Transoral Route Research Articles

Transoral endoscopic approach versus transcervical with or without mandibular swing approach to parapharyngeal space- a retrospective cohort study in a tertiary care center in Tamil Nadu

<p class="abstract"><strong>Background:</strong> The objective of this study was to evaluate and compare patient outcomes and advantages of endoscopic transoral approach to parapharyngeal space with other approaches like transcervical with or without mandibular swing approach.</p><p class="abstract"><strong>Methods:</strong> In this retrospective cohort study, we have reviewed 13 cases of parapharyngeal space tumors resected with either trans oral endoscopic assisted approach or external approaches such as trans cervical and mandibular swing approach during the period of June 1, 2015 to May 31, 2020. </p><p class="abstract"><strong>Results:</strong> A total of 13 cases were included in the study. Among 13 cases, 9 were operated by transoral endoscopic approach, 2 by transcervical approach and 2 by transcervical with mandibular swing approach. Operative time (p=0.048), blood loss (p=0.028), hospital days (p=0.02) and postoperative patient satisfaction (p=0.008) were more in transoral route compared to transcervical route.</p><p class="abstract"><strong>Conclusions:</strong> Transoral endoscopic route is a safe route of surgery with less morbidity, less complications, less chance of neurovascular injury and cosmetically more acceptable for the patient when compared to open procedures for smaller size tumors without vascularization, present in the upper part of the parapharyngeal space and without attachment to any neurovascular structures.</p>

S0933 A Cooperative Approach for Treatment of Zenker's Diverticulum

INTRODUCTION: Symptomatic Zenker’s diverticulum management has changed from an open intervention to a less invasive transoral endoscopic route. At our center, both an ENT surgeon and gastroenterologist are present in the operating room when treating these lesions. An intraprocedural consensus is reached to undergo either stapler assisted rigid endoscopy or flexible endoscopic diverticulotomy without clipping with ENT guidance. We aimed to evaluate the real world efficacy with a combined gastroenterology-ENT approach. METHODS: This is a single center retrospective study of subjects who underwent a combined endoscopic diverticulotomy by a gastroenterologist and ENT specialist at Cleveland Clinic Florida between 2011 and 2019. Demographic and clinical data, intraprocedural findings/complications, postprocedural symptoms, recurrence rate and need for reintervention variables were extracted. Patients included in the study were >17 years old, with symptomatic typical single Zenker’s diverticulum confirmed with imaging or endoscopy. RESULTS: 63 subjects were identified. Patients were predominantly males (63.5%) and white (84.1%), with mean age 73.5 years (53–95). Most subjects presented dysphagia (98.4%), mostly to solids (79.4%). Other demographic and clinical data are described in Table 1. Mean diverticular size was 36.3 mm, intra- diverticular food in 30.1% and mean procedure time length of 38.4 minutes. All cases were performed as outpatient, without periprocedural complications. Technical success was achieved in all cases. Patients were followed for a mean of 3.24 months (0.1–22) post procedure. Other intra and post-procedural specifications are listed in Table 2. Fourteen patients (22.2%) had symptom recurrence, but only eight (12.7%) had a residual cricopharyngeal bar on imaging. Four patients had repeat endoscopic intervention and one opted open surgery. Hence, our approach was effective in 58 subjects (92%). CONCLUSION: A combined endoscopic approach by gastroenterology and ENT for symptomatic Zenker’s diverticulum management offered excellent technical and clinical success. This approach was safe and may have avoided elderly subjects with co-morbidities from undergoing two procedures at different times. This approach may provide better patient care than one performed by an unaccompanied ENT surgeon or gastroenterologist. Further studies will determine the long-term recurrence rate of this method of intervention.Table 1.: Demographic and clinical data at baseline for patients undergoing endoscopic Zenker’s diverticulotomyTable 2.: Intra and post-procedural specifications

Is Transoral Surgery Still a Relevant Procedure in Atlantoaxial Instability?

