Airway decision making in major head and neck surgery: Irish multicenter, multidisciplinary recommendations.

Major head and neck surgery poses a threat to perioperative airway patency. Adverse airway events are associated with significant morbidity, potentially leading to hypoxic brain injury and even death. Following a review of the literature, recommendations regarding airway management in head and neck surgery were developed with multicenter, multidisciplinary agreement among all Irish head and neck units. Immediate extubation is appropriate in many cases where there is a low risk of adverse airway events. Where a prolonged definitive airway is required, elective tracheostomy provides increased airway security postoperatively while delayed extubation may be appropriate in select cases to reduce postoperative morbidity. Local institutional protocols should be developed to care for a tracheostomy once inserted. We provide guidance on decision making surrounding airway management at time of head and neck surgery. All decisions should be agreed between the operating, anesthetic, and critical care teams.

The role of surgery for anaplastic thyroid carcinoma in the era of targeted therapeutics: A scoping review.

Background: Questions exist regarding patient selection for surgery in anaplastic thyroid carcinoma (ATC), particularly with the advent of neoadjuvant-targeted therapeutics. The present scoping review sought to evaluate what extent of surgical resection should be performed in ATC. Methods: A scoping review was carried out in accordance with Joanna Briggs Institute and the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) protocols. Included studies were required to provide clear description of the surgery performed for ATC. Results: The final search identified 6901 articles. Ultimately only 15 articles including 1484 patients met inclusion criteria. A total of 765 patients (51.5%) underwent attempted curative intent surgery. The approach to resection of adjacent tissues varied between studies. Eight studies considered laryngeal ± pharyngeal resection (8/15, 53.3%), eight studies (53.3%) considered tracheal resection and again eight studies (53.3%) considered esophageal resection. More extensive resections increased morbidity without improving overall survival (OS) (<9 months in the 12 studies using a combination of surgery and chemoradiotherapy). In the three studies utilizing targeted therapy in addition to surgery, OS was notably improved while surgical resection following neoadjuvant therapy was less extensive. Conclusions: There is no clear agreement in the literature regarding the limits of surgical resection in locoregionally advanced ATC. A definition of surgically resectable disease will be required to guide surgical decision making in ATC, particularly with the potential to reduce tumor burden using neoadjuvant targeted treatment in suitable patients. Level of evidence: III.

Non-conventional laryngeal malignancies: a multicentre review of management and outcomes.

PURPOSE: Non-conventional laryngeal malignancies (NSCC) often have limited published data to guide management despite individual histopathological subtypes often exhibiting heterogeneous behaviour, characteristics, and treatment responses compared to laryngeal squamous cell carcinoma (SCC). This study aimed to compare oncological outcomes with SCC, specifically disease-free survival (DFS), disease-specific survival (DSS) and overall survival (OS). Secondary objectives were to compare treatment differences and perform a state of the art review. METHODS: This was a multicentre retrospective cohort study at four tertiary head and neck centres. Survival outcomes between NSCC and SCC patients were analysed with Kaplan-Meier curves and compared by log rank testing. Univariate Cox regression analysis was performed to predict survival by histopathological subgroup, T-stage, N-stage and M-stage. RESULTS: There were no significant differences in 3-year DFS (p = 0.499), DSS (p = 0.329), OS (p = 0.360) or Kaplan Meier survival curves (DSS/OS) between SCC and overall NSCC groups. However, univariate Cox regression analysis identified "rare" histopathologies (mostly small cell carcinoma) to be predictive of less favourable OS (p = 0.035) but this result was not observed for other NSCC histopathological subgroups. N-stage (p = 0.027) and M-stage (p = 0.048) also predicted OS for NSCC malignancies. Significant differences in treatment modalities were identified with treatment of NSCC typically involving surgical resection and SCC often managed non-surgically (e.g., primary radiotherapy). CONCLUSIONS: Although overall NSCC is managed differently compared to SCC, there do not appear to be differences in survival outcomes between these groups. N-stage and M-stage appear to be more predictive of OS than histopathology than many NSCC subtypes.

