The development of a clinical algorithm for the diagnosis of tumours in the parapharyngeal space. A systematic review.

INTRODUCTION: Parapharyngeal space (PPS) is defined as a deep space, located around the upper pharynx, in the shape of an inverted pyramid. Primary tumours in this region are rare, accounting for 0.5% of head and neck neoplasms, and most are benign. The objective of this study is to propose a new study algorithm based on a systematic review and our experience. MATERIALS AND METHODS: A cross-sectional and analytical study was carried out through review of the clinical records of our hospital. Patients with tumours of the parapharyngeal space operated from January 2010 to December 2019 and a systematic review of Pubmed studies from the last 5 years were included. We considered clinical signs, diagnostic methods, presumptive diagnosis and histopathological findings. Statistical analysis was performed with STATA v.14 software. RESULTS: 53 of our cases and 1392 from the review were included. The clinical algorithm showed a sensitivity of 76.4% and a specificity of 96.3%, with an AUC of 0.57 for diagnosis. DISCUSSION: Complementary radiological examinations are essential in the topographic diagnosis of the tumour. Angio-MRI links the tissue of origin of the tumours and provides the highest diagnostic certainty. FNA has some disadvantages in PPS, but it is useful in some patients. CONCLUSION: The proposed algorithm contributes to obtaining excellent results in the management of these tumours because it turned out to be effective in diagnosis, and this enables improved surgical planning.

Desarrollo de algoritmo clínico para el diagnóstico de tumores del espacio parafaríngeo. Revisión sistemática / The development of a clinical algorithm for the diagnosis of tumours in the parapharyngeal space. A systematic review

Introducción: El espacio parafaríngeo (EPF) es definido como un espacio profundo, situado alrededor de la faringe superior, con forma de pirámide invertida. Los tumores primarios de esta región son poco frecuentes, representando el 0,5% de las neoplasias de la cabeza y el cuello, y la mayoría son benignos. El objetivo de este trabajo es proponer un nuevo algoritmo de estudio basado en una revisión sistemática y en nuestra experiencia. Material y método: Se realizó un trabajo transversal y analítico a través de la revisión de historias clínicas de nuestro hospital. Se incluyeron pacientes con tumores del espacio parafaríngeo operados desde enero de 2010 a diciembre de 2019 con revisión en Pubmed de estudios de los últimos 5años. Tuvimos en cuenta signos clínicos, métodos diagnósticos, diagnóstico presuntivo y hallazgos histopatológicos. El análisis estadístico se realizó con el software STATA v.14. Resultados: Se incluyeron 53 casos nuestros y 1.392 de la revisión. El algoritmo clínico mostró una sensibilidad del 76,4% y una especificidad del 96,3%, con una AUC de 0,57 para el diagnóstico. Discusión: Los exámenes radiológicos complementarios son imprescindibles en el diagnóstico topográfico del tumor. La angio-RNM vincula el tejido de origen de los tumores y aporte la mayor certeza diagnóstica. La PAAF tiene algunas desventajas en EPF, pero es útil en algunos pacientes. Conclusión: El algoritmo propuesto contribuye a obtener resultados excelentes en el manejo de estos tumores debido a que resultó ser eficaz en el diagnóstico, y ello permite mejorar la planificación quirúrgica.(AU)

Introduction: Parapharyngeal space (PPS) is defined as a deep space, located around the upper pharynx, in the shape of an inverted pyramid. Primary tumours in this region are rare, accounting for 0.5% of head and neck neoplasms, and most are benign. The objective of this study is to propose a new study algorithm based on a systematic review and our experience. Materials and methods: A cross-sectional and analytical study was carried out through review of the clinical records of our hospital. Patients with tumours of the parapharyngeal space operated from January 2010 to December 2019 and a systematic review of Pubmed studies from the last 5years were included. We considered clinical signs, diagnostic methods, presumptive diagnosis and histopathological findings. Statistical analysis was performed with STATA v.14 software. Results: 53 of our cases and 1392 from the review were included. The clinical algorithm showed a sensitivity of 76.4% and a specificity of 96.3%, with an AUC of 0.57 for diagnosis. Discussion: Complementary radiological examinations are essential in the topographic diagnosis of the tumour. Angio-MRI links the tissue of origin of the tumours and provides the highest diagnostic certainty. FNA has some disadvantages in PPS, but it is useful in some patients. Conclusion: The proposed algorithm contributes to obtaining excellent results in the management of these tumours because it turned out to be effective in diagnosis, and this enables improved surgical planning.(AU)