The treatment of atlantoaxial instability (AAI) involves stable fixation and fusion with adequate decompression of spinal cord. After the advent of the Goel posterior joint manipulation technique, most of the once irreducible atlantoaxial dislocations (AAD) could be reduced and the need for transoral odontoidectomy became almost nil. Here we tried to iterate the indications of anterior transoral odontoid surgery for AAI in the current scenario. A retrospective study compiling the clinical, radiological, and surgical characteristics of 6 cases (5 scenarios). These patients underwent anterior transoral surgery alone or in combination with a posterior approach. Two patients had a well-formed occipito-cervical fusion mass, with a displaced odontoid and unreduced C1-C2 joint causing cervical myelopathy. A middle-aged woman presented with unreduced AAD following failed C1-C2 joint distraction technique. A displaced dystopic os odontoideum ossicle was found in an adolescent boy, prohibiting the reduction of AAD. A young man had displacement of the fractured odontoid segment with intact transverse alar ligament and C1-C2 joint complex. One patient had a rare scenario of abnormal orientation of the C1-C2 joint. All 6 patients were successfully treated with adequate spinal cord decompression achieved by the anterior transoral route and stabilization by either the anterior approach itself or in combination with posterior surgery. All had significantly better postoperative outcomes except for 1 patient who expired due to poor respiratory reserve. We tried to emphasize the indications for using transoral anterior odontoid surgery over the posterior approach in the management of AAI. This will prevent the surgical technique of anterior odontoidectomy from becoming an obsolete procedure in the current practice.

Comparison of transnasal and transoral routes of microdebrider combined curettage adenoidectomy and assessment of endoscopy for residue: a randomized prospective study.

The aim of this study is to investigate the frequency and locations of residual adenoid tissue in conventional curettage adenoidectomy (CA) via transnasal endoscopic examination at the end of the operation and to determine the most appropriate technique for residual adenoid tissue removal by transoral or transnasal microdebrider usage. Sixty-three patients aged 4-12years who were scheduled for CA were included in this randomized prospective study in a tertiary reference center. Patients who underwent CA had the endoscopic residual tissue exploration at the end of surgery. The amount and locations of residual tissue were recorded. Patients with > 20% residual tissue were divided into two groups according to randomization list for removing the residual tissue, depending on the use of transoral microdebrider (TOMD) and transnasal microdebrider (TNMD). Two procedures were compared in terms of duration, bleeding, pain, post-anesthesia care unit (PACU) transfer time, and complications. Residual tissue was detected in 38 patients (60.2%). The most common location of residual tissue was peritubal area (41.3%). The TOMD group had lower surgical duration, blood loss, pain scores and shorter PACU transfer time (p = 0.001, p = 0.002, p˂0.001, and p = 0.006, respectively). Endoscopic exploration at the end of CA should be considered to avoid residual tissue retention. Furthermore, if residual tissue is present, the use of TOMD is easier, faster, and associated with lower morbidity than the use of TNMD.

Assessment of Surgeon Judgment during Resection of Laryngeal Carcinoma.

Introduction:Carbon dioxide (CO2) laser surgery as a conservative tool plays a peculiar role in the management of head and neck cancer. Numerous patients who were candidates for transoral laryngeal microsurgery have forced us to eliminate frozen-section evaluation of surgical margins and use a magnified view of the larynx. The present study evaluated surgeon-judged negative margins with permanent microscopic pathologic evaluation. Materials and Methods:In this cross-sectional study, we evaluated the permanent pathologic margins of the resected laryngeal specimen which were considered negative by judgment of surgeons. Patients consisted of 61 pathologic proven T1-T2 laryngeal squamous cell carcinoma (SCC) cases. In all patients, tumor resection was performed via a transoral route with CO2 laser, and no residual laryngeal tumor was observed according to judgment of the surgeon. The patients with positive margin (s) underwent another resection. Patients were followed up for 18 months for tumor recurrence.Results:The obtained results demonstrated that pathologic margins were reported in 6 patients, with the deep margin being the most common positive margin. During the 18-month follow-up, 8 cases of recurrence were detected.Conclusion:Judgment of the surgeon was in agreement with permanent pathologic evaluation in transoral laryngeal laser resection at the early stages of laryngeal SCC in most cases. Nevertheless, it is suggested that further direct studies be conducted to evaluate the frozen section on oncologic outcomes in transoral laser surgery for laryngeal cancer.

Transoral vertebroplasty for the C1 lateral mass

BackgroundOsteolytic lesions of the atlas (C1) are challenging to treat by vertebroplasty due to the vicinity of the vertebral artery and the spinal cord.ObjectiveTo present our experience with transoral vertebroplasty...

