Neck Surgeons Research Articles

Retrieval of Migrated Embedded Sewing Machine Needle from the Tongue.

Foreign body in the oral cavity can be encountered by Head and Neck Surgeons in their clinical practice. Here, we report a rare case of an embedded sewing machine needle in the posterior tongue that migrated by tongue movements, and was retrieved successfully by surgical intervention.

Epidemiology and treatment of head and neck malignancies in the AYA generation.

The Adolescent and Young Adult (AYA) population refers to the population of young adults and adolescents in the 15-39years age group. This population subgroup experiences various important life events. Head and neck malignancies are rare tumors, in general, but they are extremely rare in the AYA population. When analyzed by the primary site of the tumors, thyroid gland, soft tissue, and nasopharyngeal malignancies are the most commonly encountered head and neck malignancies in the AYA generation. The most common histopathologic subtypes are carcinomas (thyroid carcinoma, nasopharyngeal carcinoma) and rhabdomyosarcoma. Therefore, in this review, the author discusses these three diseases in the AYA population in detail. Especially, patients with parameningeal rhabdomyosarcoma are at a high risk of dysfunction and facial deformity. Infertility problems may also occur as long-term sequelae of chemotherapy in this population. Radiation therapy might be associated with considerable morbidity. Complications such as cataract, xerostomia, hearing loss, neck fibrosis, and trismus are also common. Head and neck surgeons and medical oncologists should choose the optimal treatment taking into account the curability of the tumors relative to the long-term adverse events of treatment use. Finally, little evidence has been accumulated on head and neck malignancies in the AYA population, and it is urgently necessary to build a high level of evidence for the future.

Transoral Endoscopic Diverticulostomy of Zenker’s Diverticulum With Energy Device

Zenker’s diverticulum (ZD) is an abnormally protruding space in the Killian triangle due to weakness between the inferior pharyngeal constrictor muscle and cricopharyngeal muscle. A rare disease that is found more often in the West than in the East, it occurs in the elderly, inducing dysphagia, globus symptom, reflux and etc. For the treatment, various transoral endoscopic techniques have been developed over the past 20 years: these include flexible and rigid endoscopy are used and several devices like scissors, staplers, CO<sub>2</sub> laser and energy device. We report here the first case using the endoscopic energy device assisted diverticulostomy of ZD in Korea. Transoral endoscopic treatment is less invasive than classical transcervical approach treatment, showing better clinical course and results. Both rigid endoscope and energy device are also very familiar to head and neck surgeons, so this approach can be one of the best treatments for ZD.

Otorhinolaryngologists/Head and Neck Surgeons’ Knowledge, Attitudes, and Practices Regarding Fertility Preservation in Young Cancer Patients Treated with Chemotherapy

Otorhinolaryngologists/Head and Neck Surgeons’ Knowledge, Attitudes, and Practices Regarding Fertility Preservation in Young Cancer Patients Treated with Chemotherapy

Discrimination, harassment, and intimidation amongst otolaryngology—head and neck surgeons in Canada

BackgroundUnderstanding mistreatment within medicine is an important first step in creating and maintaining a safe and inclusive work environment. The objective of this study was to quantify the prevalence of perceived workplace mistreatment amongst otolaryngology—head and neck surgery (OHNS) faculty and trainees in Canada.MethodsThis national cross-sectional survey was administered to practicing otolaryngologists and residents training in an otolaryngology program in Canada during the 2020–2021 academic year. The prevalence and sources of mistreatment (intimidation, harassment, and discrimination) were ascertained. The availability, awareness, and rate of utilization of institutional resources to address mistreatment were also studied.ResultsThe survey was administered to 519 individuals and had an overall response rate of 39.1% (189/519). The respondents included faculty (n = 107; 56.6%) and trainees (n = 82; 43.4%). Mistreatment (intimidation, harassment, or discrimination) was reported in 47.6% of respondents. Of note, harassment was reported at a higher rate in female respondents (57.0%) and White/Caucasian faculty and trainees experienced less discrimination than their non-White colleagues (22.7% vs. 54.5%). The two most common sources of mistreatment were OHNS faculty and patients. Only 14.9% of those experiencing mistreatment sought assistance from institutional resources to address mistreatment. The low utilization rate was primarily attributed to concerns about retribution.InterpretationMistreatment is prevalent amongst Canadian OHNS trainees and faculty. A concerning majority of respondents reporting mistreatment did not access resources due to fear of confidentiality and retribution. Understanding the source and prevalence of mistreatment is the first step to enabling goal-directed initiatives to address this issue and maintain a safe and inclusive working environment.Graphical

