The Need for a Motor Assessment Tool for Children with Autism-An Opinion Article.

There is a lot of evidence that early developmental therapy achieves impressive therapeutic results for those who require it. Therefore, developmental follow-up, which includes the process of monitoring the child's development over time, makes it possible to identify possible developmental problems and treat them from a young age. This assumption is true in relation to all children with developmental difficulties but is mainly true in the context of children with a diagnosis of autism. However, despite the abundance of developmental scales for the neurotypical population, there are currently no valid scales for assessing motor function for children with autism. The current article focuses on the presentation of the motor delay, identified according to the literature, in many of the children with autism and requires the provision of professional and compatible treatment for these children. This motor delay and the lack of a motor assessment tool for children with autism raises the need for an adapted motor developmental assessment tool, which will produce measurable results, to enable the monitoring of the aforementioned disability and the receiving of tailored treatment from the physiotherapists who deal with the development of children with autism at an early age. The article reviews common existing assessment tools for use in assessing normal development in children with autism, presents the limitations and the challenges that arise when using these assessment tools with children on the autism spectrum and presents the need for a new developmental assessment tool that will be built and validated specifically for children with autism.

Navigation-Guided Transnasal Endoscopic Delineation of the Posterior Margin for Maxillary Sinus Cancers: A Preclinical Study.

BACKGROUND: The resection of advanced maxillary sinus cancers can be challenging due to the anatomical proximity to surrounding critical anatomical structures. Transnasal endoscopy can effectively aid the delineation of the posterior margin of resection. Implementation with 3D-rendered surgical navigation with virtual endoscopy (3D-SNVE) may represent a step forward. This study aimed to demonstrate and quantify the benefits of this technology. MATERIAL AND METHOD: Four maxillary tumor models with critical posterior extension were created in four artificial skulls (Sawbones®). Images were acquired with cone-beam computed tomography and the tumor and carotid were contoured. Eight head and neck surgeons were recruited for the simulations. Surgeons delineated the posterior margin of resection through a transnasal approach and avoided the carotid while establishing an adequate resection margin with respect to tumor extirpation. Three simulations were performed: 1) unguided: based on a pre-simulation study of cross-sectional imaging; 2) tumor-guided: guided by real-time tool tracking with 3D tumor and carotid rendering; 3) carotid-guided: tumor-guided with a 2-mm alert cloud surrounding the carotid. Distances of the planes from the carotid and tumor were classified as follows and the points of the plane were classified accordingly: "red": through the carotid artery; "orange": <2 mm from the carotid; "yellow": >2 mm from the carotid and within the tumor or <5 mm from the tumor; "green": >2 mm from the carotid and 5-10 mm from the tumor; and "blue": >2 mm from the carotid and >10 mm from the tumor. The three techniques (unguided, tumor-guided, and carotid-guided) were compared. RESULTS: 3D-SNVE for the transnasal delineation of the posterior margin in maxillary tumor models significantly improved the rate of margin-negative clearance around the tumor and reduced damage to the carotid artery. "Green" cuts occurred in 52.4% in the unguided setting versus 62.1% and 64.9% in the tumor- and carotid-guided settings, respectively (p < 0.0001). "Red" cuts occurred 6.7% of the time in the unguided setting versus 0.9% and 1.0% in the tumor- and carotid-guided settings, respectively (p < 0.0001). CONCLUSIONS: This preclinical study has demonstrated that 3D-SNVE provides a substantial improvement of the posterior margin delineation in terms of safety and oncological adequacy. Translation into the clinical setting, with a meticulous assessment of the oncological outcomes, will be the proposed next step.

Long-term survival of head and neck squamous cell carcinoma after bone marrow transplant.

