Khalid Ghufoor

Endoscopic CO2 laser management of laryngocele.

Objective To report on the management of laryngoceles by CO2 laser‐assisted endoscopic excision.

Outcome of endoscopic treatment of adult postintubation tracheal stenosis.

Objectives/Hypothesis: To assess the results of primary endoscopic treatment of adult postintubation tracheal stenosis, to identify predictors of a successful outcome, and better define the scope and limitations of minimally‐invasive surgery for this condition.

Pharyngeal residue across the lifespan: a first look at what’s normal

Objectives:  Without good evidence, post‐swallow pharyngeal residue is considered abnormal. Our aim was to document residue from normal food and fluid boluses in young and elderly healthy populations.

Conjunctival Melanoma: The Role of Conservative Surgery and Radiotherapy in Regional Metastatic Disease

Objective: To evaluate prognostic factors and determine the role of conservative surgery and radiotherapy in managing metastatic conjunctival malignant melanoma (MM) involving preauricular/submandibular lymph nodes.

Feasibility of a synthetic temporal bone for training in mastoidectomy: face, content, and concurrent validity.

Objective To investigate the face, content, and concurrent validity of the synthetic Pettigrew temporal bone (PTB) for mastoidectomy training as compared with cadaveric temporal bone (CTB). Study Design A prospective evaluation study. Methods Participants were invited to perform a step-by-step modified radical mastoidectomy using both bones and complete a 22-item, 5-point Likert scale questionnaire. The questionnaire is divided into 4 domains: face validity (FV), global content (GC), task-specific content (TSC), and curriculum recommendation (CR). Results Thirty-six experts and 89 trainees completed all tasks, 63 using CTB and 62 using PTB. The PTB median FV was 4 (IQR: 4–5), GC of 4 (IQR: 4–5), TSC of 4 (IQR: 3–4), and CR of 4 (IQR: 4–5). The CTB was rated significantly higher than PTB by both groups in all domains; CTB FV: 5 (IQR: 4–5), GC: 5 (IQR: 4–5), TSC: 5 (IQR: 4–5), and CR: 5 (IQR: 5–5), p < 0.001 for each. Trainees rated PTB significantly higher than experts in all domains. There was no statistically significant difference between experts and trainees in rating the CTB in all domains. PTB gives similar haptic feedback to CTB, allows the use of suction and irrigation, has the important landmarks painted for identification, and contains articulating ossicles. The facial nerve anatomy was found to be inaccurate around the region of the second genu. Conclusion Participants found PTB to be valid for teaching some, yet not all, aspects of mastoid surgery, and experts agreed that it could improve global transferrable otologic skills. It is essential that the facial nerve anatomy is addressed before recommending this model.

Outcome of Treating Airway Compromise due to Bronchial Stenosis with Intralesional Corticosteroids and Cutting-Balloon Bronchoplasty

Objectives. To determine the feasibility, safety, and efficacy of treating benign bronchial stenosis with laryngoscopy, jet ventilation, intralesional corticosteroids, and cutting-balloon bronchoplasty. Study Design. Case series with planned data collection. Setting. National airway unit. Subjects and Methods. Ten adult patients with bronchial stenosis caused by Wegener’s granulomatosis (n = 6), tuberculosis (n = 2), intubation (n = 1), and photodynamic therapy (n = 1) who underwent bronchoplasty using cutting-balloon dilation via suspension laryngoscopy in 2009. Information about patient demography, etiology, lesion characteristics, and details of the interventions were recorded. Patients underwent spirometry before surgery and at last follow-up. Chest infection rate in the 6 months before bronchoplasty and from bronchoplasty to the last follow-up was ascertained. Results. There were 3 men and 7 women. Mean age at bronchoplasty was 46 ± 20 years. Length of stay was 1 day in all cases, and no treatment-related complications occurred. One patient required a second bronchoplasty at 55 days. Mean follow-up was 7 ± 2.3 months. Forced expiratory volume in 1 second increased from a prebronchoplasty mean of 1.6 ± 0.6 to 2.2 ± 0.5 at last follow-up (P < .0001; paired Student t test). Forced vital capacity rose from 2.7 ± 0.6 to 3.1 ± 0.6 (P = .02), and peak expiratory flow rate increased from 3.7 ± 0.8 to 5.0 ± 0.8 (P < .0001). Chest infection rate fell from an average of 0.7 ± 0.3 infections per month to 0.2 ± 0.2 (P < .003; paired Student t test). Conclusion. Cutting-balloon bronchoplasty via suspension laryngoscopy is an effective treatment for benign bronchial stenosis. It is safer than airway stenting and is less invasive than thoracotomy. The authors propose its use as first-line treatment for this condition.

