Ahmad Safadi

Reliability of a Transnasal Flexible Fiberoptic In-Office Laryngeal Biopsy

IMPORTANCE Transnasal fiberoptic laryngoscopy (TFL) has been used to guide various in-office procedures for the past 3 decades. Publications on in-office laryngeal biopsy have concurred that this procedure is safe, feasible, and easy to perform. However, the accuracy of in-office biopsy via TFL has not yet been established. The aim of this study was to examine this issue. OBJECTIVE To compare pathologic results obtained via in-office TFL with those of subsequent direct laryngoscopy to assess the accuracy of TFL as a diagnostic tool. DESIGN Prospective cohort study. SETTING Tertiary reference medical center. PARTICIPANTS One-hundred two patients with suspicious laryngeal lesions. INTERVENTION All patients underwent in-office biopsies. MAIN OUTCOME MEASURES All patients with malignant lesions were referred to appropriate services for treatment, and those with a diagnosis of a benign lesion or carcinoma in situ were referred for direct laryngoscopy for definitive diagnosis. The results of the pathologic testing on specimens from in-office and direct laryngoscopy were compared. RESULTS Adequate tissue for diagnostic purposes was obtained in 96 of 102 in-office TFL biopsies (94.1%). The biopsy results revealed invasive carcinoma in 34 patients (35.4%), carcinoma in situ in 17 patients (17.7%), and benign lesions in 45 patients (46.9%). All patients with benign lesions and carcinoma in situ were referred for biopsy of samples obtained using direct laryngoscopy, to which 57 patients agreed. The final pathologic results identified from the biopsies on direct laryngoscopy revealed that there was an underestimation of the TFL results in 30 of 91 patients (false-negative rate, 33.0%) and an overestimation in 1 patient (false-positive rate, 1.1%). The sensitivity of TFL biopsy compared with that of direct laryngoscopy biopsy was 69.2% and the specificity was 96.1%. CONCLUSIONS AND RELEVANCE Transnasal fiberoptic laryngoscopy yielded low sensitivity in assessing suspicious lesions of the larynx. These results may indicate that direct laryngoscopy represents the definitive pathologic diagnostic procedure whenever the pathologic results of an in-office TFL procedure are interpreted as benign or as carcinoma in situ.

One-Stage Decannulation Procedure for Patients Undergoing Oral and Oropharyngeal Oncological Surgeries and Prophylactic Tracheotomy~!2009-11-01~!2010-02-23~!2010-06-18~!

Objective: Decannulation of patients with tracheotomy usually requires decrease in tracheostomy tube size, capping for 24-48 hours and observation after tube removal. Delay in decannulation may increase cardiopulmonary load, prolong hospitalization and cause patient distress. We propose a one-stage procedure in an intensive care unit (ICU) setting for patients undergoing head and neck surgeries and temporary tracheotomy. Study Design and Setting: Patients undergoing resection of head and neck tumors involving the oral cavity or oropharynx in a tertiary cancer center were prospectively studied. Following clinical and laboratory assessments, the tracheostomy tube was removed under cardiopulmonary monitoring in the ICU. Results: All 24 study patients underwent successful decannulation and were discharged 24 hours later. Follow-up time was 5 months. None of them required reintubation or recannulation. Conclusion: A one-stage decannulation is feasible and safe for patients undergoing resection of head and neck tumors involving the oral cavity or oropharynx. This procedure may lessen hospitalization time and reduce patients distress.

Juvenile Angiofibroma: Current Management Strategies

Juvenile angiofibroma (JA) is a benign, highly vascular tumor which is diagnosed on the basis of clinical and imaging features. It has a characteristic pattern of spread commonly involving the pterygopalatine fossa and pterygoid base. The mainstay of treatment is surgery, while radiotherapy is rarely used for the treatment of recurrent lesion. Endoscopic endonasal surgery is currently the treatment of choice for small to intermediate size JAs, and is feasible even for advanced lesions; however, this should only be practiced in well-experienced centers.

Skull Base Reconstruction in the Pediatric Patient

Introduction Pediatric skull base and craniofacial reconstruction presents a unique challenge since the potential benefits of therapy must be balanced against the cumulative impact of multimodality treatment on craniofacial growth, donor‐site morbidity, and the potential for serious psychosocial issues. Objectives To suggest an algorithm for skull base reconstruction in children and adolescents after tumor resection. Materials and Methods Comprehensive literature review and summary of our experience. Results We advocate soft‐tissue reconstruction as the primary technique, reserving bony flaps for definitive procedures in survivors who have reached skeletal maturity. Free soft‐tissue transfer in microvascular technique is the mainstay for reconstruction of large, three‐dimensional defects, involving more than one anatomic region of the skull base, as well as defects involving an irradiated field. However, to reduce total operative time, intraoperative blood loss, postoperative hospital stay, and donor‐site morbidity, locoregional flaps are better be considered the flap of first choice for skull base reconstruction in children and adolescents, as long as the flap is large enough to cover the defect. Our “workhorse” for dural reconstruction is the double‐layer fascia lata. Advances in endoscopic surgery, image guidance, alloplastic grafts, and biomaterials have increased the armamentarium for reconstruction of small and mid‐sized defects. Conclusions Skull base reconstruction using locoregional flaps or free flaps may be safely performed in pediatrics. Although the general principles of skull base reconstruction are applicable to nearly all patients, the unique demands of skull base surgery in pediatrics merit special attention. Multidisciplinary care in experienced centers is of utmost importance.

