A multidisciplinary approach to identifying and managing heterotopic gastric inlet patches

INTRODUCTION

Gastric inlet patches are often incidental, but can also be a treatable cause of laryngo-esophageal symptoms.

METHODS

We retrospectively reviewed all patients whose gastric inlet patches were diagnosed following assessment for laryngopharyngeal and swallowing symptoms. Improvement following Argon Plasma Coagulation (APC) was assessed using Minimum Clinically-Important Difference methodology combining voice, throat, and swallowing domains. Correlations between APC response and measures of reflux and mucosal barrier integrity, measured during 24-h pH-impedance manometry, were obtained. Proximal and Distal Mean Nocturnal Baseline Impedance (MNBI) values were separately calculated and the novel variable of Mucosal Impedance Gradient was derived as [((Distal MNBI-Proximal MNBI)/((Distal MNBI + Proximal MMBI)/2)) x 100].

KEY RESULTS

Inlet patches were detected in 57 of 651 patients who had Transnasal Panendoscopy (8.7 ± 2.2%). There were 34 males. Mean age was 58 years. Mean duration of symptoms was 2 years. The commonest symptoms were hoarseness (n = 33), throat symptoms (n = 24), and dysphagia (n = 21), respectively. APC was used to ablate patches in 34 patients. Treatment response was 71% at a mean followup of 5.5 months. MIG > - 25% predicted response to APC, with area under the receiver operating characteristic curve of 0.875 (Sensitivity = 81%; Specificity = 100%; p < 0.0001).

CONCLUSIONS

Gastric inlet patches are common and under-recognized. They can cause protracted pharyngo-esophageal symptoms. Patch ablation is an effective treatment for carefully selected patients. Optimal patient selection requires multidisciplinary teamwork. Mucosal Impedance Gradient could further refine patient selection.

Otolaryngology contribution to the care of patients following non-fatal strangulation in the settings of alleged sexual assault

BACKGROUND

Non-fatal strangulation as a consequence of a sexual assault attack or domestic violence represents serious bodily harm. Otolaryngologists have an important role in documenting physical findings and managing airway symptoms. This study aimed to describe our otolaryngology department's experience managing patients referred from the sexual assault referral centre who suffered non-fatal strangulation.

METHOD

A retrospective analysis of patients suffering non-fatal strangulation referred to the Manchester University Hospitals NHS Foundation Trust Otolaryngology Department from Saint Mary's Sexual Assault Referral Centre in Manchester between 1 January 2017 and 31 December 2019 was carried out.

RESULTS

A total of 86 patients were referred from Saint Mary's Sexual Assault Referral Centre. Of these patients, 56 were given telephone advice and the remaining 30 were seen by the on-call otolaryngology team. In addition, 20 out of 30 (66.6 per cent) patients underwent fibre-optic nasal endoscopy. Common presenting symptoms were neck pain (81.4 per cent), dyspnoea (80.2 per cent) and dizziness (72.1 per cent). Five patients had identifiable laryngeal injury on endoscopy.

CONCLUSION

Meticulous documentation is recommended when managing patients who suffer non-fatal strangulation because medical records may be used as evidence in criminal investigations.

Predicting Pulmonary Function From the Analysis of Voice: A Machine Learning Approach

Introduction

To self-monitor asthma symptoms, existing methods (e.g. peak flow metre, smart spirometer) require special equipment and are not always used by the patients. Voice recording has the potential to generate surrogate measures of lung function and this study aims to apply machine learning approaches to predict lung function and severity of abnormal lung function from recorded voice for asthma patients.

Methods

A threshold-based mechanism was designed to separate speech and breathing from 323 recordings. Features extracted from these were combined with biological factors to predict lung function. Three predictive models were developed using Random Forest (RF), Support Vector Machine (SVM), and linear regression algorithms: (a) regression models to predict lung function, (b) multi-class classification models to predict severity of lung function abnormality, and (c) binary classification models to predict lung function abnormality. Training and test samples were separated (70%:30%, using balanced portioning), features were normalised, 10-fold cross-validation was used and model performances were evaluated on the test samples.

Results

The RF-based regression model performed better with the lowest root mean square error of 10·86. To predict severity of lung function impairment, the SVM-based model performed best in multi-class classification (accuracy = 73.20%), whereas the RF-based model performed best in binary classification models for predicting abnormal lung function (accuracy = 85%).

Conclusion

Our machine learning approaches can predict lung function, from recorded voice files, better than published approaches. This technique could be used to develop future telehealth solutions including smartphone-based applications which have potential to aid decision making and self-monitoring in asthma.

Apnoeic ventilation for shared airway surgery during the COVID-19 pandemic

This report describes the care provided to a 64-year-old woman presenting with airway obstruction following recovery from COVID-19 pneumonitis, prolonged tracheal intubation and tracheostomy weaning. Her initial admission was with COVID-19 pneumonitis during the first surge of cases in early 2020, and was complicated by multiple bilateral segmental pulmonary emboli, a 28-day stay in intensive care, 16 days of mechanical ventilation and finally, a tracheostomy with subsequent weaning of respiratory support and rehabilitation. On presentation, her symptoms of airway obstruction were because of significant granuloma of the posterior glottis and subglottis, as well as a mild lambdoid deformity at the site of her previous tracheostomy. The key learning points described relate to the use of apnoeic oxygenation during the COVID-19 pandemic, managing the shared airway, as well as the management of post-intubation laryngotracheal complications.

Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study

OBJECTIVES

Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology.

DESIGN

A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite.

MAIN OUTCOME MEASURES

Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival.

RESULTS

Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43 ± 50 days for control patients to 115 ± 140 days for ICR patients (P < .0001). Dysphagia significantly increased the risk of an ICR (odds ratio 3.34; 95% CI 1.30-8.56), and presence of classic gastroesophageal reflux symptoms (heartburn or regurgitation; OR 0.25; 95% CI 0.08-0.83) and "distal" symptoms (nausea/vomiting, abdominal pain or dyspepsia; OR 0.23; 95% CI 0.08-068) significantly reduced the risk. Eleven pharyngolaryngeal cancers (of 26; 42%) were missed by gastroenterology, and eight (of 34; 24%) oesophageal cancers were missed by otolaryngology. An ICR was an independent adverse prognostic risk factor on multivariable analysis (hazard ratio 1.76; 95% CI 1.11-2.73; P < .02; log-rank test). Two systemic root causes were poor visualisation of pharynx and larynx by per-oral oesophago-gastro-duodenoscopy (OGD) for pharyngolaryngeal cancers, and poor sensitivity (62.5%) of barium swallow when it was used to 'evaluate' oesophageal mucosa.

CONCLUSIONS

An interspecialty cancer referral occurs in a significant proportion of patients with foregut cancers. It almost triples the time to cancer diagnosis and is associated with a high incidence of missed cancers and diminished patient survival. It is a complex phenomenon, and its reduction requires an integrated approach between primary and secondary care, and within secondary care, to optimise referral pathways and ensure appropriate and expeditious specialist evaluation.

