Patient-Directed Home Drain Removal in Head and Neck Surgery.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to evaluate the efficacy and safety of at home drain removal in head and neck surgery patients. METHODS: The study population included patients who underwent head and neck surgery at an academic tertiary care center between February 2020 and November 2020 and were discharged with one to four drains with instructions for home removal. Prior to discharge, patients received thorough drain removal education. Patients were prospectively followed to evaluate for associated outcomes. RESULTS: One hundred patients were evaluated in the study. There was record for ninety-seven patients receiving education at discharge. The most common methods of education were face-to-face education and written instructions with educational video link provided. Of 123 drains upon discharge, 110 drains (89.4%) were removed at home while 13 (10.6%) were removed in office. Most drains were located in the neck (86.4%). There was one seroma, two hematomas, two drain site infections, and five ED visits; however, none of these complications were directly associated with the action of drain removal at home. Calculated cost savings for travel and lost wages was $259.82 per round trip saved. CONCLUSIONS: The results demonstrate that home drain removal can provide a safe and efficacious option for patients following head and neck surgery. This approach was safe and associated with patient cost savings and better utilization of provider's time. Furthermore, patients and healthcare providers avoided additional in-person encounters and exposures during the COVID-19 pandemic. Our findings warrant further investigation into cost savings and formal patient satisfaction associated with home drain removal. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2471-2477, 2021.

Transnasal endoscopic skull base surgery in the COVID-19 era: Recommendations for increasing the safety of the method.

Transnasal endoscopic skull base surgery (eSBS) has been adopted in recent years, in great part to replace the extended procedures required by external approaches. Though sometimes perceived as "minimally invasive", eSBS still necessitates extensive manipulations within the nose/paranasal sinuses. Furthermore, exposure of susceptible cerebral structures to light and heat emanated by the telescope should be considered to comprehensively evaluate the safety of the method. While the number of studies specifically targeting eSBS safety still remains scarce, the problem has recently expanded with the SARS-CoV-2 pandemic, which also has implications for the safety of the surgical personnel. It must be stressed that eSBS may directly expose the surgeon to potentially high volumes of virus-contaminated aerosol. Thus, the anxiety of both the patient and the surgeon must be taken into account. Consequently, safety requirements must follow the highest standards. This paper summarizes current knowledge on SARS-CoV-2 biology and the peculiarities of human immunology in respect of the host-virus relationship, taking into account the latest information concerning the SARS-CoV-2 worrisome affinity for the nervous system. Based on this information, a workflow proposal is offered for consideration. This could be useful not only for the duration of the pandemic, but also during the unpredictable timeline involving our coexistence with the virus. Recommendations include technical modifications to the operating theatre, personal protective equipment, standards of testing for SARS-CoV-2 infection, prophylactic pretreatment with interferon, anti-IL6 treatment and, last but not least, psychological support for the patient.

The endoscopic endonasal eustachian tube anterolateral mobilization strategy: minimizing the cost of the extreme-medial approach.

OBJECTIVE: The ventral jugular foramen and the infrapetrous region are difficult to access through conventional lateral and posterolateral approaches. Endoscopic endonasal approaches to this region are obstructed by the eustachian tube (ET). This study presents a novel strategy for mobilizing the ET while preserving its integrity. Qualitative and quantitative comparisons with previous ET management paradigms are also presented. METHODS: Ten dry skulls were analyzed. Four ET management strategies were sequentially performed on a total of 6 sides of cadaveric head specimens. Four measurement groups were generated: in group A, the ET was intact and not mobilized; in group B, the ET was mobilized inferolaterally; in group C, the ET underwent anterolateral mobilization; and in group D, the ET was resected. ET range of mobilization, surgical exposure area, and surgical freedom were measured and compared among the groups. RESULTS: Wide exposure of the infrapetrous region and jugular foramen was achieved by removing the pterygoid process, unroofing the cartilaginous ET up to the level of the posterior aspect of the foramen ovale, and detaching the ET from the skull base and soft palate. Anterolateral mobilization of the ET facilitated significantly more retraction (a 126% increase) of the ET than inferolateral mobilization (mean ± SD: 20.8 ± 11.2 mm vs 9.2 ± 3.6 mm [p = 0.02]). Compared with group A, groups C and D had enhanced surgical exposure (142.5% [1176.9 ± 935.7 mm2] and 155.9% [1242.0 ± 1096.2 mm2], respectively, vs 485.4 ± 377.6 mm2 for group A [both p = 0.02]). Furthermore, group C had a significantly larger surgical exposure area than group B (p = 0.02). No statistically significant difference was found between the area of exposure obtained by ET removal and anterolateral mobilization. Anterolateral mobilization of the ET resulted in a 39.5% increase in surgical freedom toward the exocranial jugular foramen compared with that obtained through inferolateral mobilization of the ET (67.2° ± 20.5° vs 48.1° ± 6.7° [p = 0.047]) and a 65.4% increase compared with that afforded by an intact ET position (67.2° ± 20.5° vs 40.6° ± 14.3° [p = 0.03]). CONCLUSIONS: Anterolateral mobilization of the ET provides excellent access to the ventral jugular foramen and infrapetrous region. The surgical exposure obtained is superior to that achieved with other ET management strategies and is comparable to that obtained by ET resection.