Outcomes of Craniofacial Open Surgery in Octogenarians

Abstract Introduction The steady increase in average life expectancy has led to a rise in the number of referrals of elderly patients for major operations. It is not clear whether age itself is a risk factor for morbidity and mortality after skull base operations. We investigated a possible link among a cohort of patients older than 80 years of age who underwent those surgeries in our department. Methods We conducted a retrospective analysis of all patients who underwent skull base surgery at the TASMC (Tel Aviv Sourasky Medical Center) between 2000 and 2016. Results A total of 369 patients underwent open skull base surgeries in our institution, and 13 were patients older than 80 years. The median age of the octogenarians was 83.4 (range 80‐89), and the male‐to‐female ratio was 7:6. Twelve patients had major systemic comorbidities. Four patients had major complications associated with surgery: three had early wound complications, and one each had early central nervous system complications, early and late systemic complications, and late orbital complications. This complication rate is comparable to that of our younger group of 356 patients. The overall survival rate was measured for 30 days, 1 year, and 3 years, and it was not significantly different between the octogenarians and that of the younger patients. Further comparison of the elderly group with 13 matched younger patients revealed no difference of morbidity and mortality between the two groups. Conclusions Despite their systemic comorbidities, the morbidity and mortality rates associated with skull base surgery in octogenarians appear to be comparable to that of younger patients undergoing the same procedures.

Continuous lumbar drainage and the postoperative complication rate of open anterior skull base surgery: Lumbar Drainage in Open Skull Base Surgery

Anterior skull base operations pose the risk for postoperative cerebrospinal fluid (CSF) leak. Routine lumbar continuous drainage catheter (LD) placement is intended to decrease CSF leaks and central nervous system (CNS) complications, but there are no sound evidence‐based data on its efficacy. The primary goal of this study was to review CNS complications following anterior open skull base surgery and their association with LD placement. The secondary goal was to define predictors for the development of early CNS complications.

Avoiding dacryocystorhinostomy in cases of epiphora caused by inferior meatus obstruction

AimsTo determine the role of inferior meatus pathologies as an underdiagnosed cause of epiphora.MethodsThis study was conducted in the oculoplastic institution of Tel Aviv medical center—a regional referral center. A retrospective review of files of patients presenting to the lacrimal clinic with nasolacrimal duct obstruction between October 2010 and September 2016. Cases in which a pathology of the inferior meatus was identified and treated are presented in this article.ResultsDuring this time frame, we preformed 186 endoscopic dacryocystorhinostomy surgeries. Out of those, eight patients (4.3%) were diagnosed and treated for pathology causing an obstruction of the inferior meatus. Seven of our patients were females; the mean age was 24 years. A wide range of pathologies were found: cysts, dacryoliths, membranes obstructing the inferior meatus, and concheal obstruction. All patients went through endoscopic treatment targeted at the cause of obstruction. During follow-up (average 35 months) only two patients remained symptomatic and were referred for an endonasal endoscopic dacryocystorhinostomy.ConclusionsInferior meatus obstruction is an underdiagnosed cause of epiphora. Multiple pathologies may co-exist in the same patient. In select cases of NLDO, diagnosis and treatment can be done endoscopically, avoiding the need for dacryocystorhinostomy.

Enhanced visualization of the surgical field in pediatric direct laryngoscopy using a three-dimensional endoscopic system

BACKGROUND Direct laryngoscopy and rigid bronchoscopy are currently performed using 2-dimensional endoscopic systems. Our objective was to determine whether a 3-dimensional endoscopic system can enhance visualization of the surgical field in pediatric direct laryngoscopy and rigid bronchoscopy. METHODS A prospective cohort study was conducted. Thirty three children who underwent direct laryngoscopies in a tertiary referral childrens hospital were enrolled. Direct laryngoscopy was performed using both 2- and 3-dimensional endoscopic systems, after which the surgeons scored the quality of the images obtained with each system on a scale from 1 (low) to 5 (high). Comparison of the scores obtained with the 2 endoscopic systems was performed. RESULTS The 33 study children (mean age 2.3 years, M:F ratio 1:1.6) underwent 47 direct laryngoscopies. The mean score for visualization of the glottis was 4.8 for the three-dimensional system compared to 4.0 for the two-dimensional system (P = .025), 4.7 vs. 3.8, respectively, (P = .019) for the subglottis, and 4.6 vs. 3.9, respectively (P = .031) for visualization of the proximal trachea. The mean score for visualization of the distal trachea was 3.0 vs. 3.7, respectively (P = .020). In a child with recurrent type 3 laryngotracheal cleft a residual tracheo-esophageal fistula could not be detected using the 2D system, but was immediately detected using the 3D system. CONCLUSIONS Visualization of the glottis, subglottis and proximal trachea during direct laryngoscopy using a 3-dimensional endoscopic system was rated by the surgeons as being superior to the conventional 2-dimensional technique. Further outcome studies that will demonstrate the clinical advantage of the 3D technology are highly required. LEVEL OF EVIDENCE 2b.