OBJECTIVES: Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) has demonstrated utility in extending the apneic window in the perioperative setting. Its benefits in facilitating tubeless anesthesia are recognized during elective laryngotracheal surgeries. The use of THRIVE and administering higher fractional inspired oxygen concentrations in laser laryngeal surgery (LLS) remains controversial due to the theoretical risk of airway fires. A scoping review of the literature describing institutional experiences with THRIVE during LLS was conducted. DATA SOURCES AND REVIEW METHODS: A systematic scoping review of the literature was performed including PubMed, Medline, Embase, Scopus, JBI EBP Database, and Cochrane Library from inception to April 2023. RESULTS: From the 472 articles identified in our review, nine articles were included representing 271 cases. THRIVE was used for preoxygenation and to maintain apneic oxygenation during LLS. Different institutional practices related to THRIVE parameters and intraoperative modifications during lasing were described in the literature, including cessation of THRIVE, reduction of FiO2 to 30%, and continuous 100% FiO2 oxygenation. One study described a brief ignition of the coating of a KTP laser fiber without injury to the patient. No adverse patient outcomes have been documented in the literature with THRIVE during LLS. CONCLUSION: THRIVE is a safe and effective form of tubeless anesthesia and apneic oxygenation during LLS, with no adverse patient safety events reported in the literature. Key determinants to maintain safety include optimal patient and team selection, effective surgeon-anesthetist cooperation, and institutional protocols that govern intraoperative practice. Laryngoscope, 2024.
High-flow nasal oxygen (HFNO) therapy is extensively used in critical care units for spontaneously breathing patients. Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a method of apnoeic oxygenation with continuous nasal delivery of warmed, humidified oxygen at high-flow rates up to 70L/min. THRIVE extends the apnoeic window before desaturation occurs so that tubeless anaesthesia is possible. The advent of THRIVE has had a monumental impact on anaesthetic practice, with a diverse range of clinical applications and it has been incorporated into difficult airway guidelines. THRIVE has many applications in otolaryngology and head and neck surgery. It is used as a pre-oxygenation tool during induction in both anticipated and unanticipated difficult airway scenarios and as a method of oxygenation for tubeless anaesthesia in elective laryngotracheal and hypopharyngeal surgeries and during emergence from anaesthesia. In this scoping review of the literature, we aim to provide an overview on the utility of THRIVE in otolaryngology, including the underlying physiologic principles, current indications and limitations, and its feasibility and safety in different surgical contexts and specific population groups.
PURPOSE: Online resources are increasingly being utilised by patients to guide their clinical decision making, as an alternative or supplement to the traditional clinical-patient relationship. YouTube is an online repository of user and community generated videos, which is one of the most popular websites globally. We undertook a study to examine the quality of information presented in YouTube videos related to tonsillectomy. METHODS: We completed a systematic search of YouTube in May 2023 and identified 88 videos for inclusion in our study. Videos were published in the English language, focussing on tonsillectomy and tonsillectomy recovery, and were greater than 2 min in length. We recorded video quality metrics and two authors independently analysed the quality of information using three validated quality assessment tools described in the literature including the modified DISCERN, Global Quality Score, and the JAMA Benchmark Criteria. RESULTS: The overall quality of the information was low with mean quality scores of Modified DISCERN (1.8 ± 1.3), GQS (2.6 ± 1.2), and JAMA Benchmark Criteria (1.6 ± 0.7). Information published by medical sources including medical professionals, healthcare organisations, and medical education channels scored significantly higher compared to non-medical sources across all quality measures and were of moderate overall quality and usefulness: Modified DISCERN (2.5 ± 1.1 vs 0.8 ± 0.9, z = -6.0, p < 0.001), GQS (3.2 ± 1.0 vs 1.7 ± 0.9, z = -5.7, p < 0.001), and JAMA (1.9 ± 0.8 vs 1.1 ± 0.3, z = -5.2, p < 0.001). Videos published during or after 2018 scored higher on Modified DISCERN (z = -3.2,p = 0.001) but not on GQS or JAMA. Video quality metrics such as total view count, likes, and comments, and channel subscriber count, did not correlate with higher video quality. However, amongst videos published by authoritative medical sources, total view count correlated positively with higher Modified DISCERN quality scores (p = 0.037). CONCLUSION: The overall quality and usefulness of YouTube videos on tonsillectomy is of low quality, but information published by authoritative medical sources score significantly higher. Clinicians should be mindful of increasing use of online information sources such as YouTube when counselling patients. Further research is needed in the medical community to create engaging, high-quality content to provide guidance for patients.
