Microvascular anastomotic coupler for venous end-to-side anastomoses in head and neck reconstructive surgery.

BACKGROUND: The use of coupler devices has become mainstream in microsurgical end-to-end venous anastomoses (EEA) for free flaps in head and neck reconstruction. Reports about end-to-side venous anastomoses (ESA) using a coupler are scarce, though. METHODS: The surgical technique of end-to-side anastomosis using a coupler device is described. End-to-side anastomoses and end-to-end anastomoses with a vascular coupler are compared with respect to postoperative vascular complications. RESULTS: 124 patients were included, 76 with EEA, 48 with ESA. Postoperative venous complications occurred in 5.3% and 2.1%, respectively. CONCLUSIONS: ESA is a valuable alternative to EEA when using a coupler device providing more flexibility to the surgeon.

Treatment of tracheoesophageal fistulas following laryngectomy by customized prostheses-A bicentric case series.

Objective: Tracheoesophageal fistulas (TEF) following laryngectomy cause immense restrictions due to the inability of oral feeding, loss of voice rehabilitation, penetration of saliva, and permanent need of inflatable tracheal cannulas. Patients are consistently in threat of fatal aspiration pneumonias. The failure rate of surgical approaches to close the fistulas is high and an ultima ratio option by customized silicone prostheses can be considered. Methods: A retrospective analysis of 26 patients with a TEF was performed. Results: The fistulas occurred in average 40 months after laryngectomy caused by an enlargement of the voice fistula in 17 patients and problems in wound healing in 6 patients. The mean diameter of the fistula was 32 × 18 mm. Eight patients were treated by a button-shaped and 18 by a tube-shaped prosthesis. Complete oral feeding was possible in 8 and additional feeding by percutaneous endoscopic gastrostomy tube in 16 patients. Voice rehabilitation by voice prostheses was possible in 18 cases. Fifteen patients died in the course of the treatment either due to oncological progression or other reasons. The median follow-up time of the patients alive was 36 months (max 88 months) with 2.2 protheses replacements in mean (max 11). Conclusion: The treatment of TEF by customized prostheses can be considered as an ultima ration option if other approaches had failed. At least, partial oral nutrition and voice rehabilitation as well as protection from aspiration can be achieved in the majority of the patients. Level of Evidence: 4-Case series.

[Case report on traumatic complete laryngotracheal separation with a positive outcome]. / Fallbericht zum traumatischen Totalabriss der Trachea vom Kehlkopf mit positivem Ausgang.

HISTORY: A 21-year-old female was injured by accidental strangulation. Dyspnea and stridor occurred with delay, and led to emergency intubation. FINDINGS: Physical examination showed strangulation marks and neck emphysema. Computed tomography confirmed laryngotracheal separation and revealed misplacement of the ventilation tube. DIAGNOSIS: Further surgical exploration revealed complete laryngotracheal (cricotracheal) separation. TREATMENT: After initial emergency tracheotomy, cricotracheal reanastomosis was achieved by a two-stage surgical approach. CONCLUSION: Laryngotracheal separation is associated with high mortality. In the case presented herein, the patient survived and was discharged from hospital without a tracheostomy tube despite bilateral recurrent laryngeal nerve palsy.

Shift of radiotherapy use during the first wave of the COVID-19 pandemic? An analysis of German inpatient data.

