Comparative analysis of GoPro and digital cameras in head and neck flap harvesting surgery video documentation: an innovative and efficient method for surgical education

BACKGROUND

An urgent need exists for innovative surgical video recording techniques in head and neck reconstructive surgeries, particularly in low- and middle-income countries where a surge in surgical procedures necessitates more skilled surgeons. This demand, significantly intensified by the COVID-19 pandemic, highlights the critical role of surgical videos in medical education. We aimed to identify a straightforward, high-quality approach to recording surgical videos at a low economic cost in the operating room, thereby contributing to enhanced patient care.

METHODS

The recording was comprised of six head and neck flap harvesting surgeries using GoPro or two types of digital cameras. Data were extracted from the recorded videos and their subsequent editing process. Some of the participants were subsequently interviewed.

RESULTS

Both cameras, set at 4 K resolution and 30 frames per second (fps), produced satisfactory results. The GoPro, worn on the surgeon's head, moves in sync with the surgeon, offering a unique first-person perspective of the operation without needing an additional assistant. Though cost-effective and efficient, it lacks a zoom feature essential for close-up views. In contrast, while requiring occasional repositioning, the digital camera captures finer anatomical details due to its superior image quality and zoom capabilities.

CONCLUSION

Merging these two systems could significantly advance the field of surgical video recording. This innovation holds promise for enhancing technical communication and bolstering video-based medical education, potentially addressing the global shortage of specialized surgeons.

Validation of the Quality Analysis of Medical Artificial Intelligence (QAMAI) tool: a new tool to assess the quality of health information provided by AI platforms

BACKGROUND

The widespread diffusion of Artificial Intelligence (AI) platforms is revolutionizing how health-related information is disseminated, thereby highlighting the need for tools to evaluate the quality of such information. This study aimed to propose and validate the Quality Assessment of Medical Artificial Intelligence (QAMAI), a tool specifically designed to assess the quality of health information provided by AI platforms.

METHODS

The QAMAI tool has been developed by a panel of experts following guidelines for the development of new questionnaires. A total of 30 responses from ChatGPT4, addressing patient queries, theoretical questions, and clinical head and neck surgery scenarios were assessed by 27 reviewers from 25 academic centers worldwide. Construct validity, internal consistency, inter-rater and test-retest reliability were assessed to validate the tool.

RESULTS

The validation was conducted on the basis of 792 assessments for the 30 responses given by ChatGPT4. The results of the exploratory factor analysis revealed a unidimensional structure of the QAMAI with a single factor comprising all the items that explained 51.1% of the variance with factor loadings ranging from 0.449 to 0.856. Overall internal consistency was high (Cronbach's alpha = 0.837). The Interclass Correlation Coefficient was 0.983 (95% CI 0.973-0.991; F (29,542) = 68.3; p < 0.001), indicating excellent reliability. Test-retest reliability analysis revealed a moderate-to-strong correlation with a Pearson's coefficient of 0.876 (95% CI 0.859-0.891; p < 0.001).

CONCLUSIONS

The QAMAI tool demonstrated significant reliability and validity in assessing the quality of health information provided by AI platforms. Such a tool might become particularly important/useful for physicians as patients increasingly seek medical information on AI platforms.

Virtual surgical planning for mandibular reconstruction in an abbreviated admission pathway

OBJECTIVES

Virtual Surgical Planning (VSP) creates individualized surgical plans for free flap reconstruction of mandibular defects. Prior studies indicate that VSP can offer cost benefits due to reduced operative time and length of stay (LOS). We assessed the impact of VSP in the context of a validated postoperative abbreviated LOS clinical pathway.

METHODS

This study assessed patients undergoing VSP vs conventional fibular free flap reconstruction for mandibular defects (12/2015-10/2020) and their operative time, ischemia time, and LOS were evaluated.

RESULTS

Forty-four patients underwent VSP reconstruction, while 52 patients underwent conventional reconstruction for mandibular defects. VSP was associated with significantly lower total operative time (6 h and 57 mins vs 7 h and 54 mins, p = 0.011), but not length of stay or ischemia time. Total OR time was significantly increased with increasing number of segments needed in both the VSP group (p = 0.002) and the conventional group (p = 0.015).

CONCLUSION

Shorter operative times and LOS have been attributed to the use of VSP in free tissue transfers. It is argued that these reductions offset the added cost of VSP. Our study indicates that there is no cost benefit for VSP utilization due to a significantly reduced operative time with no impact on length of admission in an abbreviated admission clinical pathway following free tissue transfer.

Vallecular cyst causing sleep-disordered breathing in an older child

Consensus-based recommendations are needed to better guide paediatric otolaryngologists in providing standardised care to children with sleep-disordered breathing (SDB). Here we present a unique case of vallecular cyst found during SDB workup in a patient in their middle childhood (6-12 years old). While the patient underwent successful cyst resection, he was noted to have a suspected recurrence 6 months later. Immediately prior to revision excision, repeat awake flexible fibre-optic laryngoscopy revealed complete resolution of the suspected recurrence. This case underscores the significance of performing a complete upper airway examination, including endoscopic examination, to identify structural and anatomical lesions in older children with SDB.

Appraisal of clinical practice guidelines for salivary gland cancer management utilizing AGREE II instrument

OBJECTIVE

Salivary gland cancers (SGC) are rare neoplasms which comprise 1-5 % of all head and neck cancers. SGCs can be managed by resection, radiosurgery, chemotherapy, or a combination of these. Our team appraised the quality of clinical practice guidelines (CPGs) for SGC treatment and management using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument.

DATA SOURCES

PubMed, Scopus, & EMBASE were reviewed for CPGs regarding SGC management from database inception to January 1st, 2023.

REVIEW METHODS

The AGREE-II instrument was used by 4 reviewers to independently evaluate guidelines. Domain scores were generated with a satisfactory threshold being >60 % - a "high" quality CPG required >4 satisfactory domains. Intraclass correlation coefficients (ICCs) were used, via R 4.2.1., to determine inter-reviewer variability.

RESULTS

Literature review identified 645 articles, with six being included after applying inclusion and exclusion criteria. Of the six included articles, one CPG was "high" quality and 5 were "low" quality. The domains with the highest scores were "Editorial Independence" (72.57 ± 36.60) and "Clarity and Presentation" (63.19 ± 26.08), while the lowest were "Rigor of Development" (34.03 ± 30.63) and "Applicability" (30.21 ± 30.46). ICC scores for each domain ranged from 0.937 to 0.983, indicating a high level of inter-rater agreement.