Assessment of Factors Associated With Internal Carotid Injury in Expanded Endoscopic Endonasal Skull Base Surgery.

Importance: Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery does not typically occur as an isolated circumstance but often is the result of multiple factors. Objective: To assess the factors associated with ICA injury in an effort to reduce its occurrence. Design, Setting, and Participants: This quality improvement study used a multicenter root cause analysis of ICA injuries sustained during endoscopic endonasal skull base surgery performed at 11 tertiary care centers across 4 continents (North America, South America, Europe, and Asia) from January 1, 1993, to December 31, 2018. A fishbone model was built to facilitate the root cause analysis. Patients who underwent an expanded endoscopic endonasal approach that carried a substantial potential risk of an ICA injury were included in the analysis. A questionnaire was completed by surgeons at the centers to assess relevant human, patient, process, technique, instrument, and environmental factors associated with the injury. Main Outcomes and Measures: Root cause analysis of demographic, human, patient, process, technique, instrument, and environmental factors as well as mortality and morbidity data. Results: Twenty-eight cases of ICA injury occurred during 7160 expanded endoscopic endonasal approach procedures (incidence of 0.4%). The mean age of the patients was 49 years, with a female to male predominance ratio of 1.8:1 (18 women to 10 men). Anatomical (23 [82%]), pathological (15 [54%]), and surgical resection (26 [93%]) factors were most frequently reported. The surgeon's mental or physical well-being was reported as inadequate in 4 cases (14%). Suboptimal imaging was reported in 6 cases (21%). The surgeon's experience level was not associated with ICA injury. The ICA injury was associated with use of powered or sharp instruments in 20 cases (71%), and use of new instruments or technology in 7 cases (25%). Two patients (7%) died in the operating room, and 3 (11%) were alive with neurological deficits. Overall, patient-related factors were the most frequently reported risk factors (in 27 of 28 cases [96%]). Factors associated with ICA injury catalyzed a list of preventive recommendations. Conclusions and Relevance: This study found that human factors were associated with intraoperative ICA injuries; however, they were usually accompanied by other deficiencies. These findings suggest that identifying risk factors is crucial for preventing such injuries. Preoperative planning and minimizing the potential for ICA injury also appear to be essential.

Periodic olfactory assessment in patients undergoing skull base surgery with preservation of the olfactory strip.

OBJECTIVES/HYPOTHESIS: Others have reported olfactory disturbances following endoscopic approaches to the skull base. However, there is a lack of consensus on the extent and duration of dysfunction. This study aimed to compare our results with previously published work and to validate the olfactory strip-sparing approach. STUDY DESIGN: Prospective study to assess olfaction in 50 patients scheduled to undergo resection of skull base tumors via extended endoscopic approaches. METHODS: Patients were divided into two groups. Group I had a nasoseptal flap (NSF), and group II included patients in whom rescue flaps were performed bilaterally. Olfactory outcomes were assessed using repeated University of Pennsylvania Smell Identification Test at baseline, 6 weeks, 3 months, and 6 months following surgery. RESULTS: Ultimately, 42 patients (seven group I and 35 group II) were available for assessment. Scores for group I were lower than at baseline at 6 weeks postoperatively (30.71 ± 5.5 vs. 24.5 ± 5.4; P = .05). However, by the third postoperative month the scores had improved to a level that was not significantly different from baseline (29.0 ± 3.7; P = .5). At 6 months, the score was 30.0 ± 3.9. Patients in group II showed no difference between their baseline and 6-week scores (31.5 ± 5.3 vs. 29.7 ± 5.9; P = .16). Six months postoperatively, the score was significantly higher (33.78 ± 3.6; P = .04). CONCLUSIONS: Expanded endoscopic approaches to skull base tumors involving reconstruction with an NSF are associated with a short-term negative impact on olfaction. Olfaction does not seem to be affected by the surgical resection of pituitary adenomas associated with rescue flaps. Identification of the olfactory epithelium and meticulous harvesting of the NSF are critical to preserve olfaction. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1970-1975, 2017.

Hemostasis management during completely endoscopic removal of a highly vascular intraparenchymal brain tumor: technique assessment.