A physiological study to determine the mechanism of carbon dioxide clearance during apnoea when using transnasal humidified rapid insufflation ventilatory exchange (THRIVE)

Clinical observations suggest that compared with standard apnoeic oxygenation, transnasal humidified rapid‐insufflation ventilatory exchange using high‐flow nasal oxygenation reduces the rate of carbon dioxide accumulation in patients who are anaesthetised and apnoeic. This suggests that active gas exchange takes place, but the mechanisms by which it may occur have not been described. We used three laboratory airway models to investigate mechanisms of carbon dioxide clearance in apnoeic patients. We determined flow patterns using particle image velocimetry in a two‐dimensional model using particle‐seeded fluorescent solution; visualised gas clearance in a three‐dimensional printed trachea model in air; and measured intra‐tracheal turbulence levels and carbon dioxide clearance rates using a three‐dimensional printed model in air mounted on a lung simulator. Cardiogenic oscillations were simulated in all experiments. The visualisation experiments indicated that gaseous mixing was occurring in the trachea. With no cardiogenic oscillations applied, mean (SD) carbon dioxide clearance increased from 0.29 (0.04) ml.min⁻¹ to 1.34 (0.14) ml.min⁻¹ as the transnasal humidified rapid‐insufflation ventilatory exchange flow rate was increased from 20 l.min⁻¹ to 70 l.min⁻¹ (p = 0.0001). With a cardiogenic oscillation of 20 ml.beat⁻¹ applied, carbon dioxide clearance increased from 11.9 (0.50) ml.min⁻¹ to 17.4 (1.2) ml.min⁻¹ as the transnasal humidified rapid‐insufflation ventilatory exchange flow rate was increased from 20 l.min⁻¹ to 70 l.min⁻¹ (p = 0.0014). These findings suggest that enhanced carbon dioxide clearance observed under apnoeic conditions with transnasal humidified rapid‐insufflation ventilatory exchange, as compared with classical apnoeic oxygenation, may be explained by an interaction between entrained and highly turbulent supraglottic flow vortices created by high‐flow nasal oxygen and cardiogenic oscillations.

Outcomes of Treating Early Glottic Neoplasms With a Potassium Titanyl Phosphate Laser

Objectives:

The aim of this study was to assess the outcome of treating glottic dysplasia and early squamous cell carcinoma (SCC) with potassium titanyl phosphate (KTP) photoangiolytic laser ablation.

Methods:

Patient demographics, comorbidities, and tumor characteristics were recorded. Perceptual, patient-reported, and objective voice outcomes were assessed. Use of treatment modalities in addition to the KTP laser, development of locoregional or metastatic SCC, and overall survival were recorded.

Results:

There were 23 patients with glottic dysplasia and 18 patients with glottic SCC. Mean age at treatment was 69 years. Most patients (95%) were male. Posttreatment fundamental frequency fell from 132 ± 35 to 116 ± 24 Hz ( P = .03). Overall, 61% of patients achieved a normal voice. There was a learning-curve, and most treatment failures occurred in the first half of the series. Five-year KTP-only disease-control rates were 87.1% and 53.5% for dysplasia and malignancy, respectively. Five-year overall survival was 56%, with no laryngectomies or deaths due to SCC.

Conclusions:

Ablating dysplasia and early glottic cancer using a KTP laser is a viable treatment option. It has a learning curve and a failure rate but, in this series, no ultimate loss of oncologic control. Its introduction into clinical practice should be managed carefully in the context of multidisciplinary cancer care.

Level of Evidence:

4.

Oesophageal causes of dysphagia localised only to the pharynx: Implications for the suspected head and neck cancer pathway

OBJECTIVES

Dysphagia is a presenting symptom of both pharyngeal and oesophageal cancers. The referral pathway choice is determined by whether it is thought to be oropharyngeal or oesophageal, and this is in turn influenced by whether dysphagia is perceived to be above or below the suprasternal notch. We studied the concordance between the presence of pharynx-localised dysphagia (PLD) and the location of the underlying disease processes.

DESIGN

A subset analysis of the Dysphagia Hotline Cohort, collected between 2004 and 2015, of patients with PLD and a structural diagnosis.

MAIN OUTCOME MEASURES

Information about patient demography and presenting symptoms were recorded. The incisor-to-pathology distance, and the nature of the pathology, were recorded. Logistic regression analysis was used to identify independent predictors of malignancy.

RESULTS

The study included 177 patients. There were 92 males, and mean age at presentation was 74 years. The commonest benign pathologies were cricopharyngeal dysfunction with or without pharyngeal pouch (n = 67), peptic stricture (n = 44) and Schatzki's ring (n = 11). There were 49 cases of cancer, including one hypopharyngeal cancer, one cervical oesophageal cancer, 28 cancers of the upper/mid-thoracic oesophagus, 15 cancers of the lower thoracic oesophagus and 4 cardio-oesophageal cancers. In 105 (59%) patients, PLD was caused by oesophageal disease. Independent predictors of malignancy were weight-change (loss >2.7 kg), a short history (<12 weeks) and presence of odynophagia. Nineteen (39%) of oesophageal cancers that presented with dysphagia that was localised only to the pharynx would have been beyond the reach of rigid oesophagoscopy.

CONCLUSIONS

Pharynx-localised dysphagia is more likely to be a referred symptom of structural oesophageal disease, including cancer, than a primary symptom of structural pharyngeal disease. Absence of additional alarm symptoms such as a short history, weight-loss, and odynophagia, do not adequately exclude the possibility of oesophageal cancer. When the differential diagnosis of PLD includes malignancy, cancer should be presumed to be arising from the oesophagus or the cardio-oesophageal region until proven otherwise. This requires direct visualisation of the mucosal surfaces of the oesophagus and the cardio-oesophageal region, using either transoral or transnasal flexible endoscopy, irrespective of whether the initial assessment occurs within head and neck or upper gastrointestinal suspected cancer pathways.

Vocal palsy increases the risk of lower respiratory tract infection in low-risk, low-morbidity patients undergoing thyroidectomy for benign disease: A big data analysis

OBJECTIVES

Thyroidectomy is the commonest operation that places normally functioning laryngeal nerves at risk of injury. Vocal palsy is a major risk factor for dysphonia, dysphagia, and less commonly, airway obstruction. We investigated the association between post-thyroidectomy vocal palsy and long-term risks of pneumonia and laryngeal failure.

DESIGN

An N=near-all analysis of the English administrative dataset using a previously validated informatics algorithm to identify young and otherwise low-risk patients undergoing first-time elective thyroidectomy for benign disease. Information about age, sex, morbidities, social deprivation and post-operative and late complications were derived.

MAIN OUTCOME MEASURES

Between 2004 and 2012, 43 515 patients between the ages of 20 and 69 who had no history of cancer, neurological, or respiratory disease underwent elective total or hemithyroidectomy without concomitant or late neck dissection, parathyroidectomy or laryngotracheal surgery for benign thyroid disease for the first and only time. Information about age, sex, morbidities and in-hospital and late complications was recorded.