CONCLUSION

This study found that most CPGs for the treatment and management of SGC were of "low" quality, with only one guideline being considered "high" quality based on the standard set by the AGREE-II instrument. These findings indicate that there is a high level of variability and little standardization when it comes to the quality of CPGs.

Surgical site antiseptic preparations for otolaryngology - Head and neck surgery: A current review

OBJECTIVE

To review current literature and guidelines on antiseptic surgical site preparations for preventing surgical site infections with consideration of contraindications specific to head and neck surgery.

DATA SOURCES

PubMed/MEDLINE, clinicaltrials.gov, accessdata.fda.gov, Manufacturer websites.

REVIEW METHODS

A scoping review on the literature and clinical studies comparing the efficacy of different surgical site preparations. Studies were included if they were a randomized controlled trial (RCT) comparing at least two commonly used and available antiseptic preparations. Additionally, a compilation of warnings and contraindications from manufacturer labels and articles are included. Due to the lack of randomized controlled trials concerning antiseptic preparation use in head and neck surgery specifically, an additional search was executed for articles not limited to randomized controlled trials that compared different antiseptic preparation used in surgeries concerning the head and neck.

RESULTS

Of 56,983 resulting abstracts and 3798 of them being screened, 25 RCTs were included. These RCTs included a variety of surgeries including gastrointestinal, obstetric, gynecologic, orthopedic, and vascular procedures. When searching for abstracts concerning head and neck surgeries, 9 studies were found and included.

CONCLUSIONS

To reduce surgical site infections and avoid application in situations with contraindications, practicing surgeons need to be familiar with the existing literature regarding different surgical preparations and what warnings manufacturers have listed on the products. Optimal surgical site preparation for head and neck surgery is challenging as proximity to oxygen contraindicates newer alcohol-based options that are potentially flammable. We summarize evidence-based surgical site preparation for head and neck surgery.

Trans-nasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) and its Utility in Otolaryngology, Head and Neck Surgery: A Literature Review

High-flow nasal oxygen (HFNO) therapy is extensively used in critical care units for spontaneously breathing patients. Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a method of apnoeic oxygenation with continuous nasal delivery of warmed, humidified oxygen at high-flow rates up to 70L/min. THRIVE extends the apnoeic window before desaturation occurs so that tubeless anaesthesia is possible. The advent of THRIVE has had a monumental impact on anaesthetic practice, with a diverse range of clinical applications and it has been incorporated into difficult airway guidelines. THRIVE has many applications in otolaryngology and head and neck surgery. It is used as a pre-oxygenation tool during induction in both anticipated and unanticipated difficult airway scenarios and as a method of oxygenation for tubeless anaesthesia in elective laryngotracheal and hypopharyngeal surgeries and during emergence from anaesthesia. In this scoping review of the literature, we aim to provide an overview on the utility of THRIVE in otolaryngology, including the underlying physiologic principles, current indications and limitations, and its feasibility and safety in different surgical contexts and specific population groups.

Reconstruction of an obliterated Eustachian tube: transnasal lighted guidewire catheter stenting

An obliterated Eustachian tube (ET) is a rare occurrence that can lead to chronic otitis media (OM) and aural fullness even with treatment. Our study presents a review of the literature on methods of stenting the ET. We additionally present a case of a man with mucoepidermoid carcinoma of the ET who underwent a radical nasal pharyngectomy with reconstruction and adjuvant radiation, and who had symptoms of intolerable otorrhea after tympanostomy tube placement to treat aural fullness and mucoid OM. We used a novel method of stenting the ET using a transnasal lighted guidewire catheter and steroid eluting stents placed along the entire medial ET. Previously described methods in the literature were unable to be used due to the complex middle ear anatomy filled with granulation tissue and the lack of a visible nasopharyngeal ET ostium available for straightforward placement of the stent. The procedure was successful, and postoperatively, the patient experienced decreased otorrhea.

Descending necrotising mediastinitis: a rare entity in children

We present a case of descending necrotising mediastinitis (DNM) originating from a retropharyngeal abscess in a healthy early childhood patient. The patient had a history of fever, odynophagia and refusal to eat, followed by rapid deterioration of the clinical state. Cervicothoracic CT was performed, which revealed a right parapharyngeal abscess, extending to the mediastinum and occupying the retropharyngeal/visceral space, with gaseous content throughout this collection, associated with bilateral pleural effusion, aspects compatible with DNM. She started broad-spectrum antibiotic therapy and transoral drainage of the parapharyngeal and retropharyngeal collections was performed under general anaesthesia. She was admitted to the intensive care unit. The patient showed clinical, analytical and imaging improvement, having been transferred to the ear, nose and throat department, with favourable evolution. Early diagnosis of DNM by cervicothoracic CT and multidisciplinary approaches, including intensive care, broad-spectrum antibiotics and surgical intervention, are crucial to minimise the morbidity and mortality.

Acute cervical spinal cord injury after head and neck surgery: A CARE case report

OBJECTIVE

To describe and analyze a case of acute spinal cord injury after head and neck surgery.

DESCRIPTION

One hour after left lobo-isthmectomy under laryngeal neuromonitoring for a 3-cm EU-TIRADS 4 - Bethesda 4 thyroid nodule in a 48-year-old euthyroid male without any known comorbidity, left hemiparesis occurred. Cervical spine MRI showed an anteromedial herniated C6-7 disk with medullary compression. The disk was resected, compression was released and C6-7 fusion was performed via an anterior cervical approach on postoperative day 1. Postoperative course was unremarkable, with complete recovery of motion within 2 days. One month later, neurological clinical examination was normal and interview revealed left cervicalgia with onset a few days prior to lobo-isthmectomy. One year later, at the time of writing, the patient was doing fine.

CONCLUSION

Otorhinolaryngologists and head and neck surgeons must be aware of the risk of acute cervical spinal injury after cervical mobilization in head and neck surgery, and should take all measures to avoid this exceptional but dramatic complication.

