Laryngeal exposure and margin status in glottic cancer treated by transoral laser microsurgery

Objective

Laryngeal exposure is one of the most limiting factors in transoral laser microsurgery (TLM) for glottic cancer. We evaluated the correlation between the degree of laryngeal exposure, as assessed by an easy previously described scoring tool (Laryngoscore), and histopathologic surgical margin status after TLM.

Study Design

Prospective evaluation of 147 patients affected by Tis–T2 glottic cancer treated by TLM with curative intent between January 2012 and April 2016.

Methods

All patients were preoperatively assessed and classified as having good (group A including Laryngoscore class 0–I) or suboptimal laryngeal exposure (group B including class II–III). Margins were classified as negative (more than 1 mm margin between healthy tissue and tumor) or positive (one/multiple superficial or deep margins involved by invasive or in situ carcinoma). Patients with multiple superficial or deep margin positivity were scheduled for TLM re-excision, open partial laryngectomy, or postoperative radiotherapy.

Results

Twenty-one type I, 54 type II, 19 type III, 7 type IV, 41 type V, and 5 type VI cordectomies (according to the European Laryngological Society classification) were performed with an en-bloc or multi-bloc technique according to the size, site, and exposure of the lesion. Group A included 109 (74%) and group B included 38 (26%) patients. Positive surgical margins were overall observed in 39 (26.5%) cases: 21 (19.2%) in group A versus 18 (47.4%) in group B (P = 0.001).

Conclusion

Laryngeal exposure is one of the most important factors influencing TLM resection of glottic cancer within safe surgical margins. The importance of its adequate preoperative assessment cannot be overemphasized.

Level of Evidence

2b. Laryngoscope, 2017

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What is the optimal time for removing drains in uncomplicated head and neck surgery?

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Laryngeal EMG: Preferential damage of the posterior cricoarytenoid muscle branches especially in iatrogenic recurrent laryngeal nerve lesions

Objective

Laryngeal electromyography (LEMG) of the thyroarytenoid (TA) muscle alone may not be sufficient in all patients to characterize or prove a recurrent laryngeal nerve (RLN) lesion in cases of vocal fold immobility. LEMG of the posterior cricoarytenoid (PCA) muscle may provide additional information.

Study Design

Retrospective review.

Method

Between 2008 and 2016, 339 patients in our laryngeal paralysis clinic were examined by transcutaneous needle TA-LEMG and, if tolerated, by PCA-LEMG. LEMGs were rated and compared according to criteria of the European Laryngological Society. Etiology was categorized as iatrogenic, noniatrogenic, or malignancy related.

Results

A total of 282 out of 339 patients had a partial or complete RLN or vagal nerve lesion: 178 iatrogenic, 74 noniatrogenic, and 30 because of nerve involvement by malignancies. Of paralytic vocal folds, 35.7% had normal or near-normal TA innervation, whereas corresponding PCA traces (if present) were pathologic in 94.6%. Comparing pairs of TA and PCA-LEMGs in paralysis of less than 4 months duration showed a predominance of PCA branch injuries in iatrogenic lesions (71.7 %), while in noniatrogenic lesions this was less pronounced (44.4%). In the few malignancy cases, there was an almost even distribution. Synkinetic reinnervation was earlier in iatrogenic RLN lesions.

Conclusion

PCA-LEMG was better in proving an RLN lesion than TA-EMG alone. Our findings suggest etiology-dependent differences in the TA/PCA lesion pattern. To confirm this, larger sample sizes are needed. A preferential damage to PCA innervation in iatrogenic lesions could be relevant for further improvements of intraoperative neuromonitoring.

Level of Evidence

4. Laryngoscope, 2017

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Work-related musculoskeletal symptoms among otolaryngologists by subspecialty: A national survey

Objective

Given the high prevalence of work-related musculoskeletal symptoms, increased appreciation for workplace ergonomics is critical. The purpose of this study is to assess work-related musculoskeletal symptoms and injury among otolaryngologists across subspecialties, as well as to quantify the understanding and application of ergonomic principles in the operating room.

Study Design

Cross-sectional study.

Methods

An online REDCap survey was distributed electronically to University of Kansas faculty, alumni, and residents; members of the American Academy of Facial Plastic and Reconstructive Surgery; and residency program coordinators for distribution to residents and faculty between August 2016 and March 2017. The survey assessed caseload, ergonomic practices, and associated musculoskeletal symptoms by type of procedure and impact of symptoms on surgeon practice.

Results

The survey was distributed to 3,006 individuals. We received 377 responses (12.5%), with 63.9% reporting symptoms. The majority of respondents began to experience symptoms in residency or fellowship. Neck and shoulder were the most affected body areas across all types of surgeries. One-third of surgeons were formally taught or actively sought information on ergonomics principles. Among those who applied ergonomics in practice, 69.6% observed improvement in their symptoms.

Conclusion

Although musculoskeletal issues are prevalent among otolaryngologists, awareness of surgical ergonomics principles among otolaryngologists remains limited. Early instruction in ergonomic principles is important because work-related musculoskeletal symptoms commonly present in residency. Most respondents reporting the application of ergonomic principles also acknowledge symptom improvement.

