Management of epistaxis in patients on novel oral anticoagulation therapy.

BACKGROUND: Individuals on anticoagulation therapy are at increased risk of bleeding, including epistaxis. There is a lack of available reversal agents for novel oral anticoagulation therapy. OBJECTIVE: This paper reviews the current literature on epistaxis in the context of novel oral anticoagulation use, in order to recommend guidelines on management. METHOD: A comprehensive search of published literature was conducted to identify all relevant articles published up to April 2019. RESULTS: Patients on oral anticoagulation therapy are over-represented in individuals with epistaxis. Those on novel oral anticoagulation therapy were more likely to relapse compared to patients on classic oral anticoagulants or non-anticoagulated patients. Idarucizumab is an effective antidote for bleeding associated with dabigatran use. Recommendations for epistaxis management in patients on novel oral anticoagulation therapy are outlined. CONCLUSION: Clinicians need to be aware of the potential severity of epistaxis and the increased likelihood of recurrence. High-quality studies are required to determine the efficacy and safety of andexanet alfa and ciraparantag, as well as non-specific reversal agents.

Systematic review and meta-analysis of the complications of salvage total laryngectomy.

BACKGROUND AND OBJECTIVES: Management paradigms in laryngeal cancer have shifted to "organ preservation" chemoradiotherapy protocols. In the event of treatment failure, salvage total laryngectomy remains the only curative treatment option. However a comprehensive review of the complications of this procedure has not been reported. METHODS: A systematic review of the literature was performed using keywords "salvage laryngectomy" to retrieve relevant publications between January 2000 and August 2015. RESULTS: Of the 407 articles retrieved from the literature search, 50 studies encompassing 3292 patients were included. Forty-nine studies reported pharyngocutaneous fistula which occurred in 859 patients (pooled incidence 28.9%; 95% confidence intervals 25.5-32.5%). Twenty-four studies reported complications in addition to PCF and these included wound complications (infection, dehiscence and necrosis), dysphagia, bleeding, and pharyngeal and stomal stenosis. CONCLUSIONS: Overall complication rate was 67.5%, Pharyngocutaneous fistula was the commonest complication with a pooled incidence of 28.9%.

Wide anterior neck dissection for management of recurrent thyroglossal duct cysts in adults.

OBJECTIVE: Thyroglossal duct cyst recurrence following resection is attributed to anatomical variability and residual thyroglossal ducts. In adults, thyroglossal duct cyst recurrence is extremely rare and a surgical solution is yet to be well explored. This paper describes our approach to the management of recurrent thyroglossal duct cysts and sinuses in adults using a wide anterior neck dissection. METHOD: A retrospective review was performed to identify adults who underwent a wide anterior neck dissection for recurrent thyroglossal duct cyst management between 1 January 2009 and 1 January 2015. RESULTS: Six males and one female were included in the series (mean age, 26.4 ± 10.9 years). Recurrence occurred at a mean of 18 ± 9.8 months following primary surgical management (3 patients underwent cystectomy and 4 had a Sistrunk procedure). All patients subsequently underwent wide anterior neck dissection; there was no further recurrence over the 12-month average follow-up period. CONCLUSION: This paper describes a wide anterior neck dissection technique for the management of recurrent thyroglossal duct cysts or sinuses in adults; this approach addresses the variable anatomy of the thyroglossal duct and is associated with minimal morbidity.

Endoscopic vocal fold injection using a 25-gauge butterfly needle.

OBJECTIVE: To describe a useful technique for infiltrating a bulking agent using a butterfly needle, as part of a transoral endoscopic vocal fold medialisation procedure. METHODS: This paper describes the procedure of grasping the needle with phonosurgery forceps and administering the injectate to the vocal fold through careful application of the syringe plunger via a length of rubber tubing from outside the mouth. RESULTS: This procedure is performed routinely in our institution without complication. The advantages of this technique are discussed. CONCLUSION: This is a safe and easy method of injecting into a vocal fold.

The surgical anatomy and clinical relevance of the neglected right lymphatic duct: review.