Rare encounter: facial vein thrombosis and thrombophlebitis as a complication of acute submandibular sialadenitis

Thrombosis and thrombophlebitis of the facial vein represent exceptionally rare diagnoses, particularly when occurring as complications of acute sialadenitis of the submandibular gland. This case report details the experience of a middle-aged man initially presenting at a tertiary care ear, nose and throat department with right submandibular gland sialadenitis. Despite initiating outpatient treatment involving oral antibiotics and sialagogues, the patient returned after a week with persistent and worsening pain, accompanied by swelling of the right submandibular gland and cheek. Using ultrasound, the accurate diagnosis was promptly identified, revealing thrombosis in the facial vein.The patient underwent a comprehensive treatment regimen involving anticoagulation and intravenous antibiotics. With a subsequent reduction in pain and swelling, the patient was discharged, continuing oral anticoagulation and antibiotics. Outpatient follow-up revealed a complete recovery 3 weeks later. This case underscores the importance of timely and precise diagnostic measures in managing rare complications associated with sialadenitis.

Tunnelised superiorly based preauricular flap and conchal cartilage graft for antihelix reconstruction

Reconstruction of a full-thickness defect of the auricle's anterior surface represents a challenge for plastic surgeons. This report describes the case of a man in his 70s, who underwent radical excision of a squamous cell carcinoma involving his right antihelix. We adopted an innovative approach for the reconstruction of the antihelix, using a tunnelled preauricular flap reinforced with an ipsilateral concha cartilage graft. The flap's base was de-epithelialised, allowing a single-stage procedure. Three months postoperation, no complications arose, and the scars at the donor site were effectively concealed. The aesthetic result was excellent, thanks to the perfect colour match, symmetry, shape of the auricle and the long-lasting integrity of the antihelical structure.This technique allows for accurate reconstruction of the convoluted surface of the auricle in cases of full-thickness defects of the antihelix, without the need to harvest cartilage from other donor sites and in a single surgical procedure.

Perplexing First Branchialcleft Anomalies-A Case Series with Review of Literature

Incomplete obliteration of the branchial apparatus results in the formation of branchial cleft anomalies. First branchial cleft anomalies may persist anywhere in the first branchial arch, from the external auditory canal at the level of the bony cartilaginous junction to the submandibular triangle. The majority of cases present in childhood as an opening in the skin though they may present as cysts or neck masses, mostly mistaken for neck abscesses which leads to inadequate treatment and complications. Here different cases of first branchial cleft anomalies with variable presentation and treatment are illustrated. The need for proper diagnosis and adequate treatment cannot be overemphasized to avoid mismanagement and complications.

Renal cell carcinoma (RCC) spreading to the larynx: an unusual condition

A man in his mid-70s, heavy smoker with chronic alcohol consumption and a chronic exposure to insecticides and burning of crop residues was referred to the surgical oncology department because of a 4-month onset of hoarseness, dyspnoea and laryngeal stridor. He had a history of left nephrectomy due to Fuhrman IV clear cell renal cancer 2 years ago. The patient underwent a bronchoscopy which identified a deforming tumour of the left vallecula, occlusion of 90% of the lumen and did not allow a safe biopsy. Following discussion between the oncological team, total laryngectomy and bilateral neck dissection of levels II, III, IV and V were performed, finding a transglottic tumour of approximately 4×3 cm with extension to the right anterolateral thyroid cartilage. The pathology report described metastatic RCC. The patient recovered well postoperatively and started systemic therapy with a vascular endothelial growth factor receptors inhibitor.

Therapeutic challenges in small cell carcinoma of the larynx

Primary small cell neuroendocrine carcinoma (SCNC) of the larynx is a rare subtype of laryngeal cancer, accounting for less than 1% of all laryngeal tumours. It most commonly affects smokers in their fifth to sixth decade of life and is characterised by a high incidence of advanced disease at presentation and an aggressive clinical course. Here we present a case of SCNC of the larynx, presenting initially with dysphonia, and an associated literature review collating current knowledge regarding therapeutic approaches. After review of 260 cases in the literature we determined a disease-specific survival of 33.1%. Combined chemoradiotherapy is currently the recommended first-line treatment option.

Epithelial myoepithelial carcinoma of the parotid gland with high-grade transformation

A woman presented with a painless swelling in front of her right auricle, which, on examination, seemed to be a hard, immobile mass arising from the right parotid gland. CT scan showed a heterogeneously enhancing mass lesion in the superficial lobe of the parotid gland with partial extension into the deep lobe. Fine needle aspiration cytology suggested a high-grade transformation (HGT) with the presence of bizarre tumour cells. She underwent a right-sided total parotidectomy with transient facial neuropraxia in the postoperative period. The final pathological diagnosis of the specimen came out to be epithelial myoepithelial carcinoma with HGT, which is a relatively rare entity, with no defined guidelines for management. Our patient was managed by surgical resection alone without any postoperative radiation therapy, and short-term follow-up results seem to suggest no recurrence.

Very rare tumour of the palatine tonsil: a molecular approach

Mucoepidermoid cancer (MEC) is extremely rare in the palatine tonsil with only three adequately described cases in the literature.We describe a woman in her late 70s with vague pharyngeal discomfort who underwent tonsillectomy, lymph node dissection of the neck and radiotherapy for MEC with loco-regional lymph node metastasis of the palatine tonsil. To confirm this extremely rare diagnosis and to gain deeper insight in the molecular oncogenesis, an extensive molecular study including next-generation sequencing and immunohistochemistry was performed. Immunoreactivity for p16 protein and real-time PCR showed high-risk oncogenic human papillomavirus 16 DNA and mutations in the BRAF, BARD and DNMT3A genes. Tumour mutational burden was low. After a follow-up of 7 years the patient is still alive and well without any residual or disseminated disease.

Colloid nodular goitre associated with hemiagenesis of the thyroid gland

Hemiagenesis of the thyroid gland is a rare congenital abnormality usually left unnoticed without associated thyroid disorders. The most common congenital anomaly of the thyroid gland is a thyroglossal cyst, followed by ectopic thyroid tissue and thyroid dysgenesis, which may be agenesis or hemiagenesis. Preoperative underevaluation of the thyroid hemiagenesis (THA) associated with other thyroid disorders may cause intraoperative difficulty in identifying the gland and difficulty in preservation or even identification of major neurovascular structures during neck exploration. We report a patient who presented to us with right-sided neck swelling. On further evaluation and neck exploration, the patient was diagnosed with THA of the left lobe with right colloid goitre.