RESULTS

Mean age at surgery was 46±12. There was a strong female preponderance (85%), and most patients (89%) had no recorded Charlson comorbidities Most patients (65%) underwent hemithyroidectomy. Late vocal palsy was recorded in 449 (1.03%) patients, and its occurrence was an independent risk factor for emergency hospital readmission (n=7113; Hazard Ratio 1.52; 95% confidence interval 1.21-1.91), hospitalisation for lower respiratory tract infection (n=944; HR 2.04; 95% CI 1.07-3.75), dysphagia (n=564; HR 3.47; 95% CI 1.57-7.65) and gastrostomy/tracheostomy placement (n=80; HR 20.8; 95% CI 2.5-171.2). Independent risk factors for late vocal palsy were age, burden of morbidities, total thyroidectomy, post operative bleeding, male sex, and annual surgeon volume <30.

CONCLUSIONS

There is a significant association between post-thyroidectomy vocal palsy and long-term risks of hospital readmission, dysphagia, hospitalisation for lower respiratory tract infection, and gastrostomy/tracheostomy tube placement. This adds weight to the need, from a thyroid surgical perspective, to undertake universal post-thyroidectomy laryngeal surveillance as a minimum standard of care, with a focus on post-operative dysphagia and aspiration, and from a medical/respiratory perspective, to initiate investigations to identify occult vocal palsy in patients who present with pneumonia, who have a history of thyroid surgery.

Validation of the Airway-Dyspnoea-Voice-Swallow (ADVS) scale and Patient-Reported Outcome Measure (PROM) as disease-specific instruments in paediatric laryngotracheal stenosis

OBJECTIVE

To validate the Airway-Dyspnoea-Voice-Swallow (ADVS) instrument as a disease-specific Patient-Reported Outcome Measure in paediatric laryngotracheal stenosis.

DESIGN

Prospective observational study.

SETTING

A quaternary referral centre for complex airway disease.

PARTICIPANTS

Forty-eight patients (30 males) with a mean age of 49 ± 49 months who underwent laryngotracheal surgery or microlaryngoscopy and bronchoscopy (MLB) following laryngotracheal surgery.

MAIN OUTCOME MEASURES

Airway-Dyspnoea-Voice-Swallow summary scale and Patient-Reported Outcome Measure (PROM), Paediatric Quality of Life (PedsQL) scale, Paediatric Voice Handicap Index (pVHI) and Lansky performance scale were administered to patients before and 6-8 weeks following airway examination/surgery.

RESULTS

Most patients (73%) had intubation-related subglottic stenosis, and 60% of patients had prior airway treatments. The majority of patients (77%) had more than one major chronic morbidity, and the commonest procedures were diagnostic MLB (49%), followed by airway dilation (29%). Cronbach-α value for the ADVS PROM was 0.71 overall and 0.85, 0.86 and 0.64 for the dyspnoea, voice and swallow domains, respectively. Rank correlations between Dyspnoea, Voice and Swallow summary scale and PROM scores were 0.83, 0.71 and 0.81, respectively (P < 0.0001). For those patients undergoing diagnostic MLB, pre- and post-examination scores were highly correlated (intraclass correlations >0.75). There was a significant rank correlation between ADVS PROM score and Lansky performance score (r = -0.68; P < 0.0001). There were significant correlations between PROM score and PedsQL (r = -0.57; P < 0.0001) and between voice domain of the PROM and pVHI (r = 0.78; P < 0.0001). There were strong correlations between Myer-Cotton stenosis severity and dyspnoea scale and PROM score (r = 0.68; P < 0.0001). There were significant differences in voice and swallow ADVS scales and PROM scores between patients with and without concomitant laryngeal/oesophageal pathology. Patient age and presence of high dyspnoea and swallowing PROM scores were independently associated with poorer quality of life and performance status.

CONCLUSIONS

These series of observations validate the ADVS instrument as a disease-specific outcome measure for paediatric laryngotracheal stenosis. Dyspnoea and swallowing dysfunction appear to have the greatest impact on quality of life. More widespread adoption of the ADVS instrument could help create a shared language for outcomes communication and benchmarking for children with this complex condition.

Impact of the method and success of pharyngeal reconstruction on the outcome of treating laryngeal and hypopharyngeal cancers with pharyngolaryngectomy: A national analysis

BACKGROUND

Surgical treatment of cancers that arise from or invade the hypopharynx presents major reconstructive challenges. Reconstructive failure exposes the airway and neck vessels to digestive contents.

METHODS

We performed a national N = near-all analysis of the administrative dataset to identify pharyngolaryngectomies in England between 2002 and 2012. Information about morbidity, pharyngeal closure method and post-operative complications was derived.

RESULTS

There were 1589 predominantly male (78%) patients whose mean age at surgery was 62 years. The commonest morbidities were hypertension (24%) and ischemic heart disease (11%). For 232 (15%) patients, pharyngolaryngectomy was performed during an emergency admission. The pharynx was closed primarily in 551 patients, with skin or muscle free or pedicled flaps in 755 patients and with jejunum and gastric pull-up in 123 and 160 patients, respectively. In-hospital mortality rate was 6% and was significantly higher in the gastric pull-up group (11%). Reconstructive failure had an odds ratio of 6.2 [95% confidence interval (CI) 2.4-16.1] for in-hospital death. The five-year survival was 57% and age, morbidities, emergency surgery, gastric pull-up, major acute cardiovascular events, renal failure and reconstructive failure independently worsened prognosis. Patients who underwent pharyngeal reconstruction with radial forearm or anterolateral thigh flaps had lower mortality rates than patients who had jejunum flap reconstruction (hazard ratio = 1.50 [95% CI 1.03-2.19]) or gastric pull-up (hazard ratio = 1.92 [95% CI 1.32-2.80]).

CONCLUSIONS

Pharyngolaryngectomy carries a high degree of risk of morbidity and mortality. Reconstructive failure worsens short- and long-term prognosis, and the use of cutaneous free flaps appears to improve survival.

Subclavian Cannulation Improves Outcome of Surgery for Type a Aortic Dissection

Acute type A aortic dissection is a major emergency that continues to cause significant morbidity and mortality. Given the anatomy of the lesion, different circulatory configurations achieved during cardiopulmonary bypass using different arterial inflow sites can influence outcome. Patients who had subclavian artery cannulation were compared with those who had femoral artery cannulation. Forty-nine consecutive patients (mean age, 60 ± 14 years) undergoing emergency surgery for acute type A aortic dissection between 1999 and 2004 were reviewed. Data on presentation, preoperative characteristics, operative details, hospital mortality, and neurological outcome were analyzed. Twenty-nine patients had femoral artery cannulation, and 20 had subclavian artery cannulation. The groups were comparable in terms of preoperative characteristics. The mean follow-up was 29 months. Subclavian artery cannulation conferred significant advantages in respect of hospital death (10% vs. 44%) and neurological impairment. Significantly fewer patients required re-operation following subclavian artery cannulation.