OBJECTIVE: To assess the change in inpatient radiotherapy related to COVID-19 lockdown measures during the first wave of the pandemic in 2020. METHODS: We included cases hospitalized between January 1 and August 31, 2018-2020, with a primary ICD-10 diagnosis of C00-C13, C32 (head and neck cancer, HNC) and C53 (cervical cancer, CC). Data collection was conducted within the Medical Informatics Initiative. Outcomes were fractions and admissions. Controlling for decreasing hospital admissions during holidays, calendar weeks of 2018/2019 were aligned to Easter 2020. A lockdown period (LP; 16/03/2020-02/08/2020) and a return-to-normal period (RNP; 04/05/2020-02/08/2020) were defined. The study sample comprised a control (admission 2018/19) and study cohort (admission 2020). We computed weekly incidence and IR ratios from generalized linear mixed models. RESULTS: We included 9365 (CC: 2040, HNC: 7325) inpatient hospital admissions from 14 German university hospitals. For CC, fractions decreased by 19.97% in 2020 compared to 2018/19 in the LP. In the RNP the reduction was 28.57% (p < 0.001 for both periods). LP fractions for HNC increased by 10.38% (RNP: 9.27%; p < 0.001 for both periods). Admissions for CC decreased in both periods (LP: 10.2%, RNP: 22.14%), whereas for HNC, admissions increased (LP: 2.25%, RNP: 1.96%) in 2020. Within LP, for CC, radiotherapy admissions without brachytherapy were reduced by 23.92%, whereas surgery-related admissions increased by 20.48%. For HNC, admissions with radiotherapy increased by 13.84%, while surgery-related admissions decreased by 11.28% in the same period. CONCLUSION: Related to the COVID-19 lockdown in an inpatient setting, radiotherapy for HNC treatment became a more frequently applied modality, while admissions of CC cases decreased.

Rare Diseases of the Orbit. / Seltene Erkrankungen der Orbita.

This article provides an overview of rare orbital diseases. Congenital malformations, inflammatory diseases, benign and malignant neoplasias are described. Although it represents a relatively small area of the body the orbit contains multiple different tissues. Therefore, a great variety of diseases can be found within the orbital space. That is the reason, why both the completeness and the level of detail in the description of particular diseases must be somewhat limited. Nevertheless, clinical manifestations, important aspects of diagnosis, treatment strategies, and, when specific data are available, the prognosis are described. The authors tried to highlight the most characteristic aspects of the different diseases to describe their relevant aspects in spite of the brevity of the subsections.

[Diseases and Surgery of the Orbit]. / Erkrankungen und Chirurgie der Orbita.

Most orbital diseases are rarely diagnosed in the clinic. Because the consequences for the eye can be severe, it is important to recognize the signs of orbital disease early in order to initiate the correct diagnostic and therapeutic steps in good time. This article presents the basics of the systematics, diagnostics and therapy of orbital diseases in preparation for the specialist examination for ENT medicine. Some orbital diseases are typical manifestations of systemic diseases (e. g. Graves' disease) or typical complications of diseases in the vicinity of the orbit (e. g. orbital complications from inflammatory or tumorous sinus diseases). The diseases of the lacrimal system and the eyelids as well as their therapy are closely related to the diseases of the orbit. Basically, it can be said that the diagnosis and therapy of orbital diseases should always be carried out on an interdisciplinary basis, whereby the involvement of the ophthalmologist is of particular importance.

Total versus subtotal tonsillectomy for recurrent tonsillitis - a prospective randomized noninferiority clinical trial.

Background: For many years experts have called for randomized controlled trials to resolve the question whether tonsillectomy, which is associated with significant comorbidity, can be replaced by partial tonsillectomy in patients with recurrent tonsillitis.Objective: To find out whether subtotal tonsillectomy is a suitable therapeutic alternative to total tonsillectomy in adult patients with recurrent episodes of acute tonsillitis.Material and methods: Study design - Single-blind prospective non-inferiority randomized clinical trial with intraindividual design. Setting - 80 patients were recruited at a tertiary referral center. Subjects - Adult patients with recurrent tonsillitis received total tonsillectomy on one side and subtotal tonsillectomy on the other side after randomization. Main outcome measure was frequency of postoperative tonsillitis on the side of subtotal tonsillectomy and postoperative pharyngitis in the former tonsil area on the side of total tonsillectomy. The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00015628).Results: Within 12 months none of the subjects suffered from recurrent tonsillitis after subtotal tonsillectomy. Subtotal tonsillectomy caused less pain than total tonsillectomy.Conclusion: Subtotal tonsillectomy might be an alternative treatment option associated with lower morbidity than total tonsillectomy in adults with recurrent tonsillitis.

The nasal valve: new insights on the static and dynamic NV with MR-imaging.