BACKGROUND: The major lymphatic vessels may be damaged during neck dissection or other cervical surgery, resulting in chyloma or chyle fistula. While commonly considered to be predominantly a complication of left-sided surgery, the thoracic duct may be damaged on either side of the neck due to the extreme variability in the anatomy of the central lymphatic system. METHOD AND RESULTS: This paper reviews the variable anatomy and embryology of the thoracic and right lymphatic ducts, particularly aspects relevant to head and neck surgery.

Oncological safety of the Hayes-Martin manoeuvre in neck dissections for node-positive oropharyngeal squamous cell carcinoma.

INTRODUCTION: The Hayes-Martin manoeuvre involves ligation of the posterior facial vein and superior reflection of the investing fascia below the mandible to preserve the marginal mandibular nerve. The peri-facial nodes thus remain undissected. We perform this manoeuvre routinely during modified radical neck dissection for metastatic oropharyngeal squamous cell cancer. Here, we review the oncological safety and marginal mandibular nerve preservation rates of this manoeuvre from 2004 to 2009. METHOD: Retrospective review of the head and neck oncology database (2004-2009) at Addenbrooke's Hospital, Cambridge, UK, a tertiary referral centre for head and neck oncology. RESULTS: Thirty-four patients underwent modified radical neck dissection for metastatic oropharyngeal squamous cell carcinoma. The primary tumour included the tonsil in 19 cases, base of tongue in 10 and posterior pharyngeal wall in 5. The neck nodal status was N1 in 4 cases, N(2a) in 11, N(2b) in 10, N(2c) in 4 and N(3) in 5. All patients had adjuvant radiotherapy. Median follow up was four years (range, two to five). No peri-facial nodal region recurrences were seen. Four patients had temporary marginal mandibular nerve weakness; beyond two months, no weakness was seen. CONCLUSION: In neck dissections for oropharyngeal squamous cell carcinoma, the marginal mandibular nerve and accompanying facial nodes can be safely preserved without oncological risk using the Hayes-Martin manoeuvre.

Endoscopic treatment of glottic stenosis: a report on the safety and efficacy of CO2 laser.

BACKGROUND: Treatment of glottic stenosis is a considerable challenge to the otolaryngologist. Glottic airway patency can be compromised by bilateral vocal fold palsy, anterior webbing or a posterior segment scar, which may be significant enough to impair arytenoid movement. METHOD: A retrospective analysis of a prospective database of patients (n = 34) treated by a specialist airway surgeon. All patients underwent endoscopic treatment with a CO(2) laser in an attempt to improve airway calibre and, in 12 patients, to decannulate tracheostomy tubes. RESULTS: Twenty-one patients had bilateral vocal fold palsy and 13 had predominantly posterior glottic stenosis. A variety of pathology-directed treatment approaches were used to achieve good functional results. Four patients required a second endoscopic procedure. The overall revision rate was 5 per cent for bilateral fold palsy and 23 per cent for posterior glottic stenosis (p < 0.05). All patients had an adequate functional airway calibre, and all 12 tracheotomised patients were decannulated. DISCUSSION: Pathology-directed endoscopic laser surgery is safe and effective treatment for glottic stenosis. Rather prescriptive use of unilateral or bilateral cordotomy or combined cordo-arytenoidectomy, clinicians must perform the procedure that will treat the lesion most adequately. Our success rate compared favourably with the best reported results.

Safety of extracapsular dissection in benign superficial parotid lesions.