Non-invasive Assessment and Symptomatic Improvement of the Obstructed Nose (NASION): a physiology-based patient-centred approach to treatment selection and outcomes assessment in nasal obstruction

OBJECTIVES

To evaluate the impact of selecting treatment for nasal obstruction on the basis of a structured physiology-based assessment protocol on patient outcomes.

DESIGN

Prospective longitudinal study.

SETTING

District general hospital.

PARTICIPANTS

A population of 71 patients with a mean age of 33 years, containing 36 males, presented with nasal obstruction for consideration of nasal surgery. All patients underwent a structured clinical assessment, skin prick allergy testing and oral-nasal flow-volume loop examination. Fifty-one patients completed the follow-up, and mean follow-up was 11 months.

MAIN OUTCOME MEASURES

NOSE, SNOT-22 and NASION scales.

RESULTS

Of the 51 patients who completed follow-up, six had conservative treatment, 28 had septal/turbinate surgery, and 17 underwent nasal valve surgery. Mean NOSE score fell from 68 ± 18 to 39 ± 31 following the treatment. Mean SNOT-22 score fell from 47 ± 20 to 29 ± 26 following the treatment. The difference between pre-treatment and post-treatment NOSE and SNOT-22 scores were statistically significant. Success rate of septal/turbinate surgery in patients without nasal allergy was 88%, and this fell to 42% in patients undergoing septal/turbinate surgery who also had nasal allergy. Presence of nasal allergy was the only independent predictor of treatment failure. Patients with nasal valve surgery reported significantly greater symptomatic improvement following surgery. The newly formed NASION scale demonstrated internal consistency with a Cronbach α of 0.9 and excellent change-responsiveness and convergent validity with correlation coefficients of 0.64 and 0.77 against treatment-related changes in SNOT-22 and NOSE scales, respectively.

CONCLUSIONS

Successful surgical outcomes can be achieved with the use of a structured history, clinical evaluation and physiological testing. Flow-volume loops can help elucidate the cause of nasal obstruction. The newly formed NASION scale is a validated retrospective single time-point patient outcome measure.

Disease homogeneity and treatment heterogeneity in idiopathic subglottic stenosis

OBJECTIVES/HYPOTHESIS

Idiopathic subglottic stenosis (iSGS) is a rare and potentially life-threatening disease marked by recurrent and progressive airway obstruction frequently requiring repeated surgery to stabilize the airway. Unknown etiology and low disease prevalence have limited the ability to characterize the natural history of iSGS and resulted in variability in surgical management. It is uncertain how this variation relates to clinical outcomes.

STUDY DESIGN

Medical record abstraction.

METHODS

Utilizing an international, multi-institutional collaborative, we collected retrospective data on patient characteristics, treatment, and clinical outcomes. We investigated variation between and within open and endoscopic treatment approaches and assessed therapeutic outcomes; specifically, disease recurrence and need for tracheostomy at last follow-up.

RESULTS

Strikingly, 479 iSGS patients across 10 participating centers were nearly exclusively female (98%, 95% confidence interval [CI], 96.1-99.6), Caucasian (95%, 95% CI, 92.2-98.8), and otherwise healthy (mean age-adjusted Charlson Comorbidity Index 1.5; 95% CI, 1.44-1.69). The patients presented at a mean age of 50 years (95% CI, 48.8-51.1). A total of 80.2% were managed endoscopically, whereas 19.8% underwent open reconstruction. Endoscopic surgery had a significantly higher rate of disease recurrence than the open approach (chi(2) = 4.09, P = 0.043). Tracheostomy was avoided in 97% of patients irrespective of surgical approach (95% CI, 94.5-99.8). Interestingly, there were outliers in rates of disease recurrence between centers using similar treatment approaches.

CONCLUSION

Idiopathic subglottic stenosis patients are surprisingly homogeneous. The heterogeneity of treatment approaches and the observed outliers in disease recurrence rates between centers raises the potential for improved clinical outcomes through a detailed understanding of the processes of care.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1390-1396, 2016.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways

Emergency and difficult tracheal intubations are hazardous undertakings where successive laryngoscopy-hypoxaemia-re-oxygenation cycles can escalate to airway loss and the 'can't intubate, can't ventilate' scenario. Between 2013 and 2014, we extended the apnoea times of 25 patients with difficult airways who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high-flow humidified oxygen, initially to provide pre-oxygenation, and continuing as post-oxygenation during intravenous induction of anaesthesia and neuromuscular blockade until a definitive airway was secured. Apnoea time commenced at administration of neuromuscular blockade and ended with commencement of jet ventilation, positive-pressure ventilation or recommencement of spontaneous ventilation. During this time, upper airway patency was maintained with jaw-thrust. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) was used in 15 males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25-81]) years. The median (IQR [range]) Mallampati grade was 3 (2-3 [2-4]) and direct laryngoscopy grade was 3 (3-3 [2-4]). There were 12 obese patients and nine patients were stridulous. The median (IQR [range]) apnoea time was 14 (9-19 [5-65]) min. No patient experienced arterial desaturation < 90%. Mean (SD [range]) post-apnoea end-tidal (and in four patients, arterial) carbon dioxide level was 7.8 (2.4 [4.9-15.3]) kPa. The rate of increase in end-tidal carbon dioxide was 0.15 kPa.min(-1) . We conclude that THRIVE combines the benefits of 'classical' apnoeic oxygenation with continuous positive airway pressure and gaseous exchange through flow-dependent deadspace flushing. It has the potential to transform the practice of anaesthesia by changing the nature of securing a definitive airway in emergency and difficult intubations from a pressured stop-start process to a smooth and unhurried undertaking.

Not always asthma: clinical and legal consequences of delayed diagnosis of laryngotracheal stenosis

Laryngotracheal stenosis (LTS) is a rare condition that occurs most commonly as a result of instrumentation of the airway but may also occur as a result of inflammatory conditions or idiopathically. Here, we present the case of a patient who developed LTS as a complication of granulomatosis with polyangiitis (GPA), which was misdiagnosed as asthma for 6 years. After an admission with respiratory symptoms that worsened to the extent that she required intubation, a previously well 14-year-old girl was diagnosed with GPA. Following immunosuppressive therapy, she made a good recovery and was discharged after 22 days. Over subsequent years, she developed dyspnoea and "wheeze" and a diagnosis of asthma was made. When she became pregnant, she was admitted to hospital with worsening respiratory symptoms, whereupon her "wheeze" was correctly identified as "stridor," and subsequent investigations revealed a significant subglottic stenosis. The delay in diagnosis precluded the use of minimally invasive therapies, with the result that intermittent laser resection and open laryngotracheal reconstructive surgery were the only available treatment options. There were numerous points at which the correct diagnosis might have been made, either by proper interpretation of flow-volume loops or by calculation of the Empey or Expiratory Disproportion Indices from spirometry data.

Impact of unilateral vocal fold mobility impairment on laryngopulmonary physiology

OBJECTIVE

To examine the impact of unilateral vocal fold mobility impairment (UVFMI) on airway physiology.

STUDY DESIGN

Cross-sectional observational study.

PARTICIPANTS

There were 21 patients with UVFMI and 53 controls.