PURPOSE: We assessed the static nasal valve angle with MR imaging in healthy subjects and evaluated the complex mechanism of nasal valve dynamics during physiologic and forced inspiration. METHODS: In 17 healthy subjects, measurements of the static nasal valve angle were conducted on MR scans, using a TSE Axial T2-weighted sequence and a 3 mm slice thickness. The dynamic changes of nasal valve movement were detected using MR Cine-imaging techniques. RESULTS: The static median angle of the nasal valve was found to be 28.6° with a range of 12.7°-39.3°. The median degree of nasal valve collapse during forced inspiration was 68% (range 20-99%) of the baseline (static nasal valve angle). In the moderately forced inspiration (3 s) the median nasal valve angle declined to 76% of the baseline angle (range 42-100%). In the physiologic or unforced inspiration, the median nasal valve angle was reduced to 86.3% of the baseline angle (range 52-100%). CONCLUSION: MRI, as a non-invasive tool, is a reliable method for evaluation of the static nasal valve angle and for the illustration of the complex nasal valve dynamics.

Influence of coupler size on revision rate and timing of revision after free flap tissue transfer in the head and neck.

OBJECTIVE: Microvascular coupler devices have been proven an effective alternative to standard hand-sutured anastomoses in reconstructive surgery. Until now, the influence of the coupler size on the revision rate after free flap tissue transfer in head and neck surgery has not been investigated. Neither has its influence on the timing of venous revisions. MATERIALS AND METHODS: A retrospective mono-center cohort study was performed in order to analyze the influence of coupler size on timing and revision rate of microvascular procedures. RESULTS: 437 patients who had undergone surgery between 2009 and 2015 were included. The statistical analysis of coupler size and revision rate due to venous complications showed a significant reduction of more than 40% in the revision rate for each additional mm in the coupler size. We observed revisions due to venous congestion until the fourth day postoperatively within our cohort. However, when the coupler size used was ≥ 3 mm, no venous congestion occurred later than 12 h after surgery. CONCLUSION: The quantitative effects of coupler size on the revision rate in head and neck reconstruction were demonstrated for the first time. We recommend spending extra time and effort on dissecting the largest possible vein in order to be able to choose the largest possible coupler size for the venous anastomosis. As a consequence of our findings, we limit our postoperative monitoring for patients with a coupler ≥ 3 mm to 24 h, as later venous congestions are very unlikely.

Reduction of olfactory sensitivity during normobaric hypoxia.

OBJECTIVE: Acute mountain sickness (AMS) is caused by a low partial pressure of oxygen and may occur above 2500m. The aim of this research was to evaluate olfactory and gustatory abilities of healthy subjects during baseline conditions and after seven hours of normobaric hypoxia. METHODS: Sixteen healthy subjects were assessed using the Sniffin' Sticks, as well as intensity and pleasantness ratings. Gustatory function was evaluated utilizing the Taste Strips. Experiments were carried out under baseline conditions (518m altitude) followed by a second testing session after seven hours of normobaric hypoxia exposure (comparable to 4000m altitude). RESULTS: During normobaric hypoxia olfactory sensitivity and intensity estimates were significantly reduced. CONCLUSIONS: We conclude that normobaric hypoxia leads to a significant decrease of olfactory sensitivity and intensity ratings.

The "Comprehensive ICF Core Set for Head and Neck Cancer": a Delphi consensus survey among German speaking speech and language therapists.

The "Comprehensive ICF Core Set for Head and Neck Cancer" (ICF-HNC) is an application of the "International Classification of Functioning, Disability and Health" (ICF), representing the characteristic spectrum of issues in patients with head and neck cancer (HNC). Our primary aim was to evaluate which categories of the ICF-HNC are dealt with by speech and language therapists (SLTs) in Germany, Austria, and Switzerland. The secondary aim was to identify outcome measures used by SLTs to measure the categories of the ICF-HNC in clinical practice. SLTs experienced in the treatment of HNC patients evaluated the categories of the ICF-HNC in a three-round Delphi survey. They were asked whether the listed categories represented issues treated by SLTs in HNC patients, and what outcome measures were used to assess them. Altogether, 31 SLTs completed the survey. 47 of 108 previously selected categories of the ICF-HNC achieved the cut-off value. Out of these, 40.4% were derived from the component "Body Functions", 36.2% from "Body Structures", 12.8% from "Environmental Factors", and 10.6% from "Activities and Participation". Altogether, 82 of the mentioned outcome measures were considered as reasonable from the perspective of SLTs. Of these, only 37 achieved more than 50% approval. This study emphasises the importance of "Body Structures" and "Body Functions" for SLTs in Germany and Switzerland in treating patients with HNC. Moreover, the results highlighted the need to agree on evidence-based outcome measures in speech and language therapy.