Pattern of nodal metastasis of cutaneous squamous cell carcinoma involving the temporal bone.

Objective: The objective of this study was to explore the pattern of lymph-node spread of SCCs involving the temporal bone. Methods: We retrospectively reviewed all cutaneous SCCs involving the temporal bone over a 20-year time-period. Forty-one patients were eligible. Results: Mean age was 72.8 years. The diagnosis was cutaneous SCC in all cases.All patients underwent a temporal bone resection, 70.7% had a neck-dissection and 78.0% a parotidectomy.Level 2 was the most common area of neck metastasis, and occurred in 12.2%. The parotid had disease in 34.1%. 51.2% of patients underwent free-flap reconstruction.Mean overall survival of the cohort was 4.2 years. Conclusions: Overall, the rate of cervical nodal metastasis was 22.0% and 13.5% in the occult setting. The parotid was involved in 34.1% and 10.0% in the occult setting. Results from the present study support consideration for performing a parotidectomy at the time of temporal bone resection, while a neck dissection can be performed for adequate staging of the nodal basin. Level of Evidence: 3.

Metastatic and locally aggressive BCC: Current treatment options.

The treatment of locally advanced and metastatic BCC presents a significant clinical challenge. Treatment options have evolved recently to include the use of hedgehog inhibitors Vismodigib and Sonidigib and immunotherapy with Cemiplimab.

The Royal College of surgeons multidisciplinary guidelines on elective tracheostomy insertion in COVID-19 ventilated patients.

BACKGROUND: The current COVID-19 pandemic has placed enormous strain on healthcare systems worldwide. Understanding of COVID-19 is rapidly evolving. Pneumonia associated with COVID-19 may lead to respiratory failure requiring mechanical ventilation. The rise in patients requiring mechanical ventilation may lead to an increase in tracheostomies being performed in patients with COVID-19. Performing tracheostomy in patients with active SARS-CoV-2 infection poses a number of challenges. METHODS: These guidelines were written following multidisciplinary agreement between Otolaryngology, Head and Neck Surgery, Respiratory Medicine and the Department of Anaesthetics and Critical Care Medicine in the Royal College of Surgeons in Ireland. A literature review was performed and a guideline for elective tracheostomy insertion in patients with COVID-19 proposed. CONCLUSION: The decision to perform tracheostomy in patients with COVID-19 should be undertaken by senior members of the multidisciplinary team. Steps should be taken to minimise risks to healthcare workers.

Infiltrative thyrotoxicosis: an unusual case of diffuse large B cell lymphoma.

Thyrotoxicosis is most commonly caused by Graves' disease, toxic multinodular goitre, a functioning thyroid adenoma, or thyroiditis. Extrinsic infiltrative conditions affecting the thyroid gland are typically destructive, and associated with thyroid hypofunction. We describe the case of a 61-year-old woman who presented to our hospital with symptoms of thyrotoxicosis, neck swelling and thyroid function tests consistent with hyperthyroidism. An ultrasound revealed a multinodular goitre with retrosternal extension, but CT imaging suggested thyroid gland infiltration, with cervical lymphadenopathy. An excisional lymph node biopsy confirmed the diagnosis of diffuse large B cell lymphoma causing infiltrative thyrotoxicosis. Treatment with six cycles of Rituximab-CHOP lead to rapid normalization of symptoms, imaging, and thyroid function.

Significant laryngeal destruction in a northern European cohort of Behçet's disease patients.

