Re-thinking congenital piriform aperture stenosis: Modern imaging demonstrates narrowing of the full nasal cavity length.

OBJECTIVE: Measure the width of the nasal cavity in cases of piriform aperture stenosis using computerised tomography scans. METHODS: Retrospective study performed at a paediatric tertiary referral centre in Australia. Comparison nasal cavity widths (measured on computerised tomography scans in the axial plane) at the piriform aperture, choana and points 25, 50 and 75% along the length of nasal cavity, between cases with piriform aperture stenosis and controls. RESULTS: In cases of piriform aperture stenosis the piriform aperture along with the nasal cavity is statistically significantly narrower than controls, measured at 25, 50 and 75% along the distance between the piriform aperture and the choana. CONCLUSION: This modern imaging review has illustrated the need for a change in the treatment paradigm for neonates with this condition, suggesting the need for further investigation of techniques that treat narrowing beyond the aperture.

A novel approach in managing challenging tracheoesophageal fistulae.

OBJECTIVE: To analyze the outcomes of an open anterior cervical approach and tospecifically describe a novel extended tracheotomy incision ("Key-hole technique") torepair H-type and other challenging tracheoesophageal fistulae (TOF) at a singletertiary pediatric center. METHOD: A retrospective chart analysis of pediatric patients (0-18 years old) who had undergone repair of TOF's between January 2006 and March 2020 were reviewed. A case series of patients who had undergone open cervical utilizing three different techniques were included. Patient demographics, surgical management and post-operative surgical outcomes including complications were evaluated. RESULTS: During the study period, 117 pediatric patients were diagnosed and anaged with TOFs with or without oesophageal atresia. Within this group, 12 patients (10%) had anterior open cervical repair of congenital or persisting TOFs (6 males and 6 females). Eight cases (7%) had congenital Type E (known as H-type), two had type D, one type B and one type C TOF. Median gestational age was 37 weeks (range 28-41 weeks), age of presentation ranged from 1 day old to 3 years old with 67% being diagnosed within the first month of life. At the time of definitive surgery all patients had a bronchoscopy and oesophagoscopy to confirm the diagnosis, identify the level of the fistula and place a catheter through the fistula. This cases series of open anterior cervical repair of TOFs comprised of seven (58%) patients who had primary extraluminal tracheal approach, four (33%) with extended tracheotomy incision ('Key-hole' technique) and one (9%) patient with slide tracheoplasty for recurrent type C TOF in the presence of subglottic stenosis. Eleven of the twelve patients had successful open anterior cervical repair of TOF. One patient who had primary open anterior cervical repair with the 'Key-hole' technique had recurrence managed successfully with slide tracheoplasty. There were no cases of recurrent laryngeal nerve injury. CONCLUSION: This series demonstrates that open anterior cervical approach to correct TOFs is an effective and safe method in the majority of cases of congenital and acquired fistulae where there is no oesophageal atresia or the atresia is corrected (in the case of recurrent or second fistulae). We also present the outcomes of a novel surgical "Keyhole" technique to manage TOF fistulas via an extended-tracheotomy incision. We also found that slide tracheoplasty is an effective salvage operation in the case of complex recurrent fistulae.

Papillary cystadenocarcinoma of the sublingual gland.

A 68-year-old Caucasian gentleman presented with a 6-month history of a left sided Level I/II neck swelling involving the floor of mouth. MRI revealed a large cystic lesion and histology confirmed a diagnosis of primary papillary cystadenocarcinoma of the sublingual gland. Papillary cystadenocarcinoma was first described in 1991 by the World Health Organisation [WHO], and is a rare malignant neoplasm characterised by cysts and papillary endo-cystic projections. Papillary cystadenocarcinoma arising from the sublingual glands is extremely rare and has the potential to metastasise to cervical lymph nodes. This patient we report was therefore treated with surgical excision and post-operative radiotherapy.

Through-and-Through Mattress Suturing Versus Tie-Over Dressing in Full-Thickness Skin Graft Reconstruction.

OBJECTIVE: To compare the outcomes of securing full-thickness skin grafting (FTSG) with through-and-through mattress suturing versus the classic tie-over and pressure dressing and identify the associated risk factors of graft failure. METHODS: A single-institution, retrospective case series of patients who had undergone excision of head and neck skin lesions requiring FTSG over a 10-year period was reviewed. RESULTS: In total, 128 FTSG reconstructions were performed. The follow-up period ranged from 1 to 192 weeks. The observed graft take rate was 86.4%. There was no significant difference in the outcome when the surgical fixation technique was compared. Age, sex, or defect area did not affect the graft take rate. Smoking and the use of anticoagulants were not found to be contributory factors to graft failure. CONCLUSION: Simple through-and-through mattress suturing provides adequate graft take, while minimizing tissue handling of the graft and reducing surgical time in comparison to the traditional tie-over and pressure technique.