MAIN OUTCOME MEASURES

All patients and patient controls underwent a maximum-effort flow-volume loop examination. Forced expiratory flow in one second (FEV1 ), forced expiratory volume (FVC), peak inspiratory flow rate and peak expiratory flow rate (PIFR and PEFR, respectively) and area under the inspiratory and expiratory flow-volume loops (AUCI nspiratory and AUCE xpiratory, respectively) were measured. The ratio of PEFR to PIFR and AUCE xpiratory to AUCI nspiratory was derived.

RESULTS

There were 48 males and 26 females. Mean age at measurement was 39 ± 11 years. Patients and controls were matched for age, sex, height and weight. None of the expiratory variables were significantly different between the groups. PIFR was significantly lower in UVFMI patients compared with controls (3.4 ± 1.2 versus 5.3 ± 1.8; P < 0.0001), as was AUCI nspiratory (11.5 ± 6.3 versus 17.5 ± 8.5; P = 0.0002). PEFR/PIFR provided the best differentiation between patients with UVFMI and controls with an area under the Receiver Operating Characteristic (ROC) curve of 0.96 and at a threshold of 1.9, and PEFR/PIFR had sensitivity and specificity of 95.2% and 90.6%, respectively.

CONCLUSIONS

Flow-volume loops are a non-invasive method of studying vocal abduction and could compliment voice assessment and laryngoscopy in UVFMI. With further research, they could provide an outcome measure for laryngeal rehabilitative procedures, and a shared physiological language for screening and surgical quality assurance.

An estimation of the population incidence of adult unilateral vocal fold mobility impairment in England

We estimate the population incidence of adult unilateral vocal fold mobility impairment at 5.13 per 100,000 per year.

Diagnosis of laryngotracheal stenosis from routine pulmonary physiology using the expiratory disproportion index

OBJECTIVE/HYPOTHESIS

The study's objective was to determine the utility of expiratory disproportion index (EDI), the ratio of forced expiratory volume in 1 second (FEV1) to peak expiratory flow rate (PEFR) (EDI = FEV1[L] /PEFR[L/s] × 100), in differentiating between laryngotracheal stenosis (LTS) and other respiratory diagnoses. LTS is an uncommon complication of mechanical ventilation or vasculitis or a manifestation of airway compression or malignancy. It frequently masquerades as asthma and evades timely diagnosis, causing prolonged morbidity and airway-related mortality.

STUDY DESIGN

Observational study.

METHODS

We compared spirometry results of 9,357 healthy subjects and nonstenosis pulmonary patients with 217 cases of LTS. Bootstrap analysis, receiver-operating characteristic (ROC) statistics, and Pearson correlation were used to assess the diagnostic utility of the EDI and its correlation with stenosis severity.

RESULTS

Mean EDI values were 36 ± 7 in nonstenosis cases, 76 ± 17 in benign stenoses, and 69 ± 23 in tracheal cancer (P < .0001). A significant correlation existed between anatomic stenosis severity and EDI (P < .0001; R = 0.61). Area under the ROC curve was 0.98, and at a threshold of >50, EDI had a sensitivity of 95.9% and a specificity of 94.2% in differentiating between stenosis and nonstenosis cases.

CONCLUSIONS

EDI can reliably diagnose LTS using routine lung function data. Its simplicity and clinical utility, first recognized by Duncan Empey, are underpinned by a unique physiology whereby PEFR, being determined by total tracheobronchial tree resistance, falls disproportionately compared with FEV1 , which is determined within small intrathoracic airways. EDI provides valuable information about the presence and extent of LTS particularly in nonspecialist clinical settings and its routine inclusion within standard lung function reports could prevent the prolonged morbidity and mortality that currently result from missed and delayed diagnoses.

Outcome of a multimodality approach to the management of idiopathic subglottic stenosis

OBJECTIVES/HYPOTHESIS

To assess the results of treating idiopathic subglottic stenosis (ISS), determine predictors of treatment success and outcome, and better define roles and limitations of endoscopic and open surgery.

STUDY DESIGN

Prospective observational study.

METHODS

Fifty-four consecutive patients were treated between 2004 and 2012. Patient, stenosis and treatment details, complications, open surgery rates, and outcomes were recorded. Regression analyses were used to identify predictors of endoscopic treatment success; treatment frequency; and functional outcomes in airway, dyspnea, voice, and swallowing domains.

RESULTS

All patients were female and mean age at diagnosis was 48 ± 12 years. Symptoms-to-diagnosis latency was 21 ± 20 months. There were 10 concomitant glottic and subglottic stenoses. Most lesions were Myer-Cotton grade 3 (48%). Overall, 78% of patients were managed endoscopically. Treatment included intralesional corticosteroids, laser surgery, balloon dilation, and temporary silastic stenting in selected cases. Annual intervention rate was 1.07 ± 0.79. Mean follow-up was 45 months. Factors associated with intervention frequency were stenosis location and severity. Twelve patients underwent anteroposterior laryngotracheal reconstruction with biological inhibition. This resulted in disease remission in all patients with subglottic stenosis, and in most patients with concomitant glottic and subglottic stenosis. Patients with total laryngotracheal stenosis required ongoing treatment for glottic disease. All patients maintained prosthesis-free airways, but in one patient this required a laryngectomy. Most patients achieved good functional outcomes. Stenosis location was the only independent predictor of dyspnea and voice outcomes.

CONCLUSIONS

ISS can be effectively treated with endoscopic surgery or a bespoke open reconstructive procedure that does not compromise on female voice quality.

LEVEL OF EVIDENCE

4.

Remote ischemic preconditioning in percutaneous coronary revascularization: a double-blind randomized controlled clinical trial

OBJECTIVE

To assess the impact of pre-procedural remote ischemic preconditioning on the incidence of myocardial complications following percutaneous coronary intervention.

BACKGROUND

Ischemic preconditioning of a remote vascular territory improves the subsequent ischemic tolerance of distant organs.

METHOD

The Myocardial Event Reduction with Ischemic Preconditioning Therapy (MERIT) trial recruited 80 consecutive patients undergoing elective angioplasty with drug-eluting stents to receive two 5-min lower limb tourniquet occlusions or an un-inflated tourniquet (controls) 1 h before the procedure. The primary outcome was troponin T level at 24 h. Secondary outcomes were intra-procedural chest pain and ST-segment deviation.

RESULTS

6 patients in the control group and 2 in the ischemic preconditioning group had pre-procedural raised troponin T (p = 0.23). This increased to 16 (40%) in the control group and 5 (12.5%) in the study group at 24 h (p = 0.01). Fewer patients in the study group experienced intra-procedural chest pain (1 vs. 7, p = 0.056). Mean ST-segment deviation time was 13 ± 35 s in the study group and 58 ± 118 s in the control group (p = 0.02). At a mean follow-up of 11 months, the major adverse cardiac event rate did not differ significantly between the groups.

CONCLUSION

These data suggest that ischemic preconditioning reduces the absolute risk of post-procedure cardiomyocyte necrosis by 27.5%, and reduces intra-procedural chest pain and ST-segment deviation in patients undergoing percutaneous coronary interventions. We suggest its routine use in percutaneous coronary intervention, although the long-term prognostic impact in this patient group warrants further investigation.

