Laryngectomy with a Tritube® and flow-controlled ventilation.

We describe the novel use of the TriTube® and Evone® ventilator (Ventinova, Eindhoven, Netherlands) to facilitate curative resection of a transglottic squamous cell carcinoma. A 43-year-old man presented with acute laryngeal and subglottic airway obstruction secondary to a stage 4 transglottic squamous cell carcinoma. The patient underwent magnetic resonance imaging followed by a diagnostic panendoscopy. It was decided that tumour resection was appropriate and a management plan was established by a multi disciplinary team. A total laryngectomy was performed. It was determined that failure of translaryngeal tracheal intubation could be rescued with emergency surgical front-of-neck airway. General anaesthesia was induced using a total intravenous anaesthesia technique, oxygenation was achieved with high-flow nasal oxygen and the airway was secured using the TriTube and flow-controlled ventilation was delivered throughout the procedure using the Evone ventilator. This avoided an awake or emergency tracheostomy, with the associated theoretical risk of tumour seeding, allowed for excellent gas exchange throughout and permitted the surgeons to maintain a closed system during much of the procedure, including during fashioning of the stoma. When traditional laryngectomy tubes are used, this process ordinarily involves multiple extubations and apnoeic periods. Furthermore, the small subglottic tube allowed intra-operative assessment of the extent of the subglottic tumour, facilitating curative en bloc resection.

Patterns, timing and consequences of post-thyroidectomy haemorrhage.

INTRODUCTION Post-thyroidectomy bleeding is a low frequency but potentially life threatening event that is very difficult to predict. Given the increasing drive towards thyroidectomy with same day discharge, this study was conducted with the aim of identifying patterns, timing and consequences of post-thyroidectomy bleeding to assess the feasibility of day-case thyroidectomy. METHODS All patients who underwent a thyroidectomy between 2008 and 2015 at our institution were identified. Patterns, timing and consequences in all those who developed post-thyroidectomy bleeding were studied. RESULTS Of the 805 patients included in the study, 14 required re-exploration for bleeding; 7 (50%) of these within 8 hours of surgery, 6 (43%) between 18 and 30 hours, and 1 (7%) at 49 hours. Just under half (43%) of those with post-thyroidectomy bleeding had thyrotoxicosis. CONCLUSIONS A significant number of postoperative haemorrhages occurred beyond the immediate postoperative period. Same day discharge after thyroidectomy cannot therefore be recommended as a routine practice.

Bedside saccadometry as an objective and quantitative measure of hemisphere-specific neurological function in patients undergoing cranial surgery.

Cranial surgery continues to carry a significant risk of neurological complications. New bedside tools that can objectively and quantitatively evaluate cerebral function may allow for earlier detection of such complications, more rapid initiation of therapy, and improved patient outcomes. We assessed the potential of saccadic eye movements as a measure of cerebral function in patients undergoing cranial surgery peri-operatively. Visually evoked saccades were measured in 20 patients before (-12 hours) and after (+2 and +5 days) undergoing cranial surgery. Hemisphere specific saccadic latencies were measured using a simple step-task and saccadic latency distributions were compared using the Kolmogorov-Smirnov test. Saccadic latency values were incorporated into an empirically validated mathematical model (Linear Approach to Threshold with Ergodic Rate [LATER] model) for further analysis (using Wilcoxon signed rank test). Thirteen males and seven females took part in our study (mean age 55 ± 4.9 years). Following cranial surgery, saccades initiated by the cerebral hemisphere on the operated side demonstrated significant deteriorations in function after 2 days (p < 0.01) that normalised after 5 days. Analysis using the LATER model confirmed these findings, highlighting decreased cerebral information processing as a potential mechanism for noted changes (p < 0.05). No patients suffered clinical complications after surgery. To conclude, bedside saccadometry can demonstrate hemisphere-specific changes after surgery in the absence of clinical symptoms. The LATER model confirms these findings and offers a mechanistic explanation for this change. Further work will be necessary to assess the practical validity of these changes in relation to clinical complications after surgery.

Identification of predictors and development of a screening protocol for cerebello-pontine lesions in patients presenting with audio-vestibular dysfunction.

OBJECTIVES: Magnetic resonance imaging (MRI) scanning in the investigation of cerebellopontine angle lesions represents a finite resource, the use of which needs to be carefully rationalised. Our aim was to identify predictive factors that can distinguish between patients with and without cerebellopontine angle lesions, and develop a screening protocol which could be useful in the clinical setting as an aid to clinical judgment. DESIGN: Case-control study. SETTING: Secondary care. PARTICIPANTS: Audio-vestibular features were collated on 136 patients (M : F 1.39 : 1) and 288 controls (M : F 1 : 1.1). INTERVENTION: Diagnostic by analysis of symptoms and audiometric data using logistic regression, receiver-operator characteristic curves and backwards elimination. MAIN OUTCOME MEASURES: Development of a predictive algorithm comprising those factors which are most strongly predictive of the presence of a cerebellopontine angle lesion. RESULTS: Positive predictors of a cerebellopontine angle lesion include the interaural threshold difference at 1 (P = 0.044) and 4 kHz (P = 0.034). The threshold in the better hearing ear at 0.25 kHz exerts a negative predictive (i.e. protective) effect (P = 0.005). The presence of tinnitus does not appear to influence the outcome on logistic regression. Although vertigo does exert an influence on the overall model, its impact is highly equivocal. CONCLUSIONS: We have identified audiometric factors which exert a positive and negative predictive influence on the presence of a cerebellopontine angle lesion, and audiovestibular symptoms which appear to exert little effect on the model. Our predictive equation represents a user-friendly standardised method of risk-stratification of patients within a general otolaryngology clinic.