Ultrasound-guided Drainage vs Surgical Drainage of Deep Neck Space Abscesses: A Randomized Controlled Trial.

INTRODUCTION: The most common cause of deep neck infections is dental infection. They are diagnosed with physical examination, imaging studies, ultrasound, or computed tomography. Surgical drainage of collections should always be performed early in a classical or percutaneous way, depending on the case. The aim of the study was to compare ultrasound-guided percutaneous drainage techniques vs. surgical drainage in deep cervical abscesses of odontogenic origin in a controlled and randomized trial. METHODS: A randomized controlled clinical trial was performed from January 2015 to December 2019. Hospital stay was evaluated as an efficiency variable. Epidemiological and secondary variable data (tumour, trismus, fever, pain), leukocytosis, cosmetic result comparing both techniques were analysed. Statistical analysis was carried out with STATA v 14.0. RESULTS: 128 patients were analysed, 51 women and 77 men. Average age 27.3 (SD = 10.13). The percutaneous group had a mean hospital stay of 3.03 (SD = 2.86) days and the surgical group 5.46 (SD = 2.96). The P-value was <.001. Cosmetic results showed differences favouring the percutaneous drainage group. None of the other variables showed statistically significant results. DISCUSSION: Surgical treatment (cervicotomy and debridement) should be undertaken early with evidence of extensive collection in deep spaces. Minimally invasive image-guided procedures are an alternative. These can be performed in well-located, unilocular collections, without compromising of the patient's airway. Percutaneous drainage and suction techniques if necessary, serially, or drainage placement may be performed. CONCLUSIONS: Ultrasound-guided and serially guided percutaneous drainage is the best therapeutic option in patients with mild and/or moderate dental infections.

Drenaje percutáneo ecoguiado vs. drenaje quirúrgico en abscesos cervicales profundos de origen odontógeno. Ensayo clínico controlado y aleatorizado / Ultrasound-guided drainage vs surgical drainage of deep neck space abscesses: A randomized controlled trial

Introducción: La causa más frecuente de infecciones profundas del cuello son las infecciones odontógenas. Son diagnosticadas con examen físico, estudios por imágenes, ecografía o tomografía computarizada. Debe realizarse siempre el drenaje quirúrgico de forma clásica o percutánea según el caso de las colecciones en forma precoz. El objetivo fue comparar las técnicas de drenaje percutáneo guiado por ecografía vs. drenaje quirúrgico en abscesos cervicales profundos de origen odontógeno en forma controlada y aleatorizada. Métodos: Se realizó un ensayo clínico controlado aleatorizado de enero de 2015 a diciembre de 2019. Se evaluó como variable de eficacia los días de ingreso. Se analizaron los datos epidemiológicos y variables secundarias (tumoración, trismus, fiebre, dolor), leucocitosis, resultado cosmético comparando ambas técnicas. El análisis estadístico se llevó a cabo con STATA v 14.0. Resultados: Fueron analizados 128 pacientes, 51 mujeres y 77 hombres. Edad promedio 27,3 (SD = 10,13). El grupo percutáneo presentó una media de 3,03 (SD = 2,86) días de ingreso y el grupo quirúrgico 5,46 (SD = 2,96). El valor de p resultó <0,001. Los resultados cosméticos mostraron diferencias favor del grupo de drenaje percutáneo. Ninguna de las demás variables mostró resultados estadísticamente significativos. Discusión: Ante la evidencia de una colección extensa en espacios profundos la realización del tratamiento quirúrgico (cervicotomía y desbridamiento) debe hacerse en forma precoz. Los procedimientos mínimamente invasivos guiados por imágenes son una alternativa. Estos pueden realizarse en colecciones bien localizadas, uniloculares, y siempre que no exista compromiso de la vía aérea del paciente. Pueden realizarse técnicas de punción y aspiración, y si es necesario en forma seriada, o bien punción con colocación de drenajes. (AU)