PURPOSE: The risk of developing head and neck squamous cell carcinoma (HNSCC) in patients with graft versus host disease (GVHD) after bone marrow transplant (BMT) is well established but large series reporting outcomes are sparse. METHODS: Retrospective, single institution, study of patients with GVHD and HNSCC after BMT, between January 1, 1968, and June 30, 2016. RESULTS: In total, 25 patients were studied, of which 21 (84%) were male and 4 (16%) were female. Mean age for BMT was 41 (18-65) years. All patients developed GVHD, most common site was oral cavity (19 patients, 76%). Mean age for diagnosis of HNSCC was 52 (28-76) years. Mean time between BMT and diagnosis of HNSCC was 12 (2-13) years. The 2-year progression-free survival (PFS) was 61.4%, 5-year PFS was 56.7%. The 2-year overall survival (OS) was 82.8%, 5-year OS was 68.7%. CONCLUSION: HNSCC can develop many years after BMT in patients without the classic risk factors for head and neck cancer. The majority were seen with oral cancer and with early-stage disease likely due to active surveillance and early detection in this patient population.

Cricotracheal resection for adult subglottic stenosis: Factors predicting treatment failure.

OBJECTIVES/HYPOTHESIS: Identify predictors of decannulation failure after cricotracheal resection (CTR) and thyrotracheal anastomosis (TTA) in patients with subglottic stenosis (SGS). STUDY DESIGN: Retrospective cohort study. METHODS: Charts of patients undergoing CTR and TTA for SGS at the University Health Network, Toronto, Ontario, Canada between 1988 and 2017 were reviewed. Patient, pathology, treatment, and outcome data were collected. The end points for statistical analysis were development of restenosis and permanent tracheostomy. RESULTS: One hundred fourteen patients (n = 114) were eligible for inclusion in this review. The mean age at primary resection was 46.9 years, 95 (83%) were females, and 19 (17%) were males. The rate of restenosis and permanent tracheostomy was 13% and 5%, respectively. Sixty-two patients (54%) underwent a CTR and TTA, and 52 patients (46%) underwent a CTR, laryngofissure, and TTA. Traumatic stenosis (odds ratio [OR] = 10.3, P = .017), longer T-tube duration (OR = 1.2, P = .011), combined glottic/subglottic stenosis (OR = 10.47, P = .010), start of the stenosis at the vocal cords (OR = 6.6, P = .029), postoperative minor complications (OR = 13.6, P = .028), and need for repeat surgery (OR = 44.1, P < .001) were associated with an increased risk of requiring permanent tracheostomy. CONCLUSIONS: CTR and TTA are excellent surgical approaches for adult patients with subglottic stenosis. In this study, 5% of patients required permanent tracheostomy. Factors predicting treatment failure include traumatic stenosis, longer T-tube duration, combined glottic/subglottic stenosis, start of stenosis at the level of vocal cords, postoperative minor complications, and need for repeat surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1634-1639, 2020.

Intraoperative cone-beam CT-guided osteotomy navigation in mandible and maxilla surgery.

OBJECTIVES: Surgical navigation systems based on preoperative imaging are now increasingly used for guidance of head and neck resection and reconstruction. The primary aim of this study was to quantify osteotomy cutting accuracy using an image-guidance system for intraoperative cone-beam computed tomography (CBCT) imaging and surgical saw navigation. To enable clinical translation of this CBCT-guided navigation system, a secondary aim of the study was to design and fabricate a patient reference tracker suitable for clinical use on a mobile mandible. METHODS: First, a preclinical cadaveric study was performed to quantify navigation accuracy with the use of clinically suitable patient reference trackers. Second, a proof-of-principle patient study was conducted to evaluate this technique under clinical conditions. RESULTS: In both preclinical (5 cadavers) and clinical (5 patients) experiments, the mean cutting accuracy was less than 2 mm. In all preclinical specimens, bilateral mandibulectomies and bilateral maxillectomies were performed, for a total of 20 cut planes for analysis. The mean (standard deviation [SD]) values for distance, pitch, and roll were 1.4 mm (1.1 mm), 4.2° (3.5°), and 2.9° (2.5°) mm, respectively. Five mandibulectomies were performed on five patients, for a total of 10 cut planes for analysis. The mean (SD) values for distance, pitch, and roll were 1.7 mm (0.8 mm), 5.4° (1.5°), and 6.7° (4.6°) mm, respectively. CONCLUSIONS: The overall performance in comparison to alternative approaches warrants further consideration. In terms of accuracy, the results presented here are comparable to recent systematic reviews assessing CAD-CAM cutting guides that cite accuracies of ~2 to 2.5 mm. LEVEL OF EVIDENCE: 2 Laryngoscope, 130:1122-1127, 2020.