INTRODUCTION: The current practice for removal of clinically benign superficial parotid lesions is an appropriate superficial parotidectomy with a cuff of normal parotid tissue for complete pathological clearance. This technique requires the identification of the facial nerve at the main trunk and dissection of the segment of the facial nerve deep to the lesion. The reported major complications of this procedure include temporary or permanent facial nerve weakness, Frey's syndrome and salivary leaks. In order to avoid these complications, a local extracapsular dissection technique can be utilised in the management of small inferiorly located benign lesions of the parotid gland. METHODS: A retrospective case note review was performed for all parotidectomies between 2004 and 2009 in Addenbrooke's Hospital, Cambridge by the senior authors. RESULTS: A total of 172 cases were identified out which 46 underwent an extracapsular dissection. The average size of these lesions was 1.9 cm (0.9-2.4 cm) with all universally located inferior or posterior to the angle of the mandible. The pathologies were 14 pleomorphic adenomas, 24 Warthin's tumours, 6 lymphangiomas and 2 simple cysts. There were no post-operative facial nerve weaknesses, Frey's syndrome or salivary leaks within the extracapsular dissection group. The median follow-up of these patients were 4.6 years (2-6 years) with 6 patients lost to follow-up. No recurrences have been noted in the cohort at follow-up.

Pediatric caustic ingestion: 50 consecutive cases and a review of the literature.

Caustic injury to the aerodigestive tract remains a significant medical and social concern despite various efforts to minimize hazards of caustic household products. Agents with a pH less than two or greater than 12 are extremely corrosive, causing damage that can range from mild to extensive, including esophageal perforation leading to mediastinitis and death at the extreme scale. Methods include retrospective case note review of all admissions to the otolaryngology unit with caustic injury that underwent esophagoscopy to the Children's Hospital Westmead between 1990 and 2007. A protocol-based management system with antibiotics and steroids together with esophagoscopy at 48 hours was implemented. A total of 50 admissions were identified with an average follow-up of 5 years. There were a total of 28 males and 22 females with a median age of 22 months. Forty-nine cases (98%) were accidental. Thirty-eight cases (76%) occurred within the interiors of the family home with the kitchen being the common location. Another seven (14%) occurred within the external environment of the home, usually in the garage or pool shed. The causative agents were varied with 37 (74%) being alkali, three cases (6%) being acidic, and other agents, such as chlorine bleach, being the remainder. The most frequently ingested alkalis were dishwashing powder and disinfectants closely followed by degreasers. Twenty-five children (50%) drank directly from a container with the remainder ingesting granules or powder directly. At esophagoscopy, 17 cases (34%) had grade 1 injury and 10 (20%) had grade 2 injury. Fifty percent of patients of grade 2 injury subsequently developed strictures requiring multiple dilatations. Importantly, six cases (12%) had evidence of esophageal injury without oral injury. Caustic injuries continue to be a significant morbidity in the pediatric patient group. Most cases are still happening as a result of accidental ingestion from unmarked containers within reach of children at home. Oral injury is not always a useful marker of more significant distal injury. A protocol-based management can identify children at risk for long-term stricture earlier.

Liver resection in octogenarians.

BACKGROUND: Liver resections are increasingly being performed safely in elderly patients. There are no present reports of the operative safety of liver resection in octogenarians who represents a rapidly increasing segment of the population. The purpose of this study was to analyse the results of liver resection in octogenarians over a 5 year period within a tertiary referral liver surgery unit. METHODS: Prospective data collection and analysis of octogenarians having liver resection between 1999 and 2004. Retrospective detailed case note analysis was performed to determine peri-operative mortality and morbidity. Comparison were made to other large series of liver resection in younger patient cohorts. The primary outcome measure was 30 day mortality and secondarily a detailed analysis of post-operative complications was performed. RESULTS: A total 15 octogenarians (median age 82) were identified from the database. There was 1 peri-operative mortality. The remaining patients were all alive at 1, 3 and 6 month follow-ups with a median follow-up of 18 months. The commonest indication for liver resection was metastatic colorectal cancer (n=1). The median operating time was 142.5 minutes and 67% of patients (n=10) had portal clamping for a median of 21.5 minutes. The median length of hospitalization was 12 days with an ICU stay of 1 day, 27% (n=4) had major surgical complications. A further 20% (n=3) had exacerbations of pre-existing comorbidities. CONCLUSION: Liver resection can be performed safely in octogenarians within a tertiary referral unit. It has a low mortality and an acceptable level of morbidity in carefully selected octogenarians.