Introduction: The most common cause of deep neck infections is dental infection. They are diagnosed with physical examination, imaging studies, ultrasound, or computed tomography. Surgical drainage of collections should always be performed early in a classical or percutaneous way, depending on the case. The aim of the study was to compare ultrasound-guided percutaneous drainage techniques vs. surgical drainage in deep cervical abscesses of odontogenic origin in a controlled and randomized trial. Methods: A randomized controlled clinical trial was performed from January 2015 to December 2019. Hospital stay was evaluated as an efficiency variable. Epidemiological and secondary variable data (tumour, trismus, fever, pain), leukocytosis, cosmetic result comparing both techniques were analysed. Statistical analysis was carried out with STATA v 14.0. Results: 128 patients were analysed, 51 women and 77 men. Average age 27.3 (SD = 10.13). The percutaneous group had a mean hospital stay of 3.03 (SD = 2.86) days and the surgical group 5.46 (SD = 2.96). The p-value was <.001. Cosmetic results showed differences favouring the percutaneous drainage group. None of the other variables showed statistically significant results. Discussion: Surgical treatment (cervicotomy and debridement) should be undertaken early with evidence of extensive collection in deep spaces. Minimally invasive image-guided procedures are an alternative. These can be performed in well-located, unilocular collections, without compromising of the patient's airway. Percutaneous drainage and suction techniques if necessary, serially, or drainage placement may be performed. (AU)

Ultrasound-guided drainage vs surgical drainage of deep neck space abscesses: A randomized controlled trial. / Drenaje percutáneo ecoguiado vs. drenaje quirúrgico en abscesos cervicales profundos de origen odontógeno. Ensayo clínico controlado y aleatorizado.

INTRODUCTION: The most common cause of deep neck infections is dental infection. They are diagnosed with physical examination, imaging studies, ultrasound, or computed tomography. Surgical drainage of collections should always be performed early in a classical or percutaneous way, depending on the case. The aim of the study was to compare ultrasound-guided percutaneous drainage techniques vs. surgical drainage in deep cervical abscesses of odontogenic origin in a controlled and randomized trial. METHODS: A randomized controlled clinical trial was performed from January 2015 to December 2019. Hospital stay was evaluated as an efficiency variable. Epidemiological and secondary variable data (tumour, trismus, fever, pain), leukocytosis, cosmetic result comparing both techniques were analysed. Statistical analysis was carried out with STATA v 14.0. RESULTS: 128 patients were analysed, 51 women and 77 men. Average age 27.3 (SD = 10.13). The percutaneous group had a mean hospital stay of 3.03 (SD = 2.86) days and the surgical group 5.46 (SD = 2.96). The p-value was <.001. Cosmetic results showed differences favouring the percutaneous drainage group. None of the other variables showed statistically significant results. DISCUSSION: Surgical treatment (cervicotomy and debridement) should be undertaken early with evidence of extensive collection in deep spaces. Minimally invasive image-guided procedures are an alternative. These can be performed in well-located, unilocular collections, without compromising of the patient's airway. Percutaneous drainage and suction techniques if necessary, serially, or drainage placement may be performed. CONCLUSIONS: Ultrasound-guided and serially guided percutaneous drainage is the best therapeutic option in patients with mild and/or moderate dental infections.