Social Media , Tonsillectomy , Video Recording , Humans , Tonsillectomy/education , Information Dissemination/methods , Patient Education as Topic/standards , Patient Education as Topic/methods
The floor of the maxillary sinus is partly formed by the alveolar process of the maxilla, and this anatomical relationship forms an interface for collaboration between rhinologists, maxillofacial and dental surgeons, and dentists. Odontogenic maxillary sinusitis (ODMS) occurs secondary to infectious processes of the maxillary molar and premolar teeth or following complications from dental procedures. Extruded dental foreign bodies within the sinus can cause chronic mucosal irritation leading to mucociliary dysfunction and sinogenic symptoms. Anteriorly placed foreign bodies are difficult to access via the conventional endoscopic maxillary antrostomy. Endoscopic approaches to access the anterior maxillary sinus involve extended resection of the medial maxillary wall, potentially with the removal of the inferior turbinate and nasolacrimal duct mobilisation. The prelacrimal window approach (PLWA) is a favourable modification that provides excellent visualisation of the maxillary sinus with minimal tissue resection and displacement. We describe the case of an extruded distobuccal 27 tooth root into the anterior maxillary sinus, presenting with acute sinusitis. The patient was successfully managed via a PLWA. This case represents the importance of recognition of ODMS with early referral to otorhinolaryngologists.
Background: Laryngeal paragangliomas (LP) comprise a rare subset of head and neck neoplasms and are an important differential in the patient with a submucosal laryngeal mass. Methods: We discuss an operative technique using coblation assisted excision via laryngofissure in the cases of four confirmed LPs and discuss the current literature with respect to diagnosis and management of these patients. Results: Our case series of four patients demonstrate the laryngofissure approach for LP is safe, provides oncological cure and preserves laryngeal function. This technique with coblation has not been previously discussed in the surgical management of LPs. Patient-reported postoperative voice and swallowing outcomes were excellent in all patients. Whole body imaging techniques were utilized in all patients, with octreotide scintigraphy demonstrating synchronous lesions in two of the four patients-one had a retroperitoneal lesion, whilst another patient had multiple lesions in the skull base, paravertebral region, liver, and adrenal gland. Conclusions: Our cases also highlight the changing clinical paradigms in the diagnostic approach of LPs and an emerging role for octreotide scintigraphy in the workup of these patients. Coblation assisted excision via laryngofissure is efficient and effective in the surgical resection of LP. In patients with multicentric forms of LP, the size, side, and anatomic location of synchronous lesions should be considered in surgical planning to determine feasibility and safety of operative management. Level of Evidence: IV.
BACKGROUND: Tracheoesophageal puncture (TEP) with voice prosthesis (VP) insertion is the gold standard of surgical voice restoration in postlaryngectomy patients. The conventional technique involves rigid esophagoscopes and trocar performed by ENT surgeons alone, with technical limitations encountered in patients with cervical abnormalities - in particular those with free or rotational flap reconstructions and postradiotherapy strictures. We report our technique using flexible endoscopy which we show to be feasible and without major safety events, as a possible consideration in the anticipated difficult TEP. METHODS: Our study describes a multidisciplinary approach to secondary TEP involving a combined upper gastrointestinal (UGI) and (Ear, Nose, and Throat) ENT procedure, under the guidance of flexible esophagoscopy, with intraoperative involvement of the speech pathologist to guide VP insertion and placement. The procedure was performed with ease without major complications. RESULTS: We identified nine postlaryngectomy and laryngopharyngectomy patients in our institution who underwent secondary TEP with VP insertion using flexible esophagoscopy and multidisciplinary intra-operative involvement. All patients had pharyngeal reconstruction, including radial forearm free flap (n = 4), pectoralis major rotational flap (n = 3), and anterolateral thigh flap (n = 2). Eight out of nine patients underwent adjuvant radiotherapy. The technique was successfully performed in all patients. There were three cases of early TEP displacement in two patients, of which one patient had a successful repeat procedure. We found the technique advantageous in terms of feasibility and practicality compared to the conventional approach, and without intraoperative difficulties encountered in achieving the desired field of views or navigating the challenging anatomy in a free flap and post-radiotherapy patients. This includes distorted cervical anatomy, the presence of bulky and hair-bearing flap skin, and stricture formation. Minor complications in our cohort included pharyngo-esophageal spasm, TEP displacement, granulation tissue, and peri-prosthetic leaks. CONCLUSION: Our multidisciplinary approach to secondary TEP was performed with flexible esophagoscopy without major related complications. The technique is advantageous in the surgical approach to VP insertion in postlaryngectomy and laryngopharyngectomy patients who have had radiotherapy or pharyngeal reconstruction. It allows for safe anatomical insertion and thorough evaluation of the upper aerodigestive tract for comorbid benign or malignant esophageal pathology.
