Tonsillectomy and residents: a safe match?

Letter to the Edito

Dissection with harmonic scalpel versus cold instruments in parotid surgery.

The harmonic scalpel (HS) has been used successfully in several head and neck surgical procedures. Some authors highlighted its advantages in reducing operative time, blood loss, and damages to surrounding tissue. In our study, we compared the results obtained during parotidectomy using the HS with the traditional approach to determine the benefits of the HS.130 patients with benign parotid tumors were enrolled and randomized into two groups for this prospective study. 63 patients underwent HS parotidectomy, and 67 patients received a parotidectomy using cold instruments and bipolar electrocautery hemostatic control (CI). 20 HS and 2 CI patients did not meet the inclusion criteria requirements, and were excluded.The admission time was significantly shorter in the HS group than the CI group (3.9 ± 1.2 days and 4.7 ± 1.4 days, respectively, p < 0.01). In the early post-operative period, 84\% of HS patients and 60\% of CI cases showed no facial nerve impairment (p = 0.01). Significantly more CI patients than HS patients showed the onset of Frey's syndrome (29\% and 9\%, respectively, p = 0.01). Multivariate stepwise regression analysis confirmed the reduction in admission length (Odds Ratio (OR): 0.62; p = 0.02) and the lower risk of Frey's syndrome (OR: 0.29; p = 0.04) in HS compared to CI parotidectomies.In parotid surgery, the HS is useful in preventing Frey's syndrome and reducing early transitory facial nerve dysfunction and admission times, and results in decreased medical costs and increased quality of life

Long-term subjective outcomes of barbed reposition pharyngoplasty for obstructive sleep apnea syndrome treatment

Background: The purpose of this study was to evaluate long-term subjective outcomes of barbed reposition pharyngoplasty for obstructive sleep apnea syndrome (OSAS) treatment using a specific questionnaire, the Palate Postoperative Problem Score (PPOPS). Methods: 140 patients who underwent barbed reposition pharyngoplasty (BRP) surgery in the Morgagni Pierantoni Hospital of Forlì, Italy were enrolled in the study. Postoperative outcomes were evaluated in a short- and long-term follow-up using the PPOPS questionnaire. The average period of follow-up was 26 months. All patients received the PPOPS questionnaire by telephone in a period between April and August 2019. Results: 51% of patients complained of swallowing problems after surgery. In 91% of cases, the problem cleared up spontaneously. At the time of the interview, only 9% of patients had a residual swallowing difficult. At the time of PPOPS evaluation, rhinolalia was observed in 8% of patients, whereas nose regurgitation was present in 2% of patients. In 20% of patients, the foreign body sensation was present during follow-up. The value of apnea-hypopnea index (AHI) reduced from the preoperative value of 31.5 to the postoperative value of 11.4. Conclusions: BRP surgery proved to be an effective technique, appreciated by the majority of patients. Use of the PPOPS questionnaire has demonstrated that the BRP technique seems to ensure efficacy and lower morbidity, with few complications after surgery

Risk Factors for Multiple Malignancies in the Head and Neck

Original research articl

Allergic fungal rhinosinusitis infiltrating anterior skull base and clivus.

Bone erosion and skull base invasion are often suggestive of a malignant mass in paranasal and nasal cavities. Nevertheless, forms of chronic rhinosinusitis, such as allergic fungal rhinosinusitis (AFRS), could mimic malignant features. Here, we report AFRS patient with orbital, anterior cranial fossa, Turkish saddle and clivus erosion. A 48-year-old Caucasian female with history of drug-resistant headache, nasal obstruction and anosmia was referred to our institution. Imaging showed hyperdense featureless tissue with signs of medial orbital wall, cribiform lamina and clivus erosions and encasement of right internal carotid artery. Massive amounts of thick and grayish mucoid material were evacuated during surgery. In case of bony erosion, malignancy should always be excluded. Often the correct diagnosis will be obtained only by operative specimens. AFRS could usually be managed endoscopically. Appropriate medical management of the AFRS should be administered in order to prevent relapses

Is open tracheotomy performed by residents in otorhinolaryngology a safe procedure? a retrospective cohort study.

Surgical or percutaneous tracheotomy is one of the commonest operations in the ENT practice and one of the first procedures to be taught to residents. No study exists that demonstrates the safety of this surgical procedure performed by unexperienced surgeons. The purpose was to compare outcomes of tracheotomies performed by supervised residents and surgeons in terms of postoperative complications and mortality, and identify risk factors for the onset of complications. Retrospective cohort study. Otolaryngology-Head and Neck Surgery Department, University of Florence, Italy. We included all patients undergoing tracheotomy from July 2008 to January 2013 and compared tracheotomies performed by supervised residents or surgeons. During the study period, 304 patients were submitted to tracheotomy. Patients operated by surgeons had a significantly higher number of tracheal rings fracture (p = 0.05), subcutaneous emphysema (p = 0.003) and tracheostomy tube displacement (p = 0.003), while supervised residents had a higher number of tracheitis/pneumonia (p = 0.04) as early complications. Patients operated by supervised residents had a significantly higher number of tube obstructions as late complication (p = 0.04). Using multivariate model, risk factors for early postoperative complications were male sex (p = 0.04) and delayed time to substitution with cuffless tube (p = 0.01), while only a trend to statistical significance was observed for urgent tracheotomies concerning the risk for late postoperative complications (p = 0.08). The current practice where residents perform tracheotomies supervised by a surgeon should not be disheartened. Our study demonstrates that it is safe and does not lead to higher risk of complications nor negatively affects the quality of care

Is elective neck dissection necessary in cases of laryngeal recurrence after previous radiotherapy for early glottic cancer?

