Safely performing percutaneous dilatational tracheostomies on COVID-19 patients in the intensive care unit: A standardized approach.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus disease 2019 (COVID-19) have afflicted hundreds of millions of people in a worldwide pandemic. During this pandemic, otolaryngologists have sought to better understand risk factors associated with COVID-19 contamination during surgical procedures involving the airways such as tracheostomies. OBJECTIVE: This study provides a standardized technique of performing an ultrasound (US)-guided percutaneous dilatational tracheostomy (PDT) on COVID-19 patients in the intensive care unit (ICU). It also outlines safety strategies for health care providers that includes proper use of personal protective equipment (PPE) and regular testing of otolaryngologists for COVID-19 contamination. METHODS: This study analyzed data from 44 PDT procedures performed on COVID-19 patients in the ICU of hospitals in Sao Paulo and Santos, Brazil. The PDT procedures were conducted between April 2020 and August 2020, which coincided with a peak of the COVID-19 pandemic in São Paulo, Brazil. Surgeons were tested for COVID-19 using a two-stage serological enzyme-linked immunosorbent assay specific for SARS-CoV-2 antigens. CONCLUSION: This study describes a safe standardized technique of US-guided PDT for COVID-19 patients in the ICU using a method that also decreases the risk of surgeon contamination.

Trans Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Brazil: Safety and complications during learning curve.

OBJECTIVE: The aim of this study was to address the first cases of TOETVA done in Brazil, by TOETVA-Bra study group, regarding safety and complications. METHODS: Series of the first 93 TOETVAs cases in Brazil. All authors except LPK, AJG JOR and RPT received TOETVA training including cadaveric hands-on in Thailand or United States (Johns Hopkins Medicine) during 2017. After they came back to Brazil and started doing their first TOETVA cases in the cities of Rio de Janeiro, Sao Paulo and Chapecó they agreed to collaborate and gather data using an online spreadsheet. All patients were submitted to the technique described by Anuwong. RESULTS: A total of 93 patients underwent TOETVA. Most patients (58.1%) were submitted to total thyroidectomy and 59.1% had benign disease. Two patients (2.2%) needed conversion to open surgery. Five patients (9.3%) developed transient hypoparathyroidism and there were 3 (2.0%) temporary recurrent laryngeal nerve palsy. There was one (0.7%) permanent unilateral palsy. Twenty patients had some sort of complication, 16.1% were minor and 5.4% were major. A total of 73 patients (78.5%) had an uneventful recovery. CONCLUSION: The technique is reproducible with a low complication rate. While further studies are needed to confirm equivalency, early efforts suggest that TOETVA is not inferior to traditional open thyroidectomy in appropriately selected patients.

Trans Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Brazil: Safety and complications during learning curve

ABSTRACT Background: The aim of this study was to address the first cases of TOETVA done in Brazil, by TOETVA-Bra study group, regarding safety and complications. Materials and Methods: Series of the first 93 TOETVAs cases in Brazil. All authors except LPK, AJG JOR and RPT received TOETVA training including cadaveric hands-on in Thailand or United States (Johns Hopkins Medicine) during 2017. After they came back to Brazil and started doing their first TOETVA cases in the cities of Rio de Janeiro, Sao Paulo and Chapecó they agreed to collaborate and gather data using an online spreadsheet. All patients were submitted to the technique described by Anuwong. Results: A total of 93 patients underwent TOETVA. Most patients (58.1%) were submitted to total thyroidectomy and 59.1% had benign disease. Two patients (2.2%) needed conversion to open surgery. Five patients (9.3%) developed transient hypoparathyroidism and there were 3 (2.0%) temporary recurrent laryngeal nerve palsy. There was one (0.7%) permanent unilateral palsy. Twenty patients had some sort of complication, 16.1% were minor and 5.4% were major. A total of 73 patients (78.5%) had an uneventful recovery. Conclusion: The technique is reproducible with a low complication rate. While further studies are needed to confirm equivalency, early efforts suggest that TOETVA is not inferior to traditional open thyroidectomy in appropriately selected patients.

Metástase gigante de carcinoma papilífero / Giant metastasis of thyroid papillar carcinoma

O carcinoma papilífero da tireoide, o mais comum deste órgão, geralmente se apresenta como lesões parenquimatosas pequenas e, eventualmente, com metástases cervicais numerosas, raramente volumosas. É descrito um caso raro de uma paciente do gênero feminino, 44 anos, com um tumor cervical anterior, nodular e volumoso há nove anos. Após o tratamento cirúrgico, o anatomopatológico mostrou tratar-se de metástases linfonodais de carcinoma papilífero. O objetivo deste estudo é relatar um caso clínico de apresentação incomum de carcinoma papilífero da tireoide, de diagnóstico inicial difícil e apresentando-se com metástases linfonodais volumosas. Arq Bras Endocrinol Metab. 2014;58(9):967-9 Papillary thyroid carcinoma, the most common type of thyroid cancer is usually presented as small parenchymatous lesions and, eventually, with cervical lymph node metastasis, rarely voluminous. Here we describe a rare case of a 44-year-old woman presenting a visible anterior cervical tumor, nodullary and voluminous, for nine years. After surgical treatment, the anatomical pathology sample revealed that the mass was composed of several cervical lymph node metastatic lesions of a papillary thyroid carcinoma. We report the discovery of an uncommon papillary thyroid carcinoma manifestation, with a difficult initial diagnosis and presenting voluminous lymph node metastases.

Tratamento seletivo do hipoparatireoidismo após tireoidectomia total baseado nos valores de PTH / Selective treatment for hypoparathyroidism after total thyroidectomy based on PTH levels

Introdução: A hipocalcemia é a complicação mais comum após a tireoidectomia total e responsável por um maior tempo de internação. A fim de evitar manifestações da hipocalcemia, alguns autores rotineiramente fazem suplementação oral de cálcio, outros, por sua vez, prolongam a estadia do doente aguardando dosagens séricas de cálcio para indicar a reposição. Objetivo: Avaliar a eficácia da suplementação de cálcio/calcitriol baseado em valores pós operatórios de paratormônio(PTH) , afim de evitar manifestações clínicas de hipocalcemia em pacientes submetidos à tireoidectomia total. Materiais e Métodos: Estudo prospectivo com 31 pacientes submetidos à tireoidectomia total ou totalização, com ou sem esvaziamento recorrencial. O PTH foi colhido após 1 hora de pós operatório. A suplementação seletiva foi determinada pelo valor do PTH com cálcio (PTH >5 e <15pg/ml), cálcio e calcitriol (PTH <5pg/ml) e foram correlacionadas com sintomas de hipocalcemia durante 10 dias de pós operatório. Resultados: Nenhum paciente com PTH>15pg/ml desenvolveu sintomas (p=0,007). Dentre os pacientes com PTH <15pg/ml, 9 (52,84%) permaneceram assintomáticos com uso da medicação. Cinco pacientes (29,41%) não fizeram uso da suplementação prescrita e todos apresentaram sintomas. Três pacientes apresentaram sintomas, apesar do uso correto da suplementação.(p=0,009). Conclusão: A suplementação seletiva de cálcio ou cálcio associada ao calcitriol, baseada no PTH, é eficaz para evitar os sintomas de hipocalcemia.

Background: Hypocalcemia is the most common complication after total thyroidectomy and the major determinant in delay of discharge. Because of this, some authors routinely use oral supplementation of oral calcium, while others postpone hospital discharge waiting of multiple calcium dosages. Objectives: To test a selective oral calcium/calcitriol supplementation to avoid clinical manifestations of hypocalcemia based on parathyroid hormone levels after total thyroidectomy. Methods: Prospective study with 31 patients undergoing total thyroidectomy or completion, with or without central neck dissection. Parathyroid hormone (PTH) was measured 1 hour postoperative period. Selective supplementation was determined by serum PTH levels with oral calcium (PTH>5pg/ ml and <15pg/ml) or oral calcium plus calcitriol (PTH<5pg/ml) and correlated with symptoms of hypocalcemia during 10 days postthyroidectomy. Results: None of the patients (14/31) with PTH levels > 15pg/ml developed symptoms (p=0,007). Among seventeen patients with PTH<15pg/ml, 9 (52,84%) patients had adequate supplementation and remained asymptomatic. Five patients (29,41%) had clinical manifestations without correct supplementation. Three patients developed symptoms taking correct supplementation. (p=0,009). Conclusions: The selective supplementation based on postthyroidectomy PTH levels can be used safely to avoid clinical manifestations of hypocalcemia.

Avaliação da efetividade e dos custos da sutura mecânica nas laringectomias totais comparados ao fechamento tradicional / Mechanical versus manual suture in total laryngectomy: Costs and effectiveness

Introdução: A ocorrência de fístulas faringocutâneas apóslaringectomias totais é um fator de grande impacto no tempode internação do doente enquanto a demora no fechamentoda faringe é significativa no tempo de permanência em salacirúrgica. Ambos afetam o custo final do procedimento cirúrgico.O uso da sutura mecânica pode reduzir estes tempos e,consequentemente, dos custos do procedimento. Objetivos:Comparar os custos resultantes do fechamento manual emecânico da faringe. Método: estudo retrospectivo, avaliandoo tempo de permanência em sala cirúrgica e permanênciahospitalar de pacientes submetidos a laringectomia total, quantoaos dois tipos de fechamento da faringe: Manual ou mecânico.Resultados: A fístulas faringocutâneas ocorreram apenas noscasos de fechamento manual (17,3%), resultando em uma maiorpermanência hospitalar neste grupo (12,23 x 6,5 dias da suturamecânica). O tempo operatório também foi maior naquele grupo(2h20min maior). A média dos custos do fechamento manual foramR$5.799,24. Isto supera o custo do grampeador, de R$ 1033,00.Conclusão: O fechamento da faringe com grampeador deve serpreferido, sempre que possível, pois apresenta menores índicesde complicações e custos menores, apesar do preço do mesmo.

Tireoidectomia no idoso: 15 anos de experiência / Thyroidectomy in the elderly: 15 years institutional experience

Introdução: As doenças mais prevalentes nos idosos têm-se tornado cada vez mais comum com o envelhecimento da população mundial. No paciente idoso, além do aumento da incidência de nódulos tireoidianos, há maior incidência de câncer, com comportamento mais agressivo. A idade elevada não contra-indica a cirurgia, porém, a conduta cirúrgica pode ser influenciada pelo número elevado de comorbidades. Objetivos: Estudar a freqüência da doença tireoidiana de indicação cirúrgica no idoso, caracterizando-a. Métodos: Trata-se de um estudo retrospectivo com 69 pacientes entre 65 e 84 anos de idade (mediana, 71) submetidos a qualquer procedimento cirúrgico sobre a glândula tireóide em nosso serviço, entre 1991 e 2006. Avaliamos dados da identificação, história, comorbidades, dados pré-operatórios, exames complementares, dados cirúrgicos, anátomo-patológicos e da evolução, pormenorizando a ocorrência de complicações. Resultados: A queixa principal foi aumento do volume cervical, com duração média de 67 meses. O diagnóstico clínico mais freqüente foi de bócio multinodular atóxico. Em 62% foi realizada a tireoidectomia total, seguidas pela hemitireoidectomia e pela totalização. Comorbidades clínicas estavam presentes em 77% dos pacientes, prevalecendo a hipertensão arterial sistêmica, seguida pelo diabetes mellitus e arritmia cardíaca. A análise histológica revelou malignidade em 21,7% dos casos, sendo o principal tumor o carcinoma papilífero, seguido pelo carcinoma folicular e carcinoma anaplásico. Complicações foram descritas em 29%, sendo mais freqüente o hipoparatireoidismo transitório. Conclusão: No paciente idoso, as doenças associadas e a maior freqüência de tumores malignos agressivos demandam cuidados peri-operatórios adequados, com maior preocupação com o rigor da conduta cirúrgica.

Introduction: The diseases prevalent in the elderly have been increasing with the aging of the world's population. In the elderly patient, besides the increasing incidence of thyroid nodules, there is a higher incidence of cancer, which behaves more aggressively. Old age does not rule out surgery. However, the surgical treatment can be influenced by a higher number of comorbidities. Objective: To study the frequency of the thyroid disease with surgical indication in the elderly, characterizing it. Methods: We did a retrospective study with 69 patients between 65 and 84 years of age (median, 71) who received any surgical proceeding at the thyroid gland in our hospital, between 1991 and 2006. Data collected were identification, history, comorbidities, preoperative data, complementary exams, surgery, pathological data and the patient's evolution, with attention to possible complications. Results: The most frequent chief complaint was an increase of cervical volume, with average duration of 67 months. The most frequent clinical diagnosis was of nontoxic multinodular goiter. In 62% total thyroidectomy was carried out, followed by hemithyroidectomy and completion of previous surgery. Clinical comorbidities were present in 77% of the patients, mainly hypertension, followed by diabetes and arrhythmia. Histopatological exams revealed malignity in 21.7% of cases, being papillary carcinoma the most frequent, followed by follicular carcinoma and anaplastic carcinoma. Complications were described in 29% and transient hypoparathyrodism was most frequent. Conclusion: Due to increased comorbidities and more aggressive malignant tumors, the elderly demands close peri-operatory care and increased concern with the impact of the surgical treatment.

Selective neck dissection for treating node-positive necks in cases of squamous cell carcinoma of the upper aerodigestive tract.

CONTEXT AND OBJECTIVE: Modified radical neck dissection (MRND) is the classical treatment for neck metastases of squamous cell carcinoma (SCC) of the upper aerodigestive tract. However, it may still be accompanied by significant sequelae. One alternative for this treatment would be selective neck dissection (SND), which has a lower incidence of sequelae. The aim of this study was to define which neck metastasis cases would really be suitable candidates for SND. DESIGN AND SETTING: Retrospective clinical-surgical trial at the Division of Head and Neck Surgery, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP). METHODS: We retrospectively studied 67 patients with SCC of the upper aerodigestive tract, divided into two groups: 1) 47 patients treated by means of SND (node-negative or node-positive), 2) 20 patients treated by means of MRND (all node-positive). RESULTS: Our results demonstrated that there was no difference between the patients treated with SND or MRND in relation to disease evolution, and that the main prognostic factor was lymph node involvement. We observed that patients with pharyngeal SCC and older patients presented worse evolution and would probably not be suitable candidates for SND. CONCLUSIONS: SND may be a good option for treating node-positive necks in selected cases.

Selective neck dissection for treating node-positive necks in cases of squamous cell carcinoma of the upper aerodigestive tract / Esvaziamento cervical seletivo para o tratamento do pescoço positivo em carcinomas epidermóides do trato aerodigestório alto

CONTEXT AND OBJECTIVE: Modified radical neck dissection (MRND) is the classical treatment for neck metastases of squamous cell carcinoma (SCC) of the upper aerodigestive tract. However, it may still be accompanied by significant sequelae. One alternative for this treatment would be selective neck dissection (SND), which has a lower incidence of sequelae. The aim of this study was to define which neck metastasis cases would really be suitable candidates for SND. DESIGN AND SETTING: Retrospective clinical-surgical trial at the Division of Head and Neck Surgery, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP). METHODS: We retrospectively studied 67 patients with SCC of the upper aerodigestive tract, divided into two groups: 1) 47 patients treated by means of SND (node-negative or node-positive), 2) 20 patients treated by means of MRND (all node-positive). RESULTS: Our results demonstrated that there was no difference between the patients treated with SND or MRND in relation to disease evolution, and that the main prognostic factor was lymph node involvement. We observed that patients with pharyngeal SCC and older patients presented worse evolution and would probably not be suitable candidates for SND. CONCLUSIONS: SND may be a good option for treating node-positive necks in selected cases.

CONTEXTO E OBJETIVO: O esvaziamento cervical radical modificado (ECRM) é o tratamento clássico para as metástases cervicais do carcinoma espinocelular (CEC) do trato aerodigestório alto (TADA). Este procedimento é considerado oncologicamente satisfatório, porém pode ser acompanhado de seqüelas significativas devido à extensão do procedimento e a grande manipulação de estruturas nobres, especialmente as nervosas. Assim, tem sido proposto o esvaziamento cervical seletivo (ECS) para o tratamento de casos selecionados, pN1, pN2 sem ruptura capsular, minimizando, ou mesmo evitando, deste modo, as seqüelas do ECRM. O grande questionamento atual é a definição de quais casos seriam eleitos para este procedimento, sem alterar o resultado oncológico de médio e longo prazo. TIPO DE ESTUDO E LOCAL: Estudo clínico retrospectivo realizado na Disciplina de Cirurgia de Cabeça e Pescoço do Departamento de Cirurgia da Faculdade de Ciências Médicas da Santa Casa de São Paulo. MÉTODOS: Estudamos 67 doentes portadores de CEC do TADA de 1990 a 2001 dividindo-os em dois grupos: 1) 47 doentes tratados com ECS e 2) 20 doentes tratados com ECRM (todos N+). Os casos do grupo 1 eram clinicamente N0 e, 11 tornaram-se pN+, após o exame histopatológico. Assim, no grupo 1 obtivemos doentes pN+ tratados com ECS e seguimos estes grupos por, no mínimo, 2 anos. O grupo 2 serviu como controle da evolução dos doentes pN+. RESULTADOS: Nossos resultados mostraram que na comparação do ECS com o ECRM, não houve diferença significativa quanto à evolução (sobrevivência ou recidiva), no entanto, foi possível evidenciar uma pior evolução nos doentes N+ quando comparados aos N0, demonstrando que o principal fator prognóstico é o comprometimento linfonodal. Além disso, apesar do pequeno número de doentes, observamos que os doentes mais idosos e com CEC de faringe tiveram pior evolução e, por isto, talvez não sejam candidatos ao ECS. CONCLUSÕES: Concluímos, portanto, que o ECS pode...

[Fine needle aspiration in salivary gland tumors: specificity and sensitivity]. / Punção aspirativa nos tumores das glândulas salivares: especificidade e sensibilidade.

UNLABELLED: Neoplasms of salivary glands represent almost 3% of all head and neck tumors. Proper surgical treatment depends upon accurate histological findings, especially in the case of malignant lesions. As such, knowledge of correct cytological findings prior to surgery is important for therapeutic planning. This is not easily established since it is usually based only on the patients' clinical history and imaging exams OBJECTIVE: To evaluate results obtained from fine needle aspiration biopsy (FNAB), comparing them to the histological findings of the respective surgical specimens and analyzing the sensitivity, specificity and accuracy of this method in relation to the diagnosis of malignancy or benignancy. METHODS: Retrospective study with the medical records of 73 patients who had salivary gland neoplasms and were submitted to FNAB and surgical treatment. RESULTS: Data disclosed that values of sensitivity were 87.9 % and specificity 85.7 % for diagnosis of benign tumors. For malignant tumors 42.5 % of sensitivity and 98.3 of specificity, were observed. Overall values of accuracy were, respectively, 85.7 % and 87.8 % for positive and negative predictive values in the diagnosis of malignancy by FNAB. CONCLUSIONS: It was shown that FNAB, as supplementary diagnostic method, can be useful for preoperative evaluation and surgical planning especially for malignant neoplasms.

Punção aspirativa nos tumores das glândulas salivares: especificidade e sensibilidade / Fine needle aspiration in salivary gland tumors: specificity and sensitivity

As neoplasias das glândulas salivares são afecções que constituem aproximadamente 3 por cento de todos os tumores da cabeça e pescoço. O tratamento cirúrgico adequado depende do correto conhecimento do tipo histológico, principalmente quando se trata de lesões malignas. Dessa maneira, a correta determinação do diagnóstico histológico pré-operatório auxilia em muito o planejamento terapêutico, porém, geralmente, isto é difícil de se estabelecer baseado apenas nos achados da história, exame clínico e de imagem. OBJETIVOS: O presente estudo avalia comparativamente os resultados de exames citológicos obtidos através de punção aspirativa com agulha fina (PAAF) de tumores de glândulas salivares, realizados no período pré-operatório, com os dados histológicos de espécimes cirúrgicos, analisando a sensibilidade, especificidade e acurácia do método quanto ao diagnóstico de malignidade e benignidade. MÉTODOS: Estudo retrospectivo de 73 prontuários de pacientes portadores de neoplasia de glândulas salivares, todos submetidos a tratamento cirúrgico. RESULTADOS: Obtivemos 87,9 por cento de sensibilidade e 85,7 por cento de especificidade para diagnóstico de tumores benignos; sensibilidade de 42,9 por cento e especificidade de 98,3 por cento para diagnóstico de tumores malignos. O valor global da acurácia foi de 87,7 por cento, o valor preditivo positivo de 85,7 por cento e o negativo de 87,8 por cento para diagnóstico de malignidade com a PAAF. CONCLUSÃO: Concluiu-se que a PAAF como método diagnóstico auxiliar, pode ser útil na avaliação pré-operatória, especialmente se o diagnóstico for de malignidade, contribuindo assim para um melhor planejamento cirúrgico do doente.

Neoplasms of salivary glands represent almost 3 percent of all head and neck tumors. Proper surgical treatment depends upon accurate histological findings, especially in the case of malignant lesions. As such, knowledge of correct cytological findings prior to surgery is important for therapeutic planning. This is not easily established since it is usually based only on the patients' clinical history and imaging exams OBJECTIVE: To evaluate results obtained from fine needle aspiration biopsy (FNAB), comparing them to the histological findings of the respective surgical specimens and analyzing the sensitivity, specificity and accuracy of this method in relation to the diagnosis of malignancy or benignancy. METHODS: Retrospective study with the medical records of 73ee patients' who had salivary gland neoplasms and were submitted to FNAB and surgical treatment. RESULTS: Data disclosed that values of sensitivity were 87.9 percent and specificity 85.7 percent for diagnosis of benign tumors. For malignant tumors 42.5 percent of sensitivity and 98.3 of specificity, were observed. Overall values of accuracy were, respectively, 85.7 percent and 87.8 percent for positive and negative predictive values in the diagnosis of malignancy by FNAB. CONCLUSIONS: It was shown that FNAB, as supplementary diagnostic method, can be useful for preoperative evaluation and surgical planning especially for malignant neoplasms.