Stéphane Hans

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.

Postoperative Hemorrhage after Transoral Oropharyngectomy for Cancer of the Lateral Oropharynx

Objective: Assessment of incidence, risk factors, management, and outcome of postoperative hemorrhage after transoral oropharyngectomy for cancer of the lateral oropharynx. Methods: Retrospective review of a cohort of 514 cancers of the lateral oropharynx consecutively resected. Results: Incidence of postoperative hemorrhage was 3.6%. In 31.5% of cases, onset was after hospital discharge. No hemorrhages occurred after the end of the fourth postoperative week. Variables associated with increased risk of hemorrhage were advanced age (P = .004), antithrombotic treatment (P = .012), and robotic assistance (P = .009). When the source of hemorrhage could be identified, hemostasis, performed transorally in most cases, was highly effective; no patients in this subgroup showed recurrence. In spontaneously resolved hemorrhage under observation or when no active site of bleeding was found on exploration under general anesthesia, the recurrence rate was 18.1%. Overall, hemorrhage resulted in death in 2 patients. Conclusion: Exploration under general anesthesia in case of active bleeding and observation with discussion of arterial exploration of the ipsilateral external carotid system in patients in whom no source of bleeding can be identified are the keys to successful management of this potentially lethal complication.

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.

Guidelines of the French Society of Otorhinolaryngology (SFORL), short version. Diagnosis of local recurrence and metachronous locations in head and neck oncology

Surveillance is fundamental to the management of head and neck cancer. The present guidelines of the French ENT society (SFORL) were drawn up by a group of experts in the field, and are intended to specify the modalities of management, based on a review of the literature and, where data are lacking, to provide expert opinion. The present paper deals with guidelines for the diagnosis of local and regional recurrence and metachronous head and neck locations. Locoregional recurrence usually occurs within 3 years of primary treatment and is mainly related to the characteristics of the primary tumor and the treatment measures taken. Laryngeal location, safe primary resection margins, low level of lymph node invasion, unimodal primary treatment and early diagnosis of recurrence are factors of good prognosis. Systematic imaging surveillance may be considered for patients for whom a curative technique exists and when surveillance is difficult. The role of PET-scanning remains to be determined. Metachronous locations are frequent, even in the late course; prolonged surveillance is appropriate. The best preventive measure is cessation of alcohol abuse and smoking. Patient education is primordial.