To assess the clinical utility of elective neck dissection in node-negative recurrent laryngeal carcinoma after curative radiotherapy for initial early glottic cancer.A retrospective review was undertaken of 110 consecutive early glottic cancer patients who developed laryngeal recurrence after radiotherapy (34 recurrent T1, 36 recurrent T2, 29 recurrent T3 and 11 recurrent T4a) and received salvage laryngeal surgery between 1995 and 2005.Six patients presented with laryngeal and neck recurrence and underwent salvage laryngectomy with therapeutic neck dissection, 97 patients with recurrent node-negative tumours underwent salvage laryngeal surgery without neck dissection and only 7 underwent elective neck dissection. No occult positive lymph nodes were documented in neck dissection specimens. During follow up, only three patients with neck failure were recorded, all in the group without neck dissection. There was no significant association between the irradiation field (larynx plus neck vs larynx) and the development of regional failure. A higher rate of post-operative pharyngocutaneous fistula development occurred in the neck dissection group than in the group without neck dissection (57.2 per cent vs. 13.4 per cent, p = 0.01). Multivariate logistic regression analysis showed that early (recurrent tumour-positive, node-positive) or delayed (recurrent tumour-positive, node-negative) neck relapse was not significantly related to the stage of the initial tumour or the recurrent tumour. An age of less than 60 years was significantly associated with early neck failure (recurrent tumour-positive, node-positive).Owing to the low occult neck disease rate and high post-operative fistula rate, elective neck dissection is not recommended for recurrent node-negative laryngeal tumours after radiation therapy if the initial tumour was an early glottic cancer

Risk factors for obstructive sleep apnea syndrome in children: state of the art

The obstructive sleep apnea syndrome (OSAS) represents only part of a large group of pathologies of variable entity called respiratory sleep disorders (RSD) which include simple snoring and increased upper airway resistance syndrome (UARS). Although the etiopathogenesis of adult OSAS is well known, many aspects of this syndrome in children are still debated. Its prevalence is about 2% in children from 2 to 8 years of age, mostly related to the size of the upper airways adenoid tissue. Several risk factors linked to the development of OSAS are typical of the pediatric age. The object of this paper is to analyze the state of the art on this specific topic, discussing its implications in terms of diagnosis and management

First bite syndrome as presenting symptom of parapharyngeal adenoid cystic carcinoma.

First bite syndrome refers to the development of pain in the parotid region after the first bite of each meal.A man was referred to our institution with first bite syndrome as his only symptom. Magnetic resonance imaging of the head and neck revealed a deep lobe parotid mass in close contact with the external carotid artery. Computed tomography guided fine needle biopsy indicated adenoid cystic carcinoma. Total parotidectomy was performed, with en bloc resection of the infiltrated external carotid artery and a selective neck dissection of levels Ib to III. High-weight ion radiotherapy was administered post-operatively.First bite syndrome has hitherto only been described following parapharyngeal space surgery. We present the first case of parotid gland adenoid cystic carcinoma presenting with first bite syndrome as the only symptom. The presence of first bite syndrome should prompt the clinician to investigate the parapharyngeal space and deep lobe of the parotid gland, especially in the absence of other signs or symptoms

Subtotal supracricoid laryngectomy: changing in indications, surgical techniques and use of new surgical devices.

The aim of this study is to evaluate the evolution of supracricoid partial laryngectomy (SCPL) in indications, surgical techniques and outcomes through last decades.A retrospective analysis of 146 patients affected by laryngeal cancer treated with SCPL was carried on. We defined: (1) group A, 100 patients treated by cold instruments between 1995 and 2004; (2) group B, 46 patients treated by harmonic scalpel between 2005 and 2010. Complications rate, and functional and oncological results were documented and a comparison between the two groups was made; histopathological analysis of surgical margins was evaluated and correlated with local incidence of recurrence.Significant differences in age mean-value (p=0.02), T classification (p=0.007), and in indication for more advanced-staged patients were found in group B (p=0.001). Surgical procedure was shorter in group B (p<0.001), with shorter swallowing recovery (p=0.003). Oncological outcomes did not report any significant differences. Group B showed a higher incidence of post- operative arytenoid edema (p=0.03) associated with a lower rate of pneumonia (p=0.038). Despite a higher rate of close or positive-margins found in group B no higher incidence of local-recurrence was reported (p=0.02) compared to group A.We documented changing in indications and surgical technique for SCPL because of the development of modern diagnostic techniques and the introduction of low-thermal injury device allowing a more challenging tumor excision as well as with a shorter swallowing recovery in our series