Objective: Autoimmune inner ear disease (AIED) is a rare disorder characterized by rapidly progressive, sensorineural hearing loss that demonstrates good responsiveness to corticosteroid and immunosuppressive therapy. The pathophysiology is likely driven by chronic trafficking of immune cells into the inner ear, targeting inner ear proteins to coordinate inflammation. Suppression or modulation of the immune response can minimize cochleitis allowing for potential recovery of hearing. It is an otologic emergency requiring a multidisciplinary approach to management to commence immunosuppressive therapy. This can be achieved using steroids, immunomodulators, plasmapheresis, intravenous immunoglobulin, or biologic agents. Treatment decisions are further complicated in pregnancy and require supervision by an obstetrician and maternal-fetal medicine (MFM) specialist. Concerns include safe dosing of steroids and potential for transplacental migration of immune complexes. We provide the first comprehensive literature review on AIED and its implications in pregnancy. We frame our discussion in the context of the second reported case of primary AIED in pregnancy and the first to show excellent response to immunosuppressive therapy. Methods: We reviewed the presented case and literature on AIED. Results: A 27-year-old, pregnant, HSP-70 positive woman was diagnosed with AIED and had excellent recovery of hearing and balance following a combination of steroid treatment, augmented by oral immunomodulators, plasmapheresis, and IVIG. Conclusion: AIED is a diagnostic challenge, and treatment considerations are complex when encountered in pregnancy. Management requires multidisciplinary involvement between otolaryngologists, immunologists, and obstetricians to balance maternal and fetal health outcomes.
BACKGROUND: Ramsay Hunt Syndrome (RHS) is a neurotological disorder involving the reactivation of the varicella-zoster virus (VZV) in the geniculate ganglion of the facial nerve (Sweeney and Gilden in J Neurol Neurosurg Psychiatry 71:149-154, 2001). The characteristic presentation involves ipsilateral lower motor neuron type facial paresis, auricular pain with or without hearing impairment, and vesicular lesions of the external auditory canal and outer ear. Involvement of the facial and vestibulocochlear nerve is typical in RHS, whilst multiple cranial neuropathies are rare and associated with poorer prognosis and systemic complications (Arya et al. in Am J Case Rep 19:68-71, 2017; Shinha and Krishna in IDCases 2:47-48, 2015; Shim et al. in Acta Otolaryngol 131:210-215, 2011; Coleman et al. in J Voice 26:e27-e28, 2012; Morelli et al. in Neurol Sci 29:497-498, 2008;). Likely mechanisms involved in the pathogenesis of cranial polyneuropathy include direct peri-neural and trans-axonal spread of viral inflammation between contiguous cranial nerves and haematogenous dissemination between nerves with shared blood supply. Impairments in speech, swallowing, hearing, and oculo-protection can contribute to morbidity and requires a multidisciplinary approach to patient care. METHODS: We present a rare case of RHS with multiple cranial neuropathies followed by a comprehensive review of current literature with regard to the pathophysiology, diagnostic workup, and the management strategies employed in these patients. CONCLUSION: RHSs with multiple cranial neuropathies are important to recognise as they are associated with significant morbidity and poor prognosis. A multidisciplinary approach to patient management is required to address the several complications that can arise from cranial nerve deficits, especially in regard to speech and swallow.
Cranial Nerve Diseases , Facial Paralysis , Herpes Zoster Oticus , Cranial Nerve Diseases/complications , Cranial Nerve Diseases/diagnosis , Cranial Nerves , Facial Paralysis/diagnosis , Herpes Zoster Oticus/complications , Herpes Zoster Oticus/diagnosis , Herpesvirus 3, Human , Humans
BACKGROUND: Cardiac magnetic resonance feature tracking (CMR-FT) and speckle tracking echocardiography (STE) are well-established strain imaging modalities. Multilayer strain measurement permits independent assessment of endocardial and epicardial strain. This novel and layer specific approach to evaluating myocardial deformation parameters may provide greater insight into cardiac contractility when compared to whole-layer strain analysis. The aim of this study is to validate CMR-FT as a tool for multilayer strain analysis by providing a direct comparison between multilayer global longitudinal strain (GLS) values between CMR-FT and STE. METHODS: We studied 100 patients who had an acute myocardial infarction (AMI), who underwent CMR imaging and echocardiogram at baseline and follow-up (48 ± 13 days). Dedicated tissue tracking software was used to analyse single- and multi-layer GLS values for CMR-FT and STE. RESULTS: Correlation coefficients for CMR-FT and STE were 0.685, 0.687, and 0.660 for endocardial, epicardial, and whole-layer GLS respectively (all p < 0.001). Bland Altman analysis showed good inter-modality agreement with minimal bias. The absolute limits of agreement in our study were 6.4, 5.9, and 5.5 for endocardial, whole-layer, and epicardial GLS respectively. Absolute biases were 1.79, 0.80, and 0.98 respectively. Intraclass correlation coefficient (ICC) values showed moderate agreement with values of 0.626, 0.632, and 0.671 respectively (all p < 0.001). CONCLUSION: There is good inter-modality agreement between CMR-FT and STE for whole-layer, endocardial, and epicardial GLS, and although values should not be used interchangeably our study demonstrates that CMR-FT is a viable imaging modality for multilayer strain.