OBJECTIVES: Behçet's disease (BD) is a multisystem autoimmune disease of unknown origin typically affecting the triad of oral and genital mucosa and the eye. Limited data are available in the literature regarding the otolaryngology-related manifestations of BD, particularly in northern Europeans. This is a novel study detailing surprising and significant laryngeal structural changes in a northern European cohort of BD. METHODS: Patients meeting the International Study Group for Behçet's Disease (ISGBD) and the International Criteria for Behçet's Disease (ICBD) criteria for diagnosis were identified from an institutional database. Patients underwent examination with an otolaryngologist, including flexible laryngoscopy. Intra-oral, pharyngeal and laryngeal manifestations of BD were documented and characterised. Patients underwent hearing assessment with pure-tone audiometry. RESULTS: Fifteen patients with BD were identified (4 male, 11 female; median age 36 years). 60% (n=9) showed evidence of disease on examination and flexible laryngoscopy. 33% (n=5) showed laryngeal changes related to BD. 13% (n=2) demonstrated bilateral sensorineural hearing loss. The 5 cases demonstrating laryngeal manifestations of disease are described in detail with photographic records. CONCLUSIONS: Limited data has been published regarding the laryngeal manifestations of BD, particularly in a northern European population. Our cohort of BD patients demonstrate significant laryngeal structural changes. It would appear that these clinically relevant changes may be more common than was previously thought. Raised awareness of the risk of laryngeal pathology in BD patients, often in the absence of overt clinical symptomatology, may result in earlier diagnosis and treatment. Rheumatologists and otolaryngologists should consider closer multi-disciplinary co-operation in the management and follow up of patients with BD.

Advanced and rapidly progressing head and neck cancer: good palliation following intralesional bleomycin.

The authors herein report the case of a 61-year-old man undergoing adjuvant therapy for locally advanced laryngeal cancer, who developed parastomal recurrence in his radiation field around his tracheotomy site, while he was undergoing radiation therapy, and compromised the secure placement of his tracheotomy tube and maintenance of his upper airway. MRI restaging and biopsy confirmed recurrence and progressive disease in his mediastinum. He underwent local therapy with intralesional bleomycin with good palliation, and ability to maintain the patency of his upper airway.

Transpalatal advancement pharyngoplasty for obstructive sleep apnea syndrome: results and analysis of failures.

OBJECTIVE: To assess the polysomnographic outcomes of patients with obstructive sleep apnea undergoing transpalatal advancement pharyngoplasty for retropalatal collapse and to compare responders with nonresponders to surgery. DESIGN: Retrospective medical record review. SETTING: Tertiary referral teaching hospital and private practice. PATIENTS: Sixty patients undergoing transpalatal advancement pharyngoplasty alone at a single sitting with preoperative and postoperative sleep studies were reviewed. INTERVENTION: Transpalatal advancement pharyngoplasty. MAIN OUTCOME MEASURES: Preoperative and postoperative polysomnographic data were analyzed and comparisons were assessed between responders and nonresponders. RESULTS: Following surgery, the mean (SD) respiratory disturbance index (RDI) decreased from 37.2 (20.4) to 15.4 (12.3), with an overall change of 21.8 (21.8) (95% confidence interval [CI], 16.2-27.4). Similarly, the mean (SD) arterial oxygen saturation nadir after transpalatal advancement pharyngoplasty surgery improved from 83.9% (5.4%) to 87.4% (4.3%), with an overall change of 3.5% (5.9%) (95% CI, 2.0%-5.0%). Between the traditional Gothic arch incision (n = 31) and the propeller incision (n = 29) an observed 31% (95% CI, 7%-51%) difference in success rate in favor of the latter was noted. CONCLUSIONS: Transpalatal advancement pharyngoplasty appears to be an effective and safe treatment option in selected patients. No preoperative variable was associated with surgical success in this study. The association of the propeller incision and surgical success requires further analysis.

Bilateral stapedectomy: association between first- and second-ear surgical findings and their effects on the second-ear outcome.

