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.
Background
Organ preservation protocols have increasingly been applied for the treatment of head and neck cancers, including hypopharyngeal squamous cell carcinoma (HSCC). We sought to evaluate ...whether patients treated with primary surgery followed by adjuvant therapy had survival benefit over patients treated with initial nonsurgical modalities.
Methods
We retrospectively reviewed patients with new diagnosis of HSCC at the University of Pittsburgh (1994‐2014) treated with either primary total laryngectomy with pharyngectomy or organ preservation.
Results
One hundred thirty‐seven patients were identified. Surgical cases were more likely to be of advanced T stage. Initial surgery was more likely to be performed in the earlier years of the cohort. After adjusting for this imbalance using a propensity score, primary surgery was associated with improved survival compared with nonoperative therapy (P = 0.02).
Conclusions
Due to its survival advantage, primary surgery followed by adjuvant treatment should be considered as a viable treatment of HSCC.
Poorly differentiated thyroid cancer and anaplastic thyroid cancer (ATC) are rare yet lethal malignancies with limited treatment options. Many malignant tumors, including papillary thyroid cancer ...(PTC) and ATC, are associated with increased expression of ICAM-1, providing a rationale for utilizing ICAM-1-targeting agents for the treatment of aggressive cancer. We developed a third-generation chimeric antigen receptor (CAR) targeting ICAM-1 to leverage adoptive T-cell therapy as a new treatment modality.
ICAM-1 CAR T cells were applied to multiple malignant and nonmalignant target cells to investigate specific target cell death and "off-tumor" toxicity
therapeutic efficacy of ICAM-1 CAR T cells was examined in ATC mouse models established from a cell line and patient-derived tumors that rapidly develop systemic metastases.
ICAM-1 CAR T cells demonstrated robust and specific killing of PTC and ATC cell lines
Interestingly, although certain ATC cell lines showed heterogeneous levels of ICAM-1 expression, addition of cytotoxic CAR T cells induced increased ICAM-1 expression such that all cell lines became targetable. In mice with systemic ATC, a single administration of ICAM-1 CAR T cells mediated profound tumor killing that resulted in long-term remission and significantly improved survival. Patient-derived ATC cells overexpressed ICAM-1 and were largely eliminated by autologous ICAM-1 CAR T cells
and in animal models.
Our findings are the first demonstration of CAR T therapy against both a metastatic, thyroid cancer cell line and advanced ATC patient-derived tumors that exhibit dramatic therapeutic efficacy and survival benefit in animal studies.
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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.
Objectives/Hypothesis
Previous studies report high‐accuracy rates for intraoperative frozen sections, but reliability of frozen sections in predicting the ultimate final margin status is unknown. We ...compared frozen and permanent reads to identify risk factors for overall discrepancies between intraoperative and final margin status.
Study Design
Retrospective chart review.
Methods
Pathology reports of 437 surgical resections between 2010 and 2013 were retrospectively reviewed. A total of 253 cases, generating 1,109 individual specimens, met inclusion criteria. Patient demographics, treatment, recurrence, and survival, as well as pathology data pertaining to the specimen, were recorded.
Results
Frozen read accuracy was 96.7% (83.1% sensitivity, 97.9% specificity) relative to permanent evaluation. However, 4.3% of cases had a final positive margin not detected by frozen section; 17.8% had a close margin not detected by frozen section. In eight of 11 cases with missed positive margins, the involved margin was never sampled intraoperatively. Cases where intraoperative margins were only taken from surrounding tissue had a higher risk of missing a close or positive final margin when compared to cases where some or all margins were taken from the specimen (odds ratio = 5.05, 95% confidence interval 2.31, 11.07, P <0.0001). Disease subsite, risk score, prior radiation, staging, and p16 expression were not significantly associated with the likelihood of missing a close or positive final margin.
Conclusion
Individual frozen section reads are highly accurate. However, negative intraoperative margins do not guarantee margin‐negative resections. The process of selecting representative margins for intraoperative analysis, specifically the practice of sampling the resection bed, should be refined.
Level of Evidence
N/A. Laryngoscope, 126:1768–1775, 2016
Summary
Computed tomography (CT)-guided percutaneous biopsy of deep-seated head and neck lesions can be a less invasive and equally effective alternative to surgical techniques. There are multiple ...approaches for needle biopsy that target varying spaces within the head and neck while successfully avoiding critical anatomy. In the paramaxillary approach, the needle is advanced through the infrazygomatic buccal space, in between the maxilla and mandible. In this study, we examine the safety and diagnostic yield of FNA without core needle biopsy performed via the paramaxillary approach in 19 patients yielding 20 fine needle aspirates between 2014 and 2022. Of the fine needle aspirates, 85.0% (17/20) were diagnostic. Concordant histopathologic diagnosis was obtained in 100% (17/17) diagnostic fine needle aspirates. There were no postprocedural complications.
