Long-term Outcomes of Cricothyroidotomy Versus Endotracheal Intubation in Military Personnel: A Retrospective Comparative Analysis Cohort Study.

INTRODUCTION: Emergency airway management is critical in trauma care. Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data is needed regarding the short and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI. METHODS: Data on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the Israel Defense Forces trauma registry. Patient data was then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel. RESULTS: Of the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% versus 65%, P = 0.02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% versus 29%, P = 0.002). Injury Severity Score was comparable between groups.No significant difference was found in intensive care unit length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 y, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. One patient in the CRIC group suffered from esophageal stricture. CONCLUSIONS: This retrospective comparative analysis did not reveal significant short or long-term sequelae among military personnel who underwent prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers. The findings of this study could provide valuable insights into managing difficult airway in trauma care and inform clinical decision-making in emergency settings.

Subacute Thyroiditis Following COVID-19 and COVID-19 Vaccination.

OBJECTIVE: COVID-19 infection and immunizations have been implicated in developing a range of thyroid diseases, including subacute thyroiditis (SAT). This study aimed to evaluate the association between COVID-19 infection and/or COVID-19 vaccination with SAT. METHODS: A population of 3 million adults insured by Clalit Health Services was evaluated from March 2020 to September 2022. Patients with a new diagnosis of SAT were identified and matched in a 1:10 ratio to a control group. Each control was assigned an index date that was identical to that of their matched case, defined as the date of SAT diagnosis. Multivariate conditional logistic regression models were used to evaluate the association between COVID-19 infection, vaccine, and thyroiditis. RESULTS: A total of 3221 patients with SAT were matched with 32 210 controls. Rates of COVID-19 vaccination (first, second, or third dose) and COVID-19 infection were evaluated prior to the date of SAT diagnosis (disease group) or index date (control group) to detect a possible association. No difference was detected between the groups in relation to vaccinations at the 30 days, 60 days, and 90 days of time points (P = .880/0.335/0.174, respectively). No difference was found between groups in relation to COVID-19 infection at these time points (P = .735/0.362/0.956, respectively). There was higher use of medications for the treatment of thyroiditis, including nonsteroidal anti-inflammatory drugs (28.6% vs 7.9%, P < .01), steroids (10.3% vs 1.8%, P < .01), and beta-blockers (18.3% vs 5.4%, P < .01). CONCLUSION: Based on this large population study, no association was found between COVID-19 infection and/or the COVID-19 vaccine and SAT.

Management of first branchial anomalies in children: 20 years of experience.

PURPOSE: Branchial cleft anomalies (BCAs) are common pediatric head and neck lesions; however, only 1-4% involve the first branchial cleft. The rare occurrence of first BCAs, their presentation at a young age, and the possible facial nerve involvement make diagnosis and treatment challenging. METHODS: A retrospective chart review was conducted for children diagnosed with their first BCA between 2000 and 2020. Data on demographics, presenting symptoms, physical findings, imaging features, previous surgery, and treatment outcomes were collected and analyzed. RESULTS: The cohort included 17 patients with a median age of 5 years at presentation. Seven (41%) had undergone previous surgical intervention before definitive surgery. Eight were classified as Work Type II anomalies, and nine as Work Type I. Sixteen patients (94%) underwent definitive surgical excision at a median age of 6.9. A parotid approach was used in 10 (62%), with dissection of the mass from the facial nerve, and a retro-auricular or end-aural approach was used in 6 (38%). Complete excision was achieved in 14/16 patients (88%). Three patients had transient facial nerve paresis postoperatively. Recurrence was noted in 3/16 patients (18%). Enhancement in imaging was positively correlated with post-operative complications (R = 0.463, P = 0.018). CONCLUSIONS: First, BCA poses a diagnostic and surgical challenge; thus, definitive surgical treatment is often delayed. The surgical approach should be tailored to the type of anomaly (Work type I or II) and possible facial nerve involvement. Risk factors for post-operative complications are a history of recurrent infections and previous surgical interventions. The presence of contrast enhancement in preoperative imaging should alert surgeons to perioperative challenges and the risk of post-operative complications.

Intelligence among ear deformities and cleft lip and/or alveolus and/or cleft palate patients during 50 years in Israel.