Routine evaluation of tonsillectomy specimens: a cross-sectional survey of Canadian Otolaryngology: Head and Neck Surgeons

BackgroundTonsillectomy is a commonly performed procedure in Canada. The rate of occult malignancy is rare in adult and pediatric populations. At present, no guidelines exist surrounding the need for routine histopathological evaluation of tonsil specimens when no malignancy is suspected.MethodsWe sent a confidential online survey to active members of the Canadian Society of Otolaryngology – Head and Neck Surgery (CSO-HNS) about their current tonsillectomy practice and beliefs surrounding the need for routine histopathological evaluation of tonsillectomy specimens when no malignancy is suspected. We used Opinio survey software for data collection and descriptive statistics.Results95 participants completed our survey (response rate 19.3%). Most participants reported performing both adult and pediatric tonsillectomies. When no malignancy is suspected, participant responses were split between whether they send tonsil specimens in pediatrics only (4.2%), in adults only (31.6%), or not sending specimens (29.5%). Half of the participants reported that routinely sending specimens to rule out occult malignancy is an institutional policy. Approximately 75% of participants were in favour of removing this practice in both the pediatric and adult populations.ConclusionEliminating the practice of automatically sending tonsil specimens for histopathological evaluation when no malignancy is suspected was supported by the majority of study participants. This is in keeping with Choosing Wisely, a campaign designed to facilitate conversations about unnecessary medical tests and procedures. Institutional change is likely required in order to alter this practice.Graphical

Clinical study of postoperative complications of thyroidectomy

Background: Thyroid surgery is one of the common surgeries performed by general surgeons, Head and neck surgeons, and endocrine surgeons today. The most common complications of thyroid surgery are bleeding, injury to recurrent laryngeal nerves, and parathyroid glands. Other complications include airway obstruction, superior laryngeal nerve injury, infections, and sometimes thyroid crisis. Patients with permanent recurrent laryngeal nerve palsy and hypocalcaemia have life-long problems with a need for continued medication, further surgeries, and rehabilitation. They have a compromised quality of life by an increase in individual's healthcare costs and requiring lifelong alternative therapies. Objectives: To evaluate the incidence of post thyroidectomy complications. It also intends to evaluate the preoperative and intra-operative factors that contribute to these complications. To assess the modalities to prevent such complications. Methods: A Prospective study was done from January 2018 to December 2019 on thyroid complications. A total of 78 patients were studied regarding the diagnosis, type of surgery, and the complications in them. The patients were followed up for 1 year. Results: The majority of patients (59%) were in the 3rd and 4th decade of life age. Female domination more than male. Multinodular goiter is the most common diagnosis. The most common complication was transient Hypocalcaemia (15.38%) and recurrent laryngeal nerve( 6.41%). Wound infections in 6.41%and seromas are 2.56%. The incidence of major bleed with respiratory obstruction and thyrotoxicosis is zero. No permanent debilitating complications of RL nerve injury or hypocalcaemia were noted. Conclusion: A thorough preoperative preparation, with adequate knowledge of Thyroid anatomy and steps of surgery is essential. A clean dissection, meticulous haemostasis and, identification and preservation of Recurrent Laryngeal and Parathyroids can relate to a low rate of complications. Extensive surgeries are associated with a higher rate of complications. Early recognition and prompt treatment of complications enable a better outcome for the patient.

Postoperative care in ICU versus non-ICU after head and neck free-flap surgery: a systematic review and meta-analysis

ObjectiveAdmission to the intensive care unit (ICU) has long been considered as routine by most head and neck surgeons after microvascular free-flap transfer. This study aimed to answer the question...

Treating a Rare Angiomyomatous Hamartomas of Head and Neck Region, Our Experience: Case Repor

Angiomyomatous hamartoma of head and neck region is very are disease, of unknown etiology and more often than not it can be misdiagnosed preoperatively. Materials and Methods: In a study we present a case of angiomyomatous hamartoma in the carotid triangle, a site where a tumor has an invasion to external carotid artery, treatment carried out by surgical excision, after histological examination, the final diagnosis was made. The patient was under observation for 3 years, there were no relapses. Conclusion: The diagnosis of angiomyomatous hamartoma is based on histologic examination. Although this entity is rare, we believe that head and neck surgeons should include it in the differential diagnosis of head and neck masses

THE IMPACT OF COVID-19 ON HEAD AND NECK CANCER TREATMENT DELAY.