Role of Bronchopulmonary C‐fibers in Bleomycin‐induced Rapid Shallow Breathing (RSB) and Idiopathic Pulmonary Fibrosis (IPF) in Mice

IPF is characterized by an irreversible loss of lung function associated with RSB, dyspnea, and hypoxemia, which often leads to death within 3–5 years due to respiratory failure. Inflammation and abnormal wound healing of the interstitial and alveolar spaces in the lungs with excessive proliferation of myofibroblasts (over‐secretion/expression of collagens and α‐smooth muscle actin, α‐SMA) result in fibrosis. Substance P (SP) is known to participate in fibrosis in multiple organs, such as cardiac, renal and liver fibrosis, and wound healing process, but its role in pathogenesis of IPF is unexplored. Because inflammation mediators could stimulate bronchopulmonary C‐fibers (PCFs) to release SP (the major source of inflammatory SP releasing in the lungs) and evoke neurogenic inflammation and RSB (dyspnea), here we asked whether PCFs and neurogenic SP would involve in the pathogenesis of IPF. To this end, four groups of mice pretreated with neonatal capsaicin (for PCF degeneration) or its vehicle received endotracheally (by transoral route) saline (Ctrl) or bleomycin (BLM) respectively. On the 21st day post pretreatment, ventilation, heart rate, and SpO2 were measured. After subsequent euthanasia, BALF and the right lung tissues were collected to detect inflammatory cells, SP, and hydroxyproline, while the left lungs were fixed for histological assessment of IPF, pulmonary inflammation, and α‐SMA immunoreactivity. The results showed that in PCF intact mice, BLM induced RSB, hypoxemia, IPF (upregulation of pulmonary SP, α‐SMA, and hydroxyproline), and pulmonary inflammation. PCF degeneration: 1) eliminated the BLM‐induced RSB and SP upregulation; 2) failed to affect the BLM‐induced hypoxemia; and 3) aggravated IPF (upregulation of α‐SMA and hydroxyproline) and pulmonary inflammation. Our results suggest that PCFs are responsible for the BLM‐induced RSB. On the other hand, PCFs, likely via releasing SP, are protective for the lungs from genesis of IPF through suppressing pulmonary inflammation, α‐SMA and hydroxyproline.

Clinical Outcomes of Endoscopic Endonasal Odontoidectomy: A Single-Center Experience

Odontoidectomy for basilar invagination and craniovertebral junction pathology traditionally has been performed using a transoral route. However, the endoscopic endonasal approach to the anterior craniovertebral junction may offer safer and more effective access when compared with transoral approaches. The objective of this study is to review the surgical outcomes and complications associated with endoscopic endonasal odontoidectomy. This study is a retrospective chart review of all adult patients who underwent an endoscopic endonasal odontoidectomy at a single tertiary care center between January 2011 and May2019. Seventeen patients who underwent endoscopic endonasal odontoidectomy were included. The median age at admission was 67 years (range: 33-84 years) and 65% of the patients were female. One patient (1/17, 6%) had vertebral artery injury, which had to be coiled with no neurologic deficits, and 4 patients (4/17, 24%) had intraoperative CSF leaks with no postoperative leak. Fourteen (14/17, 82%) patients were extubated by postoperative day 1. Three patients (3/17, 18%) developed postoperative sinus infections and required antibiotics. Eight patients (8/17, 47%) developed transient postoperative dysphagia. One patient (1/17, 6%) had postoperative epistaxis and 1 patient (1/17, 6%) had postoperative lower cranial nerve symptoms. The median length of hospital stay was 13 days (range: 2-44 days). Although the transoral approach has been the traditional route for anterior decompression of the craniovertebral junction, endoscopic endonasal odontoidectomy is a feasible and well-tolerated procedure associated with satisfactory patient outcomes and low morbidity.