Echocardiography , Magnetic Resonance Imaging, Cine , ST Elevation Myocardial Infarction/diagnostic imaging , Ventricular Function, Left , Adult , Aged , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Prognosis , Reproducibility of Results , ST Elevation Myocardial Infarction/physiopathology , ST Elevation Myocardial Infarction/therapy , Time Factors
BACKGROUND: Multilayer strain measurement with cardiac magnetic resonance feature tracking (CMR-FT) allows independent assessment of endocardial and epicardial strain. This novel method of layer-specific quantification of myocardial deformation parameters provides greater insight into contractility compared to whole-layer strain analysis. The clinical utility of this technique is promising. The aim of this study is to investigate the intra- and inter- observer reproducibility of CMR-FT derived multilayer global longitudinal strain (GLS) and global circumferential strain (GCS) parameters in the setting of normal cardiac function, cardiac pathology, and differing MRI field strengths. METHODS: We studied 4 groups of 20 subjects, comprising of patients with dilated cardiomyopathy, ischemic heart disease, and patients without cardiac pathology at both 1.5 and 3 T. Quantitative measures of whole-layer and multi-layer longitudinal and circumferential strain were calculated using CMR-FT software. RESULTS: Intraclass correlation coefficients (ICC) for intraobserver reproducibility of endocardial, epicardial, and whole-layer measurements of GLS were 0.979, 0.980, and 0.978 respectively, and those for GCS were 0.986, 0.977, and 0.985. ICCs for inter-observer reproducibility of endocardial, epicardial, and whole-layer measurements of GLS were 0.976, 0.970, and 0.976, and those for GCS were 0.982, 0.969, and 0.981. Bland Altman analysis showed minimal bias and acceptable limits of agreement (LOA) within each patient subgroup and the overall cohort. Circumferential and longitudinal strain parameters were equally reproducible in the overall cohort. CONCLUSIONS: CMR-FT derived multilayer measurements of longitudinal and circumferential strain demonstrate high intra- and inter- observer reproducibility, with suitability for use in clinical practice.
BACKGROUND: Prospective studies demonstrate that over one-third of patients undergoing standard suture closure of laparotomy wounds will develop incisional hernias (IHs). Whilst prophylactic mesh has been demonstrated to decrease IH rates in clean laparotomy wounds, mesh has been associated with high rates of seroma formation (>30%), infection (>10%) and pain, discouraging many surgeons from using mesh, especially combined with intestinal surgery. The aim of this study is to review the experience of a single colorectal surgeon who, after noting high IH rates in his own patients, started placing prophylactic mesh routinely in patients judged to be at high risk of IH. METHODS: The records of all patients undergoing bowel resections and ileostomy closure by one surgeon from 2008 to 2018 were independently retrospectively analysed. RESULTS: Of the 935 procedures identified, 662 patients underwent midline laparotomy with bowel resection and 273 patients underwent closure of loop ileostomy. Mesh was placed prophylactically in 221 (23.6%) of 935 procedures. Comparing the mesh and non-mesh groups, wound infections occurred in nine (4.1%) versus 23 (3.2%) (P = 0.53), seromas occurred in nine (4.1%) versus six (0.8%) (P = 0.003) and chronic pain was noted in 12 (5.4%) versus 17 (2.4%) (P = 0.04). The mean follow-up was 33 months in both the mesh and non-mesh groups. IHs have occurred in three (1.3%) of the mesh group compared to 95 (13.3%) of the non-mesh group procedures (P = 0.0001). CONCLUSION: In colorectal operations, prophylactic mesh decreases the risk of IH without prohibitive complications.
Abdominal Wall , Abdominal Wound Closure Techniques , Colorectal Neoplasms , Hernia, Ventral , Incisional Hernia , Abdominal Wall/surgery , Hernia, Ventral/epidemiology , Hernia, Ventral/surgery , Humans , Incisional Hernia/epidemiology , Incisional Hernia/prevention & control , Prospective Studies , Retrospective Studies , Surgical Mesh
