ill trauma patients is a high-risk procedure that may be associated with an increased rate of severe complications such as failed intubation, failure of oxygenation, hypoxia, hypotension, or need for surgical airway. The objective of this study was to describe the factors associated with difficult intubation in prehospital RSI as defined by more than a single look at laryngoscopy to achieve tracheal intubation. METHODS: This is an observational study using prospectively collected data. RESULTS: Four hundred forty-three RSIs were performed. Paramedics were the initial laryngoscopist in 290 (65.5%). First-look laryngoscopy resulted in successful tracheal intubation (TI) in 372 (84.0%) (95% confidence interval, 80.3%-87.1%). Intubation was achieved on second look at laryngoscopy in 58 (13.1%). "First-pass" TI was achieved in 394 (88.9%). Overall, successful TI was achieved in 438 (98.9%) (95% confidence interval, 97.4%-99.5%). Complications occurred in 116 (26.2%), with desaturation the commonest in 77 (17.4%). CONCLUSION: Factors associated with more than 1 look at laryngoscopy before TI included paramedic laryngoscopist and the presence of at least 1 of the following indicators: blood/vomitus in the airway, limited mouth opening, and limited neck movement. Trauma to face/neck, obese body habitus, C-spine precautions, cricoid pressure, midline stabilization, and intubation on the ground did not influence the level of difficulty encountered.