Avishay Golz

Tracheotomy Complications: A Retrospective Study of 1130 Cases

BACKGROUND: Tracheotomy is one of the most frequently performed surgical procedures in the critically ill patient. It is frequently performed as an elective therapeutic procedure and only rarely as an emergency procedure. Complications occur in 5% to 40% of tracheotomies depending on study design, patient follow-up, and the definition of the different complications. The mortality rate of tracheotomy is less than 2%. Numerous studies demonstrate a greater complication and mortality rate in emergency situations, in severely ill patients, and in small children. METHODS: A retrospective study of 1130 consecutive tracheotomies performed during 1 decade (January 1987 through December 1996) is presented. We studied the indications for surgery, the major complications of tracheotomy, and their treatment and outcome. We also noted the overall mortality rate and the specific complications that led to these deaths. RESULTS: In total, 1130 tracheotomies were performed. Major complications occurred in 49 of the cases, and 8 deaths were directly attributed to the tracheotomy. The most common complication was tracheal stenosis, which occurred in 21 cases. Hemorrhage was the second most common complication, which occurred in 9 cases. CONCLUSION: This is one of the largest series of consecutive tracheotomies compiled. We found a relatively low overall complication and mortality rate compared with other large series. Tracheal stenosis was the most common complication in contrast to other series. Our opinion is that this may reflect tracheal damage originally caused by prolonged intubation before the tracheotomy. We believe that all other complications of tracheotomy may be prevented or minimized by careful surgical technique and postoperative tracheotomy care. (Otolaryngol Head Neck Surg 2000;123:495-500.)

Retropharyngeal abscess : a clinical review

Retropharyngeal abscesses are uncommon but potentially lethal infections, especially in the paediatric population under the age of five years. Abscesses in this group are classically secondary to upper respiratory infections especially oropharyngeal infections, while in the adult group they are usually secondary to trauma, foreign bodies, or as a complication of dental infections. Early diagnosis and the wide spread use of antibiotics have made these infections less common today. Between the years 1985-1996, 19 cases of retropharyngeal abscesses were treated in our department. Factors such as age, sex, aetiology, presenting signs, symptoms, methods of diagnosis, treatment and complications were reviewed. Thirty-two per cent of the cases were secondary trauma. A lateral neck film showing widening of the prevertebral space was the most important diagnostic tool, computed tomography (CT) scan was used in 63 per cent of cases to verify the signs of an abscess and to provide more accurate anatomical localization. Thirteen cases required surgical drainage. The single most commonly-isolated pathogen was Streptococcus pyogenes. There were no deaths and only one recurrence requiring repeated surgical drainage. One case was complicated by a spinal canal abscess. We also report two cases of retropharyngeal abscess in children caused by swallowing of unusual foreign bodies.

Fluorodeoxyglucose-positron emission tomography/computed tomography imaging in patients with carcinoma of the larynx: diagnostic accuracy and impact on clinical management.

Objectives: The objectives of this study were to assess the value of 18F‐fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in patients with carcinoma of the larynx as compared with PET and CT alone and to assess the impact of PET/CT on further clinical management.

The beverage maté: a risk factor for cancer of the head and neck.

Maté is a tealike beverage consumed habitually in South America and among South Americans throughout the world. It is brewed from the dried leaves and stemlets of the perennial tree Ilex paraguariensis (yerba maté), a species that belongs to the Aquifoliaceae family. Maté consumption has been associated with an increased rate of oral, oropharyngeal, esophageal, and laryngeal cancers. The purpose of this study is to review the literature and discuss the role of Maté consumption as a risk factor for head and neck cancers.

Tracheotomy: Changing indications and a review of 1130 cases

BACKGROUND Tracheotomy is one of the oldest known operations, dating back to ancient Egypt and India some 3000 years ago. The indications for tracheotomy have changed and expanded during the twentieth century. Today, owing to advancements in intensive care and the widespread use of mechanical ventilation, tracheotomy is one of the most commonly performed surgical procedures and is encountered on a regular basis by hospital physicians in all fields. We present one of the largest series of consecutive tracheotomies spanning one decade. We review and discuss the modern indications for tracheotomy and emphasize the changes in these indications over the past century. METHODS A retrospective study of 1,130 consecutive tracheotomies performed over one decade is presented. We studied the indications for surgery, the complications and mortality rate, and the various hospital departments requiring tracheotomies. RESULTS A total of 1,130 tracheotomies were performed: 859 to assist in mechanical ventilation, 124 as an adjunct to head and neck or chest surgery, and 68 to relieve upper airway obstruction. Major complications occurred in 49 of the cases, and there were 8 deaths directly attributed to the tracheotomies. The most common complication was tracheal stenosis, occurring in 21 cases. Hemorrhage was the second most common complication, occurring in 9 cases. CONCLUSION Tracheotomy, once used almost exclusively to bypass upper airway obstruction, is now a very common elective therapeutic procedure used mostly to facilitate prolonged intubation and ventilation of the critically ill. Today tracheotomy is not and should not be an emergency procedure owing to the huge complication and mortality rate of emergency tracheotomy and the existence of alternative routes to obtain immediate airway control in the acutely obstructed upper airway.

Paper patching for chronic tympanic membrane perforations.