OBJECTIVES: We assessed the association between first-ear and second-ear surgical findings in patients undergoing second-ear stapedectomy for bilateral otosclerosis and the impact of such findings on the audiometric outcome of the second ear. METHODS: A retrospective chart review of all stapedectomy patients who underwent stapes surgery by one of two surgeons in a single tertiary referral institution from 1962 to 2001 was performed, and those patients who underwent bilateral stapedectomy were identified. Patient demographic data, surgical findings, procedure performed, and preoperative and postoperative audiometric data were recorded. RESULTS: A total of 459 patients (918 ears) underwent bilateral stapedectomy for bilateral otosclerosis during the study period, of whom 426 had complete data for analysis. The finding of a white or obliterated footplate in the second ear was significantly higher if the first ear had this disease manifestation (p < .001, chi2 test). The association between a second drill-out's being performed and a drill-out in the first operation was significant (p < .001, chi2 test). Statistical analysis identified that those who underwent a drill-out procedure had a 2.9-fold increase in unsuccessful outcome in comparison to those who did not have a drill-out (odds ratio, 2.89; 95% confidence interval, 1.41 to 5.89). Facial nerve anomalies were infrequently encountered, affecting only 23 patients, of whom 3 had bilateral abnormalities. The finding of an overhanging or dehiscent facial nerve in the second ear was significantly more likely if such an abnormality was identified during the first procedure (23% versus 2.5%; p = .005, Fisher's exact test). CONCLUSIONS: Second-ear hearing results are poorer in those who require a drill-out of this ear, and this is more likely to be required if a drill-out was required in the first ear, regardless of a successful outcome of the first procedure. Patients should be aware of the reduced likelihood of success in these cases and be counseled regarding risks and benefits of second-ear surgery based, in part, on the findings from the first ear. This study confirms that bilateral advanced footplate obliteration and overhanging or dehiscent facial nerves may be anticipated in patients found to have these abnormalities during first-ear stapedectomy.

The "Propeller" incision for transpalatal advancement pharyngoplasty: a new approach to reduce post-operative oronasal fistulae.

OBJECTIVE: To present a new soft tissue approach for transpalatal advancement pharyngoplasty (TPA), the propeller incision, and to compare the rates of post-operative oronasal fistula in those undergoing TPA with the traditional "Gothic Arch" incision described by Woodson and those with the propeller incision. METHODS: A prospectively maintained adult sleep apnoea surgery database was used to identify those patients undergoing TPA, either alone or in combination with other procedures, for obstructive sleep apnoea syndrome (OSAS) between February 2001 and September 2006 in a tertiary referral centre by a single surgeon (RHL). In addition to the incision used during TPA, patient demographic data, previous surgery of the upper airways, smoking history, pre-operative body mass index, respiratory disturbance index, oxygen saturation index and the occurrence of oronasal fistula post-operatively, were recorded. The propeller incision technique is described. RESULTS: A total of 89 patients who underwent TPA were identified. A total of 49 patients had a "Gothic Arch" incision and 40 had a "Propeller" incision. The two groups of patients were comparable in age, sex, previous tonsillar and uvulopalatopharyngoplasty surgery, smoking histories and pre-operative disease severity. In the "Gothic Arch" group, eight patients (16%) developed oronasal fistulae in the post-operative period versus only one patient (2.5%) in the "Propeller" group. The difference between the two groups was statistically significant (P=0.038, Fisher's exact test). Of the total cases with post-operative oronasal fistula (n=9), only one patient (from the Gothic Arch incision group) required operative closure which was performed under local anesthesia and healed without complication. CONCLUSION: The propeller incision provides an anatomically sensible axial-based flap that provides adequate access to perform TPA. It is associated with a lower incidence of oronasal fistula and is recommended by the authors.

Adenotonsillectomy for obstructive sleep apnea in obese children: effects on respiratory parameters and clinical outcome.

