Background
The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a novel technique that eliminates a cervical scar. This procedure carries unique risks, and data on outcomes are ...needed as more cases are performed.
Methods
We describe two cases of airway injury during the TOETVA. A description of the procedure and management of the injuries is outlined.
Results
In one case, a 3‐mm injury in the thyrohyoid membrane was identified. The TOETVA was converted to an open approach due to significant inflammation in the setting of Graves' and the repair was performed while open. In the second case, a fracture occurred from the thyroid notch to Broyle's ligament without avulsion. A primary repair was endoscopically performed.
Conclusions
Airway injury is a possible complication of both open thyroidectomy and TOETVA. For TOETVA, trauma is most likely to occur in the midline during Hegar dilation and trocar placement through the central incision.
The aim of this study was to report the safety, efficacy, and early results of tracheostomy in patients with COVID-19 and determine whether differences exist between percutaneous and open methods.
...Prolonged respiratory failure is common in symptomatic patients with COVID-19, the disease process caused by infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Tracheostomy, although posing potential risk to the operative team and other healthcare workers, may be beneficial for safe weaning of sedation and ventilator support. However, short- and long-term outcomes remain largely unknown.
A prospectively collected database of patients with COVID-19 undergoing tracheostomy at a major medical center in New York City between April 4 and April 30, 2020 was reviewed. The primary endpoint was need for continued mechanical ventilation. Secondary outcomes included complication rates, sedation weaning, and need for intensive care unit (ICU) level of care. Patient characteristics, perioperative conditions, and outcomes between percutaneous and open groups were analyzed.
During the study period, 67 consecutive patients underwent tracheostomy, including 48 males and 19 females with a median age of 66 years interquartile range (IQR) 52-72. Two surgeons alternated techniques, with 35 tracheostomies performed percutaneously and 32 via an open approach. The median time from intubation to tracheostomy was 23 days (IQR 20-26). At a median follow-up of 26 days, 52 patients (78%) no longer required mechanical ventilation and 58 patients (87%) were off continuous sedation. Five patients (7.5%) died of systemic causes. There were 11 total complications (16%) in 10 patients, most of which involved minor bleeding. There were no significant differences in outcomes between percutaneous and open methods.
Tracheostomy under apneic conditions by either percutaneous or open technique can be safely performed in patients with respiratory failure due to COVID-19. Tracheostomy facilitated weaning from continuous intravenous sedation and mechanical ventilation. Continued follow-up of these patients to ascertain long-term outcome data is ongoing.
We present the case of a patient with a recent history of ischemic stroke who presented with clicking larynx syndrome, a condition in which clicking noises in the larynx can be provoked by movement ...of the head and neck. Diagnostic imaging revealed unusual development and posterior angulation of the superior horn of the thyroid cartilage that potentially was causing trauma to the left common carotid artery. We deduced that symptomatic impingement of the carotid artery by the thyroid cartilage was not only the cause of the patient's clicking larynx syndrome, but also suspected to be the cause of her prior strokes due to repetitive trauma resulting in thrombus. The patient was managed surgically with thyroplasty and transcervical resection of the left greater cornu of the thyroid cartilage with resolution of her symptoms. Anatomical displacement of the thyroid cartilage can manifest as clicking larynx syndrome as well as cause mechanical injury to the carotid artery, resulting in turbulent flow, possible thrombosis, and stroke. Laryngoscope, 132:1410–1413, 2022
Abstract
Background
Intraoperative frozen section histopathology (IFSH) in sinonasal and skull base surgery although widely used is not well studied.
Methods
We reviewed a database of sinonasal and ...anterior skull base tumors, between 1973 and 2019, and identified 312 suitable operative cases. Clinicopathologic data was collected and analyzed, in addition to descriptive data for histopathological reports classified as “ambiguous,” or “limited/insufficient‐quality/quantity.”
Results
Overall, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for IFSH were 90.2%, 97.5%, 94.2%, 95.6%, and 95.2%, respectively. IFSH for adenocarcinoma, salivary carcinoma, and SCC all demonstrated a better clinical utility with a sensitivity of 90% or greater, while it was less than 90% for esthesioneuroblastoma, melanoma, and sarcoma. Other factors such as unclear reporting, poor quality specimens, or limited quality specimens were shown to lower diagnostic performance. Based on limitations identified, we proposed a novel IFSH reporting algorithm to improve IFSH in sinonasal and skull base surgery.
Conclusions
IFSH is an accurate and clinically useful technique in sinonasal and skull base surgery patients; however, limitations exist.
Objective
Report long‐term tracheostomy outcomes in patients with COVID‐19.
Study Design
Review of prospectively collected data.
Methods
Prospectively collected data were extracted for adults with ...COVID‐19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge.
Results
One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all‐cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty‐three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6–11) and 18 (95% CI 14–22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32–47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943–0.998; P = .037).
Conclusion
Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID‐19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID‐19 is warranted.