Outcome of endoscopic resection tracheoplasty for treating lambdoid tracheal stomal stenosis

OBJECTIVES/HYPOTHESIS

To evaluate the efficacy of endoscopic resection tracheoplasty (ERT) for treating post-tracheotomy stomal stenosis caused by inward collapse of tracheal ring remnants.

STUDY DESIGN

Prospective observational study.

METHODS

Between 2007 and 2012, we treated 40 patients with "lambdoid" tracheal deformity with a two-staged minimally invasive procedure undertaken using suspension microtracheoscopy and high-frequency jet ventilation. The first procedure entailed CO₂ laser photoablation of collapsed tracheal rings and dilatation. The second procedure, performed 6 to 8 weeks later, involved ablation of residual structural obstruction, removal of granulation tissue, and intralesional corticosteroid injection. Perioperative patient and lesion characteristics and results of treatment were assessed.

RESULTS

There were 22 males and 18 females, and mean age at first treatment was 59 years. There were 17 cases of scarring at the postero-lateral tracheal groove (trachealis blunting), and 22 patients had age-adjusted Charlson comorbidity scores greater than 4. All patients without trachealis blunting were successfully managed endoscopically, with only one patient requiring one additional endoscopic treatment. Seven patients with trachealis blunting needed additional treatment, and four patients had tracheal resection (P = 0.013). All patients were decannulated, and 75% of patients achieved good dyspnea outcomes. Patients with low morbidities were significantly more likely to achieve good dyspnea outcomes (P < 0.027). There were no treatment-related worsenings of voice or swallowing.

CONCLUSIONS

ERT is an effective minimally invasive treatment for intubation-related lambdoid tracheal stenosis. It achieves a successful outcome while avoiding the risks associated with open surgery. We recommend its more widespread use for treating patients with this condition.

Objective assessment of the hemisphere-specific neurological outcome of carotid endarterectomy: a quantitative saccadometric analysis

BACKGROUND

Carotid endarterectomy (CEA) improves the cerebrovascular prognosis of patients with carotid stenosis but carries a risk of causing postoperative neurological deterioration.

OBJECTIVE

We assessed hemisphere-specific changes in saccadic eye movements to determine the utility of saccadometry as a quantitative neurosurgical outcome measure.

METHODS

Visually evoked saccades were recorded at the bedside before and 2 days after surgery from 30 patients undergoing CEA for symptomatic carotid stenosis. Hemisphere-specific latency distributions were compared using Kolmogorov-Smirnov statistics. Latency distributions were fitted using the Linear Approach to Threshold with Ergodic Rate model and compared with binomial logistic regression.

RESULTS

There were 21 males and mean age at surgery was 71±7 years. Following CEA, the distribution of saccades initiated by the cerebral hemisphere distal to the operated artery significantly changed in 25 patients. By contrast, there were 14 significant contralateral-hemisphere saccadic changes (P<.001). Significant contralateral saccadic changes always co-occurred with significant ipsilateral changes and 10 of 14 patients with contralateral saccadic change had contralateral carotid stenosis. There was a significantly greater postoperative reduction in early saccades generated by the ipsilateral hemisphere than by the contralateral hemisphere (P<.02)

CONCLUSION

CEA leads to significant hemisphere-specific subclinical changes in saccadic performance and, in particular, differentially affects the proportion of early saccades, a measure of the ability of the frontal cortex to successfully inhibit lower centers, generated by the 2 hemispheres. Saccadometry, a bedside test, provides data that can be statistically compared for individual and groups of patients. It could allow the neurological outcome of carotid surgery to be objectively quantified.

Validation of the Clinical COPD Questionnaire as a psychophysical outcome measure in adult laryngotracheal stenosis

OBJECTIVES

To validate the Clinical Chronic Obstructive Pulmonary Disease Questionnaire (CCQ), a patient-administered instrument developed for bronchopulmonary disease as a disease-specific psychophysical outcome measure for adult laryngotracheal stenosis.

DESIGN

Prospective observational study.

SETTINGS

Tertiary/National referral airway reconstruction centre.

PARTICIPANTS

Thirty-three tracheostomy-free patients undergoing endoscopic laryngotracheoplasty.

MAIN OUTCOME MEASURES

CCQ and the Medical Research Council (MRC) Dyspnoea scale, a previously validated but more limited scale, were administered to patients 2 weeks before surgery, preoperatively, and 2 weeks after endoscopic laryngotracheoplasty. Pulmonary function was assessed preoperatively. Internal consistency was assessed with Cronbach alpha statistics and test-retest reliability was determined using intraclass correlation. Correlations between CCQ and MRC scale, and pulmonary function were used to assess convergent and divergent validity respectively. Instrument responsiveness was assessed by correlating total and domain-specific CCQ scores with anatomical disease severity and post-treatment effect size.

RESULTS

There were 12 males and 21 females. Mean age was 44 +/- 15 years. Cronbach alpha coefficient and intraclass correlation coefficient were 0.88 and 0.95 respectively. Total and domain-specific CCQ scores significantly correlated with the MRC scores (P < 0.001) and significant correlations between CCQ and peak expiratory flow rate and FEV(1) were identified (P < 0.03). There were statistically significant changes in total and domain-specific CCQ scores when different stenosis severities were compared. Clinical COPD Questionnaire scores also changed significantly and congruently following surgery (P < 0.05 in both cases).

DISCUSSION

Clinical COPD Questionnaire is a valid and sensitive instrument for assessing symptom severity and levels of function and well-being in adult patients with laryngotracheal stenosis and can be used as a patient-centred disease-specific outcome measure for this condition.

Impact of rhinoplasty on objective measurement and psychophysical appreciation of facial symmetry

OBJECTIVES

To determine the impact of rhinoplasty on the objective measurement and subjective appreciation of facial symmetry and to investigate whether perceptual shifts are correlated with objective changes in facial proportions.

DESIGN

Frontal view photographs were used to measure bilateral symmetry ratios of the medial and lateral canthi, tragus, ala, and oral commissure in 100 patients before and 6 months after rhinoplasty. Gestalt dichotomous impressions of facial symmetry were also obtained in all cases. Paired t tests and chi(2) tests were used to compare facial proportions and the proportion of faces perceived as symmetrical, respectively, before and after surgery. The receiver operating characteristic and analysis of variance were used to assess whether perceptual shifts in symmetry could be correlated with objectively measurable changes in facial proportion.

RESULTS

The number of faces perceived as symmetrical increased from 42 to 62 after rhinoplasty (P < .001, chi(2) test). Objectively, midline-to-ala symmetry increased from an average of 91.1% (5.5%) (mean [SD]) to 93.8% (4.5%) after rhinoplasty (P < .001, paired t test). Other facial proportions did not change significantly (P > .10). The degree of change in midline-to-ala symmetry was the only objective measure that was significantly associated with the subjective perception of the face as symmetrical or asymmetrical (P < .01, 1-way analysis of variance). Most positive perceptual shifts were associated with an objective improvement in nasal symmetry that was greater than 2%. Conversely, most negative perceptual shifts were associated with minimal postoperative improvement or loss of nasal symmetry.