PURPOSE: We evaluated hearing loss and general intelligence among persons with auricle anomalies and cleft lip and/or alveolus and/or cleft palate (CLAP). METHODS: A nationwide cross-sectional study of data recorded during 1966-2019, as mandatory pre-military recruitment of individuals. RESULTS: Of 3 182 892 adolescents, 548 were diagnosed with auricle anomalies and 2072 with CLAP. For the latter, the adjusted odds ratios for the low, low to medium and medium general intelligence categories compared to the highest category were 1.4 [95% CI 1.5-1.2], 1.2 [95% CI 1.4-1.1] and 1.1 [95% CI 1.2-0.9] respectively. The corresponding values for the auricle anomalies were not significant. CONCLUSIONS: General intelligence was impaired among individuals with CLAP, but no significant correlation was found among individuals suffering from auricle anomalies.

Predictors of residual disease following pediatric thyroglossal duct cyst excision.

OBJECTIVES: Residual thyroglossal duct cyst (TGDC) following surgical excision is not uncommon. This study aimed to search for risk factors for residual disease that either required revision surgery or were resolved with only conservative treatment and follow up. METHODS: A retrospective study of consecutive children who underwent surgical excision for thyroglossal duct cysts between 2008 and 2021 at Schneider Children's Medical Center of Israel, a tertiary referral center in Israel. RESULTS: Out of 102 children, 54 (53 %) had an uneventful recovery, 32 (31 %) had post-operative complications which were managed without revision surgery, and 16 (16 %) underwent revision surgery. A comparison of the three groups showed that children who had early post-operative complications (up to one month) were more likely to respond to conservative treatment (57 %). In contrast children with late complications had a higher probability (59 %) of undergoing revision surgery. The presence of a pre-operative cutaneous fistula was significantly associated with revision surgery (p = 0.012). In addition, children with no prior history of neck infection were more likely to have an uneventful recovery (p = 0.005). CONCLUSIONS: TGDC disease has a wide range of clinical presentations both before and after surgery. A significant percentage of children with persistent post-operative symptoms may resolve without revision surgery. The presence of a pre-operative cutaneous fistula and late post-operative complications are the main risk factors for revision surgery.

Traumatic maxillofacial injuries: Patterns, outcomes, and long-term follow-up of a military cohort.

BACKGROUND/AIMS: Maxillofacial trauma poses a distinct challenge on the modern battlefield, and data on its long-term implications are scarce. The aim of this study was to investigate maxillofacial injury characteristics, outcomes, and complications along the continuum of care among hospitalized military personnel from the pre-hospital setting through long-term rehabilitation. MATERIALS AND METHODS: A registry-based study was undertaken of three national trauma and rehabilitation registries: The Israel Defense Forces Trauma Registry (IDF-TR), which records pre-hospital data. The Israeli National Trauma Registry for in-hospital data and the Israel Ministry of Defense Rehabilitation Department (MOD-RD) registry contain long-term disability data. The cohort comprised IDF soldiers who suffered maxillofacial injuries between 1997 and 2020. RESULTS: A total of 672 patients with maxillofacial injuries were included in the study, and 6.4% of all trauma admissions were related to maxillofacial injuries. Of these, 366 (54%) were injured in non-military (NMC) circumstances, and 306 (46%) were wounded in military circumstances (MC). The mechanisms of injury were mainly traffic-related among the NMC group compared with an explosion in the MC group. Maxillofacial fractures were frequently associated with traumatic brain injuries with higher rates in the NMC group than in the MC group (55% vs. 30%, p < .001). In a multivariate analysis, zygomatic and orbital fractures were associated with higher odds of concomitant head injury. The most common categories of long-term disability included central nervous system disorders, skull injuries, epilepsy, hearing impairment, ophthalmologic conditions, and post-traumatic stress disorder. CONCLUSIONS: Maxillofacial injuries are often associated with concomitant traumatic brain injury. Long-term disabilities associated with these injuries included the central nervous system, hearing, ophthalmologic impairments, and post-traumatic stress disorder.

Efficacy of Oral Steroids for Acute Acoustic Trauma.

OBJECTIVE: This study aimed to study the effect of steroid treatment on new-onset sensorineural hearing loss (SNHL) in subjects presenting shortly after an audiometry-confirmed acute acoustic trauma (AAT) injury. STUDY DESIGN: This is a case-control study. METHODS: We identified healthy military personnel who presented with AAT injury to the Israeli Defense Forces Medical Corps Otolaryngology/Audiology Services during 2016-2020. Patients were nonrandomly allocated to a treatment arm, where they received steroids (prednisone, 1 mg/kg, 60 mg maximal daily dose), administered for either ≥7 days or <7 days, or to a control arm, in which no treatment was offered besides loud noise avoidance. Audiometries were conducted within 7 days following the AAT and within 1 month later. We compared changes in bone conduction (BC) and air conduction (AC) thresholds at 2-8 kHz. RESULTS: Of the 263 enrolled subjects, 137 (52%) received steroids and 126 (48%) received no treatment. Subjects who were treated early (<24 h) with high-dose steroids and for ≥7 days demonstrated significantly better hearing outcomes, compared with the nontreatment group. Subjects in the steroids group demonstrated 13-14 dB average improvement in BC thresholds at 3 and 4 kHz (p = 0.001) and additional 7-8 dB average improvement in AC thresholds at 6 and 8 kHz, compared with the nontreatment group (p < 0.0001). These observations were more compelling in patients who initially presented with worse hearing losses (>35 dB). No statistically significant differences were observed in AC/BC pure tone average between the two groups. CONCLUSIONS: Early oral steroids are recommended in AAT injuries and were shown to improve hearing outcomes within 1 month.