Purpose
To identify areas of critical otolaryngology contributions to inpatient care resistant to disruption by the COVID-19 pandemic.
Methods
Medical records of 614 otolaryngology consults seen ...between January and June of 2019 and 602 seen between January and June of 2020 were reviewed. Extracted data included patient demographics, SARS-CoV-2 status, medical comorbidities, consult location, consult category, reason for consult, procedures performed, and overall outcome. Prevalence of data items was compared using
t
tests and Chi-squared tests.
Results
The number of monthly consults to the otolaryngology service remained approximately stable after the onset of the COVID-19 pandemic. However, there was a substantial increase in ICU consults and a decrease in ER and floor consults. The proportion of otology, rhinology, and head and neck consults decreased while that of airway consults—most of which were tracheostomy-related—greatly increased. While the top ten reasons for consult remained essentially the same, they dramatically increased as a percentage of consults during COVID-19 (55–92%), whereas there was a dramatic decrease in the proportion of less frequent consults.
Conclusion
The changes in otolaryngology consultation patterns seen after the onset of the pandemic are multifactorial, but may be attributed to novel pathologies, attitudes, and policies. Nonetheless, these patterns reveal that a set of core otolaryngologic issues, including acute airway issues, head and neck lesions, severe sinusitis and epistaxis, are essential and need to be addressed in the inpatient setting, whereas the significant drop in other consults suggests that they may be appropriately managed on an outpatient basis.
Patients presenting with advanced aerodigestive malignancy and respiratory compromise often undergo tracheotomy as initial airway management. Tumor debulking is a potential alternative. We present a ...case series with chart review to communicate our institutional experience with this technique. T3/4 glottic and supraglottic cancers treated between 2004 and 2014 underwent review, and 14 patients were identified for this study. Of these, 5 (35.7%) required subsequent tracheotomy, and 9 (64.3%) did not. Patients requiring subsequent tracheotomy had a delay in initiating definitive treatment when compared with those who did not (83.3 vs 31.3 days, P = .0025). No patient required a tracheotomy after initiation of definitive treatment. Our experience suggests that tumor debulking may be a viable option in select patients but that a delay in initiating treatment is associated with patients requiring tracheotomy subsequent to debulking. Further research is needed to better delineate patient scenarios in which tumor debulking alone is sufficient.
Objectives/Hypothesis
To identify compressive symptomatology in a patient cohort with benign thyroid disease who underwent thyroidectomy. To determine radiographic/clinicopathologic features related ...to and predictive of a compressive outcome.
Study Design
Retrospective cohort study.
Methods
Medical records of 232 patients with benign thyroid disease on fine needle aspiration who underwent thyroidectomy from 2009 to 2012 at an academic medical center were reviewed. Data collection and analyses involved subjects' demographics, compressive symptoms, preoperative airway encroachment, intubation complications, specimen weight, and final pathologic diagnosis.
Results
Subjects were ages 14 to 86 years (mean: 52.4 years). Ninety‐six subjects (41.4%) reported compressive symptomatology of dysphagia (n =74; 32%), dyspnea (n = 39; 17%), and hoarseness (n = 24; 10%). Ninety‐seven (42.2%) had preoperative airway encroachment. Dyspnea was significantly related to tracheal compression, tracheal deviation, and substernal extension. Dysphagia was related to tracheal compression and tracheal deviation. Compressive symptoms and preoperative airway encroachment were not related to intubation complications. Final pathologic diagnosis was not related to compressive symptoms, whereas specimen weight was significantly related to dyspnea and dysphagia. Final pathology revealed 74 subjects (32%) with malignant lesions. Malignant and benign nodular subject groups differed significantly in substernal extension, gland weight, tracheal deviation, and dyspnea. Logit modeling for dyspnea was significant for tracheal compression as a predictor for the likelihood of dyspnea.
Conclusion
Dyspnea was closely related to preoperative airway encroachment and most indicative of a clinically relevant thyroid in our cohort with benign thyroid disease. Tracheal compression was found to have predictive value for the likelihood of a dyspneic outcome.
Level of Evidence
4. Laryngoscope, 127:993–997, 2017
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