OBJECTIVE: To assess the efficacy of adenotonsillar surgery on respiratory sleep parameters and avoiding continuous positive airway pressure (CPAP) treatment in morbidly obese children with obstructive sleep apnea syndrome (OSAS). DESIGN: Retrospective. SETTING: Tertiary referral institution. PATIENTS: Children aged 2 to 18 years, with a body mass index (BMI) at or higher than the 95th percentile (adjusted for age and sex), undergoing adenotonsillar surgery for OSAS. INTERVENTIONS: Adenotonsillectomy. MAIN OUTCOME MEASURES: Preoperative and postoperative respiratory disturbance index, oxygen saturation nadir, overall severity of OSAS (mild, moderate, or severe) and candidacy for CPAP treatment were assessed and compared. Variables such as age, severity of disease, adenotonsillar size, and BMI z scores were compared between responders and nonresponders to surgical treatment. RESULTS: A total of 19 patients with full preoperative and postoperative data for evaluation were identified. The median (SD) age was 78 months (53.3 months). The median (SD) BMI z score was 2.84 (0.94). Eighteen patients (95%) had OSAS preoperatively to warrant CPAP treatment. Surgery reduced the overall median (SD) respiratory disturbance index from 20.7 (24.5) to 7.3 (14.9) (P<.001) and improved the median (SD) oxygen saturation nadir from 77.5% (16.3%) to 88.5 (13.1%) (P<.01). A total of 7 patients (37%) were cured by surgery. Ten patients (53%) had postoperative disease of sufficient severity to require CPAP. Surgery obviated the need for further treatment in only 8 (44%) of the 18 patients with preoperative disease warranting CPAP. No differences were identified between responders and nonresponders to surgical treatment. CONCLUSIONS: Adenotonsillar surgery improves sleep respiratory parameters in morbidly obese children with OSAS. Most patients have residual OSAS requiring further treatment.

Airway management of three cases of congenital cervical teratoma.

Cervical teratomas are rare congenital tumors derived from all three germ cell layers. The vast majority are histologically benign, but the significant size they may attain can potentiate life-threatening upper airway obstruction. All cases require the specialist airway skills of the pediatric anesthetist. This may be planned, in the case of antenatally diagnosed lesions, when the pediatric anesthetist is part of a multidisciplinary team involved in an EX utero Intrapartum Treatment (EXIT) or Operation On Placental Support (OOPS) procedure, or when a neonate is undergoing elective excision in the early neonatal period as definitive treatment. Alternatively the anesthetist may be called upon urgently to secure a compromised airway immediately postpartum when no antenatal diagnosis has been made. Furthermore, after elective surgical excision, airway compromise is possible, which may again require anesthetic intervention. The aim of this study is to report the authors' experience in managing the airway in three cases of congenital cervical teratoma in the study institution over the last 24 months. These cases highlight the possible airway scenarios that may confront the anesthetist in the immediate postpartum, elective surgery and postoperative stages and the variety of techniques that may be employed in order to overcome the potential difficulties encountered.

Solitary fibrous tumor of the floor of the mouth: case report and review of the literature.

Solitary fibrous tumor is an uncommon spindle cell neoplasm that is believed to be of mesenchymal origin. Rarely does it originate in the oral cavity, and only 1 case of this lesion in the floor of the mouth has been previously reported. We describe a new case of solitary fibrous tumor arising from the soft tissues of the floor of the mouth.

Parotid lymphomas--clinical and computed tomographic imaging features.

OBJECTIVE: To review the clinical presentation and computed tomography (CT) imaging characteristics of all parotid lymphomas diagnosed at the study institution over a 7-year period. DESIGN: Retrospective chart review of parotid lymphomas diagnosed between 1997 and 2004. SUBJECTS: A total of 121 patients with parotid lesions were identified. After retrospective chart review, a total of 10 patients with histologically proven parotid lymphoma were included in the study, 8 of whom had CT scans available for assessment. RESULTS: Ten patients with histologically proven lymphoma of the parotid gland were identified from among 121 patients with parotid neoplasms, an incidence in this series of 8.3%. All lymphomas were of non-Hodgkin's type. All patients presented with a painless unilateral parotid swelling. Most patients had a short history of less than 4 months' duration, of whom 3 presented with a rapidly evolving swelling of less then 1 month's duration. No patient had a background of Sjögren's disease or any other autoimmune disorders. The commonest finding noted on CT was of a unilateral, single mass of relative soft-tissue homogeneity with poorly defined, indistinct tumour margins. Associated loco-regional lymphadenopathy was identified in 2 cases, 1 clinically and another radiologically; multiple ipsilateral lesions were noted in 2 cases. No cases of contralateral disease were observed. CONCLUSION: Lymphoma has a clinical presentation similar to other neoplasms arising within the parotid gland. A unilateral, non-tender swelling was a universal finding. A history of less than 4 months may suggest the possibility of lymphoma. CT scanning is a useful adjunctive investigation to determine the site and extent of the disease, loco-regional nodal status and contralateral gland and neck status. Multifocality and associated adenopathy are associated with, but not exclusive to, parotid lymphoma. Although poor tumour boundary definition on CT imaging is a strong predictor of malignancy, no pathognomonic finding specific for lymphoma has been identified. The potential diagnosis of parotid lymphoma should be considered in all patients who present with a parotid mass.