Chronic heart failure in patients undergoing major head and neck surgery: A hospital-based study

OBJECTIVE

To investigate the effects of chronic heart failure on various post-operative outcomes in head and neck cancer patients undergoing major cancer surgery.

STUDY DESIGN

For this retrospective cohort study of patients undergoing major head and neck cancer surgery, a sample of 10,002 patients between 2017 and 2019 were identified through the Nationwide Inpatient Sample.

SETTING

Patients were selected as undergoing major head and neck cancer surgery, defined as laryngectomy, pharyngectomy, glossectomy, neck dissection, mandibulectomy, and maxillectomy, then separated based on pre-surgical diagnosis of chronic heart failure.

METHODS

The effects of pre-operative chronic heart failure on post-surgical outcomes in these patients were investigated by univariable and multivariable logistic regression using ICD-10 codes and SPSS.

RESULTS

A diagnosis of chronic heart failure was observed in 265 patients (2.6 %). Patients with chronic heart failure had more preexisting comorbidities when compared to patients without chronic heart failure (mean ± SD; 4 ± 1 vs. 2 ± 1). Multivariable logistic regression showed that chronic heart failure patients had significantly greater odds of dying during hospitalization (OR 2.86, 95 % CI 1.38-5.91) and experiencing non-routine discharge from admission (OR 1.89, 95 % CI 1.41-2.54) after undergoing major head and neck cancer surgery.

CONCLUSION

Chronic heart failure is associated with greater length of stay and hospital charges among head and neck cancer patients undergoing major head and neck cancer surgeries. Chronic heart failure patients have significantly greater rates of unfavorable post-operative outcomes, including death during hospitalization and non-routine discharge from admission.

Point Cloud Registration for Measuring Shape Dependence of Soft Tissue Deformation by Digital Twins in Head and Neck Surgery

Introduction

A 2½ D point cloud registration method was developed to generate digital twins of different tissue shapes and resection cavities by applying a machine learning (ML) approach. This demonstrates the feasibility of quantifying soft tissue shifts.

Methods

An ML model was trained using simulated surface scan data obtained from tumor resections in a pig head cadaver model. It hereby uses 438 2½ D scans of the tissue surface. Tissue shift was induced by a temperature change from 7.91 ± 4.1°C to 36.37 ± 1.28°C.

Results

Digital twins were generated from various branched and compact resection cavities (RCs) and cut tissues (CT). A temperature increase induced a tissue shift with a significant volume increase of 6 mL and 2 mL in branched and compact RCs, respectively (p = 0.0443; 0.0157). The volumes of branched and compact CT were decreased by 3 and 4 mL (p < 0.001). In the warm state, RC and CT no longer fit together because of the significant tissue deformation. Although not significant, the compact RC showed a greater tissue deformation of 1 μL than the branched RC with 0.5 μL induced by the temperature change (p = 0.7874). The branched and compact CT forms responded almost equally to changes in temperature (p = 0.1461).

Conclusions

The simulation experiment of induced soft tissue deformation using digital twins based on 2½ D point cloud models proved that our method helps to quantify shape-dependent tissue shifts.

Auricular leishmaniasis mimicking squamous cell carcinoma of the pinna

Cutaneous leishmaniasis can occur on any exposed area of the body; however, the pinna is an exceptionally rare site for the disease. Caused by the parasite Leishmania, cutaneous leishmaniasis has a wide range of presentations and thus is very easy to misdiagnose or mistake for a neoplastic lesion. Here, we report the case of a middle-aged male patient presenting with a painful, ulcerated lesion on the left auricle initially suspected to be a malignancy with histopathology eventually revealing a diagnosis of auricular leishmaniasis. The patient received appropriate therapy and was found to be disease free at follow-up. These isolated lesions of the pinna often resemble neoplastic lesions and thus may escape diagnosis for months at a time, increasing patient stress as well as expenditure. In addition, prompt recognition may also help mitigate recurrence of the disease, making it worthwhile to include cutaneous leishmaniasis as part of the differential, especially in endemic areas.

Modified intraoperative temperature management prevents prolonged length of stay after head and neck surgery with free flap reconstruction

The present study aimed to investigate the association between intraoperative body temperature and prolonged length of stay (PLOS) after free flap reconstruction. A total of 753 patients who underwent head and neck surgery with free flap reconstruction were collected and randomly assigned into primary and validation cohorts. In the primary cohort, univariable and multivariable analyses were conducted to evaluate associations between intraoperative time-weighted (TW) temperature (TW average [TWA] temperature, TW hypothermia and TW hyperthermia) and PLOS. Nomograms were developed with and without intraoperative TW temperature, and validated in the validation cohort. Severe intraoperative TW hypothermia (OR = 1.004; 95% CI: 1.000, 1.007; p = 0.032) was identified as an independent risk factor for PLOS. Intraoperative TWA temperature and TW hypothermia showed linear related predictive effect for PLOS. The nomogram incorporating intraoperative TW temperature showed higher C-index (0.652, 95% CI: 0.591, 0.713) and improved net reclassification improvement for non-event (0.277, 95% CI: 0.118, 0.435; p < 0.001). Lower TWA temperature with mild TW hypothermia had a preventive effect on PLOS with a linear association, which may provide a modified range for intraoperative temperature management. The proposed nomogram incorporating intraoperative TW temperature could be used to develop personalized preventive strategies for PLOS after free flap reconstruction. IRB NUMBER: SYSEC-KY-KS-2022-037. CLINICAL TRIAL REGISTRATION NUMBER: Not applicable.

Percutaneous tracheostomy in the surgical management of oral malignancy: an emerging standard of care

Percutaneous tracheostomy insertion is commonly performed in the critical care setting. However, its applicability and safety in head and neck (H&N) surgery remains uncertain. This study aimed to compare complications and postoperative recovery for percutaneous tracheostomy versus surgical tracheostomy in H&N surgery. A total of 66 patients undergoing percutaneous tracheostomy as part of H&N microvascular surgery were identified retrospectively. A control cohort of 70 consecutive surgical tracheostomy cases performed by another surgical team in the same department was similarly determined. Generally, the complication rates in the percutaneous and surgical tracheostomy groups were similar, with overall rates being 42% and 31%, respectively. The percutaneous group experienced a higher rate of airway obstruction (15%), primarily due to tube displacement. Time to decannulation and duration of inpatient stay were similar in both groups. Notably, an analysis of tracheostomy tube displacement identified high body mass index (BMI) and bilateral neck dissection as potential risk factors, and all cases occurred on postoperative day one. To mitigate this risk we recommend implementation of a percutaneous tracheostomy management protocol, precise tube selection using preoperative imaging, and careful passage of the stoma intraoperatively. In conclusion, this study found that the percutaneous technique exhibited a similar complication profile. It remains unclear whether the rates of longer-term complications, such as delayed stoma healing and tracheal stenosis, differ between techniques. A future prospective study with appropriate elimination of selection and reporting bias would help address this and similar pertinent issues, including patients' perspectives.