Characterization of Fanconi Anemia Patients with Head and Neck Squamous Cell Carcinoma: Israel Fanconi Registry.

BACKGROUND: Recent studies show a high risk of developing malignancy in patients with Fanconi anemia. The most common solid tumor in this condition is head and neck squamous cell carcinoma (HNSCC) and there is often uncertainty and about disease behavior as well as chemotherapy and radiation response. OBJECTIVES: To describe and characterize HNSCC among Fanconi anemia patients on the Israeli Fanconi Registry. METHODS: Our study population included patients in Israel's inherited bone marrow failure registry who were diagnosed with Fanconi anemia between1980 and 2016. Demographic, clinical, and laboratory data were collected from patient charts. RESULTS: From the collected data, HNSCC was confirmed in 6/111 (5.4%) Fanconi anemia patients; 1 (17%) had classic HNSCC risk factors of tobacco abuse and 4 (56%) had undergone primary surgery. The 3 (50%) receiving concurrent chemoradiotherapy had mild side effects, while half developed metachronous primary malignancy, and all developed > 2 primary malignancies. The overall median survival of the patients in our study was 14 (0.5-57) months. CONCLUSIONS: Fanconi anemia patients have a very high risk of developing HNSCC. Proactive screening for malignancies is needed for the head and neck regions. We also found that chemoradiotherapy can be used safely in high-stage cancers.

A retrospective study of oral pathoses in Israeli military divers and non-divers: 2011-2020.

BACKGROUND/AIM: Self-contained underwater breathing apparatus (SCUBA) diving has grown tremendously as a recreational sport over the past decade. The pain divers experience due to barometric changes is referred to as barodontalgia, and it is known to cause various oral pathoses. Furthermore, divers suffer more frequently from temporomandibular disorders than non-divers. The aim of the study was to characterize oral pathoses between military divers and military non-divers. MATERIAL AND METHODS: Data from the dental files of healthy Israel Defense Forces (IDF) soldiers aged 18-40 years were collected retrospectively for the years 2011-2020. The data for subjects exposed to diving were compared to commando and special forces soldiers. RESULTS: The study population was composed of 6398 soldiers, which included 1036 divers and 5362 non-divers. All participants were male, with a median age of 22 years (mean = 22.1 years). Overall, higher rates of faulty dental restorations were seen among divers than non-divers (9.3% vs. 6.7% p = .006). Temporomandibular disorders were more prevalent among divers, specifically Disc Displacement Without Reduction (DDWOR) (0.4% vs. 0.1% p = .003). While dental fractures showed no significant difference between divers and non-divers (3.8% vs. 3.5% p = 0.8), other oral injuries were nine times more prevalent among divers versus non-divers. CONCLUSION: Military divers are, overall, at a higher risk of oral pathoses than non-divers. This may be related to the characteristics and intensity of their military service.

Balloon Eustachian tuboplasty in a professional Navy SEAL diver: case report.

Middle ear barotrauma due to dilatory Eustachian tube dysfunction (ETD) is probably the most common medical disorder related to diving. Moreover, ETD makes divers prone to other diving-related accidents, including inner ear barotrauma and alternobaric vertigo. Until the development of Eustachian tube balloon dilation no diving-compatible surgical options existed to effectively and safely prevent recurrence. We present a case of an Israeli Navy SEAL diver who dives in extreme strenuous combat-related closed-circuit rebreather (CCR) dives. Due to repeated middle ear barotrauma, the patient underwent Eustachian tube balloon dilation of the affected side. Following surgery, the patient returned to both CCR and scuba dives but still suffered from middle ear symptoms and repeated barotrauma hence was eventually disqualified from further combat diving.

Foregoing elective neck dissection for elderly patients with oral cavity squamous cell carcinoma.