Endoscopic Thyroidectomy Through Oro-Vestibular Route (ETOVR)

Nodular goitre is the most common endocrine disease requiring surgical thyroidectomy for its cure. Though surgical exploration is routinely performed through conventional open-neck approach, a wide range of minimal access and minimally invasive endoscopic techniques (gasless and with gas) have been attempted in the past two decades. In this context, we report the feasibility and safety of an innovative transoral endoscopic thyroidectomy technique, which marks a paradigm shift in the endocrine surgery. This is a prospective study conducted at a tertiary care endocrine surgery department in Southern India from May 2016 to November 2018. We employed a novel transoral, lower vestibular route for endoscopic thyroidectomy. All the clinical, investigative, operative, pathological and post-operative data were collected from our prospectively filled proformas. Statistical analysis was performed with SPSS 20.0 version. Descriptive analysis was done. Out of the 604 goitre cases operated during the study period, 123 (20.4%) were operated by this technique. Hemithyroidectomy was performed in 104 and total thyroidectomy in 19 cases respectively. Mean operative time was 124 ± 18 min (100–220). There was extended subcutaneous emphysema on to upper chest in one case. Otherwise, the post-operative course was uneventful with no major morbidity, hypocalcemia, or recurrent laryngeal nerve palsy. All the cases had benign histopathology. We conclude that this novel transoral vestibular route thyroidectomy is a comparably optimal approach for nodular thyroid goitres, especially in benign cases.

Morphometry of nasopalatine line for transnasal endoscopic access to craniovertebral junction: A cadaveric study

Background and Aims: Lesions in craniovertebral junction (CVJ) are approached either through transnasal or transoral route. Endoscopic transnasal route reduces significant morbidity, and nasopalatine line (NPL) predicts the inferior-most limit of surgical dissection. The purpose of the present study was to measure the NPL in the cadavers, which is beneficial for the endoscopic transnasal anterior approach to access odontoid process and anterior CVJ, especially in surgical decompression of medulla oblongata. Materials and Methods: The present study was done on forty midline sagittal head-and-neck specimens obtained from 10% formalin-fixed cadavers in the Department of Anatomy, Rajarajeswari Medical College and Hospital, Bangalore. Using slide calipers, the hard palate line (HPL), which extends from the anterior nasal spine of maxillary bone to the posterior nasal spine of palatine bone and NPL which extends from the inferior-most point of nasal bone to the posterior nasal spine were measured. In addition, HPL was extended to the lower limit of the anterior margin of the foramen magnum, and NPL was further extended posteriorly to the ventral surface of the second cervical vertebra to know the inferior limit of transnasal endoscopic access for surgeries on ventral skull base lesions. Results: The average of HPL and its extension to foramen magnum was found to be 45.83 mm and 40.97 mm respectively. The NPL and its extension to the ventral surface of C2 vertebra were found to be 58.22 mm and 37.18 mm, respectively. Conclusion: HPL & NPL provide useful information for the neurosurgeons to access the lesions in the ventral CVJ and to achieve a good outcome.

Vocal fold schwannoma in a 13-year-old girl

Laryngeal neurogenic tumors are extremely rare clinical entity. It is a benign and slowly growing neoplasm. Schwannoma of the larynx often arises from the aryepiglottic fold and false vocal cord. Schwannoma of the larynx particularly at the true vocal fold is extremely uncommon. Laryngeal schwannoma typically presents with hoarseness of voice and globus sensation. If the tumor is increases to bigger size, it may lead to dyspnea and stridor. It has an excellent prognosis with low potential for malignant transformation. It should be considered as a differential diagnosis of sublingual pathologies such as salivary gland lesions such as vocal fold polyp. Surgical excision of the tumor is the primary treatment of choice in case of lingual schwannoma. The endoscopic transoral route is considered as the most commonly used approach for vocal fold schwannoma. We report a case of vocal fold schwannoma in a 13-year-old girl which was excised endoscopically.

Endoscopic Endonasal Odontoidectomy.

Odontoidectomy is a standard procedure employed in the treatment of irreducible, compressive ventral pathologies of the craniovertebral junction (CVJ). The traditionally used transoral route is often challenging due to the increased depth of the surgical corridor and risk of injuries to the soft tissues in the oral cavity. The emergence of endoscopic endonasal (EE) surgery has provided an attractive alternative route to the traditional treatment algorithm, and it has the advantages of avoiding complications related to tongue swelling, tracheal swelling, prolonged intubation, velopharyngeal insufficiency, dysphagia, and dysphonia.We present a case of a 66-year-old man with no pertinent past medical history, who presented with progressive quadriparesis and gait ataxia over last 6 months (Nurick's grade 2). Neurological exam revealed pattern suggestive of high-cervical myelopathy with no evidence of cranial nerve paresis. Magnetic resonance imaging (MRI) of his CVJ revealed a large pannus behind the dens with severe spinal cord compression, mild contrast enhancement was noted posterior to the pannus, likely from the ligamentous structures; pannus was hypointense on both T1- and T2-weighted images. Further, a computerized tomography (CT) scan did not reveal any obvious malalignment. He underwent an EE odontoidectomy, followed by posterior cervical fusion. He had an unremarkable postoperative period and recovered fully from his myelopathy over the next 6 months. The histopathological examination of the pannus revealed a degenerated disk. In this video, we have a step by step description of the EE approach to the odontoid and discuss the surgical nuances. The link to the video can be found at: https://youtu.be/pjg68_vK0C4 .