IgG4-related disease of the mastoid: a rare presentation of a novel diagnosis

IgG4-related disease (IgG4-RD) is an inflammatory condition characterised by infiltration of tissue by IgG4-positive plasma cells. This is the seventh reported case of IgG4-RD affecting the mastoid and informs clinicians in diagnosing patients affected by this rare condition.A woman in her 20s presented with unilateral otalgia, hearing loss and vertigo. She deteriorated despite antibiotic therapy and cross-sectional imaging revealed a destructive extra-axial lesion of the mastoid cells. Biopsy confirmed a diagnosis of IgG4-RD. She was successfully treated with prednisolone and azathioprine.Inflammatory conditions should be considered in patients with persistent middle ear symptoms after infection and malignancy are excluded. Delays in diagnosis can lead to irreversible mass effects and may occur as current diagnostic criteria exclude mastoid-specific features.IgG4-RD remains a rare diagnosis. To avoid significant effects on a patients' quality of life, prompt multidisciplinary treatment is vital alongside development of diagnostic criteria specific to otolaryngology.

Lost and found: foreign body in submandibular gland

A young adult male patient presented with the history of a retained foreign body in the oral cavity. The object in question was a stapler pin that got accidentally lodged while the patient tried removing food particles from his mouth 28 days earlier. Aside from intermittent pain upon digital palpation on the right side of the floor of his mouth, he was asymptomatic. Clinical examination was unremarkable. Plain radiography and a computed tomogram revealed a linear foreign body in the right submandibular gland. The patient underwent a submandibular gland excision, during which a 2 cm long stapler pin was retrieved. This case highlights that not all foreign bodies cause inflammatory reactions as a telltale sign of their presence.

Challenging management of an enlarged tracheoesophageal fistula in an irradiated patient

Speech restoration after total laryngectomy may be achieved in different ways, the gold standard being tracheoesophageal puncture (TPE) with the positioning of a speech prosthesis. TPE is not immune to complications, the most common of which being leakage through or around the prosthesis. When dealing with an enlarged tracheoesophageal fistula, the management can be either conservative or surgical. In the following case report, we present a particularly challenging case, in which every conservative strategies failed and a major surgery was required to close the fistula.

Minimally invasive fenestration for decompression of C2-C3 spinal stenosis

Conventional techniques in neurosurgery such as laminectomy have been extensively displaced by minimally invasive types, owing to the character of complexity of cervical spinal region. Spinal canal stenosis at C2-C3 level is documented in the literature with the majority being caused by intervertebral disc herniations.This case reports a patient who presented with classical myelopathy symptoms and significant thickening of ligamentum flavum, while minimal spondylosis was detected at C2-C3 level. The decompression was performed from posterior approach and limited to the removal of ligamentum flavum with minimal resection of adjacent laminae, no fixation and no disc evacuation. After surgery, there was a significant improvement with preserved spinal stability.Although the anterior approach is more common for cervical spine, universal access site has not been defined in literature. We suggest that minimal decompression produces desirable effects with no need for fusion and preserving adequate stability of spinal complex.

Assessing the accuracy of ChatGPT references in head and neck and ENT disciplines

PURPOSE

ChatGPT has gained popularity as a web application since its release in 2022. While artificial intelligence (AI) systems' potential in scientific writing is widely discussed, their reliability in reviewing literature and providing accurate references remains unexplored. This study examines the reliability of references generated by ChatGPT language models in the Head and Neck field.

METHODS

Twenty clinical questions were generated across different Head and Neck disciplines, to prompt ChatGPT versions 3.5 and 4.0 to produce texts on the assigned topics. The generated references were categorized as "true," "erroneous," or "inexistent" based on congruence with existing records in scientific databases.

RESULTS

ChatGPT 4.0 outperformed version 3.5 in terms of reference reliability. However, both versions displayed a tendency to provide erroneous/non-existent references.

CONCLUSIONS

It is crucial to address this challenge to maintain the reliability of scientific literature. Journals and institutions should establish strategies and good-practice principles in the evolving landscape of AI-assisted scientific writing.

A 5-year experience with midline catheters in the management of major head and neck surgery patients

BACKGROUND

In the perioperative management of major head and neck surgery (HNS) patients, the performance of midline catheters (MCs) has been never tested. We present here our 5-year experience by reporting MC-related complications and by identifying the preoperative risk factors associated with their development.

METHODS

Clinical variables were extracted and the dwell time, the number, and the type of postprocedural complications of MCs were retrieved. Complications were classified into major (needing MCs removal and including catheter-related bloodstream infection or deep vein thrombosis or catheter occlusion) and into minor (accidental dislodgement, leaking, etc.). Descriptive statistics and logistic regression models were used in order to identify the predictors of complications.

RESULTS

A total of 265 patients were included, with a mean age of 67.4 years. Intraprocedural complications occurred in 1.1% of cases, while postprocedural complications occurred in 13.9% of cases (12.05/1000 days), but they were minor in more than 7.0% (5.4/1000 catheter-days). There were 19 minor complications (7.1% or 5.4/1000 catheter-days) while 18 (7%, 5.1/1000 catheter-days) patients experienced at least one major complication. Female sex (OR = 1.963, 95% CI 1.017-3.792), insertion in the right arm (OR = 2.473, 95% CI 1.150-5.318), and an ACE-27 score >1 (OR = 2.573, 95% CI 1.295-5.110) were independent predictors of major complications.

CONCLUSIONS

MCs appear to represent an effective option in the setting of major HNS. The identification of patients most at risk for MC-related complications should prompt a postoperative watchful evaluation.