Simulating the Surgical Patient Pathway for Undergraduates.

BACKGROUND: A changing National Health Service structure and a reduction in time available for teaching have led to the increasing tensions in both clinical and university settings, to deliver high-quality patient care, research, and teaching. This, coupled with the increasing emphasis placed on ensuring safe surgical practice, has resulted in a need for change in teaching methods. We have designed an innovative surgical teaching program that aims to overcome these difficulties, by providing undergraduate medical students with a simulated surgical patient pathway. METHODS: This prospective study compared 2 independent groups of medical students during their first-year clinical attachments, with the study group receiving the newly implemented simulated surgical patient pathway compared against a control group receiving traditional surgical education programs. RESULTS: Students in the study group demonstrated a significantly improved subjective experience of surgical teaching, with greater awareness and confidence of safe surgical principles. Additionally, these students receiving the newly implemented simulation pathway performed significantly better than the control group in an objective knowledge-based assessment. DISCUSSION: Simulation is not a substitute to clinical experience and it should not be considered as a replacement to real patients; but when used carefully, it can be an effective and essential adjunct in bridging the gap between classroom medicine and clinical practice.

How reliable is the "scratch test" versus the Weber test after tympanomastoid surgery?

OBJECTIVES: To identify whether the scratch test can be used as an alternative to the Weber's test after tympanomastoid surgery. METHODS: This twin-center prospective study assessed major tympanomastoid surgery patients over a 6-month period. Patients were assessed postoperatively on Day 0 or Day 1 of surgery using a standardized proforma. A Weber's test was performed using a 512-Hz tuning fork, placed midline on the forehead to assess the direction of sound localization. This was directly compared with a scratch test, by asking the patient the following while scratching the head bandage in the midline: "Can you hear this? And which side is loudest?" RESULTS: Fifty-six patients were assessed in total. Sixteen mastoid explorations, 14 tympanoplasties, 18 combined approach tympanoplasties, and 8 other procedures were included, all of which had standard external auditory canal packing and head bandage. Assessment with Weber's test found 41 patients to have sound lateralizing to the operated ear. In comparison, 50 patients lateralized sound to the operated ear with the scratch test. Overall, Weber's test had a sensitivity of 73.2% and specificity of 100% compared with a sensitivity of 89.3% and specificity of 100% for the "Scratch Test." No patients had a dead ear after surgery. CONCLUSION: The scratch test proved to be more accurate than traditional postoperative tuning fork assessment and provides a quick, accurate, and simple solution for when such equipment is unavailable.

Sentinel node micrometastases in breast cancer: clinical outcome.

AIM: The sentinel lymph node biopsy has steadily replaced axillary lymph node dissection for staging clinically node-negative breast cancer. This study assesses surgical and adjuvant practice in relation to micrometastases and isolated tumor cells found on biopsy in a single surgeon cohort. METHODS: Clinicopathological characteristics were collated from 700 breast cancer patients undergoing sentinel lymph node biopsies between 1999 and 2007. The status and details of the node biopsies, continuing treatment and adverse outcomes were reported. Patient details at the time of diagnosis were entered into Adjuvant! online to look at likely prognosis. For both isolated tumor cells and micrometastases, data input was conducted twice, once as node-negative and again as node-positive, thus providing two predicted benefit data series. RESULTS: A total of 665 women were eligible for inclusion, 67 with micrometastases and 20 with isolated tumor cells. Overall 33 patients developed recurrence with nine breast-cancer related deaths. Women with isolated tumor cells or micrometastases were more likely to receive adjuvant radiotherapy to the axilla compared with women with node-negative disease. Compared to those with isolated tumor cells, a higher number of women with micrometastases received systemic chemotherapy despite similar predicted benefits. Individual comparisons showed significantly higher rates of recurrence in women with isolated tumor cells than in node-negative disease (P < 0.0001). CONCLUSION: The biological behavior of early breast cancer with isolated tumor cells on sentinel node biopsy is similar to both micrometastases and macrometastases, i.e. they behave in a node-positive fashion. This is an early indication that these patients should be treated with more aggressive adjuvant therapy.