Impact of comorbidity and anemia in patients with oropharyngeal cancer primarily treated with surgery in the human papillomavirus era.

BACKGROUND: Comorbidity and anemia strongly influence treatment and outcome of oropharyngeal squamous cell carcinomas (SCCs), but respective data are frequently lacking in clinical studies. We evaluated 149 cases of oropharyngeal SCC primarily treated with surgery regarding the impact of these factors on disease-free survival (DFS) and overall survival (OS). METHODS: Data were recorded during treatment and follow-up visits. Human papillomavirus (HPV) association of oropharyngeal SCC was detected by p16 immunohistochemistry. RESULTS: Patients with p16-positive disease were significantly less comorbid and anemic, and treated more aggressively. Comorbidity and anemia, but not p16 status, significantly influenced DFS and had more impact on OS than p16 status. CONCLUSION: In our study, p16-positive seems a good surrogate marker for healthier patients. Patients with p16-positive disease showed improved survival, but this was limited to none/mild comorbid and/or nonanemic individuals in this group. On the basis of our results, we strongly suggest the inclusion of these factors in risk stratification for clinical studies. © 2016 Wiley Periodicals, Inc. Head Neck 39: 7-16, 2017.

The development of an ICF-based clinical guideline and screening tool for the standardized assessment and evaluation of functioning after head and neck cancer treatment.

The assessment and evaluation of functioning and quality of life after tumor treatment in head and neck cancer (HNC) are considered as essential aspects of clinical routine and studies. A huge number of instruments are available that have been designed to evaluate functioning and quality of life after HNC treatment. The diversity of these instruments in terms of content, response options and administration hinders the comparability of available studies and the performance of meta-analyses. The objective of this paper is to inform about the development of a screening tool for the standardized assessment and evaluation of functioning based on the International Classification of Functioning, Disability and Health (ICF) Core Set for HNC. We followed a multi-step approach including (1) preparatory studies to identify and preselect suitable instruments for the assessment of functioning, (2) a decision-making process to agree on an ICF-based clinical guideline including instruments assessing functioning and (3) the development of a computer-based standardized screening tool to assess and evaluate functioning based on this guideline in clinical routine. Twenty-one experts participated in a consensus meeting and decided on instruments to be included in an ICF-based clinical guideline and screening tool for the assessment and evaluation of functioning in HNC patients in cancer treatment. The chosen instruments cover all aspects of the ICF Core Set for HNC addressing therapy control, pain, food intake/swallowing, voice/speech/breathing, other somatic complaints and psychosocial aspects. The screening tool contains patient-reported outcome measures and a clinician's checklist. It has to be further tested in clinical practice.

Bystander cricothyroidotomy with household devices - A fresh cadaveric feasibility study.

INTRODUCTION: In various motion pictures, medical TV shows and internet chatrooms, non-medical devices were presented as tools for life-saving cricothyroidotomies. However, there is uncertainty about whether it is possible for a bystander to perform a cricothyroidotomy and maintain gas exchange using improvised household items. This study examines the ability of bystanders to carry out an emergency cricothyroidotomy in fresh human cadavers using only a pocket knife and a ballpoint pen. MATERIALS AND METHODS: Two commonly available pens and five different pocket knives were used. Ten participants with no or only basic anatomical knowledge had to choose one of the pens and one of the knives and were asked to perform a cricothyroidotomy as quickly as possible after a short introduction. Primary successful outcome was a correct placement of the pen barrel and was determined by the thoracic lifting in a mouth-to-pen resuscitation. RESULTS: Eight (80%) participants performed a successful approach to the upper airway with a thoracic lifting at the end. Five participants performed a cricothyroidotomy and three performed an unintentional tracheotomy. Injuries to muscles and cartilage were common, but no major vascular damage was seen in the post-procedural autopsy. However, mean time in the successful group was 243s. CONCLUSION: In this cadaveric model, bystanders with variable medical knowledge were able to establish an emergency cricothyroidotomy in 80% of the cases only using a pocketknife and a ballpoint pen. No major complications (particularly injuries of arterial blood vessels or the oesophagus) occurred. Although a pocket knife and ballpoint pen cricothyroidotomy seem a very extreme procedure for a bystander, the results of our study suggest that it is a feasible option in an extreme scenario. For a better outcome, the anatomical landmarks of the neck and the incision techniques should be taught in emergency courses.