Predictors of opioid requirement among patients receiving free flap reconstruction to the head and neck

BACKGROUND

Opioids are a part of standard of care treatment of acute, severe postoperative pain. However, increased opioid requirements have been shown to be associated with increased postoperative complications, morbidity, and mortality. The aim of this study was to identify potential predictive factors associated with increased or decreased opioid requirements after free tissue transfer (FTT) to the head and neck.

MATERIALS/METHODS

A retrospective review was conducted on subjects who underwent head and neck reconstruction (HNR) from 2015 to 2021 at a single tertiary care center. Patients with inpatient stay over 10 days and those receiving fentanyl for sedation purposes were excluded due to EMR limitations and confounding, respectively. The total dose of opioid medication each patient received was calculated and summed using morphine milligram equivalents (MME). Statistical analysis was conducted using poisson regression and multivariable regression models.

RESULTS

Two hundred and ninety-one patients were included. The mean opioid requirement for all subjects was 228.6 (SD 250.0) MMEs during their entire postoperative stay and the mean length of stay was 6.0 (SD 1.7) days. An established opioid prescription prior to surgical resection was the greatest predictor of increased risk for opioid requirement according univariate and multivariate analysis 2.356 (2.321-2.392), p ≤ 0.0001 and 1.833 (1.802-1.863), p ≤ 0.0001, respectively. Fibula transfers were associated with higher opioid requirements while scapula transfers were associated with decreased opioid requirements compared to other free tissue transfer types.

CONCLUSION

Preoperative opioid use was associated with higher postoperative opioid requirements. Multimodal pain management (MMPM) was not associated with a decreased opioid requirement; however, further studies are needed to investigate the hierarchy, dosing, and timing of MMPM in relation to opioid requirements and pain control.

ChatGPT in head and neck scientific writing: A precautionary anecdote

PURPOSE

To evaluate the accuracy of ChatGPT references in scientific writing relevant to head and neck surgery.

MATERIALS AND METHODS

Five commonly researched keywords relevant to head and neck surgery were selected (osteoradionecrosis of the jaws, oral cancer, adjuvant therapy for oral cancer, TORS, and free flap reconstruction in oral cancer). The AI chatbot was then asked to provide ten complete citations for each of the keywords. Two independent authors reviewed the results for accuracy and assigned each article a numerical score based on pre-selected criteria.

RESULTS

Among 50 total references provided by ChatGPT, only five (10 %) were found to have the correct title, journal, authors, year of publication, and DOI. Merely 14 % of the presented references had correct DOI. References regarding free flap reconstruction for oral cancer were the least accurate from all the five categories, with no correct DOI. Complete inter-rater agreement was noted while evaluating the citations.

CONCLUSION

Only 10 % of the articles provided by ChatGPT, relevant to head and neck surgery, were correct. A high degree of academic hallucination was noted.

Displaced transverse laryngeal fracture from attempted hanging

Laryngeal fractures are life-threatening injuries, frequently associated with long-term morbidity. We present a case of a man sustaining a displaced laryngeal fracture and rupture of supraglottic structures following attempted suicide by hanging from a bridge. His injuries included a tear of the thyrohyoid membrane, avulsed epiglottis and complete autopharyngotomy. All laryngeal functions were significantly impaired. Early tracheostomy, careful surgical repair, extensive multidisciplinary team (MDT) input and intensive rehabilitation all contributed towards a successful recovery. By 7 months following the initial injury, the patient had achieved excellent breathing and voicing, and a safe and competent swallow despite the extent of his initial injuries. This case demonstrates the importance of early airway management in laryngeal trauma and the role of surgical management in conjunction with swallow rehabilitation. Fundamentally, an MDT approach is essential for the holistic management of patients with laryngeal trauma.

Endovascular repair of radial artery non-anastomotic pseudoaneurysm in a radial forearm free flap

The development of pseudoaneurysm is an uncommon, life-threatening complication of head and neck microvascular surgery. Only a handful of reports have been published describing microvascular pseudoaneurysms, which usually occur at the arterial anastomosis and present as a pulsatile neck mass or as haemorrhage in case of pseudoaneurysm rupture. Management is highly variable, especially in the acute setting. In patients with pseudoaneurysm where flap inosculation is inadequate, endovascular approaches may be appropriate. In this report, we describe a ruptured distal pedicle pseudoaneurysm of a radial forearm free flap salvaged with a flow-diverting stent with complete flap survival and pedicle preservation. We demonstrate further evidence and feasibility of endovascular treatment of a non-anastomotic pseudoaneurysm arising from small vessels when parent vascular integrity is critical to flap survival.

Severe unprovoked hypertrophic obstructive cardiomyopathy: anaesthetic concerns in patient undergoing parathyroidectomy

This case highlights the role of an anaesthetist as a perioperative physician involved in diagnosing and optimising asymptomatic but severe hypertrophic obstructive cardiomyopathy. The modifications in anaesthetic technique for safe conduct of general anaesthesia during parathyroidectomy in a patient are also presented. These include those due to an extremely high left ventricular outflow tract obstruction with echocardiographic Doppler-derived maximum pressure gradient of 105 mm Hg at rest.

Coexistence of Rosai-Dorfman disease and Hodgkin's lymphoma in a patient with cervical lymphadenopathy

A man in his 40s, with no tobacco or alcohol habit, was referred to the otorhinolaryngology department presenting with a 2-month history of enlarged left cervical lymphadenopathy with no other signs or symptoms. The ear, nose and throat examination showed no abnormalities apart from the described lymphadenopathy. An ultrasound scan suggested these nodes to be part of either an inflammatory or a malignant process. Subsequent positron emission tomography-CT proved those lymph nodes to be metabolically active, as well as others within the thorax. Cervicotomy was performed and the histopathological analysis showed dilated sinuses and histiocytes with emperipolesis. Suspecting Rosai-Dorfman disease (RDD), high-dose steroid therapy was started; but given no improvement was observed, a second cervicotomy was performed, with the histopathological diagnosis of the latter of Hodgkin's lymphoma. The present article aims to emphasise the need to exclude haematological disorders whenever RDD histology is observed, given their possible coexistence, and a worse outcome and clinical and histopathological semblance.