CONCLUSION

Rhinoplasty leads to objectively measurable changes in nasal symmetry that correspond with psychophysical modifications in the perception of a face as symmetrical or asymmetrical.

A multidisciplinary audit of clinical coding accuracy in otolaryngology: financial, managerial and clinical governance considerations under payment-by-results

OBJECTIVES

To audit the accuracy of otolaryngology clinical coding and identify ways of improving it.

DESIGN

Prospective multidisciplinary audit, using the 'national standard clinical coding audit' methodology supplemented by 'double-reading and arbitration'.

SETTINGS

Teaching-hospital otolaryngology and clinical coding departments.

PARTICIPANTS

Otolaryngology inpatient and day-surgery cases.

MAIN OUTCOME MEASURES

Concordance between initial coding performed by a coder (first cycle) and final coding by a clinician-coder multidisciplinary team (MDT; second cycle) for primary and secondary diagnoses and procedures, and Health Resource Groupings (HRG) assignment.

RESULTS

1250 randomly-selected cases were studied. Coding errors occurred in 24.1% of cases (301/1250). The clinician-coder MDT reassigned 48 primary diagnoses and 186 primary procedures and identified a further 209 initially-missed secondary diagnoses and procedures. In 203 cases, patient's initial HRG changed. Incorrect coding caused an average revenue loss of 174.90 pounds per patient (14.7%) of which 60% of the total income variance was due to miscoding of a eight highly-complex head and neck cancer cases. The 'HRG drift' created the appearance of disproportionate resource utilisation when treating 'simple' cases. At our institution the total cost of maintaining a clinician-coder MDT was 4.8 times lower than the income regained through the double-reading process.

CONCLUSIONS

This large audit of otolaryngology practice identifies a large degree of error in coding on discharge. This leads to significant loss of departmental revenue, and given that the same data is used for benchmarking and for making decisions about resource allocation, it distorts the picture of clinical practice. These can be rectified through implementing a cost-effective clinician-coder double-reading multidisciplinary team as part of a data-assurance clinical governance framework which we recommend should be established in hospitals.

Variations in paranasal sinus anatomy: implications for the pathophysiology of chronic rhinosinusitis and safety of endoscopic sinus surgery

OBJECTIVES

To study the radiologic anatomy of the paranasal sinuses in patients with and without chronic rhinosinusitis to assess whether anatomic variations are associated with disease pathology, and to identify those variants that may impact operative safety.

SETTING

Tertiary referral otolaryngology unit.

MAIN OUTCOME MEASURES

Incidence and nature of anatomic variants with potential impact on operative safety, and the presence or absence of sinus mucosal disease and its correlation with anatomic variants with a potential impact on mucociliary clearance.

METHODS

We reviewed 278 computed tomographic scans from patients with rhinosinusitis symptoms to investigate anatomic variations that may predispose to sinusitis or impact on operative safety. The incidence of variants with potential impact on sinus drainage was compared between patients with and without sinus mucosal disease with logistic regression.

RESULTS

A closed osteomeatal complex was identified in 148 patients (53%), followed by concha bullosa in 98 patients (35%). Closed osteomeatal complex and nasal polyposis were independent risk factors for sinus mucosal disease. Anatomic variants with a potential impact on operative safety included anterior clinoid process pneumatization (18%), infraorbital ethmoid cell (12%), sphenomaxillary plate (11%), and supraorbital recess (6%). In 92% of patients, the level difference between the roof of the ethmoid cavity and the cribriform plate was Keros I.

CONCLUSIONS

Bony anatomic variants do not increase the risk of sinus mucosal disease. However, anatomic variants with a potential impact on operative safety occur frequently and need to be specifically sought as part of preoperative evaluation.

Outcome of Endoscopic Treatment of Adult Postintubation Tracheal Stenosis

OBJECTIVES/HYPOTHESIS

To assess the results of primary endoscopic treatment of adult postintubation tracheal stenosis, to identify predictors of a successful outcome, and better define the scope and limitations of minimally-invasive surgery for this condition.

METHODS

Sixty-two consecutive patients treated between April 2003 and 2006 with initial endoscopic surgery were prospectively studied. Patient and lesion characteristics, treatment details, complications, decannulation, and open surgery rates were recorded. Actuarial analysis and Cox regression were used to identify predictors of decannulation and freedom from external surgery.

RESULTS

There were 34 male patients and the average age was 45 +/- 16 years. The average stenosis height was 18 mm (range: 5-55 mm), and 82% of lesions were Myer-Cotton grades III or IV. Lesion height and intubation-to-treatment latency independently predicted success of endoscopic surgery. Ninety-six percent of patients with lesions <30 mm in height were treated endoscopically, but the success rate fell to 20% for lesions longer than 30 mm. Patients with recalcitrant lesions underwent airway augmentation (n = 11) or resection (n = 3), with a 79% success rate. All patients were decannulated, but some, predominantly morbidly obese patients, required long-term stents for dynamic airway compromise. Ninety-eight percent of re-interventions occurred within 6 months.

CONCLUSIONS

Minimally invasive treatment is effective in postintubation airway stenosis and obviates the need for open cervicomediastinal surgery in most patients. Patients with old and long lesions are less likely to be cured endoscopically. For most patients in this subgroup, endoscopic surgery makes airway augmentation a viable, less invasive alternative to resection. Patients were unlikely to require further therapy after 6 months of symptom-free follow-up.

Analysis of complications following surgical treatment of benign parotid disease

BACKGROUND

The objective of the study was to study the incidence of, and risk factors for developing complications following parotidectomy for benign disease, to improve preoperative patient counselling and better inform future surgical management.

METHODS

An 11-year retrospective review of 162 parotidectomies for benign disease, collecting and analysing data about presentation, investigations, surgical treatment, postoperative facial nerve function, Frey's syndrome and other surgical complications.

RESULTS

The mean age at presentation was 58 years. The commonest pathology was benign pleomorphic adenoma (43%), followed by Warthin's tumour (30%) and chronic sialadenitis (22%). Sialadenitis was a significant risk factor for facial nerve palsy and increased the incidence of salivary fistulas. Parotid duct ligation increased the risk of nerve palsy in the distribution of zygomatic and buccal branches. Operations for Warthin's tumour were associated with an increased risk of dysfunction of the cervical branch of the nerve. Half the patients had intraoperative facial nerve stimulation and this did not influence the likelihood of facial paresis. The recovery of facial nerve function showed a biphasic distribution, with 90% of patients having normal function within 12 months, followed by a slower recovery rate for up to 2 years.

CONCLUSION

The incidence of postoperative complications was influenced by the pathology, with inflammatory lesions significantly increasing the risk of facial nerve dysfunction and other complications, but also by variations in surgical practice, such as parotid duct ligation. Overall, the incidence of permanent facial paralysis was less than 2%, but temporary nerve palsy was common at 40%, with most patients regaining normal function within 1 year of the operation.