Prevalence of Headache in Cochlear Implant Patients: A Cross-sectional Study.

INTRODUCTION: In Internet forums and other social media many reports regarding chronic headaches after cochlear implantation can be found. Although quite rare, there are also some reports in the literature. However, little is known regarding the true prevalence of headaches in persons who have undergone cochlear implant surgery. OBJECTIVES: The primary aim of this study was to investigate the 1-year prevalence of headache in patients having received a cochlear implantation ("cochlear implant group") in comparison with patients having undergone middle ear surgery ("surgery group") and persons with no history of head and neck surgery ("non-ear-nose-throat [ENT] group"). METHODS: Cross-sectional, monocentric study using a validated headache questionnaire. RESULTS: Three hundred persons were asked to participate. Two hundred thirty four valid questionnaires were returned. The participants' median age was 62 years, of whom 45% were women. The prevalence of headache was 31% (95%-confidence interval [CI]: [21; 42]) in the cochlear implant group and 46% (95%-CI: [35; 57]) in the surgery group with no significant difference between these two subgroups (p = 0.071). In the non-ENT group the prevalence of headache was significantly higher than in the other two subgroups (64%, 95%-CI: [52; 74]). DISCUSSION: The prevalence of headache is not higher in cochlear implant patients in comparison to middle ear surgery patients, other, non-ENT patients and the general German or European population. CONCLUSION: Cochlear implantation does not seem to be associated with an increased risk for developing headache.

Residual Hearing Outcomes After Cochlear Implant Surgery Using Ultra-flexible 28-mm Electrodes.

OBJECTIVE: To evaluate the preservation of low frequency residual hearing after cochlear implant surgery using an electrode for atraumatic implantation and complete cochlear stimulation. STUDY DESIGN: Retrospective clinical record study. SETTING: Tertiary referral center. PATIENTS: Fifty-six patients with functional deafness who had undergone cochlear implant surgery and received a Flex electrode (MED-EL GmbH, Innsbruck, Austria) between 2011 and 2014. INTERVENTION: Audiometric testing was performed before surgery and at the time of initial fitting. MAIN OUTCOME MEASURE: Change in low frequency residual hearing measured by pure tone audiometry. RESULTS: Preoperative hearing was relatively poor. After surgery low frequency residual hearing was partially preserved in most cases, however there was a significant hearing loss at all frequencies compared with the preoperative state. In only 23% of all cases complete hearing preservation was observed. CONCLUSION: Despite the use of a flexible electrode, complete preservation of low frequency residual hearing can only be achieved in a minority of patients. The use of a full insertion electrode of 28 mm in patients with poor preoperative thresholds does not allow for usable additional hearing at present.

Bystander cricothyrotomy with ballpoint pen: a fresh cadaveric feasibility study.

OBJECTIVE: In motion pictures and anecdotal reports, ballpoint pens have been used for life-saving cricothyroidotomies. The objective of this study was to examine the widespread belief that ballpoint pens can perforate the skin and cricothyroid ligament and could be used as substitute tracheostomy sets in an emergency setting. METHODS: Three different ballpoint pens were examined regarding their inner diameter, their demountability to form a cannula and their airflow properties. Ten medical laypersons were asked to try to puncture the trachea through the skin and the cricothyroid ligament in 10 fresh cadavers just using the ballpoint pens. RESULTS: Two of three pens had inner diameters of >3 mm and were both suitable as cannulas in a tracheotomy. All participants could perforate the skin with both ballpoint pens. However, almost no one could penetrate through the cricothyroid ligament or the ventral wall of the trachea, except for one participant. He performed the tracheostomy after three attempts in >5 min with a lot of patience and force. CONCLUSIONS: A cricothyroidotomy just with a ballpoint pen is virtually impossible. First, the airflow resistance in commercially available ballpoint pens is too high to produce effective ventilation. Second, the cricothyroid ligament is too strong to be penetrated by ballpoint pens.