Preoperative flurbiprofen diminishes the rate of reoperation after free flap reconstruction: A retrospective study

This study aimed to evaluate the association between preoperative flurbiprofen, a non-selective COX inhibitor, and reoperation for flap crisis after free flap reconstruction. In this retrospective study, patients who underwent head and neck surgery with free flap reconstructions were collected. To identify risk factors for reoperation from demographic features and perioperative variables, univariate and multivariate logistic analyses were conducted. After propensity score matching (PSM), univariate and adjusted multivariate analyses were employed to explore the impact of preoperative flurbiprofen on reoperation after free flap reconstruction. This study comprised 437 patients, 33 of whom underwent reoperations for flap crisis. After multivariate analysis, radiotherapy history (P = 0.005; odds ratio [OR] = 0.225; 95% CI, 0.080-0.636) and preoperative flurbiprofen (P = 0.038; OR = 5.059; 95% CI, 1.094-23.386) were identified as independent factors for reoperation. PSM was achieved, and preoperative flurbiprofen was found to diminish the reoperation rate (P = 0.046; OR = 4.765; 95% CI, 1.029-22.202) without increasing bleeding complications. Within the limitations of the study, flurbiprofen should be administered preoperatively to reduce the rate of reoperations for flap crisis whenever appropriate.

Transoral Robotic Excision of Paediatric Lingual Thyroglossal Duct Cyst

Lingual thyroglossal duct cyst (TGDC) is a rare variant of TGDC that emerges within the tongue base. It presents a unique surgical challenge. There are different approaches to managing this condition. Transoral robotic surgery (TORS) has been successfully used for lesions of the tongue base in adults. This report presents a 7 year old boy with a cystic lesion in the base of tongue, which was diagnosed to be a lingual TGDC. The cyst was excised transorally using Da Vinci Robotic system. The surgery was performed in a short operating time with no complications or recurrence on follow up. TORS is an effective and reliable method of excision of lingual TGDC in the paediatric population. Lingual TGDC can be managed by simple excision of the cyst without excision of hyoid bone. Further studies are needed to confirm the safety and recurrence rates of this technique in paediatric population.

Submandibular nodal schwannoma: where did it come from?

SummarySchwannoma, a type of benign neurological tumour arising from Schwann cells, is commonly seen in the head and neck region. However, the incidence of cervical lymph node schwannoma is extremely rare, with only two cases reported in the literature. Schwannomatosis is a disease characterised by a constellation of multiple schwannomas seen in a patient, guided by at least one confirmational histological diagnosis. This is a case of a painless progressively enlarging submandibular swelling which is confirmed as a schwannoma based on histology. The patient is also diagnosed with schwannomatosis as the patient has multiple neurological tumours. Nodal schwannoma has a good prognosis and no documentation of recurrence in the literature. It may arise from sympathetic nerves located within the lymph node.

Kimura disease of naso-orbito-ethmoid region and review of surgical approaches to naso-orbito-ethmoid region

SummaryA man in 30s had complaints of glabellar and upper nasal swelling for 8 years. It was insidious in onset and gradually progressive causing epiphora and restriction of nasal visual field. Fine-needle aspiration cytology and biopsy revealed features which were suggestive of Kimura's disease (KD). CT scans showed a well-defined subcutaneous swelling in the naso-orbito-ethmoid (NOE) region. KD presents as lymphoglandular swelling; however, NOE region is an uncommon site of occurrence. A thyroid-shaped tumour was excised by H-shaped incision approach to the NOE region.

Construction of a system for head and neck tumor traceless resection with non-inflatable transaxillary total endoscopic surgery

Radical cure and functional preservation of tumors are the fundamental goals of surgical treatment of head and neck tumors, and the preservation of good aesthetics is a higher pursuit on this basis. Fully hiding the surgical incision and reducing the visibility of scars are important goals of cosmetic surgery. Using complete endoscopy for the head and neck is an effective method. CO₂-free transaxillary total endoscopic surgery is a method with many advantages, which has been widely used in the resection of thyroid tumors, but for other parts and types of tumors in the head and neck, this surgical method is rarely used. The research team expanded its application scope and applied it to submandibular gland tumor resection and other head and neck surgeries for the first time. Through this exploration, it improved traction devices such as retractors, strictly limited the surgical indications, analyzed and summarized the key points, steps and methods of surgery, and built a treatment system for head and neck tumor surgery under complete endoscopy using the non-inflatable transaxillary approach. In this article, we introduce the system and select typical cases to share.

'Juvenile' nasal angiofibroma presenting in adulthood

Juvenile nasopharyngeal angiofibromas (JNAs) are rare hyper vascular, benign tumours typically demonstrating a locally aggressive growth pattern. The cardinal presenting symptoms are unilateral nasal obstruction and recurrent, spontaneous epistaxis. Cases outside the adolescent male population are exceedingly rare and present a diagnostic challenge. We present the case of a man in his 30s referred to our tertiary skull base centre, presenting with left nasal obstruction. Examination showed left nasopharyngeal fullness without a discrete mass. Cross-sectional imaging detailed a 2.5×2.1×1.3 cm mass localised to his left sphenoid sinus with bony erosion. Due to the suspicion of malignancy, multidisciplinary consensus was to perform a diagnostic excisional biopsy and this revealed a JNA. He remains clinically well and asymptomatic following surgery. This case highlights the potential for subtle symptomatology in the presentation of these tumours and the challenge in diagnosing a JNA outside the adolescent male population.

Chondrosarcoma of the hyoid bone: a case of mistaken identity in the submandibular region

We describe a case of woman in her 60s who presented with a painless mass in her left submandibular region that biopsies and imaging suggested was a pleomorphic adenoma. Intraoperative findings showed a submandibular mass originating from the hyoid bone, and subsequent histopathological examination showed a grade 2 chondrosarcoma of the hyoid bone. Chondrosarcomas in the head and neck region are uncommon and presentations in the hyoid bone are very rare with only approximately 27 previously published cases. Presentations that pose as more benign pathology can cause diagnostic dilemmas for clinicians.

Metastatic recurrence of lung adenocarcinoma in thyroid clinically masquerading as primary thyroid cancer and immunohistochemically positive for thyroglobulin

We report a case of a man in his 60s with metastatic lung adenocarcinoma in the thyroid and cervical lymph nodes. The lung cancer was resected 5 years prior to presentation. The metastasis mimicked primary thyroid cancer by clinical examination and CT. However, fine-needle aspiration cytology of the thyroid and the lymph node lesions favoured lung cancer metastasis rather than thyroid cancer. Left thyroid lobectomy and lymphadenectomy were performed. Pathology confirmed the presence of an adenocarcinoma in the thyroid and two lymph nodes, which was similar to the previous lung cancer. The tumour cells in the thyroid were immunohistochemically positive for TTF1 and thyroglobulin and negative for PAX8. This is the second reported case of metastatic lung cancer in the thyroid that was focally positive for thyroglobulin. This can be a pitfall in differentiating between primary thyroid tumour and metastatic lung adenocarcinoma by pathological and cytological examination.

