Andre Lamothe

Adult Epiglottitis in a Canadian Setting

The objective of this study was to determine stable estimates of the incidence, case fatality, and epidemiologic features of adult epiglottitis, and risk factors for intubation. The authors designed a retrospective cohort combined with a nested casecontrol study, followed by detailed analysis of cases from two tertiary care institutions. Among 813 cases, the incidence was 2.02 cases/105 population per year. Ten recorded deaths constituted a case fatality rate of 1.2% (95% confidence interval [CI]: 0.5% to 1.9%). The eight fully documented deaths indicated no sudden episodes of catastrophic upper airway obstructions without previous dyspnea. A detailed review of 51 cases revealed that 18% of patients underwent expeditious intubation. Patients managed without initially requiring intubation did not need emergency airway interventions. Only the presence of dyspnea (noted in 29% of patients) at the time of admission ( P < 0.001) predicted the need for intubation. A low case fatality rate in a conservatively managed cohort and the absence of sudden upper airway catastrophes in patients without dyspnea suggest that prophylactic intubation and intensive care unit monitoring is not warranted in all patients. An early complaint of dyspnea may safely discriminate between patients requiring invasive airway management and close observation.

Description and Evaluation of the Vallecula Sign: A New Radiologic Sign in the Diagnosis of Adult Epiglottitis

STUDY OBJECTIVE To describe and prospectively evaluate a new radiologic sign with the potential to increase the diagnostic accuracy of soft-tissue radiography of the neck in the identification of adult epiglottitis. METHODS We conducted a prospective, before-and-after blinded study at two tertiary care institutions. A convenience sample of four staff emergency physicians, three otolaryngology residents, four radiology residents, and four senior medical students volunteered to participate. We assembled 26 soft-tissue radiographs of the neck from consecutive patients ED with the diagnosis of epiglottitis made on the basic of direct visualization. Twenty-six control radiographs were identified from ED patients who were being evaluated for the presence of foreign bodies or minor cervical trauma. We then randomly mixed the two sets of radiographs. Participants were asked to identify epiglottis among the 52 randomly sequenced radiographs. A standardized 5-minute tutorial on the vallecula sign was presented to all participants after the first interpretation. We then asked the participants to make a second interpretation of the 52 radiographs without knowledge of correct answers from the initial evaluation. RESULTS The participants accurately classified 80.5% of all radiographs reviewed before the tutorial and 98.8% after the tutorial (P < .0001). Similarly, sensitivity improved from 78.5% to 98.2% (P < .0001) and specificity improved from 82.8% to 99.5% (P < .0001). We found no significant differences in performance characteristics among the different types of participants. CONCLUSION We have described a new radiographic sign that improves the diagnostic accuracy of soft-tissue radiography of the neck. If reproduced in prospective studies, the absence of the vallecula sign on radiography might obviate the need for routine use of direct visualization as an initial screen.

Interstitial low‐dose‐rate brachytherapy in the treatment of recurrent head and neck malignancies

Recurrent head and neck malignancies are therapeutically challenging. Brachytherapy is a retreatment alternative to external‐beam radiation therapy (EBRT).

Planum-Clival Angle Classification: A Novel Preoperative Evaluation for Sellar/Parasellar Surgery.

Objective Endonasal approaches are increasingly used to treat sellar pathologies, leading to increased interest in achieving maximal safe resection. We propose a tool-the planum-clival angle (PCA)-and explore its surgical implications for sellar pathology resections. Design Retrospective analysis. Participants Consecutive patients with pituitary lesions between 2003 and 2013. Outcome Measures The PCA and suprasellar extension ratios; head position and extent of surgical resection. Results We enrolled 89 patients (ages 21-88 years). There were 15 type A patients (17%), 13 with suprasellar extension (89%) and ratios between 0.12 and 0.70. There were 61 type B patients (70%), 49 with suprasellar extension (81%) and ratios from 0.09 to 0.66. Finally, there were 13 type C patients (13%), 10 with suprasellar extension (73%) and ratios from 0.21 to 0.76. Type B was treated with a sphenoidectomy and neutral head positioning, type A with 10 to 20 degrees of flexion and an additional posterior ethmoidectomy with or without posterior planum resection, and type C with 10 to 20 degrees of extension and an additional superior clival resection. Conclusions Sellar anatomy and PCA influence the growth patterns of sellar lesions. Thus PCA should allow for better surgical planning and thereby improve surgical efficacy.