Patient positioning for direct laryngoscopy--A national survey of 320 UK ENT consultant surgeons: Our experience.

Dear Editor, Direct laryngoscopy is a common procedure, with 31 000 cases beingperformed last year acrossUKENTdepartments. It is essential that optimal views of the larynx are obtained so that the procedure can be carried out safely and effectively, for both diagnostic and therapeutic purposes. This requires the cervical spine to be manoeuvred carefully and appropriately for optimum visualisation of the glottis. Since the first direct laryngoscope was inventedmore than 100 years ago, various different patient positions have been described to obtain views of the larynx. To understand these in more detail, we have briefly revisited the history and evolution of the various positions that have been described for direct laryngoscopy. Initially, it was Chevalier Jackson who described a range of manoeuvres to achieve optimal views for direct laryngoscopy in 1913. He proposed the use of a neutral position (where the head is rested on a pillow) for a diagnostic examination of the larynx, however, suggested that ‘for insertion of an insufflation tube, bronchoscope, or other instrument, it is absolutely necessary. . .to have the head in full extension’. The latter was achieved by Jackson’s assistant, Boyce, by supporting the patient’s head and neck in an elevated position off the end of the table; this has since been coined the ‘Boyce-Jackson’ position. In 1936, Sir Ivan Magill described the ‘sniffing position’ (‘the position the head assumes when one wished to sniff the air’) for direct laryngoscopy. The patient’s head is elevated by placing it on a pillow, which facilitates cervical flexion and extension at the atlanto-occipital joint. Other neck manoeuvres that have been described include the ‘sword swallow’ position, which is thought to provide cervical extension and therefore aligns the oro-oesophageal axis. A number of studies have evaluated the different positions used for direct laryngoscopy. Takenaka and colleagues compared radiological examinations of 30 patients in the neutral, sniffing and head extension positions. They identified that the sniffing position provided greater occipitoatlanto-axial extension than simple head extension alone and suggested that this could facilitate the procedure. Greenland and colleagues reported that the sniffing position allowed better alignment of the oral, pharyngeal and laryngeal axes in comparison with the neutral position through the use of MRI in 10 patients. On the other hand, Adnet and colleagues reviewed 456 patients and reported that the sniffing position offered no significant benefit when compared to simple head extension alone in the majority of patients. However, the authors did suggest that it could improve glottic exposure in obese patients or those with reduced neck mobility, cohorts in which adequate laryngeal views are known to be considerably difficult to achieve. It is perhaps the description of the three-axis alignment theory by Bannister and Macbeth in 1944 that provides the most persuasive argument as to why the sniffing position is considered to provide optimal views. This theory clearly demonstrates that whilst neck flexion aligns the pharyngeal and laryngeal axis, head extension at the atlanto-occipital joint aligns the oral axis with these two axes, thereby facilitating a straight line of vision on the glottis. This ‘sniffing’ position is now widely accepted as the ideal position for direct laryngoscopy, which provides optimal views of the larynx. In today’s practice, this position is most frequently achieved by elevating the head on a head ring to provide cervical flexion together with extension at the atlanto-occipital joint. Furthermore, recent literature has supported the superiority of this position, as it has been shown that head elevation in conjunction with cervical flexion not only improves exposure of the glottis, but also reduces the pressure on the oropharyngeal tissues during the procedure and therebymay minimise the risk of postoperative complications caused by tissue trauma. Despite this evidence, a recent questionnaire-based study of UK ENT Specialist Registrar trainees suggested no general consensus in patient positioning when performing microCorrespondence: S.Mahalingam,Department of Otolaryngology, Head and Neck Surgery, East Surrey Hospital, RH1 5RH, UK. Tel.: 01737768511; Fax: 01293600428; e-mail: smahalingam@doctors.org.uk Correspondence 727