BACKGROUND: Recently, stereotactic-guided removal of intraparenchymal lesions using endoscopic visualization through a brain port has been successfully reported. Although endoneurosurgical tumor resection uses the same principles as those used in microneurosurgery, the ability to control bleeding through the port requires an adapted technique. MATERIAL AND METHODS: We present a patient that underwent a completely endoscopic resection of a vascular brain tumor through a brain port and describe the hemostatic technique. RESULTS: A 68 year-old female presented with progressive gait difficulties. She had been previously treated for a breast cancer. Magnetic resonance imaging (MRI) showed a right subcortical solitary cerebellar lesion that homogeneously enhanced. The patient underwent an endoscopic brain port removal of a supposed brain metastasis. After port cannulation, the tumor partly delivered itself into the port. Following initial tumor biopsy, active bleeding occurred. Irrigation and application of Surgifoam allowed to control the bleeding. Coagulation with an adapted bipolar and removal of coagulated tissue with the side-cutting aspiration device were sequentially repeated. Once the tumor was resected, the suction served as counter-traction elongating the vessels whereas the bipolar cauterized them over a long segment. Hemostasis was performed circumferentially along the cavity's walls from deep to superficial, benefiting from the endoscope's dynamic properties and magnification. Pathology confirmed intraoperative suspicion of hemangioblastoma. CONCLUSION: Removal of vascular tumors is feasible through the brain port, despite a relatively narrow corridor of 11.5 mm. However, specific hemostasis techniques are required and adapted instruments are needed to ensure hemostasis through these small corridors.

Neuronavigation in endonasal pituitary and skull base surgery using an autoregistration mask without head fixation: an assessment of accuracy and practicality.

BACKGROUND: Intraoperative navigation is an important tool used during endonasal surgery, which typically requires rigid head fixation. Herein we describe a navigational technique using an autoregistration mask without head fixation. MATERIAL AND METHODS: Prospective evaluation of a surface autoregistration mask used without rigid head fixation in 12 consecutive endonasal endoscopic skull base procedures was performed with patients positioned in a horseshoe head holder. We assessed the accuracy by recording the surface registration error (SRE) and target registration error (TRE). We also noted the time required for installation and the occurrence of system failure. The system's accuracy was validated using a deep target simultaneously viewed with endoscopic. RESULTS: In 12 consecutive endonasal cases performed by a neurosurgeon and ENT team, pathologies included pituitary macroadenomas (9), chordoma (1), craniopharyngioma (1), and sinonasal melanoma (1). Median time required for the registration and accuracy verification was 84 seconds (interval 64 to 129 seconds). The mask stayed on the patient throughout the procedure. The mean SRE was 0.8 mm (interval 0.6 to 0.9 mm). The mean TRE was 0.9 ± 0.7 mm and 1.0 ± 0.8 mm measured respectively at the beginning and end of the case. In every case, the system was judged accurate by the surgical team using the sphenoid keel or an intrasphenoidal bony septation as a deep target for internal validation. No system failure occurred during these 12 cases. CONCLUSION: A facial surface autoregistration mask maintained in place throughout surgery without rigid head fixation allows excellent operational accuracy in endonasal pituitary and skull base surgery. This navigation system is practical, reliable, and noninvasive.

Safety and cost-effectiveness of intra-office flexible videolaryngoscopy with transoral vocal fold injection in dysphagic patients.

SETTING: A tertiary care referral-based otolaryngology practice. OBJECTIVES: To evaluate the safety of office-based transoral oral vocal fold injection in an ambulatory dysphagic population and to evaluate cost-effectiveness in comparison with traditional injection laryngoplasty done under general anesthesia in the operating room. Dysphagia is a nonspecific and common symptom of many head and neck and systemic disease processes. In patients with glottal incompetence, the presenting complaint of dysphagia generally portends to more global oropharyngeal dysfunction than dysphonia alone. Although many authors have reported on and advocated the use of office injection technique in the management of dysphonia caused by glottal insufficiency, there is a paucity of literature regarding the use of this technique in a more medically compromised dysphagic patient population (Ann Otol Rhinol Laryngol 1997;106:778-83). We describe our experience with vocal fold injection in the office setting using a transoral technique under flexible videolaryngoscopy for the treatment of glottal insufficiency in dysphagic patients. The safety and cost-effectiveness of this approach are highlighted.

Assessment of swallowing function in patients with head and neck cancer.

Difficulty in swallowing is a common complaint among patients with head and neck cancer. Preexistent dysphagia is often compounded by any of the side effects and sequelae of the current treatment modalities for malignancies of the head and neck. Surgery, radiotherapy, and chemoradiotherapy produce sensory and motor denervation and fibrosis of the upper aerodigestive tract musculature and mucosa. Clinicians must learn to anticipate and identify the various deficits of swallowing function in these patients. Flexible fiberoptic evaluation of swallowing and the modified barium swallow are critical tests for delineating the pathophysiology of these patients and establishing a protocol for their rehabilitation. Rehabilitation for patients with swallowing disorders decreases the morbidity of aspiration and allows for better nutrition, better hydration, and overall improvement in quality of life.