OBJECTIVE This study was designed to evaluate the results of paper-patch myringoplasty in patients with chronic perforations of the tympanic membrane of different sizes. STUDY DESIGN AND SETTING A retrospective survey of paper-patch myringoplasties performed in a tertiary referral academic medical center on 77 patients with chronic perforations of the eardrum was carried out. Data consisted of the causes of the perforations, time the perforations had been present, their size, number of patch applications, duration of application, and number of successfully closed perforations. RESULTS Closure rate was 63.2%, 43.5%, and 12.5% for small, medium, and large perforations, respectively. Small perforations needed the least number of repeated applications and the least time for closure. CONCLUSIONS AND SIGNIFICANCE Paper patching is technically simple, time saving, safe to perform, cost effective, and suitable as an outpatient procedure and has a good success rate, It should be tried in perforations smaller than 5 mm before a patient is referred for surgery.

The role of FDG-PET/CT imaging in head and neck malignant conditions: impact on diagnostic accuracy and patient care.

BACKGROUND: To assess the value of positron emission tomography/computed tomography (PET/CT) with 18 F-Fluorodeoxyglucose (FDG) in patients with head and neck carcinoma as compared with PET and conventional imaging alone, and to assess the impact of PET/CT on further clinical management. STUDY DESIGN: Prospective nonrandomized study. SETTING: Ninety patients with head and neck tumors had 107 PET/CT examinations. RESULTS: The study analysis showed that PET/CT had a sensitivity of 89%, specificity 95%, PPV 94%, NPV 90%, and accuracy of 92%. PET/CT altered management in 51 patients (56%). PET/CT eliminated the need for previously planned diagnostic procedures in 24 patients, induced a change in the planned therapeutic approach in 21 patients and guided biopsy in 6 patients. CONCLUSIONS: PET/CT is an imaging modality with high diagnostic performance in the assessment of head and neck cancer, and induced a change in further clinical management in more than half of the study population.

Prednisone Treatment for Vestibular Neuritis

Objective: To evaluate the value of corticosteroids in the treatment of vestibular neuritis (VN). Design: Prospective controlled randomized. Methods: Thirty VN patients, 15 in the study and 15 in the control group, were the subjects of the study. The study group was treated by 1 mg/kg prednisone for 5 days, followed by gradually reduced doses of prednisone for an additional 15 days, and vestibular sedatives for symptomatic relief during the first 5 days after presentation. The control group received a placebo and similar vestibular sedatives. The patients had a baseline evaluation and follow-up examinations after 1, 3, 6, and 12 months. The groups were compared for the presence of symptoms and signs, caloric lateralization on the electronystagmography (ENG), the presence of other pathologic findings in the ENG, and Dizziness Handicap Inventory scores. Results: No differences were found between the groups in the occurrence of symptoms and signs, degree of caloric lateralization, presence of other ENG pathologic findings, and Dizziness Handicap Inventory scores at the end of the study. Complete resolution was observed in 64% of the study and in 80% of the control group. The study group showed earlier recovery of ENG lateralization at the 1- and 3-month follow-up evaluations and higher rates of complete resolution at the 3- and 6-month follow-up points. Conclusion: Prednisone therapy might enhance earlier recovery but does not improve the long-term prognosis of VN. The clinical and laboratory parameters in VN are not correlated, and both are required for complete patient evaluation.

EFFECTS OF MIDDLE EAR EFFUSION ON THE VESTIBULAR SYSTEM IN CHILDREN

Vertigo and dizziness are not common in childhood, but are probably present more often than was formerly thought. These symptoms caused mainly by otitis media and middle ear effusion, two of the most common diseases in children, have been neglected for a long time, both in the literature and in practice, until recently. The purpose of this study was to determine objectively the incidence of balance-related symptoms in children with long-lasting middle ear effusion and to discover whether these symptoms resolve after the insertion of ventilation tubes. One hundred thirty-six children, ages 4 to 9 years, were given electronystagmographic tests and the Bruininks-Oseretsky tests for motor proficiency before and after tube ventilation of the middle ear. The results were compared with those in 74 healthy children with no history of middle ear diseases. Pathologic findings were found in 58% of the children with chronic middle ear effusion, as compared with only 4% of the control group. The symptoms and signs of balance disturbances resolved in 96% of the children after ventilation tube insertion. The results of this study indicate that balance-related symptoms often encountered in young children may result from chronic middle ear effusion and that these symptoms will resolve after evacuation of the effusion and ventilation of the middle ear.

The epiglottis and obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is caused by obstruction or narrowing of the airway at various levels. The repair of one site only will not alleviate the syndrome if there are obstructions in other sites. Epiglottis prolapse during inspiration is an unusual cause of airway obstruction and a rare cause of OSA. Twelve cases of OSAS due to an abnormal epiglottis are presented. We present our approach to the diagnosis using fibre-optic examination of the hypopharynx, and our treatment using endoscopic carbon dioxide laser partial epiglottidectomy. We found in our series that in 11.5 per cent of patients who failed the uvulopalatopharyngoplasty procedure, the reason was a narrow airway at the hypopharyngeal level caused by an abnormal epiglottis. It is our suggestion that in these cases a laser partial epiglottidectomy should be performed. The results of this study show that partial epiglottidectomy can increase the cure rate of patients with obstructive sleep apnoea syndrome by 10-15 per cent.