Sobia F. Khaja

Use of the King LT for emergency airway management.

OBJECTIVE To discuss the role of the King LT reusable supraglottic airway in emergency airway management. DESIGN Retrospective case series review. SETTING Tertiary academic medical facility. PATIENTS We studied patients who presented to the emergency trauma center having undergone intubation at an outside facility or at the scene of the incident. The otolaryngology service was consulted for definitive management of the airway. MAIN OUTCOME MEASURE Airway evaluation and management once the King LT has been placed. RESULTS Six patients with known prehospitalization use of the King LT presented to the emergency trauma center and subsequently required emergency tracheostomy for establishment of a secure airway. Fiberoptic and/or direct laryngoscopic evaluation performed with the tube in place failed to reveal whether safe oral endotracheal intubation could be performed because of visualization problems. Examination after tracheostomy and removal of the King LT revealed that in 2 patients, orotracheal intubation would have been difficult or impossible, whereas another 4 patients could have been intubated. One patient had prehospitalization placement of a King LT, which resulted in subcutaneous emphysema because of placement within the mediastinum. The patient was able to be successfully intubated and did not require tracheostomy. CONCLUSIONS The King LT offers benefits in emergency situations, but evaluation of the airway is challenging and often necessitates tracheostomy for establishment of a safe and secure airway. Even if tracheostomy is not required, serious complications may occur.

Benign Parotid Tumors.

This article reviews the epidemiology, embryology, risk factors, clinical presentation, diagnostic work-up, and basic management principles for the more common benign parotid neoplasms. The various histopathologies are also discussed and summarized.

Airway algorithm for the management of patients with a King LT.

To discuss an algorithm for managing the airway in patients presenting with a King LT in place.

Lymphoepithelial carcinoma of the major salivary glands: Predictors of survival in a non-endemic region

INTRODUCTION Lymphoepithelial carcinoma (LEC) of the salivary glands is extremely rare worldwide, with studies limited to small case reports and case series from endemic areas (Southern China, Arctic Inuits) and strong association to Epstein Barr Virus (EBV). Studies on non-endemic regions are even more limited given the reality of only sporadic cases in these areas. Using the National Cancer Database (NCDB), we present the largest study on salivary LEC from a non-endemic region, the United States. METHODS A retrospective review of the NCDB from 1998-2012 for LEC of the major salivary glands was performed. Demographic and clinical variables were extracted for analysis. Multivariate COX regression was used to assess predictors of survival. RESULTS Two hundred and thirty-eight cases were identified (0.66% of all salivary cancers). Median age at diagnosis was 62 with peak incidence in ages 50-70. Most patients were Caucasian (81.2%), without gender preference. Regional metastasis was common (45.1%) and did not significantly impact survival. Distant metastasis was rare (2%). Overall survival (OS) at 5- and 10 years was 77% and 56%. Surgery and radiotherapy significantly showed better survival outcomes than surgery alone (p<0.001). Age >62, advanced stage, and dual modality therapy were significant predictors of survival in multivariate analysis. CONCLUSION Lymphoepithelial carcinoma in the US mostly affects an older, Caucasian demographic. Regional metastasis is common and survival is fair at 5- and 10 years. Surgery and radiation are recommended for early and advanced disease stages. Age, stage, and therapy are significant predictors of survival outcomes.

Local repair of persistent tracheocutaneous fistulas.

Tracheocutaneous fistulas may persist after tracheostomy. Suture closure of the fistula may result in complications, including infection, wound dehiscence, and pneumomediastinum. We present a simplified and relatively safe technique to close persistent fistulas that may be performed under local anesthesia. A retrospective chart review was performed on 13 patients who were successfully treated, including 1 with incomplete closure that was successfully addressed by additional procedures. Our review included analysis of reported risk factors for persistence of tracheocutaneous fistulas: previous irradiation of the neck, an extended duration of cannulation, previous tracheostomies, obesity, and use of a Bjork flap or 4-flap epithelial-lined tracheostomy. All 13 patients in the study were found to have at least 1 of these risk factors.