Lesión del nervio laríngeo recurrente en cirugía tiroidea / Recurring laryngeal nerve injury in thyroid surgery

La lesión del nervio laríngeo recurrente (NLR) es una de las complicaciones más severas en las tiroidectomías. La lesión unilateral genera trastornos disfónicos que se manifiesta por voz débil y una posición paramedial de la cuerda vocal afectada, mientas que la bilateral genera trastornos respiratorios, incluyendo la asfixia. Se ha estimado que la lesión del NLR en las tiroidectomías se encuentra entre un rango de 0.3%- 18.9%. Se ha visto que con el neuromonitoreo intraoperatorio ha disminuido la incidencia de lesión, aunque debemos tener en cuenta un factor muy importante a la hora de solicitarlo y utilizarlo, el económico. La tasa de lesión permanente del nervio laríngeo recurrente debe permanecer por debajo de 1 a 2 %. Sin embargo, existen circunstancias en las cuales los nervios están expuestos a un mayor riesgo y son muchos los factores involucrados en su mecanismo de lesión. Este artículo pretende hacer una revisión del tema enfatizando en la importancia de la preservación de la funcionalidad e integridad de ambos nervios laríngeos recurrentes.

Recurrent laryngeal nerve injury (RLN) is one of the most severe complications in thyroidectomies. Unilateral injury generates dysphonic disorders manifested by weak voice and a paramedial position of the affected vocal cord, while bilateral injury generates respiratory disorders, including suffocation. RLN injury in thyroidectomies has been estimated to be in the range of 0.3% - 18.9%. It has been seen that with intraoperative neuromonitoring the incidence of injury has decreased, although we must take into account a very important factor when requesting and using it, the economic one. The rate of permanent injury to the recurrent laryngeal nerve should remain below 1% to 2%. However, there are circumstances in which the nerves are exposed to greater risk and many factors are involved in their mechanism of injury. This article aims to review the subject, emphasizing the importance of preserving the functionality and integrity of both recurrent laryngeal nerves

The development of a clinical algorithm for the diagnosis of tumours in the parapharyngeal space. A systematic review. / Desarrollo de algoritmo clínico para el diagnóstico de tumores del espacio parafaríngeo. Revisión sistemática.

INTRODUCTION: Parapharyngeal space (PPS) is defined as a deep space, located around the upper pharynx, in the shape of an inverted pyramid. Primary tumours in this region are rare, accounting for 0.5% of head and neck neoplasms, and most are benign. The objective of this study is to propose a new study algorithm based on a systematic review and our experience. MATERIALS AND METHODS: A cross-sectional and analytical study was carried out through review of the clinical records of our hospital. Patients with tumours of the parapharyngeal space operated from January 2010 to December 2019 and a systematic review of Pubmed studies from the last 5years were included. We considered clinical signs, diagnostic methods, presumptive diagnosis and histopathological findings. Statistical analysis was performed with STATA v.14 software. RESULTS: 53 of our cases and 1392 from the review were included. The clinical algorithm showed a sensitivity of 76.4% and a specificity of 96.3%, with an AUC of 0.57 for diagnosis. DISCUSSION: Complementary radiological examinations are essential in the topographic diagnosis of the tumour. Angio-MRI links the tissue of origin of the tumours and provides the highest diagnostic certainty. FNA has some disadvantages in PPS, but it is useful in some patients. CONCLUSION: The proposed algorithm contributes to obtaining excellent results in the management of these tumours because it turned out to be effective in diagnosis, and this enables improved surgical planning.

Abscesos cervicofaciales de origen odontógeno: ¿cuándo y cómo debemos drenarlos? / 6 EFFICACY OF PERCUTANEOUS TREATMENT AND SURGICAL DRAINAGE IN DENTAL ABSCESSES

