Daniel Brasnu

Post-intubation laryngeal injuries and extubation failure: a fiberoptic endoscopic study

PurposeTo describe laryngeal injuries after intubation in an intensive care unit and assess their risk factors and their association with post-extubation stridor (PES) and extubation failure.MethodsProspective study including 136 patients extubated after more than 24xa0h of mechanical ventilation. Fiberoptic endoscopic examination of the larynx was systemically performed within 6xa0h after extubation in order to record four types of laryngeal anomalies: edema, ulceration, granulation, and abnormal vocal cord (VC) mobility.ResultsMedian duration of intubation was 3xa0days (min 24xa0h, max 56xa0days). Laryngeal injuries were frequent (73% of patients) and were associated with duration of intubation [odds ratios (OR) 1.11, 95% confidence interval (CI) 1.02–1.21, Pxa0=xa00.02] and absence of use of myorelaxant drugs at intubation (OR 0.13, 95% CI 0.01–0.99, Pxa0=xa00.05). Eighteen patients presented a PES. Lesions associated with PES were edema (67%, Pxa0<xa00.01) and abnormal VC mobility (67%, Pxa0<xa00.01). These injuries were associated with duration of intubation (OR 1.05, 95% CI 1.01–1.09, Pxa0=xa00.04), emergency intubation (OR 2.7, 95% CI 1.2–6.4, Pxa0=xa00.02), and height/endotracheal tube size ratio (OR 0.97, 95% CI 0.95–0.99, Pxa0=xa00.01). Seventeen patients were reintubated within 48xa0h following extubation. Laryngeal examination of these patients more frequently showed granulation (29.4%, Pxa0=xa00.02) and abnormal VC mobility (58.8%, Pxa0<xa00.01).ConclusionThis study found a high frequency of laryngeal injuries after extubation in ICU, which were associated with intubation duration and patient’s height/ETT size ratio. Edema was not the only injury responsible for PES, and although edema is frequent it is not the only injury associated with reintubation.

Transoral robotic surgery in head and neck cancer

Robots have invaded industry and, more recently, the field of medicine. Following the development of various prototypes, Intuitive Surgical® has developed the Da Vinci surgical robot. This robot, designed for abdominal surgery, has been widely used in urology since 2000. The many advantages of this transoral robotic surgery (TORS) are described in this article. Its disadvantages are essentially its high cost and the absence of tactile feedback. The first feasibility studies in head and neck cancer, conducted in animals, dummies and cadavers, were performed in 2005, followed by the first publications in patients in 2006. The first series including more than 20 patients treated by TORS demonstrated the feasibility for the following sites: oropharynx, supraglottic larynx and hypopharynx. However, these studies did not validate the oncological results of the TORS technique. TORS decreases the number of tracheotomies, and allows more rapid swallowing rehabilitation and a shorter length of hospital stay. Technical improvements are expected. Smaller, more ergonomic, new generation robots, therefore more adapted to the head and neck, will probably be available in the future.

Transoral robotic total laryngectomy

Minimally invasive surgery has become the standard of care in many organ systems. Head and neck surgery has incorporated transoral surgery, either laser microsurgery or robotic resection, in the management of pharyngeal and laryngeal cancers. To date, the laryngeal procedures have taken the form of partial laryngectomy, as transoral approaches have not allowed reconstruction following total laryngectomy. We present the first series of transoral total laryngectomies.

Transoral robotic surgery for head and neck carcinomas

The objective of this study was prospectively to assess the feasibility and safety of transoral robotic surgery (TORS) in head and neck carcinomas and to report our learning curve and 2-year outcomes. Patients with oropharyngeal, hypopharyngeal and laryngeal tumors treated with TORS were prospectively included. We evaluated: the feasibility of TORS, robotic set-up time, transoral robotic surgery time, blood loss, surgical margins, tracheotomy, feeding tube, time to oral feeding and surgery-related complications. Twenty-three patients were treated for 25 carcinomas. Twenty-two patients underwent successful robotic resection for 24 carcinomas (96%). One patient required conversion to open surgery due to massive bleeding. The mean robotic set-up time was 25xa0min (range: 15–100xa0min) and mean TORS operating time was 70xa0min (range: 20–150xa0min). Positive margin of resection was observed in one patient (classified pT3) out of the 24 cancers and was managed by postoperative chemoradiation. No tracheotomy was performed. Three patients required prolonged intubation for a mean of 22xa0h. Two patients required a temporary gastrostomy (for 2 and 3.5xa0months, respectively). All other patients resumed oral feeding between the first and third postoperative day. The mean hospital stay was 6.4xa0days (range: 4–19xa0days). No postoperative complication occurred. Mean follow-up was 20xa0months (median: 19, range: 14–26). No death and no case of local or metastatic failure were observed. TORS is feasible and safe for the resection of selected head and neck carcinomas. The occurrence of intraoperative bleeding emphasizes the need for surgeons to be skilled in both transoral and open approaches.