The aim of this study was to demonstrate the impact of COVID-19 pandemic on the number and characteristics of head and neck cancer patients in two consecutive periods, pre-pandemic and pandemic. For this purpose, we performed a retrospective analysis of patients with primary carcinomas of head and neck mucosal sites, salivary gland tumors, as well as neck metastases. Two pre-COVID-19 years (2018-2019) and two pandemic years (2020-2021) were compared. Demographic data, overall number of patients, TNM classification of the two most affected sites (oral cavity and larynx), time from symptom onset to first outpatient admission to our department, and time from first admission to treatment initiation were noted. Study results revealed a higher number of patients during the pandemic period and difference in the distribution of tumor sites (χ2=33.68, df=9, p<0.001). Oral cavity cancer prevailed over laryngeal cancer during the pandemic period. A statistically significant difference was observed in delay of initial presentation to head and neck surgeon for oral cavity cancer during the pandemic period (p=0.019). Furthermore, significant delay was found for both sites concerning time from initial presentation to the beginning of treatment (larynx: p=0.001 and oral cavity: p=0.006). Despite these facts, there were no differences in TNM stages comparing two observed periods. Study results indicated that there was a statistically significant delay of surgical treatment for both cancer sites observed (oral cavity and larynx) during the COVID-19 pandemic. A survival study is necessary in the future to definitely reveal the true consequences of COVID-19 pandemic on treatment outcomes.

DELAYED ORAL FEEDING IN PATIENTS OF SALVAGE LARYNGECTOMY AND ITS EFFECT ON DEVELOPMENT OF PHARYNGOCUTANEOUS FISTULA

Objective: Pharyngocutaneous fistula (PCF) is a complication of post radiotherapy total laryngectomy. Early post operative feeding is a risk factor for development of PCF. Delayed oral feeding (DOF) and inserting a nasogastric tube has been considered a safe practice among head and neck surgeons, and there is no general agreement on the timing of initiation of the oral intake. This study compared the effect of EOF and DOF on PCF formation.&#x0D; Study Design: Prospective case-controlled trial.&#x0D; Place and Duration of Study: Combined Military Hospital Rawalpindi, from Apr 2019 to Jul 2020.&#x0D; Methodology: Non-probability convenience sampling was done for both groups. The patients were not matched and were assigned to either EOF or DOF alternately. EOF was defined as feeding at seventh post operative day and DOF criterion was feeding on fourteenth post operative day. The primary outcome was development of PCF within the 30th post operative day. A total of 20 patients with prior radiotherapy for laryngeal cancer who presented with recurrence of carcinoma were included in the study. Same technique closure of neopharynx was done in all cases of laryngectomy.&#x0D; Results: Overall PCF frequency was 20% (4/20). In EOF group, 30% (3/10) of patients developed PCF whereas 10% (1/10) of patients in DOF developed PCF. However, the difference in outcome of two groups was not statistically significant.&#x0D; Conclusion: DOF in cases of Salvage total laryngectomy is a safe practice and it might help to reduce the frequency of pharyngocutaneous fistula.

Suprahyoid pharyngotomy – a rare, but a simple approach in head and neck surgery

The surgical transcervical approach creates a corridor to oropharynx and hypopharynx, which provides excellent exposure for removal of different lesions at these sites. The suprahyoid pharyngotomy technique can be used in situations similar to the lateral pharyngotomy, like the management of benign and malignant tumors of the base of the tongue, hypopharynx, and posterior pharyngeal wall, and excision of lingual thyroid. Here, we have discussed in detail about two patients for which this suprahyoid pharyngotomy approach was used – one, for a case of laryngeal schwannoma and another, for a case of lingual thyroglossal duct cyst. We have also reviewed many articles related to suprahyhoid pharyngotomy and came across 36 cases for which this approach was successfully used.

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Editorial

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Impact of Superior and Inferior Approach in Identification and Preservation of Spinal Accessory Nerve during Modified Radical Neck Dissection in Patients with Oral Squamous Cell Carcinoma

Background: During neck dissection, injuries to spinal accessory nerve (SAN) are most common cause of post-operative shoulder morbidity. Which is known as ‘Shoulder Syndrome’. Despite the evolution in neck dissection procedures from radical to super-selective neck dissection, post-operative shoulder dysfunction remains a point of exasperation for head and neck surgeons. It significantly impacts the standard of living for patients with head and neck cancer. According to the anatomic course and branching of SAN, there are various dissection technique for identification and preservation. Our comparison of superior dissection approach with inferior dissection approach for identification, preservation, and complete skeletonization of SAN in posterior neck dissection has not been studied based on its anatomical course.&#x0D; Objective: To compare Superior Vs. Inferior approach group in regards to safety and superiority of the approach for SAN preservation with minimal or no intraoperative and or post-operative functional complications.&#x0D; Methods: The patients will be randomly divided into two groups according to the approach used to identify and preserve SAN (superior Vs. inferior approach group). The intraoperative clinical and post-operative data will be collected and evaluated with appropriate statistical analysis.&#x0D; Results: Collected data from 24 patients will undergo statistical analysis to obtain the results.&#x0D; Conclusion: This study expects to find a superior modality amongst the Superior dissection approach and inferior dissection approach in terms of identification, preservation, and post-operative functional deficit for spinal accessory nerve.