Level of Evidence
3 Laryngoscope, 131:E2849–E2856, 2021
In this study of 45 patients with COVID-19 undergoing tracheostomy, nasopharyngeal and tracheal cycle threshold (Ct) values were analyzed. Ct values rose to 37.9 by the time of tracheostomy and ...remained >35 postoperatively, demonstrating that persistent test positivity may not be associated with persistent transmissible virus in this population.
Background
Standard of care for management of thyroglossal duct cysts (TGDCs) is a Sistrunk procedure performed through a transcervical incision. We describe the first series of Sistrunk procedures ...performed through a transoral endoscopic vestibular approach, eliminating a visible external scar.
Methods
The transoral endoscopic vestibular approach to the Sistrunk (TEVAS) was performed in patients with TGDCs meeting inclusion criteria who desired a scarless approach.
Results
Six patients (five females and one male) underwent TEVAS, with a mean age of 38 years (range 16–56 years) and a mean TGDC size of 1.8 cm (range 1.1–2.4 cm). Mean operative time was approximately 5 h (range 2–8 h). There were no surgical complications or recurrences.
Conclusions
For appropriately selected patients, the TEVAS is an alternative to open neck surgery that provides improved cosmesis while maintaining successful resection outcomes. More data on outcomes including complications and recurrences are needed as additional case information is collected.
Medication related osteonecrosis of the jaw (MRONJ) requiring free flap (FF) reconstruction is uncommon with limited reported findings.
Multicenter, retrospective case series of 49 consecutive adult ...patients presenting with advanced MRONJ requiring FF reconstruction from 2010 to 2022. Perioperative complications and outcomes were analyzed.
Eighty-two percent (n = 40) of cases were of the mandible and 18% (n = 9) were of the maxilla. The mean follow-up was 15 months (±19.6). The majority of FF survived (96%, n = 47). FF reconstructions of the maxilla were more likely to require postoperative debridement (56%, 95% CI 27, 81% vs. 15%, 95% CI 7, 25%, p = 0.008) or develop intraoral bone exposure (56%, 95% CI 27, 81% vs. 18%, 95% CI 9, 27%, p = 0.02). Most patients (71%, n = 35) received preoperative antibiotics which was associated with a higher rate of FF survival (100% vs. 86%, 95% CI 60, 96%, p = 0.02) and fewer complications.
Patients undergoing FF reconstruction for MRONJ do well with high rates of FF success. MRONJ of the maxilla have a higher rate of some complications. Preoperative antibiotics correlated with higher FF survival and fewer postoperative complications.
Methods of assessing final margin status in patients undergoing surgery for oral cavity squamous cell carcinoma, such as intraoperative frozen section histopathology (IFSH) taken from the tumor bed, ...may have limitations in accuracy.
To evaluate the accuracy and implications of using IFSH samples to assess tumor bed margins in patients undergoing surgery for oral cavity squamous cell carcinoma (SCC).
This cross-sectional study included 1257 patients who underwent surgery for oral cavity SCC between January 1, 2000, and December 31, 2015, at an academic cancer center. A total of 4821 IFSH samples were examined from 1104 patients (87.8%) who had at least 1 IFSH sample. Institutional practice is to harvest margins for IFSH from the tumor bed. Statistical analysis was performed from August 1, 2021, to April 4, 2022.
Sensitivity and specificity were calculated for IFSH samples of margins compared with the permanent pathology samples of the same tissue and for IFSH compared with the final tumor specimen histopathology (FTSH). Results were classified using a binary method, with histopathologic reports interpreted as either negative (including negative or atypia or dysplasia) or positive (including carcinoma in situ, suspicious, or positive).
A total of 1257 patients met the inclusion criteria, including 709 men (56.4%), with a median age of 62 years (IQR, 52-73 years); 1104 patients (627 men 56.8%; median age, 62 years IQR, 52-72 years) had IFHS samples. For IFSH relative to permanent sections of the IFSH tissue, sensitivity and specificity of IFSH were high (sensitivity, 76.5% 95% CI, 67.5%-85.5%; specificity, 99.9% 95% CI, 99.8%-100%), with discordant results in 24 of 4821 total specimens (0.5%). Final specimen margins were positive in 11.7% of patients (147 of 1257). Compared with FTSH, the sensitivity of IFSH for defining margin status was 10.8% (95% CI, 5.8%-15.8%), and the specificity was 99.1% (95% CI, 98.8%-99.4%). The rate of discordance was 4.0% (171 of 4284 specimens) between IFSH and FTSH.
The findings of this cross-sectional study suggest that IFSH is accurate compared with permanent pathologic characteristics of the same tissue, but less reliable at assessing final margin status on the tumor specimen. Despite a high specificity, the sensitivity of IFSH compared with FTSH is low, which may be associated with the inherent inability of tumor bed IFSH margin analysis to accurately account for the 3-dimensional association of tumor margins with the periphery of the specimen and the overall low rate of positive final tumor margins. Although tumor bed IFSH is widely used in the management of oral cavity cancer, this study suggests that there are limitations of this modality in assessing the final surgical margin status.
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