Organ preservation surgery for laryngeal squamous cell carcinoma: Low incidence of thyroid cartilage invasion

Determine the incidence and risk factors for thyroid cartilage invasion in early and midstage laryngeal cancer.

CT-scan prediction of thyroid cartilage invasion for early laryngeal squamous cell carcinoma

Treatment choice for laryngeal cancer may be influenced by the diagnosis of thyroid cartilage invasion on preoperative computed tomography (CT). Our objective was to determine the predictive value of CT for thyroid cartilage invasion in early- to mid-stage laryngeal cancer. Retrospective study (1992–2008) of laryngeal squamous cell carcinoma treated with open partial laryngectomy and resection of at least part of the thyroid cartilage. Previous laser surgery, radiation therapy, chemotherapy and second primaries were excluded. CT prediction of thyroid cartilage invasion was determined by specialized radiologists. Tumor characteristics and pathologic thyroid cartilage invasion were compared to the radiologic assessment. 236 patients were treated by vertical (20xa0%), supracricoid (67xa0%) or supraglottic partial laryngectomy (13xa0%) for tumors staged cT1 (26xa0%), cT2 (55xa0%), and cT3 (19xa0%). The thyroid cartilage was invaded on pathology in 19 cases (8xa0%). CT’s sensitivity was 10.5xa0%, specificity 94xa0%, positive predictive value 13xa0%, and negative predictive value 92xa0%. CT correctly predicted thyroid cartilage invasion in only two cases for an overall accuracy of 87xa0%. Among the false-positive CT’s, tumors involving the anterior commissure were significantly over-represented (61.5xa0% vs. 27xa0%, pxa0=xa0.004). Tumors with decreased vocal fold (VF) mobility were significantly over-represented in the group of false-negatives (41 vs. 13xa0%, pxa0=xa0.0035). Preoperative CT was not effective in predicting thyroid cartilage invasion in these early- to mid-stage lesions, overestimating cartilage invasion for AC lesions and underestimating invasion for lesions with decreased VF mobility.

Thyroid cartilage invasion in early-stage squamous cell carcinoma involving the anterior commissure

Anterior commissure (AC) carcinoma is in close proximity to the thyroid cartilage. Our objective was to evaluate risk factors for thyroid cartilage invasion.

Transoral robotic-assisted free flap reconstruction after radiation therapy in hypopharyngeal carcinoma: report of two cases

The objective was to assess the feasibility and safety of transoral robotic surgery (TORS)-assisted free flap reconstruction for hypopharyngeal carcinoma after radiation therapy. The study evaluated the feasibility, surgical margins, the need for a tracheotomy, a nasogastric tube as well as surgery-related complications. Two patients underwent TORS-assisted free flap reconstruction after radiation therapy. The resection margins were free of tumor in both patients. A tracheotomy was performed in one patient who had been decannulated on the sixth postoperative day. One patient resumed satisfactory oral feeding in the fourth postoperative month and the second patient on postoperative day 7. No intraoperative complication and one postoperative complication (neck hematoma) were reported. After a follow-up period of 24 and 30xa0months, no local recurrence was observed. TORS is feasible for hypopharyngeal resection and assisted free flap reconstruction after radiation therapy. It represents a further step in the development of minimally invasive surgery for the treatment of head and neck cancers with laryngeal preservation.

Contemporary Surgical Management of Early Glottic Cancer

For early-stage T1-T2 glottic squamous cell carcinoma, transoral laser microsurgery (TLM) is the main surgical modality, with rates of local control and laryngeal preservation ranging from 85% to 100% and low morbidity. For extensive lesions, open conservation laryngeal surgery may enable wider resections than TLM but at costs of longer hospital stay and higher postoperative morbidity. Surgery provides results that are comparable to nonsurgical treatment options while reserving radiation therapy for recurrences or second primary cancers, particularly in younger patients. In the future, transoral robot-assisted surgery may enable more extensive transoral resections than laser alone, decreasing further the indications for open surgery.

An unusual human papillomavirus type 82 detection in laryngeal squamous cell carcinoma: Case report and review of literature

Squamous cell carcinoma (SCC) of the larynx is extremely rare in adolescent or younger adult and typically has an aggressive nature. The mechanism of laryngeal oncogenesis is complex and little is known about the role of human papillomaviruses (HPVs) in SCC in young age. HPV infection may occur during birth or latter by oro-genital contact. Most HPV genotypes detected were HPV 6, 11, 16, 18, 33 and 51. Herein, we report a case of invasive laryngeal SCC expressing an HPV 82 in an 18 year-old man with a history of unexplored severe acute dysphonia that started in early childhood.