Navigation-guided osteotomies improve margin delineation in tumors involving the sinonasal area: A preclinical study.

OBJECTIVES: To demonstrate and quantify, in a preclinical setting, the benefit of three-dimensional (3D) navigation guidance for margin delineation during ablative open surgery for advanced sinonasal cancer. MATERIALS AND METHODS: Seven tumor models were created. 3D images were acquired with cone beam computed tomography, and 3D tumor segmentations were contoured. Eight surgeons with variable experience were recruited for the simulation of osteotomies. Three simulations were performed: 1) Unguided, 2) Guided using real-time tool tracking with 3D tumor segmentation (tumor-guided), and 3) Guided by 3D visualization of both the tumor and 1-cm margin segmentations (margin-guided). Analysis of cutting planes was performed and distance from the tumor surface was classified as follows: "intratumoral" when 0 mm or negative, "close" when greater than 0 mm and less than or equal to 5 mm, "adequate" when greater than 5 mm and less than or equal to 15 mm, and "excessive" over 15 mm. The three techniques (unguided, tumor-guided, margin-guided) were statistically compared. RESULTS: The use of 3D navigation for margin delineation significantly improved control of margins: unguided cuts had 18.1% intratumoral cuts compared to 0% intratumoral cuts with 3D navigation (p < 0.0001). CONCLUSION: This preclinical study has demonstrated the significant benefit of navigation-guided osteotomies for sinonasal tumors. Translation into the clinical setting - with rigorous assessment of oncological outcomes - would be the proposed next step.

Laryngeal Split and Rib Cartilage Interpositional Grafting: Treatment Option for Glottic and Subglottic Stenosis in Adults.

Optimal management of tracheal stenosis depends on identifying causative factors. Risk factors include high tracheostomy, cricothyroidotomy, prolonged intubation, and proximal migration of an endotracheal tube cuff. Management ranges from conservative observation to endoscopic procedures or open surgical resections. The goal of surgical repair is an adequate airway, decannulation, and normal laryngeal function. For early stage disease, management of refractory conditions is via endoscopic procedures. An understanding of the respiratory function of the glottis and subglottis is essential when an optimum functional reconstruction of the glottic/subglottic area is considered. In this article we discuss different airway assessments and surgical management techniques.

Real-time continuous image-guided surgery: Preclinical investigation in glossectomy.

OBJECTIVES/HYPOTHESIS: To develop, validate, and study the efficacy of an intraoperative real-time continuous image-guided surgery (RTC-IGS) system for glossectomy. STUDY DESIGN: Prospective study. METHODS: We created a RTC-IGS system and surgical simulator for glossectomy, enabling definition of a surgical target preoperatively, real-time cautery tracking, and display of a surgical plan intraoperatively. System performance was evaluated by a group of otolaryngology residents, fellows, medical students, and staff under a reproducible setting by using realistic tongue phantoms. Evaluators were grouped into a senior and a junior group based on surgical experience, and guided and unguided tumor resections were performed. National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores and a Likert scale were used to measure workloads and impressions of the system, respectively. Efficacy was studied by comparing surgical accuracy, time, collateral damage, and workload between RTC-IGS and non-navigated resections. RESULTS: The senior group performed more accurately (80.9% ± 3.7% vs. 75.2% ± 5.5%, P = .28), required less time (5.0 ± 1.3 minutes vs. 7.3 ± 1.2 minutes, P = .17), and experienced lower workload (43 ± 2.0 vs. 64.4 ± 1.3 NASA-TLX score, P = .08), suggesting a trend of construct validity. Impressions were favorable, with participants reporting the system is a valuable practice tool (4.0/5 ± 0.3) and increases confidence (3.9/5 ± 0.4). Use of RTC-IGS improved both groups' accuracy, with the junior group improving from 64.4% ± 5.4% to 75.2% ± 5.5% (P = .01) and the senior group improving from 76.1% ± 4.5% to 80.9% ± 3.7% (P = .16). CONCLUSIONS: We created an RTC-IGS system and surgical simulator and demonstrated a trend of construct validity. Our navigated simulator allows junior trainees to practice glossectomies outside the operating room. In all evaluators, navigation assistance resulted in increased surgical accuracy. LEVEL OF EVIDENCE: NA Laryngoscope, 127:E347-E353, 2017.