OBJECTIVE: Elective neck dissection (END) improves outcomes among clinically node-negative patients with oral cavity squamous cell carcinoma (OCSCC). However, END is of questionable value, considering the potentially higher comorbidities and operative risks in elderly patients. METHODS: A retrospective review of all patients older than 65 years of age who were treated for OCSCC at a tertiary care centre between 2005 and 2020 was conducted. RESULTS: Fifty-three patients underwent primary tumour resection alone, and 71 had simultaneous END. Most primary tumours were located on the mobile tongue. The patients who did not undergo END had a higher mean age (81.2 vs. 75.1 years, P < 0.00001), significantly shorter surgeries, and shorter hospitalizations. Occult cervical metastases were found in 24% of the patients who underwent END. The two groups showed no significant differences in overall survival or recurrence rates. Similar results were shown in a subpopulation analysis of patients older than 75 years. CONCLUSION: Foregoing END in elderly patients with no clinical evidence of neck metastases did not result in lower survival rates or higher recurrence rates.

Opioids and Cancer: Current Understanding and Clinical Considerations.

Pain is one of the most common symptoms in patients with cancer. Pain not only negatively affects the quality of life of patients with cancer, but it has also been associated with reduced survival. Pain management is therefore a critical component of cancer care. Prescription opioids remain the first-line approach for the management of moderate-to-severe pain associated with cancer. However, there has been increasing interest in understanding whether these analgesics could impact cancer progression. Furthermore, epidemiological data link a possible association between prescription opioid usage and cancer development. Until more robust evidence is available, patients with cancer with moderate-to-severe pain may receive opioids to decrease suffering. However, future studies should be conducted to evaluate the role of opioids and opioid receptors in specific cancers.

Prognostic Significance of Regional Disease in Young Patients with Oral Cancer: A Comparative Study.

BACKGROUND: Regional metastases are considered the most important prognostic factor in OSCC patients. We aimed to investigate the impact of regional disease among different age groups with OSCC. METHODS: A retrospective comparison between patients 40 years old or younger, 41-69 years old, and 70 years or older treated for OSCC between 2000 and 2020 in a tertiary-care center. RESULTS: 279 patients were included. The mean age was 65 ± 17.7 and 133 were male (47.7%). Thirty-six (12.9%) were 40 years old or younger, 101 (36.2%) were 41-69 years and 142 (50.9%) were 70 years or older. Five-year overall survival and disease-specific survival (DSS) were significantly better among patients younger than 40 compared to the mid-age group and patients 70 years or older (76.7% vs. 69.4% vs.48.2%, Log-rank p < 0.001, and 76.7% vs. 75.3% vs. 46.5%, Log-rank p < 0.001, respectively). While an association between regional spread and overall survival and DSS was demonstrated among all age groups, the odds ratio (OR) for death of any cause and death of disease regarding cervical metastasis was much higher among patients younger than 40 compared with the 41-69 and 70+ age groups (death of any cause-OR = 23, p-value = 0.008, OR = 2.6, p-value = 0.026, OR = 2.4, p-value = 0.13, respectively. Death of disease-OR = 23, p-value = 0.008, OR = 2.3, p-value = 0.082, OR = 4.1, p-value = 0.001, respectively). In univariate  analysis, regional metastasis was associated with disease-free survival only among patients younger than 40 (p-value = 0.04). CONCLUSIONS: Regional metastases correspond with worse prognosis in young patients compared to older patients. These patients may benefit from a comprehensive treatment approach with close post-treatment follow-up. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2212-2220, 2024.

Hearing Impairment and Severe Attention Deficit/Hyperactivity Disorder: A Nationwide Study.

BACKGROUND: The association between hearing impairment and attention-deficit/hyperactivity disorder (ADHD) is unclear. Therefore, we aimed to assess this association in Israel's national sample of over 1.1 million adolescents. METHODS: We conducted a nationwide, population-based, cross-sectional study of all Israeli adolescents (n = 1,175,534, 58% males; mean age, 17 yrs) who were examined before mandatory military service during 2004 to 2020. Board-certified specialists confirmed diagnoses of hearing impairment and severe ADHD. MAIN OUTCOMES AND MEASURES: We compared the prevalence of severe ADHD in adolescents with and without hearing impairment. Associations were analyzed using logistic regression models and sensitivity analyses accounting for hearing impairment type (sensorineural vs. conductive) and severity. RESULTS: Of the 8,769 adolescents with hearing impairment, 57 were diagnosed with severe ADHD (prevalence = 0.65%). Of the 1,166,765 adolescents without hearing impairment, 3,936 were diagnosed with severe ADHD (prevalence = 0.29%). We found a significant association between hearing impairment and severe ADHD (odds ratio = 1.93 [95% confidence interval, 1.47-2.49]), which persisted in a multivariable model adjusted to age, sex, socioeconomic status, educational status, cognitive performance, and immigration status (odds ratio = 1.70 [95% confidence interval, 1.29-2.20]). The association also persisted when stratified by hearing impairment type (sensorineural vs. conductive) and severity. CONCLUSIONS: Adolescents with hearing impairment had 70% increased odds of severe ADHD. Study findings suggest that active screening of patients with hearing impairment for ADHD should be considered.