Level of Evidence

NA. Laryngoscope, 2017

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European guidelines on perioperative venous thromboembolism prophylaxis: Surgery in the elderly.

: The risk for postoperative venous thromboembolism (VTE) is increased in patients aged more than 70 years and in elderly patients presenting with co-morbidities, for example cardiovascular disorders, malignancy or renal insufficiency. Therefore, risk stratification, correction of modifiable risks and sustained perioperative thromboprophylaxis are essential in this patient population. Timing and dosing of pharmacoprophylaxis may be adopted from the non-aged population. Direct oral anti-coagulants are effective and well tolerated in the elderly; statins may not replace pharmacological thromboprophylaxis. Early mobilisation and use of non-pharmacological means of thromboprophylaxis should be exploited. In elderly patients, we suggest identification of co-morbidities increasing the risk for VTE (e.g. congestive heart failure, pulmonary circulation disorder, renal failure, lymphoma, metastatic cancer, obesity, arthritis, post-menopausal oestrogen therapy) and correction if present (e.g. anaemia, coagulopathy) (Grade 2C). We suggest against bilateral knee replacement in elderly and frail patients (Grade 2C). We suggest timing and dosing of pharmacological VTE prophylaxis as in the non-aged population (Grade 2C). In elderly patients with renal failure, low-dose unfractionated heparin (UFH) may be used or weight-adjusted dosing of low molecular weight heparin (Grade 2C). In the elderly, we recommend careful prescription of postoperative VTE prophylaxis and early postoperative mobilisation (Grade 1C). We recommend multi-faceted interventions for VTE prophylaxis in elderly and frail patients, including pneumatic compression devices, low molecular weight heparin (and/or direct oral anti-coagulants after knee or hip replacement) (Grade 1C). (C) 2017 European Society of Anaesthesiology

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Risk Vessels of Retropharyngeal Hematoma During Stellate Ganglion Block.

Background and Objective: Bleeding into the retropharyngeal space is a potential complication in stellate ganglion block (SGB). Retropharyngeal hematoma formation is considered to be due to damage of small arteries in the region, although only scanty details of the region are available. The aim of this study was to map the risk blood vessels in the retropharyngeal space to avoid accidental damage during SGB. Methods: Contrast-enhanced 3-dimensional computed tomography images performed on 80 patients were reanalyzed retrospectively to construct detailed map of cervical blood vessels that are prone to damage and bleeding during SGB. Results: Of the 160 bilateral necks, 6 (3.8%) and 82 (51.3%) small arteries were identified in the medial portions of the ventral surface of the transverse processes of the sixth and seventh cervical vertebrae, respectively. In particular, 5 of the 6 small arteries detected in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra were the inferior thyroid artery (ITA). Of the 160 vertebral arteries, 2 arteries were missing, 4 (2.5%) entered the transverse foramen of the fifth cervical vertebra, whereas 1 artery (0.6%) entered the transverse foramen of the fourth cervical vertebra. Conclusions: Three-dimensional computed tomography identified the ITA in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra. The risk vessels of retropharyngeal hematoma during SGB could include the ITA. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Outcomes of Bone Anchored Hearing Aid Implant at Universiti Kebangsaan Malaysia Medical Centre (UKMMC)

Abstract

The cross sectional study was conducted in Universiti Kebangsaan Malaysia Medical Center (UKMMC), Malaysia from August 2012 to December 2013. All patients implanted with in UKMMC from December 2001 until December 2012 was included. Glasgow Benefit Inventory (GBI) questionnaires and UKMMC questionnaires were used as part of the assessment tool. The GBI is a scoring which measures the change in health status produced by surgical interventions. UKMMC questionnaires was invented by our department to assess questions related to social and life style of patients and also the cosmetic perspective Baha implant and other daily related activities. The audiological assessment was assessed using hearing aid gain threshold. Complication with regards to skin reaction was graded using Holger Skin Classification. A total of 40 patients underwent Baha implant were recruited but only 35 patients fulfilled the criteria and included in this study for analysis. Age of patients ranged from 5 year old to 38 year old, with median of 13 years old. There were 22 patients (62.8%) were male and 13 patients (37.1%) were females. Almost all cases were canal atresia except one adult patient was a case of bilateral chronic discharging ear with chronic irritation with ear mould. Majority of patients 21 (60%) have hearing level of moderate to severe hearing loss (40–89 dB) and 14 patients (40%) have mild to moderate hearing loss (20–39 dB). The level of hearing was retested post operatively. All of the patients have improvement in their aided hearing with the range of 10–25 dBL which is statistically significant at p value of <0.05. The GBI was scored positively in all subscales. Majority of patients (91.4%) used BAHA more than 4 h per day and 88.6% agreed that BAHA is cosmetically acceptable. All patients experienced some form of skin irritation (Holger grade 1–2) however only 20% required surgical intervention. All our patients have range of 10–25 dB improvement of their aided hearing which is statistically significant at p value of <0.05. BAHA has been proven to show significant benefit in audiological improvement and quality of life.

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