Large congenital facial teratoma

This case report discusses a presentation of a giant facial teratoma, a rare congenital neoplasm. Head and neck locations of the tumour uncommonly distort the face and may be associated with functional problems. We present a case of teratoma arising from the right parotid extending to the extracranial regions, successfully managed by surgical resection. Reviewing this case with the supporting body of literature anticipates further investigation to address patients' needs more thoroughly.

Ventilation failure with elective tracheostomy during oral cancer surgery: a case of tracheal diverticulum

Tracheal diverticulum is usually detected incidentally. Rarely, it may lead to difficulty in securing the airway intraoperatively. Our patient underwent oncological resection under general anaesthesia for advanced oral cancer. Elective tracheostomy was performed at the end of the surgery, and a cuffed tracheostomy tube (T-tube) of 7.5 mm size was inserted through the tracheostoma. Despite repeated attempts at T-tube insertion, ventilation could not be established. However, on advancing the endotracheal tube beyond tracheostoma, ventilation was restored. The T-tube was inserted into the trachea under fibreoptic guidance achieving successful ventilation. A fibreoptic bronchoscopy through the tracheostoma performed after decannulation revealed a mucosalised diverticulum extending behind the posterior wall of the trachea. The bottom of the diverticulum showed mucosa-lined cartilaginous ridge with differentiation into smaller bronchiole-like structures. Tracheal diverticulum should be considered as a possible differential in case of failed ventilation following an otherwise uneventful tracheostomy.

Atraumatic intraoral buccal fat pad herniation in a neonate

An approximately 2-day-old neonate was brought with a fleshy intraoral mass and an inability to suckle adequately, without a preceding history of trauma. Contrast-enhanced CT revealed a fat density mass-like lesion occupying and partially filling the oral cavity. Following detection of a defect in the buccinator muscle with associated herniation of the buccal pad of fat into the mouth, a surgical approach was adopted to tackle the condition. Intraoperatively, the defects in the buccinator muscle and buccal mucosa were repaired after excision of the prolapsed fat pad. Age-appropriate feeding practices were initiated following surgery without residual anatomical or functional limitation. Early radiological diagnosis directing surgical intervention was helpful in management of a benign but functionally impeding lesion.

Thunderbeat®: a new step forward in transoral surgery-systematic review of literature and our experience

INTRODUCTION

Minimally invasive surgery is today the main challenge of ENT surgeons who aim to achieve oncological radicality with less aesthetic and functional impact. This is the basis for the widespread transoral surgical techniques, as the Thunderbeat^®.

OBJECTIVE

To date, the use of Thunderbeat^® in transoral surgery is still little known and widespread. So, this study analyzes, with a systematic review, current literature about the transoral use of Thunderbeat^® and shows our case studies.

METHODS

The research was carried out on Pubmed, Scopus, Web of Science and Cochrane databases using specific keywords. Then, a retrospective study was carried out on 10 patients who underwent transoral surgery by Thunderbeat^® in our ENT Clinic. Both in our cases and in the systematic review the following parameters have been evaluated: treated anatomical site and subsite, histological diagnosis, type of surgery, duration of nasogastric tube and hospitalization, post-operative complications, tracheostomy, resection margin status.

RESULTS

The review included 3 articles that described transoral use of Thunderbeat^® for a total of 31 patients suffering from oropharyngeal, hypopharyngeal and/or laryngeal carcinoma. Nasogastric tube was removed after 21.5 days on average, temporary tracheostomy was performed in 6 patients. The main complications were: bleeding (12.90%) and pharyngocutaneous fistula (29.03%). Thunderbeat^® shaft was 35 cm long and 5 mm large. Our case studies included 5 males and 5 females, mean age 64.4 ± 10.28, with oropharyngeal or supraglottic carcinoma, parapharyngeal pleomorphic adenoma and cavernous hemangioma of the tongue base. Temporary tracheostomy was performed in 8 patients. Free resection margins were achieved in all cases (100%). No peri-operative complications occurred. Nasogastric tube was removed after 5.3 ± 2 days on average. All patients were discharged without tracheal tube and NGT after 18.2 ± 4.72 days on average.

CONCLUSION

This study demonstrated that Thunderbeat^® has several advantages over other transoral surgical approaches, such as CO2 laser and robotic surgery, in terms of best combination of oncological and functional success, less post-operative complications and costs. So, it could represent a step forward in transoral surgery.

Functional outcomes of hyoid suspension in anterior oromandibular reconstruction

BACKGROUND

Hyoid suspension can be considered in major oromandibular reconstruction. The impact of hyoid suspension on flap viability, swallowing outcomes, airway, and long term radiographic hyoid position is unknown. The objective of this study is to describe outcomes after hyoid suspension in anterior mandibular reconstruction with fibular free flaps. We hypothesized hyoid suspension would not affect flap viability and would benefit functional outcomes.

METHODS

A retrospective cohort study was conducted in an academic tertiary medical center. The study consisted of 84 adults who underwent anterior mandibular reconstruction from February 2014 to September 2020. The primary outcome studied was the post-suspension flap viability. Secondary outcomes include pre/post-operative hyomental distance on computed-tomography, duration of perioperative tracheostomy, postoperative feeding tube dependence, and post-operative aspiration pneumonia.

RESULTS

A total of 84, predominantly male (66.5 %), patients with an average age of 58.9 ± 11.5 were included in the study. Of those that met inclusion criteria, 25 (29.4 %) underwent intraoperative hyoid suspension. Univariable analysis showed no significant association between resuspension and post-operative total flap loss (p = 0.864) or partial flap loss (p = 0.318). There was no association between hyoid suspension and any of the studied postoperative functional outcomes or radiographic measures.

CONCLUSIONS

Hyoid suspension is an option during oromandibular reconstruction and does not impact flap viability. The impact on functional outcomes and long-term hyoid position in this patient subset remains unclear.