2434. Proton Pump Inhibitor Use on Efficacy of Fecal Microbiota Transplant Administered by Trans-Oral Routes for Clostridioides Difficile Infection: A Systematic Review and Analysis

BackgroundCurrent guidelines include fecal microbiota transplantation (FMT) in the management of recurrent Clostridioides difficile infections (CDI). However, FMT protocols are often facility dependent, and one variable is whether proton pump inhibitors (PPI) are given during preparation. Theoretically, PPIs reduce acidity and protects the transplanted microbiome for the most potent dose. On the other hand, PPIs have also been shown to negatively alter the microbiome and increase the risk of CDI. We conducted a systematic review of the literature to study PPI use on the efficacy of FMT delivered by the trans-oral route.MethodsWe searched PubMed/Medline, Cochrane Library, Embase, Scopus, and Web of Science through December 16th, 2018 using variations of keywords “fecal microbiota transplant” and “Clostridium difficile infection” with 4210 results. Two independent authors reviewed and excluded studies with unrelated topics, abstracts, case reports, or a low level of evidence. Studies with data on trans-oral FMT, PPI use, and the success rate were included. Final review yielded 11 studies including randomized controlled, case–control, cohort, retrospective and prospective trials. The primary outcome was the rate of FMT failure, defined as recurrence of symptoms with positive CDI testing at follow-up.ResultsOut of 233 included patients, 131 received a PPI per FMT protocol resulting in 27 cases of treatment failure. There were 23 cases of recurrence out of 102 patients who did not receive pre-FMT PPI. The primary outcome occurred in 20.6% in the group with PPI use vs. 22.6% in the group without (RR 0.91; CI 0.56 - 1.50). Limitations include the lack of studies directly comparing outcomes with respect to PPI use, and inability to control possible confounders such as chronic PPI use, amount of stool transplanted, and pre-FMT antibiotics.ConclusionWe did not find a significant difference in efficacy between FMT protocols with regard to PPI use. It is possible that the theoretical benefit from increased survival of transplanted microbiota is offset by negative effects associated with PPIs. We suggest that routine use of PPIs in FMT be reconsidered in the absence of clear benefit. Further investigation is needed to optimize protocols for safety and efficacy. Disclosures All authors: No reported disclosures.

Endoscopic sleeve gastroplasty: a modified technique with greater curvature compression sutures.

Background Endoscopic sleeve gastroplasty (ESG) is rapidly becoming established as a safe and effective means of achieving substantial weight loss via the transoral route. New ESG suture patterns are emerging. Our aim was to investigate whether superior weight loss outcomes can be achieved by using a unique combination of longitudinal compression sutures and “U”-shaped sutures. Methods This is a retrospective review of prospectively collected data of all patients undergoing ESG by a single operator in a single UK center. Results Between January 2016 and December 2017, 32 patients (23 female) underwent ESG; n = 9 cases were completed utilizing a commonly used triangular suture pattern (“no longitudinal compression”) and n = 23 cases were completed using our unique “longitudinal compression” suture pattern. In the no compression and compression groups, the mean ages were 45 ± 12 years and 43 ± 10 years, the median baseline weights were 113.6 kg (range 82.0 – 156.4) and 107 kg (range 74.0 – 136.0), and the median baseline body mass indexes (BMIs) were 35.9 kg/m 2 (range 30.9 – 43.8) and 36.5 kg/m 2 (range 29.8 – 42.9), respectively. After 6 months, body weight had decreased by 21.1 kg (range, 12.2 – 34.0) in the compression group (n = 7) versus 10.8 kg (range, 7.0 – 25.8) in the no compression group (n = 5) ( P = 0.042). Correspondingly, BMI decreased by 7.8 kg/m 2 (range, 4.9 – 11.2) and 4.1 kg/m 2 (range, 2.6 – 7.2) in each group, respectively ( P = 0.019). Total body weight loss (%TBWL) was greater in the compression group at 19.5 % (range, 12.9 – 30.4 %) compared to 13.2 % (range, 6.2 – 17.1 %) in the non-compression group ( P = 0.042). No significant adverse events were reported in this series. Conclusion The technique of ESG is evolving and outcomes from endoscopic bariatric therapies continue to improve. We provide preliminary evidence of superior weight loss achieved through a modified gastroplasty suture pattern.

