Who is performing percutaneous tracheotomies? Practice patterns of surgeons in the USA.

Tracheotomy is one of the most common surgical procedures performed in the ICU setting. Traditionally tracheotomy has been performed by otolaryngologists as well as general surgeons. While percutaneous tracheotomy (PT) has been available for some time, it has only recently gained widespread acceptance with the advent of convenient and safe kits. Over the past decade, there has been increased utilization of this technique. However, there is a relative reluctance of certain surgical specialties to perform and train residents in PT; a previous study identified that only 29% of otolaryngology head and neck surgery (OTO-HNS) departments in the USA perform PT. In this study we aim to investigate the trends of PT usage in general surgery training programs and compare them to those previously described in otolaryngology programs. The study design is multi-institution physician survey and the study method was a survey of 250 general surgery program directors. This survey was identical to a published survey of OTO-HNS and a head-to-head comparison of results was performed. The response rate was 53% (133 programs). 89% of general surgery programs performed open tracheotomy on a regular basis. 75% performed percutaneous tracheotomy on a regular basis. 79% use the Ciaglia Blue Rhino method. Simultaneous video bronchoscopy was used by 67%. 83% of general surgery residency programs train their residents in PT. 61% felt that PT was either safer than or equal to open tracheotomy. PT is performed in a majority of general surgery residency programs and taught to their trainees. This is in contrast to otolaryngology residency programs, which have been shown to prefer open tracheotomies in both practice and teaching. This trend may severely impact the skills of the next generation of otolaryngologists.

Unintentional parathyroidectomy and hypoparathyroidism in secondary central compartment surgery for thyroid cancer.

BACKGROUND: Unintentional parathyroidectomy is a complication of thyroid surgery. To our knowledge, no study has specifically examined the incidence of inadvertent parathyroidectomy exclusively in patients undergoing secondary central compartment surgery for recurrent or persistent thyroid cancer. METHODS: The records of 40 patients who underwent 42 secondary central compartment surgeries for thyroid cancer were reviewed to determine the incidence of inadvertent parathyroidectomy. RESULTS: Parathyroid tissue was present on permanent pathology in 31% of SCCSs. Unintentional parathyroidectomy did not have an effect on hypoparathyroidism. Concomitant lateral neck dissection did not have an effect on the incidence of hypoparathyroidism, but did have a statistically significant effect on inadvertent parathyroidectomy. CONCLUSION: Accidental resection of parathyroid tissue is relatively common in secondary central compartment surgery compared with primary thyroid surgery, but does not appear to correlate with postoperative hypoparathyroidism.

DaVinci robot-assisted transcervical excision of a parapharyngeal space tumor.

Neoplastic processes in the parapharyngeal space represent less than 1% of all head and neck tumors. Due to the complexity, deep location and surrounding vital structures of the parapharyngeal space, resection of tumors from this area can prove challenging. There are a number of surgical approaches traditionally used to access the parapharyngeal space; the choice is dictated by the size of the tumor, its location, its relationship to the great vessels, and suspicion of malignancy. We describe our innovative surgical technique employing DaVinci robot-assisted transcervical excision of a parapharyngeal space tumor. To the best of our knowledge this is the first report of this surgical technique.

The treatment of nasal fractures: a changing paradigm.

OBJECTIVES: To compare the efficacy of closed vs open treatment of nasal fractures, and to suggest an algorithm for nasal fracture management that includes closed and open techniques. METHODS: Retrospective study of 86 patients with nasal fractures who received either closed treatment (41 patients) or open treatment (45 patients) between January 1, 1997, and December 30, 2007. Fractures were classified as 1 of 5 types. Revision rates were calculated for each group. Preoperative and postoperative photographs were rated, if available, and patients were interviewed about aesthetic, functional, and quality of life issues related to surgical treatment. RESULTS: The revision rate for all fractures was 6%. The revision rate for closed vs open treatment was 2% vs 9%, respectively. Many closed treatment cases were classified as type II fractures, whereas most open treatment cases were classified as type IV fractures. There was no statistical difference in revision rate, patient satisfaction, or surgeon photographic evaluation scores between the closed and open treatment groups when fractures were treated in the recommended fashion. CONCLUSIONS: Patients who undergo open or closed treatment have similar outcomes if the surgical approach is well matched to the individual fracture. Our treatment algorithm provided consistent aesthetic and functional results while minimizing the need for revision procedures.

Secondary central compartment surgery for thyroid cancer.

OBJECTIVES/HYPOTHESIS: To report surgical outcomes in a large series of patients with a history of thyroid cancer who underwent secondary central compartment surgery (SCCS). STUDY DESIGN: Retrospective chart review. METHODS: The records of 44 patients who underwent 47 secondary central compartment surgeries for thyroid cancer were reviewed. RESULTS: Metastatic nodal disease was found in 59.6% (28) central neck compartments. Remnant thyroid tissue was removed from 17 necks. The rate of transient and permanent vocal cord paralysis per SCCS was 2.1% and 6.4%, respectively. Transient and permanent hypoparathyroidism occurred in 11.9% and 9.5% of cases, respectively. CONCLUSIONS: SCCS is feasible but does carry some risk. The long-term implications of early intervention in this setting are still largely unknown and will warrant future research.

Radioguided reoperative thyroid and parathyroid surgery.

This article highlights the major milestones in the development of radioguided reoperative techniques and reviews the recent literature concerning reoperative thyroid and parathyroid surgery.

Unilateral congenital facial nerve paralysis secondary to a benign epithelioid peripheral nerve sheath tumor.

OBJECTIVE: A benign epithelioid peripheral nerve sheath tumor is described in the setting of congenital facial nerve (FN) paralysis. This is the first reported case in the English literature. PATIENT: A 10-month-old girl with unilateral congenital FN paralysis. INTERVENTIONS: Auditory brainstem evoked potential study, gadolinium-enhanced magnetic resonance imaging, temporal bone computed tomography, and transmastoid FN decompression with tumor resection. MAIN OUTCOME MEASURES: Follow-up for tumor recurrence and postoperative FN function. RESULTS: The child underwent a transmastoid FN exploration with resection of a 0.6-cm spherical tumor analyzed to be a benign epithelioid peripheral nerve sheath tumor. There is no evidence of recurrence, and FN function was unchanged at 1 year postoperatively. CONCLUSION: Benign epithelioid peripheral nerve sheath tumor can cause congenital facial nerve palsy.

An unusual site of a CSF leak following resection of a retrosigmoid acoustic neuroma.

Cerebrospinal fluid (CSF) leaks may occur after acoustic neuroma resection. These leaks are usually the result of an iatrogenic injury during removal. The retrosigmoid approach is commonly associated with leaks that occur through the lateral end of the internal auditory canal, through the perilabyrinthine cells extending to the region of the internal auditory canal, or through the retrosigmoid air cells. We describe a case of an infracochlear CSF leak that developed following the retrosigmoid resection of an acoustic neuroma. To the best of our knowledge, this leak was unique for both its location and etiology.