Treatment and Survival Trends in Glottic Carcinoma in Situ and Stage I Cancer From 1988 to 2012

Objective: To identify trends in treatment and survival for patients with stage I glottic cancer and glottic carcinoma in situ (CIS). Methods: The 18-registry SEER data were analyzed for CIS and stage I glottic cancer. Treatment variables and observed and relative survival were assessed separately for stage I and glottic CIS. Results: Among 14 025 cases of stage I glottic cancer identified from 1988 to 2012, radiation was the most common treatment for all eras. An increase in surgical treatment occurred with a decline in combination therapy. There were 3169 cases of glottic CIS, with surgery the most common initial treatment but with radiotherapy increasing across the years. Relative survival was similar for treatment type and era of diagnosis. Among the 3738 patients with glottic CIS, 5.4% went on to develop invasive glottic carcinoma of any stage, with invasive cancer more common in patients treated by surgery alone compared to radiation or surgery with radiation. Conclusions: Despite changes in treatment modalities for CIS and stage I glottic cancer, there have not been significant changes in survival for CIS, with slightly improved survival for treatment with surgery alone. Patients treated with surgery alone had an increased rate of subsequent invasive cancer.

Venous Complications in One Versus Two Vein Anastomoses in Head and Neck Free Flaps

Objective: The purpose of this study was to compare rates of reexploration and flap failure in patients with 1- and 2-vein anastomoses in free flap reconstructions. Methods: Retrospective chart review of 300 patients undergoing free flap reconstruction to head and neck defects from 2010 to 2014. Results: One venous anastomosis was performed in 229 patients, and 2 venous anastomoses were performed in 71 patients. The 1-vein group had significantly more reexplorations in the operating room (36/229, 15.7%) compared with the 2-vein group (4/71, 5.6%; P = .028), even when controlling for flap type (P = .022). This finding remained true among radial forearm flaps (17/81, 21% vs 3/53, 5.7%; P = .024). The number of venous anastomoses was not significantly associated with flap failure, though patients with flap failure did have a significantly greater proportion of venous issues (P < .001). Conclusions: Two-vein anastomoses do not appear to reduce rates of flap failure or postoperative venous thrombosis but are associated with a lower number of reexplorations in the operating room even after accounting for differences in flap types and surgeons.

Predictors of survival in parotid adenocarcinoma not otherwise specified: a National Cancer Database study of 3155 patients

Parotid adenocarcinoma not otherwise specified (PANOS) is a common parotid cancer, but studies specifically on this subject are limited.

Congenital Neck Mass

An ex utero intrapartum treatment (EXIT) procedurewas performed for a neonate born by cesarean delivery at 37 weeks of gestation with a prenatally diagnosed neck mass. Initial laryngoscopywithaParsons laryngoscope identifiedairwaydeviationsecondary tomass effect, with intubation ultimately achieved with assistance of a bronchoscope. Examination revealed a large neck mass extending from the mandible to the clavicles, with mass effect causing neck extension and rotation. Themasswasmulticystic,with prominent vasculature, anda small areaof skinnecrosis. Followingbirth, themass continued togrow,with inability to palpate the sternal notch by day of life 4 (Figure, A). The patient underwent a magnetic resonance image (MRI) on day of life 3 which showed a 15.7 × 10.0 × 14.4-cm midline neckmasswith solid and cystic components. Flow voidswere present throughout the mass. The mass was isointense to hypointense on T1, and isointense to hyperintense on T2. The patient also underwent a computed tomographic (CT) scan, which demonstrated calcificationspresentwithin themulticystic neckmass.Owing to continuedgrowth and risk of airway compromise, thepatientwas taken to theoperating roomonday5of life for resectionof themassandtracheostomy.Pathologic results showedamultinodular 19-cm mass, 80% solid and 20% cystic, with multiple tissue types present (Figure, B-D). Preoperative photograph A Gross specimen after resection B

Can technique used for gastrostomy tube placement reduce the risk of gastrostomy‐site metastasis in head and neck cancer patients?

BACKGROUND Head and neck cancer patients are often malnourished as a result of dysphagia that may occur at the time of their initial presentation or that may develop subsequently. Nutritional support via gastrostomy tube decreases the morbidity associated with long-term nasogastric (NG) tube. Approximately 5% of the 200,000 percutaneous endoscopic gastrostomy (PEG) tubes placed annually in the United States are targeted to head and neck cancer patients. PEG placement is associated with the risk of tumor implantation at the PEG site. Although this occurrence is rare (estimated incidence of 0.5%–3% per year), it is associated with a poor prognosis. Recent publications propose that the risk of PEGsite metastasis may depend on the technique used for placement.