Incidence of Bleeding Complications With Flexible Bronchoscopy in Cancer Patients With Thrombocytopenia.

Bronchoscopy is a safe procedure, but current guidelines recommend transfusion for platelets <20 K/μL. Studies of bronchoscopy in thrombocytopenia are limited. Our objective was to evaluate the incidence of bleeding with flexible bronchoscopy in those with thrombocytopenia especially those <20 K/μL. We performed a retrospective review of all flexible bronchoscopies between June 1, 2008 and December 31, 2010. Biopsies and therapeutic procedures were excluded. The χ, Fisher exact, and Rank-sum test were conducted to evaluate associations of clinically significant bleeding. There were 1711 patients who underwent 2053 flexible bronchoscopies. Cancer diagnosis included hematologic (61.3%) and solid organ malignancy (34.9%). Half of the bronchoscopies had moderate to severe thrombocytopenia (<100 K/μL) with the following ranges: 14.7% with 50 to <100 K/μL, 20.6% with 20 to <50 K/μL, 10.6% with 10 to <20 K/μL, 4.1% with <10 K/μL. Platelet transfusion was given in 90.6% of those with platelets <10 K/μL and 55.5% of those with platelets 10 to <20 K/μL. The nasal route for bronchoscopy was used in 92.4%. Bleeding complication rate however was 1.1% (0.2% major) and not affected by platelets. Bronchoscopy with lavage can be safely performed without platelet transfusion in those with platelets of ≥10 K/μL. In the absence of nasal bleeding, trauma, or deformity, the nasal route can be used for bronchoscopy.

Extracervical Approaches to Thyroid Surgery: Evolution and Review.

Over the last two decades, advances and adaptation of technology have led to a variety of endoscopic thyroidectomy procedures being performed. The drive for extracervical procedures has been predominantly influenced by the desire for improved cosmesis via avoidance of visible scars. Extracervical techniques have shown considerable evolution with approaches that have included transaxillary, breast, postauricular, and transoral routes. There has been a varied evidence base for each of these approaches with regard to technical feasibility, safety, patient satisfaction, and cost-effectiveness. In recent years, robotic-assisted thyroid surgery has gained increased popularity worldwide with the introduction of the da Vinci Robot. Reports of improved postoperative outcomes and patient satisfaction have been in contrast to the financial burden, longer operative time, and increased training required which, to date, have limited widespread application. The aim of this review is to describe the evolution of extracervical procedures including surgical approaches, outcomes, advantages, and disadvantages. Consideration is also given to the future direction of extracervical thyroid surgery with regard to the safety, feasibility, and application of robotic systems.

A Review of Postoperative Pain Management for Thyroid and Parathyroid Surgery

BackgroundPerioperative opioid use has been linked to abuse potential by patients, leading surgeons to scrutinize their postoperative prescribing practices. The goal of the study was to review analgesic regimens for patients undergoing thyroidectomy and parathyroidectomy and extrapolate changes that could be made to decrease opioid use while maintaining adequate pain control. Materials and methodsA literature review was performed. Inclusion criteria were studies 1) written in English, 2) published within the last 20 years, and 3) that included human subjects. Exclusion criteria were studies that 1) evaluated anesthesia regimens exclusively, 2) compared surgical approaches and their effects on pain (e.g., open neck exposure vs. transoral route for thyroidectomy), or 3) included patients undergoing concurrent lateral neck dissection. Of 951 studies originally identified, 10 studies met the criteria. ResultsTen studies were identified, and each evaluated a different analgesic regimen. Five of the studies found a decrease in pain with multimodal regimens. Of the remaining studies, three found no difference in pain control, one found an increase in pain when only an opioid patient-controlled analgesia was used, and one found that 93% of patients required less than 20 oral morphine equivalents postoperatively. ConclusionsThere is no postoperative analgesic regimen that has been established as optimal for patients undergoing parathyroidectomy and thyroidectomy in the current medical literature. However, half of the studies included in this review found that nonopioid adjuncts decreased patients’ need for postoperative opioids.