Endonasal endoscopic approach to the petrous apex: an image-guided quantitative anatomical study

BACKGROUND

The petrous apex is a relatively inaccessible region, deeply situated within the skull base. Removal of lesions from this area, traditionally accomplished via lateral approaches, can cause significant morbidity. We undertook an anatomical study to investigate the surgical anatomy of the petrous apex through an endonasal endoscopic approach, which has been sporadically described in the literature, to investigate its feasibility and to characterise clear and consistent surgical landmarks for access.

METHODS

Cadaveric dissections were performed on five heads. Pre-dissection computed tomography scans were used, with the BrainLab navigation system, to verify entry into the petrous apex. Surgical landmarks were characterised in relation to fixed sphenoid sinus structures, and surgical access before and after drilling the sphenoid sinus rostrum was quantitatively compared.

RESULTS

The landmark for entry into the petrous apex was the intersection of a vertical line halfway between the medial surface of the internal carotid artery and the midline, with a horizontal line one-third of the way up from the postero-inferior floor of the sphenoid sinus. The dimensions of the postero-superior sphenoid sinus were characterised by the inter-carotid distance, pituitary-to-sphenoid-floor distance and the width of the sphenoid sinus floor, which were 15 +/- 3 mm, 16 +/- 3 mm and 26 +/- 1.6 mm respectively. The surface area of surgical access was 193 +/- 28 mm(2), increasing to 316 +/- 39 mm(2) after drilling of the sphenoid rostrum (P < 0.001; paired t-test).

CONCLUSIONS

Endoscopic approach to the petrous apex is anatomically feasible, and, aided by image navigation, could extend the scope of endonasal surgery to access highly-selected lesions in the middle cranial fossa.

Incidence and significance of myocardial injury after surgical treatment of head and neck cancer

OBJECTIVE/HYPOTHESIS

To review the incidence of, and risk factors for myocardial injury after head and neck surgery to help optimize patient care and develop perioperative cardioprotective strategies.

STUDY DESIGN

Observational cohort study.

METHODS

Records of 65 patients surgically treated for upper aerodigestive tract squamous cell carcinoma between 2005 and 2006 were reviewed. Information about cardiovascular history, tumor characteristics, details of surgery, and postoperative complications were recorded. Patients had troponin assays on the third postoperative day. Logistic regression was used to identify risk factors for postoperative myocardial injury.

RESULTS

The average age at presentation was 62+/-12 years. There were 46 (71%) males and 19 (29%) females. Troponin-positive and -negative groups were matched for age, sex, cardiovascular risks, comorbidity, site, tumor-node-metastasis status, and duration of the operations. Sixteen (25%) patients had postoperative myocardial injury including five clinical myocardial infarctions. Factors identified as independent predictors of postoperative myocardial injury were blood pressure level (odds ratio [OR] 1.17; 95% confidence interval [CI] 1.04-1.31; P<.02), intraoperative heart rate variability (OR 1.33; 95% CI 1.04-1.71; P<.02), and the degree of postoperative inflammatory response (OR 1.07; 95% CI 1.02-1.13; P<.001).

CONCLUSIONS

Postoperative myocardial injury is a known independent predictor of cardiovascular prognosis. Its incidence in head and neck patients could potentially be reduced through stringent blood pressure management, tight intraoperative heart rate control, and dampening of the postoperative inflammatory response. Troponin testing is a valuable screening tool, and patients who have elevated levels postoperatively should be closely monitored and referred to a cardiologist for optimization of cardiovascular care.

The Asplund-Davies vertical scar breast reduction technique preserves the sub-areolar skin thickness in the long term: a matched comparative study with the inverted T technique

BACKGROUND AND AIM

The inverted T technique, a popular method of breast reduction, relies on stretching the skin over glandular breast tissue to create the breast shape. The Asplund-Davies vertical scar method of breast reduction by contrast uses glanduloplasty to create the desired breast shape, achieving tension-free skin closure. Indeed the skin at the end of the vertical scar technique is wrinkled. It is known from tissue expansion literature that when skin is placed under tension the dermis becomes thinner. In this pilot cross-sectional study we compared breast skin thickness between two matched groups of patients undergoing breast reduction either with the inverted T or the vertical scar techniques, to determine whether the method of breast reduction impacts on breast skin thickness in the long term.

MATERIALS AND METHOD

With a high frequency ultrasound machine the breast skin thickness of 24 breasts, 12 in each group, was measured by an independent consultant radiologist. Patients were matched in terms of age, time since operation, Fitzpatrick skin type, preoperative cup size and the amount of tissue resected.

RESULTS

The breast skin in the inverted T group was significantly thinner than the vertical scar group (P<0.001). The inverted T group also had thinner skin in comparison to its control point (P<0.05). The vertical scar group had comparable skin thickness compared to its control point (P>0.05).

CONCLUSION

This pilot study suggests that tension-free closure of skin with the vertical scar technique maintains breast skin thickness. Maintenance of breast skin thickness in this group may in turn contribute to the long term preservation of breast shape and form.

Remote ischemic preconditioning reduces myocardial and renal injury after elective abdominal aortic aneurysm repair: a randomized controlled trial

BACKGROUND

Myocardial and renal injury commonly contribute to perioperative morbidity and mortality after abdominal aortic aneurysm repair. Remote ischemic preconditioning (RIPC) is a phenomenon whereby brief periods of ischemia followed by reperfusion in one organ provide systemic protection from prolonged ischemia. To investigate whether remote preconditioning reduces the incidence of myocardial and renal injury in patients undergoing elective open abdominal aortic aneurysm repair, we performed a randomized trial. METHOD AND RESULTS; Eighty-two patients were randomized to abdominal aortic aneurysm repair with RIPC or conventional abdominal aortic aneurysm repair (control). Two cycles of intermittent crossclamping of the common iliac artery with 10 minutes ischemia followed by 10 minutes reperfusion served as the RIPC stimulus. Myocardial injury was assessed by cardiac troponin I (>0.40 ng/mL), myocardial infarction by the American College of Cardiology/American Heart Association definition and renal injury by serum creatinine (>177 micromol/L) according to American Heart Association guidelines for risk stratification in major vascular surgery. The groups were well matched for baseline characteristics. RIPC reduced the incidence of myocardial injury by 27% (39% versus 12% [95% CI: 8.8% to 45%]; P=0.005), myocardial infarction by 22% (27% versus 5% [95% CI: 7.3% to 38%]; P=0.006), and renal impairment by 23% (30% versus 7%; [95% CI: 6.4 to 39]; P=0.009). Multivariable analysis revealed the protective effect of RIPC on myocardial injury (OR: 0.22, 95% CI: 0.07 to 0.67; P=0.008), myocardial infarction (OR: 0.18, 95% CI: 0.04 to 0.75; P=0.006) and renal impairment were independent of other covariables.

CONCLUSIONS

In patients undergoing elective open abdominal aortic aneurysm repair, RIPC reduces the incidence of postoperative myocardial injury, myocardial infarction, and renal impairment.