Extended cervical approach for retrosternal multinodular goiter.

Objective: Partial or total sternotomy is required for 10% of retrosternal goiter. This study reviewed our experience with an extended cervicotomic approach as an alternative surgical solution for retrosternal goiter. Methods: A retrospective study was performed on patients who underwent partial or total thyroidectomy for retrosternal goiter between 2014 and 2019 at a tertiary medical centre. Data on clinical, radiologic, and pathologic factors were analysed. Peri- and postoperative outcomes were compared between extended and standard cervical approaches to predict the need for an extended cervical approach. Results: The cohort included 265 patients, of whom 245 (92.4%) were treated by standard thyroidectomy. In 17 (6.4%), the standard approach proved insufficient, and the horizontal incision was extended to a T-shape to improve access. The remaining 3 patients required a sternotomy. Use of the extended cervical approach was significantly associated with clinical features such as male gender, diabetes, high body mass index and postoperative hypocalcaemia. Conclusions: The extended cervicotomic approach is an alternative surgical solution for retrosternal goiter, with no increased risk of significant post-operative complications.

The Long-Term Implications of Rhinitis and Chronic Rhinosinusitis in Young Adults.

BACKGROUND: The long-term impact of rhinitis and chronic rhinosinusitis (CRS) on general health and medical services utilization in young adults have been limitedly studied. METHODS: A case-control study in the Israeli Defense Forces, between the years 2005 and 2019, of all individuals with either rhinitis or CRS and a matched cohort of healthy individuals with a minimum of 5 years of consecutive follow-up. RESULTS: The study groups included 617 patients with rhinitis and 296 patients with CRS and 2739 healthy controls with an average age of 28 years. During a mean follow-up of 8 years, a significant fraction of patients in both study groups were diagnosed with asthma compared to the control group, (26.1% and 23.3% vs. 3.7%, respectively; CI 95%: 12.1%-14.9%, p < 0.0001). 7.6% of patients with rhinitis developed CRS. Significantly increased loss of productivity and medical system utilization were noted in the study groups compared to controls (p < 0.0001). Moreover, deterioration in general health, manifested as loss of physical fitness for combative service was observed in a third of patients during follow-up. CONCLUSIONS: Rhinitis and CRS significantly impact productivity and medical service utilization in young adults, as well as general health associated with development of asthma and impairment of physical fitness. A minority of rhinitis patients develop CRS overtime, further affecting this patient group. These patients should be followed up and managed to improve disease control and associated outcomes. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:3299-3303, 2023.

The Predictors of Persistent Posttracheostomy Tracheocutaneous Fistula and Successful Surgical Closure.

OBJECTIVE: Persistent tracheocutaneous fistula is a well-described complication of prolonged tracheostomy, with a prevalence of about 70% when decannulation is performed after more than 16 weeks. Predictors of its occurrence and outcome of treatment in adults remain unclear. The aim of the study was to describe our experience with the treatment of persistent posttracheostomy tracheocutaneous fistula in adults and to investigate factors associated with its formation and with the success of surgical closure. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary medical center. METHODS: Patients who underwent open-approach tracheostomy between 2000 and 2020 were identified by database review. Data on background, need for surgical closure, and the surgical outcome was collected from the medical files and analyzed statistically between groups. RESULTS: Of 516 patients identified, 127 with sufficient long-term follow-up data were included in the study. Compared to patients whose fistula closed spontaneously (n = 85), patients who required surgical closure (n = 42) had significantly higher rates of smoking, laryngeal or thyroid malignancy, and airway obstruction as the indication for tracheostomy, on both univariate and multivariate analysis. In a comparison of patients with successful (n = 29) or failed (n = 11) surgical closure, factors significantly associated with failure were prior radiotherapy and lower preoperative albumin level, on univariate analysis. CONCLUSION: Smoking, thyroid or laryngeal malignancy, and airway obstruction indication are risk factors for persistent posttracheostomy tracheocutaneous fistula. Patients should be closely followed after tracheostomy and referred for surgery if the fistula fails to close. Before surgery, careful evaluation of the patient's nutritional status and consideration of prior radiation treatment is mandatory.