ANTECEDENTES: La afectación de los espacios cervicales como resultado de focos infecciosos cervicofaciales son eventos infrecuentes, pero potencialmente mortales. La causa más frecuente de infecciones profundas del cuello son el resultado de la infección odontogénica (IO). Estas afectan a individuos de todas las edades y pueden presentar distintos grados de severidad. Son diagnosticadas con examen físico, estudios por imágenes, Ecografía o Tomografía Computada (TC). Debe realizarse siempre el drenaje quirúrgico de forma clásica o percutánea según el caso de las colecciones en forma precoz. OBJETIVO: Analizar la eficacia clínica del tratamiento percutáneo y el drenaje quirúrgico en abscesos odontogenos MATERIALES Y MÉTODOS: Se llevo a cabo un trabajo transversal de enero de 2015 a diciembre de 2019. Se realizo revisión de historias clínicas en la sección de Cirugía de Cabeza y Cuello de nuestro Hospital de todos los pacientes que requirieron internación y fueron sometidos a drenaje quirúrgico y/o percutáneo por la presencia de absceso cervical de origen odontogeno. RESULTADOS: Fueron analizados 174 pacientes. Edad promedio 36 +/- 2 años. Solo al 37% se les realizo drenaje quirúrgico abierto. Al resto se realizó punciones percutáneas en forma seriada. El 25 % presento algún signo de compromiso de vía aérea (escala de severidad 3), y solo 2 pacientes con mediastinitis que requirieron drenaje urgente. Se realizo la exodoncia a todas los pacientes durante la internación. DISCUSION: Las infecciones cervicofaciales representan un tipo de infección potencialmente fatal si no se inicia rápidamente un tratamiento eficaz. La causa principal son IO que se manifiestan como flemones o abscesos. Las caries dentales suelen ser el origen. Debe establecerse la terapéutica antibiótica empírica en forma precoz y corticoides con bajas dosis cuando hay edema y/o trismus. A estos pacientes se les realiza tratamiento antibiótico (ampicilina sulbactam), acompañado de tratamiento quirúrgico (drenaje percutáneo o drenaje quirúrgico). La complicación más temida, es la progresión de la infección al mediastino (mediastinitis descendente) y / o Angina de Ludwig. CONCLUSIONES: No está protocolizado a quienes se les debe realizar tratamiento quirúrgico o tratamiento percutáneo. El drenaje quirúrgico abierto parece ser la primera opción frente al compromiso de vía aérea o colecciones no pasibles de drenaje percutáneo. Para el resto de los pacientes, que son la mayoría, las punciones percutáneas guidas con ecografía y en forma seriada son la mejor opción

Background: The involvement of cervical spaces as a result of cervical infectious focuses are rare but life-threatening events. The most common cause of deep neck infections is the result of dental infection (DI). These affect individuals of all ages and may have varying degrees of severity. They are diagnosed with physical examination, imaging, ultrasound or computed tomography (CT). Surgical drainage should always be performed in a classic or percutaneous method early. Objective: To analyze the clinical efficacy of percutaneous treatment and surgical drainage in dental abscess Materials and methods: Cross-sectional study was carried out from January 2015 to December 2019. Medical records were reviewed in the Head and Neck Surgery Section of our Hospital of all patients who required hospitalization and were subjected to surgical and/or percutaneous drainage due to the presence of cervical abscess of dental origin. Results: 174 patients were analyzed. Average age was 36 +/- 2 years old. Only 37% were performed open surgical drainage. The rest of them were percutaneous drainage. 25% showed any signs of airway engagement (severity scale 3). Only 2 patients had mediastinitis who required urgent drainage. Exodontics was performed on all patients during hospitalization Discussion: Cervical infections represent a potentially fatal type of infection if effective treatment is not initiated quickly. The main cause is DI that manifest as phlegmons or abscesses. Tooth decay is usually the source. Empirical antibiotic therapy should be established early and low-dose corticosteroids should be established when there is edema and/or trismus. These patients are treated with antibiotics (ampicillin sulbactam), accompanied by surgical treatment (percutaneous drainage or surgical drainage). The most feared complication is the progression of infection to the mediastinum (descending mediastinitis) and/or Ludwig's Angina. Conclusions: Surgical or percutaneous treatment are not protocolized. Open surgical drainage seems to be the first choice over airway compromise or non-passable collections of percutaneous drainage. For the rest of the patients, who are the majority, guided percutaneous drainage with ultrasound and serial form are the best option