Voice outcome measures after flexible endoscopic injection laryngoplasty.

ObjectiveTo report voice outcome measures after injection laryngoplasty using the transnasal or transoral flexible endoscopic technique.MethodsA retrospective review of all patients who underwent flexible endoscopic injection laryngoplasty between June 2010 and August 2016 was carried out. Only those patients who had pre- and post-injection voice outcome measures recorded were included. Voice outcome measures recorded included perceptual voice evaluation using GRBAS, Voice Handicap Index-10 (VHI-10), maximum phonation time (MPT) and closed quotient (CQ) before and after treatment.ResultsForty-six patients were identified, of which 32 had pre- and post-injection voice outcome measures recorded. There were 19 males and 13 females. The mean age was 56.97 years (range 20–86 years) and the most common indication was unilateral vocal fold paralysis. Thirteen patients had a transnasal flexible endoscopic injection), while 19 patients were injected transorally. Following injection laryngoplasty, there was significant improvement in the mean grade of dysphonia (2.81 vs. 1.22, P < 0.01, roughness (2.44 vs. 1.34, P < 0.01), breathiness (2.72 vs. 1.13, P < 0.01), asthenia (2.78 vs. 1.06, P < 0.01), and strain (2.44 vs. 1.19, P < 0.01), MPT (3.85 s vs. 9.85 s, P < 0.01) and mean CQ (0.19 vs. 0.46, P < 0.01). There was also a decrease in the mean VHI-10 score (33.31 vs. 7.94, P < 0.01).Conclusions: Patients achieved significant improvement in both subjective and objective voice measures after flexible endoscopic injection laryngoplasty via the nasal or transoral route. Voice outcomes were comparable to those reported for other approaches. This technique provides an alternative approach for the management of patients with vocal fold paralysis or glottal insufficiency.

Applicability of transoral endoscopic parathyroidectomy through vestibular route for primary sporadic hyperparathyroidism: A South Indian experience.

Introduction:Primary hyperparathyroidism is one of the most common endocrine disorders requiring surgical parathyroidectomy for its definitive treatment. Surgical exploration is traditionally performed through conventional open neck approach. A wide range of minimal access and minimally invasive endoscopic techniques (gas less and with gas) have been attempted in the past two decades. In this context, we evaluated the feasibility and safety of an innovative transoral endoscopic parathyroidectomy (EP) technique, which represents a paradigm shift in transluminal endocrine surgery.Materials and Methods:This is a prospective study conducted at a tertiary care Endocrine Surgery Department in South India between May 2016 and August 2017. We employed a novel transoral, lower vestibular route for EP. All the clinical, investigative, operative, pathological and post-operative data were collected from our prospectively filled database. Statistical analysis was performed with SPSS 20.0 version.Operative Technique:Under inhalational general anaesthesia, access to the neck was obtained with 3 ports (central frenulotomy and two lateral port sites), dissected in subplatysmal plane and insufflated with 6 mm Hg CO2 for working space. Rest of surgical steps is similar to conventional open parathyroidectomy.Results:Out of the 38 hyperparathyroidism cases operated during the study, 12 (32%) were operated by this technique. Mean operative time was 112 ± 15 min (95–160). The post-operative course was uneventful with no major morbidity, hypocalcemia or recurrent laryngeal nerve palsy. Cure and diagnosis were confirmed by >50% fall in intraoperative parathyroid hormone levels and histopathology (all were benign solitary adenomas).Conclusions:Through this study, we opine that this novel transoral vestibular route parathyroidectomy is a feasibly applicable approach for primary sporadic hyperparathyroidism, especially with solitary benign adenomas.

How I do it: Endoscopic endonasal approach for odontoid resection

BackgroundSince it was first described in 2005 by Kassam et al., the technique of endoscopic resection of the odontoid by the transnasal route has gained broad acceptance. Its advantages over the transoral approach are currently well-demonstrated. MethodThe authors present the surgical technique developed by the senior author in a series of 12 patients, specifying the planning, complications avoidance and showing a film of the operating technique. ConclusionEndoscopic endonasal odontoidectomy is an effective procedure with low morbidity. This technique has a place in the treatment of complex pathologies of the craniovertebral junction and has many advantages over the transoral route.