Effects of malnutrition on complication rates, length of hospital stay, and revenue in elective surgical patients in the G-DRG-system.

OBJECTIVE: Malnutrition is known to independently affect patient outcomes. The aim of this study was to investigate the prevalence of patients at risk for malnutrition in an elective surgery patient cohort and to analyze the effects of malnutrition on morbidity, mortality, and hospital length of hospital (LOS). Furthermore, we aimed to evaluate the economic effect of a diligent coding of malnutrition, as a side diagnosis, in a simulation of the German Diagnosis-Related Group system. METHODS: The nutritional status of 1244 patients undergoing elective surgery was standardized on the day of admission by the Nutritional Risk Screening (NRS) 2002. To quantify the influence of malnutrition on revenue, the real DRGs of all patients were grouped. In simulation, an appropriate International Classification of Diseases code was used as a secondary diagnosis for all malnourished patients based on the NRS rating. A multivariate logistic regression analysis and a Cox regression were performed to identify potential confounders and to determine the adjusted effect of nutritional status on the occurrence of complications and hospital LOS. RESULTS: The prevalence of patients at risk for malnutrition (NRS ≥3) was 24.1% (300 of 1244). These patients showed a significant increase in hospital LOS (13 versus 7 d). Additionally, postoperative complications were significantly higher in this group (7.23% versus 6.91%). Including malnutrition in the Diagnosis-Related Group coding system resulted in a reimbursement of €1979.67 per patient at risk for malnutrition and a total reimbursement of €79,186.73 for all patients at risk for malnutrition in the present study. CONCLUSION: Establishment of a structured, comprehensive assessment of the nutritional status of hospitalized patients can repetitiously identify patients at risk for malnutrition. Additionally, the diligent codification of malnutrition can lead to cost compensation in the German Diagnosis-Related Group system.

Susceptibility-weighted angiography visualizes hypoxia in cerebral veins.

OBJECTIVES: The objective of this study was to evaluate the influence of short- and long-term hypoxia on the depiction of cerebral veins in the susceptibility-weighted angiography (SWAN) sequence. MATERIALS AND METHODS: In the context of a study on brain adaptation mechanisms to hypoxia, 16 healthy men (aged 20-28 years) were studied through magnetic resonance imaging (MRI) under room air conditions, short-term-hypoxia (7 minutes before and during the MRI scan), and long-term hypoxia (8.5 hours before and during the MRI scan). Oxygen saturation was continuously measured using a finger-mounted pulse oximeter. Two independent blinded readers compared the 3 scans of each participant and graded the SWAN source images and minimum intensity projections according to the size, number, and signal intensity of the cerebral veins. Signal intensities of deep cerebral veins were measured, and signal intensity proportions of deep cerebral veins to different parenchymal brain regions were calculated. RESULTS: Nine subjects could be included in the study. In all of them, both readers correctly distinguished the 2 hypoxia scans from the baseline scan, grading the SWAN images acquired under hypoxic conditions as visualizing cerebral veins more prominently. Signal intensities of the deep cerebral veins and signal intensity proportions were significantly lower in the hypoxia scans. No significant differences between short-term and long-term hypoxia were found on visual inspections and signal intensity measurements. This correlated with the results of the pulse oximetry: mean O2 saturation values were 97.9% ± 1.2% (baseline), 84.1% ± 3.8% (short-term hypoxia), and 82.8% ± 4.4% (long-term hypoxia), respectively. CONCLUSIONS: Hypoxia leads to visible and measurable changes in cerebral veins as depicted through SWAN. Possible clinical implications of this finding include stroke and tumor imaging and need further investigation.