Tracheostomy in COVID-19 acute respiratory distress syndrome patients and follow-up: A parisian bicentric retrospective cohort.

Tracheostomy has been proposed as an option to help organize the healthcare system to face the unprecedented number of patients hospitalized for a COVID-19-related acute respiratory distress syndrome (ARDS) in intensive care units (ICU). It is, however, considered a particularly high-risk procedure for contamination. This paper aims to provide our experience in performing tracheostomies on COVID-19 critically ill patients during the pandemic and its long-term local complications. We performed a retrospective analysis of prospectively collected data of patients tracheostomized for a COVID-19-related ARDS in two university hospitals in the Paris region between January 27th (date of first COVID-19 admission) and May 18th, 2020 (date of last tracheostomy performed). We focused on tracheostomy technique (percutaneous versus surgical), timing (early versus late) and late complications. Forty-eight tracheostomies were performed with an equal division between surgical and percutaneous techniques. There was no difference in patients' characteristics between surgical and percutaneous groups. Tracheostomy was performed after a median of 17 [12-22] days of mechanical ventilation (MV), with 10 patients in the "early" group (≤ day 10) and 38 patients in the "late" group (> day 10). Survivors required MV for a median of 32 [22-41] days and were ultimately decannulated with a median of 21 [15-34] days spent on cannula. Patients in the early group had shorter ICU and hospital stays (respectively 15 [12-19] versus 35 [25-47] days; p = 0.002, and 21 [16-28] versus 54 [35-72] days; p = 0.002) and spent less time on MV (respectively 17 [14-20] and 35 [27-43] days; p<0.001). Interestingly, patients in the percutaneous group had shorter hospital and rehabilitation center stays (respectively 44 [34-81] versus 92 [61-118] days; p = 0.012, and 24 [11-38] versus 45 [22-71] days; p = 0.045). Of the 30 (67%) patients examined by a head and neck surgeon, 17 (57%) had complications with unilateral laryngeal palsy (n = 5) being the most prevalent. Tracheostomy seems to be a safe procedure that could help ICU organization by delegating work to a separate team and favoring patient turnover by allowing faster transfer to step-down units. Following guidelines alone was found sufficient to prevent the risk of aerosolization and contamination of healthcare professionals.

The development, implementation, and efficacy of a perioperative briefing communication and treatment planning tool and its adaptation to the COVID-19 pandemic

Background: Effective communication and team alignment are critical elements in overall preparedness for surgery. We sought to assess staff perceptions of a newly implemented perioperative communication mechanism and evaluate its ongoing efficacy. Methods: A perioperative email briefing tool was developed as a virtual “huddle” process. A survey of the care team was then done after the first 6 months of its use. Implementation of the briefing for new faculty and a pandemic was observed. Results: After 6 months, all 4 head and neck surgeons had adopted this tool and utilized it for nearly 100% of cases, and the instrument was adopted by all other faculty subsequently joining the practice group. In the initial assessment, 98% of all respondents felt the process should continue. In a follow-up survey, over 88% believed the briefings reduced the risk of serious errors, near misses, and complications. Conclusions: An email perioperative briefing is feasible and improved workflow and safety.

Expert consensus statement on the perioperative management of adult patients undergoing head and neck surgery and free tissue reconstruction from the society for head and neck anesthesia

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near-consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

Expert consensus statement on the perioperative management of adult patients undergoing head and neck surgery and free tissue reconstruction from the Society for Head and Neck Anesthesia

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

Abnormal Course of Internal Carotid Artery Encountered During Neck Dissection.

Internal carotid artery (ICA) is one of the most important structures to be preserved during neck dissection. Many anomalous courses of ICA have been explained and must be kept in mind while proceeding with surgery. The variation mentioned in this article has not been described yet. This is very important for head and neck surgeons, especially while performing neck dissection or external carotid artery ligation. A 51-year-old male with no known comorbidities underwent surgery for carcinoma right buccal mucosa. As noted in preoperative imaging, intraoperatively he had a abnormal course of ICA especially with abnormal relation to the internal jugular vein (IJV). It is imperative to study the anatomy of ICA preoperatively to prevent intraoperative surprises. A careful dissection of the level II cervical region keeping in mind regarding an aberrant course of ICA especially with relation to IJV can prevent catastrophic consequences.