Digital spectral analysis of the drill-bone acoustic interface during temporal bone dissection: a qualitative cadaveric pilot study.

HYPOTHESIS: To qualitatively assess the different acoustic signatures of an otologic drill burr-bone interface during temporal bone dissection on full thickness calvarial and thin tegmen bone. BACKGROUND: An appreciable change in the sound generated by drilling occurs with progressive thinning of the bone during temporal bone dissection. To date, descriptions of this phenomenon are limited to a handful of subjective characterizations. Using digital power spectral analysis, interpretation of complex functions of time such as acoustic signals can be interpreted. METHODS: Acoustic data recorded from five cadaveric temporal bone dissections were studied using digital spectral analysis. RESULTS: The energy bandwidth concentration was between 5.0 and 7.9 kHz for full thickness bone using the cutting burr. Thin tegmen bone bandwidth concentration was lower, between 3.7 and 7.4 kHz and 3.9 and 6.0 kHz, using cutting and diamond burrs, respectively. Harmonic frequencies for thin tegmen bone-burr signals were 630 Hz. CONCLUSION: There is a consistent, reproducible qualitative difference in the spectral domain of the acoustic signature from the drill burr-bone interface between thick calvarial bone and thin tegmen bone caused by a higher harmonic peak interval and lower energy bandwidth concentration in the thinned tegmen bone-burr interface signal thus concentrating the acoustic signal within a more optimal frequency range for human perception. These results allow for a better understanding of the perceived change in sound with progressive thinning of bone with drilling. In addition, these data may allow the development of more realistic acoustic interfaces in virtual reality temporal bone dissection simulators.

Congenital cervical teratomas: diagnostic, management and postoperative variability.

OBJECTIVE: To review the diagnosis, management and outcomes of congenital cervical teratomas presenting to a tertiary referral centre. METHODS: Retrospective chart review of three cases presenting within an 18-month period. RESULTS: Of the three patients in this series, one was diagnosed antenatally. The remaining cases were diagnosed at birth. The antenatally diagnosed patient underwent an EXIT procedure whereby the airway was secured by tracheostomy. This patient subsequently died 30 min after separation from the materno-foetal circulation. Neither of the other two cases had any neonatal respiratory distress, despite having large tumours. Both patients had neonatal surgical excision of the teratomas performed. Both patients had postoperative respiratory distress, requiring intervention. Both patients made a full recovery. No recurrence has been reported. CONCLUSION: The antenatal diagnosis of large congenital cervical teratomas allows for planned intervention by experienced personnel. A successful outcome may not be obtained. All patients that undergo surgical excision of these tumours must be closely observed for post-operative respiratory distress, even in the absence of pre-operative symptoms.

Takayasu's arteritis and saddle nose deformity: a new association.

Aortitis and saddle nose deformity are extremely unusual manifestations of a variety of systemic diseases. The concurrent appearance of these apparently disparate clinical features is a clinical rarity. A case of saddle nose deformity in a patient with confirmed Takayasu's arteritis is presented. The relevant literature is reviewed with reference to the possible differential diagnosis of patients with aortitis and saddle nose deformity.

Spontaneous retropharyngeal and cervical emphysema: a rare singer's injury.

Spontaneous retropharyngeal and cervical emphysema is rare. We describe a case that was unusual in its etiology: the result of singing. Although this condition is usually benign, hospital admission for close observation and supportive therapy is prudent.