Revised recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic - what a difference a year makes.

BACKGROUND: During the early part of the COVID-19 pandemic, the Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force published recommendations on performance of tracheotomy. Since then, our understanding of the virus has evolved with ongoing intensive research efforts. New literature has helped us better understand various aspects including patient outcomes and health care worker (HCW) risks associated with tracheotomy during the COVID-19 pandemic. Accordingly, the task force has re-evaluated and revised some of the previous recommendations. MAIN BODY: Based on recent evidence, a negative reverse transcription polymerase chain reaction (RT-PCR) COVID-19 swab status is no longer the main deciding factor in the timing of tracheotomy. Instead, tracheotomy may be considered as soon as COVID-19 swab positive patients are greater than 20 days beyond initial symptoms and 2 weeks of mechanical ventilation. