The Beneficial Role of Endotracheal Lidocaine in Mitigating Hemodynamic Responses During Elective Surgical Tracheostomy in Head and Neck Cancer Patients.

BACKGROUND: The effectiveness of endotracheal lidocaine administration to reduce sympathetic stimulus after tracheostomy is still uncertain. PURPOSE: This study aimed to compare the hemodynamic responses of patients undergoing tracheostomy with and without pre-tracheostomy administration of endotracheal lidocaine. STUDY DESIGN, SETTING AND SAMPLE: A prospective cohort study was conducted at a tertiary care cancer center in the United Kingdom. Patients who underwent tracheostomy as part of their head and neck cancer surgery were included. Exclusion criteria comprised tracheostomies involving special requirements and subjects with documented cardiac history or taking specific medications. PREDICTOR VARIABLE: The predictor variable was pre-tracheostomy anesthetic management defined as the administration of endotracheal 4 ml 4% lidocaine before tracheostomy coded as lidocaine used or not used. OUTCOME VARIABLE: The primary outcome measures in this study were the observed hemodynamic responses after tracheostomy, including heart rate, systolic blood pressure, and diastolic blood pressure. The secondary outcome measure in the two groups was the time it took for subjects to return to their pre-tracheostomy baseline hemodynamic parameters, measured in minutes. ANALYSES: Data analyses included χ2, t-test, analysis of variance, and multivariable regression models. P values < .05 were considered statistically significant. COVARIATES: The patients' age, sex, body mass index, smoking status, tracheostomy tube size, and tumor stage were evaluated. RESULTS: The sample included 50 consecutive patients, the majority of whom were male (55%) with a mean age of 62 years (standard deviation[SD] 12) and a mean body mass index of 28 (SD 4). Most patients had stage III or IV oral cancers (59%). Following surgical tracheostomy, the group that received endotracheal lidocaine demonstrated significantly less hemodynamic variability when compared with the control group. The case group exhibiting lower systolic blood pressure (117 [SD 10] vs 136 [SD 18]), diastolic blood pressure (62 [SD 4] vs 68 [SD 4]), and heart rate (72 [SD 4] vs 78 [SD 4]), with statistical significance (P < .05). However, there was no significant difference in the time taken for the two groups to return to their pre-tracheostomy baseline hemodynamic parameters. CONCLUSIONS AND RELEVANCE: This study demonstrates an association between the preadministration of 4% endotracheal lidocaine with an observed attenuation in hemodynamic response following surgical tracheostomy in head and neck cancer patients.

Outcomes of microsurgical free tissue transfer performed on international surgical collaborations in low-income and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: Microsurgical free tissue transfer is the gold standard for reconstruction of significant soft tissue and bony defects following cancer resection and trauma. Many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources or training required to perform microsurgical procedures. Long-term international collaborations have been formed with annual reconstructive programmes conducting microsurgery. AIMS: To critically analyze outcomes of microsurgical free tissue transfer performed on international reconstructive collaborations in LMICs. METHODS: PRISMA-compliant systematic review and meta-analysis of outcomes for free tissue transfer performed during international collaborations in LMICs using an inverse variance model. The study protocol was published prospectively and registered with PROSPERO (ID: CRD42021225613). RESULTS: Seven studies, included 290 flaps on 284 patients. The most common sites requiring reconstruction were Head and neck (53% (n = 153)) and lower limb (7.9% (n = 23)) were lower limb reconstruction. The most common free flaps were radial forearm (22%; n = 64) and anterolateral thigh (18%; n = 51). Total Flap Failure rate was 3.8% (n = 13; 95% confidence interval (CI) = 1.9-6.3%) Overall complication rate was 38% (95% CI =27-48%), with 19% of flaps requiring emergency return to theatre (95% CI =14-26%). Flap salvage was successful in 52% of take-backs (95% CI =15% - 88%). CONCLUSIONS: Free flaps performed during international surgical collaborations in LMICs have comparable failure rates to those performed in higher-income settings. However, there are higher complication and take-back rates. This should be taken into account when planning international collaborations. These results should help preoperative counselling and the consent process.

Protocol for a systematic review of outcomes from microsurgical free-tissue transfer performed on short-term collaborative surgical trips in low-income and middle-income countries.

BACKGROUND: In many units around the world, microsurgical free-tissue transfer represents the gold standard for reconstruction of significant soft tissue defects following cancer, trauma or infection. However, many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources, infrastructure or training required to perform any microsurgical procedures. Long-term international collaborations have been formed with annual short-term reconstructive missions conducting microsurgery. In the first instance, these provide reconstructive surgery to those who need it. In the longer-term, they offer an opportunity for teaching and the development of sustainable local services. METHODS: A PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive, predetermined search strategy will be applied to the MEDLINE and Embase electronic databases from inception to August 2021. All clinical studies presenting sufficient data on free-tissue transfer performed on short-term collaborative surgical trips (STCSTs) in LMICs will be eligible for inclusion. The primary outcomes are rate of free flap failure, rate of emergency return to theatre for free flap salvage and successful salvage rate. The secondary outcomes include postoperative complications, cost effectiveness, impact on training, burden of disease, legacy and any functional or patient reported outcome measures. Screening of studies, data extraction and assessments of study quality and bias will be conducted by two authors. Individual study quality will be assessed according to the Oxford Evidence-based Medicine Scales of Evidence 2, and risk of bias using either the 'Revised Cochrane risk of bias tool for randomized trials' (Rob2), the 'Risk of bias in non-randomized studies of interventions' (ROBINS-I) tool, or the National Institute for Health Quality Assessment tool for Case Series. Overall strength of evidence will be assessed according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. DISCUSSION: To-date the outcomes of microsurgical procedures performed on STCSTs to LMICs are largely unknown. Improved education, funding and allocation of resources are needed to support surgeons in LMICs to perform free-tissue transfer. STCSTs provide a vehicle for sustainable collaboration and training. Disseminating microsurgical skills could improve the care received by patients living with reconstructive pathology in LMICs, but this is poorly established. This study sets out a robust protocol for a systematic review designed to critically analyse outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 225613.

The Implementation of COVID-19 Social Distancing Measures Changed the Frequency and the Characteristics of Facial Injury: The Newcastle (Australia) Experience.

STUDY DESIGN: A retrospective study was undertaken of a cohort of facially injured patients using matched 8-week periods: non-COVID (2019) and COVID (2020). OBJECTIVE: To determine whether there were any changes to the frequency and characteristics of facial injury due to the imposition of COVID-19 social distancing measures. METHODS: The primary predictor variable was an 8-week period of COVID-19 social distancing. The primary outcome variable was the sustaining of a facial injury. Demographic (age/gender) and injury characteristics (mechanism, site, and treatment) were also studied. Descriptive statistical analysis was undertaken and comparison made using Pearson χ2 and Fisher's exact tests. RESULTS: The number of facial injuries decreased from 103 (2019) to 73 (2020). There were statistically significant differences in changes over time for the 8-week periods. There were some clinically apparent differences seen in the characteristics of facial injuries. CONCLUSIONS: The imposition of COVID-19 social distancing changed the frequency and characteristics of facial injury.

UK Oral and Maxillofacial Surgery Trainee Perceptions of Flexible Nasal Endoscopy.

INTRODUCTION AND AIM: Flexible nasal endoscopy (FNE) is a useful adjunct in diagnosis and follow-up of oncology patients as well as in airway assessment. Proficiency in this technique is also listed as part of the Oral and Maxillofacial Surgery (OMFS) curriculum. We aimed to explore OMFS trainee perceptions of training and confidence in this technique. MATERIALS AND METHODS: An electronic survey was undertaken of OMFS higher surgical trainees in the UK. A 10-item questionnaire was formulated using online survey software (SurveyMonkey) and distributed to Specialty Registrars in all deaneries via their regional representatives. Questions on training, exposure to and confidence in FNE were asked. RESULTS: A total of 43 responses were received which included all grades of higher surgical trainees. A large proportion had undertaken FNE in oncology rotations (78.6%) and as part of airway assessment (85.6%). Nearly half of trainees (47.6%) were confident in diagnosing pathology using FNE although 16.6% had low levels of confidence in the technique. Only 38% had received formal training, and the majority of this training was a teaching session from a senior. A very large proportion of trainees (90.5%) feel formal training should be available in FNE and 76% would undertake a formal OMFS training course in FNE if available. CONCLUSIONS: Trainees have high levels of exposure to FNE but variable levels of confidence in the technique. Trainees appear to receive limited formal training in the technique, and the introduction of more formalised training could be explored.

Role of real-time colour-flow Doppler in perforator free flap head and neck reconstruction.

We discuss the use of real-time colour-flow Doppler ultrasound to optimally evaluate the vascular anatomy of patients receiving free perforator flap head and neck reconstruction. We explore the advantages of the technique and its role as a valuable adjunct for the planning and harvesting of perforator flaps.

Fulminating deep tissue space infection with Streptococcus constellatus presenting initially as a sore throat.

Management of sore throat requires robust decision-making to balance successfully the conflicting risks of unnecessary antibiotic use against those of untreated bacterial infection. We present a case of fulminant sepsis caused by Streptococcus constellatus, presenting as a sore throat, initially managed conservatively. Despite subsequent appropriate anti-microbial therapy and surgical drainage, contiguous spread ultimately involved the deep neck spaces, mediastinum and thoracic wall, and was complicated by severe aspiration pneumonia, pharyngocutaneous and bronchopleural fistulation. The complexity and widespread extent of the infected spaces, in conjunction with the catabolic response to sepsis, created a life-threatening situation. Surgical closure of the pharyngeal defect, using a pectoralis-major pedicle flap, was successfully undertaken to ensure source control of the infection and heralded a complete recovery. We describe our management of this case, discuss the current approach to the management of patients presenting with a sore throat, and review the literature on S. constellatus infections.

Head and neck ablative and microvascular reconstructive surgery in the UK: current operating team composition.

We sought to explore the current landscape of team composition in the provision of major head and neck ablative and reconstructive surgery in the UK. We conducted a survey of maxillofacial surgery units and compiled data on the operating model adopted at each institution. Our survey confirmed 54 active maxillofacial units undertaking microvascular free flap reconstructive surgery, with 44 (82%) hospitals adopting a two-team operative approach. We found no significant association between hospital type and volume of free flaps undertaken and prevailing operating team model. Our study provides an interesting snapshot of the current head and neck microvascular reconstructive practice in the UK.

Safety Profile of HTX-019 Administered as an Intravenous Push in Cancer Patients: A Retrospective Review.

INTRODUCTION: HTX-019 [CINVANTI® (aprepitant injectable emulsion)] is a neurokinin 1 receptor antagonist (NK-1 RA) approved as a 30-min infusion for preventing acute and delayed chemotherapy-induced nausea and vomiting. HTX-019 has been generally well tolerated when administered as a 30-min infusion or 2-min injection [intravenous (IV) push] in healthy subjects. This real-world analysis assesses safety of HTX-019 via IV push in patients with cancer and addresses a recent IV bag shortage. METHODS: This retrospective review involved six sites in Alabama, USA. Analyzed patients were 18-94 years old with an Eastern Cooperative Oncology Group performance status ranging from 0 to 4. Seventy-six chemotherapy regimens were utilized (emetogenicity high, n = 35; moderate, n = 35; low, n = 6) and patients received HTX-019 130 mg only or switched from fosaprepitant 150 mg to HTX-019 130 mg within a three-drug antiemetic regimen with a 5-hydroxytryptamine type 3 RA and dexamethasone. HTX-019 was administered via IV push. Electronic medical records of patients receiving HTX-019 were queried for nursing and medical documentation associated with infusion-site adverse events (ISAEs). The detailed notes were also reviewed for any discontinuation of HTX-019 or substitution of HTX-019 with another NK-1 RA. RESULTS: The HTX-019 safety profile was analyzed on the basis of 2066 IV push administrations in 591 cancer patients (most common diagnoses: lung, n = 107; breast, n = 100; colon, n = 92). No clinically significant ISAEs or adverse events associated with HTX-019 were reported. Also, no patients discontinued HTX-019 treatment, and none switched from HTX-019 to another NK-1 RA. CONCLUSION: This is the first study to demonstrate that HTX-019 can be safely administered via IV push in patients with cancer receiving emetogenic chemotherapy while negating the need for fluid bags, which are scarce. FUNDING: Heron Therapeutics, Inc., San Diego, CA, USA. Plain language summary available for this article.

Specialist titles used in clinical correspondence: a UK survey of oral and maxillofacial surgery consultants.

We explored how oral and maxillofacial (OMF) consultants describe themselves in their correspondence. We did a telephone survey of OMF surgeons' secretaries and compiled data on the specialist titles used. Data were available for 290 consultants and 19 different titles were identified. A total of 190 (66%) consultants used the title OMF surgeon alone and a further 22 (8%) combined it with the name of a subspecialty. The remaining 78 (27%) used 11 alternative titles. Of those surveyed, 212 (73%) continue to use the specialty title of OMF surgeon with or without the name of a subspecialty comprising a readily identifiable group of specialists.

Psychiatric outcomes in operatively compared with non-operatively managed patients with facial trauma: Is there a difference?

Patients who sustain facial injury and who require an operation may be at greater risk for developing psychological distress and maladaptive coping. The purpose of this study was to examine psychological responses in adult victims of facial trauma after operation. A consecutive group of adult patients attending specialist outpatient clinics after facial trauma were evaluated for psychological distress. The subjects were divided into two groups based on whether their facial injuries were managed operatively or conservatively. The primary predictor variable in this study was surgical intervention. The main outcome variable was Hospital Anxiety and Depression Scale (HADS) scores. Chi-squared, Mann Whitney U-test, and multiple regression analysis were used to analyse data. The sample consisted of 102 subjects; 71 patients had been managed operatively and 31 patients treated non-operatively. Psychometric scores suggestive of anxiety were present in 21% (n = 15) of the operatively managed group compared with 13% (n = 4) of the non-operatively managed group of patients. The prevalence of depression was comparable between both groups (14% compared with 13%). The median anxiety subscale scores for the operatively managed group when compared with the conservatively managed group of patients were significantly higher (6.6 compared with 4.4, p = 0.02); however, differences in the depression subscale scores did not reach statistical significance (6.2 compared with 4.6, p = 0.06). This study shows an association between anxiety disorders and operative interventions in patients with facial trauma (HADS-A, ß = 2.2, p = 0.04). Similar rates of depression were found in the surgically and conservatively managed patients.

The prevalence of psychological distress in a sample of facial trauma victims. A comparative cross-sectional study between UK and Australia.

AIM: The potential psycho-social sequelae of traumatic facial injury have received increasing attention in recent years, however there remains paucity of cross-national comparative data on the prevalence of psychological distress following such trauma. The aim of the present study was to investigate and compare the prevalence of anxiety and depression in an adult patient group who have been treated for maxillofacial trauma, and who attend a follow-up clinic in either the West Midlands, UK or New South Wales (NSW), Australia. By using an identical methodological and statistical approach, we hoped to add to the available information on the incidence of early psychological distress in patients following facial trauma. METHOD: This was a comparative cross-sectional study. A sample of fifty consecutive adult victims of facial trauma in the West Midlands UK, was compared to a group of fifty-two facially injured patients in NSW, Australia. Demographic data was collected, following which the Hospital Depression and Anxiety Scale (HADS) were applied to both groups of patients. RESULTS: Psychometric scores suggestive of anxiety and depressive state were common in both groups of patients. The mean HADS depression subscale score for UK patients compared to Australian patients was not significantly different (5.94 versus 5.54 p=0.62). This was also the case for the HADS anxiety subscale (5.96 versus 5.94 p=0.98). Although the number of patients achieving scores suggestive of a 'caseness' for co-morbid psychological state was higher within the UK sample when compared to the Australian group (20% versus 11.5% for HADS depression subscale, and 20% versus 15% for HADS anxiety subscales respectively); these differences did not reach statistical significance. CONCLUSION: This cross-national comparative study has shown that anxiety and depression in facial trauma victims were comparable in both settings.

Does attribution of blame influence psychological outcomes in facial trauma victims?

PURPOSE: The relative importance of different variables and specific post-traumatic psychological reactions after facial injuries is poorly understood. The aim of the present study was to assess the association between the subjective attribution of blame and anxiety and depression in facial trauma victims. MATERIALS AND METHODS: We undertook a comparative cross-sectional study of psychological outcomes in a cohort of adult patients who have sustained a facial injury. The primary predictor variable was the attribution of blame (self-blame vs blame-others). The main outcome variable was the Hospital Anxiety and Depression Scale (HADS) scores. We also considered several demographic and other clinical variables to assess their relationship with the nature of blame attribution. Cochran-Mantel-Haenszel statistics were used to assess the relationship between the primary predictor and outcome variables, adjusted for age, gender, and confounding factors. RESULTS: The sample consisted of 102 facial trauma victims (77 men and 25 women). Of the 77 patients, 63 attributed blame for their injuries to someone else and 39 patients attributed blame to themselves. Psychometric scores suggestive of anxiety and the depressive state were significantly greater in the "blame-others" group than in the "self-blame" group (HADS-Anxiety 22% vs 13%, HADS-Depression 17% vs 8%). The prevalence of psychomorbidity in the blame-others group was approximately twice that found in the self-blame group (odds ratio 2.2). Facial trauma patients who blamed others for their injury were predominantly younger men (P = .01) and typically victims of intentional trauma (P < .001). CONCLUSIONS: The results of the present study suggest that external attribution of blame for facial injury is associated with poor postinjury psychiatric outcomes.

The association between depression and anxiety disorders following facial trauma--a comparative study.

AIM: Although the surgical care provided for patients who have sustained a maxillofacial injury has advanced in recent years, psychological disorders may develop. Anxiety and depression may be a cause of significant morbidity in these patients. Such problems are often unrecognised and untreated. PATIENTS & METHODS: We undertook a comparative cross-sectional study in a cohort of adult patients to assess the association between traumatic facial injury and the presence of anxiety and depressive disorders. Study subjects were recruited during the period of June 2008 through August 2008. Fifty consecutive adult patients attending the maxillofacial outpatient clinic following facial trauma were asked to complete the Hospital Anxiety and Depression Scale (HADS). Data gathered from this group of patients were compared to 50 adult control subjects who were under follow-up following elective oral and maxillofacial surgery. We also looked at several demographic and other variables to assess its association with poor mental health outcomes. RESULTS: Ten patients (20%) in the facial trauma group achieved high scores in both subscales suggesting a probable anxiety and depression state. The mean score for the depression subscale was significantly higher in the facial trauma group compared to the control group (p=0.006). The mean score for anxiety was also higher but did not reach statistical significance (p=0.07). Stratified analysis (Mantel-Haenszel) was used to control for possible confounding variables. The odds ratio for probable depression, for facial trauma patients compared with "control" patients, was 9.02, 95% CI=2.45, 33.1, p<0.001. Variables with significant associations (p<0.05) with high depression scores in the facial trauma group were female sex, presence of a permanent facial scar, and a past psychiatric history. There was also significant correlation between patients' self-perception of facial disfigurement scores and scores obtained in both anxiety subscale (r=0.41, p=0.003) and depression subscale (r=0.46, p=0.001). CONCLUSION: Our results support the findings of previous studies and provide further evidence to clinicians for the critical identification and treatment of anxiety and depression in facial trauma victims.

Multidisciplinary management of a complicated orbital injury inflicted by a horse.

This case report describes an unusual and complicated orbital injury inflicted by a horse. Definitive management required multidisciplinary surgical collaboration to prevent significant ocular sequelae. The diagnostic role of good imaging and the potential use of bio-models are highlighted.