Ludwig's Angina-A Controversial Surgical Emergency: How We Do It.

Objectives. To review the current protocols used for management of Ludwig's angina and to assess the efficacy of conservative measures in these cases. Methods. A retrospective review of patients who were admitted to our institution for management of Ludwig's angina between 2003 and 2010. Results. Two patients were identified. Both were managed successfully with conservative measures and close airway observation. None needed an emergency intubation or surgical tracheostomy. There were no mortalities, and both had a short hospital stay. Conclusion. Recently, management of Ludwig's angina has evolved from aggressive airway management into a more conservative one. This is based on close airway observation on a specialised airway unit and a serial clinical airway assessment. Improved imaging modalities, antibiotic therapy, surgical skills, and clinical experience are the key factors behind this change in practice.

Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution.

BACKGROUND: To investigate whether knowledge of the anatomical distribution of histologically proven deeply infiltrating endometriosis (DIE) lesions contributes to understanding the pathogenesis. METHODS: Observational study between June 1992 and December 2004 (retrospective study between 1992 and 2000; prospective study between 2001 and 2004). Continuous series of 426 patients suffering from pelvic pain who underwent complete surgical exeresis of DIE. DIE lesions were classified according to four different possibilities: (i) Firstly, DIE lesions were classified as located in the anterior or posterior pelvic compartment. (ii) Secondly, DIE were classified as left, median and right. (iii) Thirdly, DIE lesions were classified as pelvic or abdominal. (iv) Fourthly, DIE lesions that could present in a right and/or left location were classified as unilateral or bilateral. RESULTS: These 426 patients presented 759 histologically proven DIE lesions: bladder (48 lesions; 6.3%); uterosacral (USL) (400 lesions; 52.7%); vagina (123 lesions; 16.2%); ureter (16 lesions; 2.1%) and intestine (172, 22.7%). DIE lesions are significantly more often located in the pelvis (n=730 lesions) than in the abdomen (n=29 lesions) (P<0.0001). Pelvic DIE lesions are significantly more often located in the posterior compartment of the pelvis [682 DIE lesions (93.4%) versus 48 DIE lesions (6.6%); P<0.0001]. Pelvic DIE lesions are significantly more frequently located on the left side. For patients with unilateral pelvic DIE lesions, the anatomical distribution is significantly different in the three groups: left (172 lesions; 32.0%), median (284 lesions; 52.8%) and right (82 lesions; 15.2%) (P<0.0001). For patients with lateral lesions, left DIE lesions (172 lesions; 67.8%) were found significantly more frequently than right DIE lesions (82 lesions; 32.2%) (P<0.0001). A similar predisposition was observed when we included patients with bilateral pelvic DIE lesions (P=0.0031). The same significantly asymmetric distribution is observed for total (pelvic and abdominal) DIE lesions. CONCLUSIONS: Our results demonstrate that distribution of DIE lesions is asymmetric. It is possible that this is related to the anatomical difference between the left and right hemipelvis and to the flow of peritoneal fluid. These findings support the hypothesis that retrograde menstruation of regurgitated endometrial cells is implicated in the pathogenesis of DIE.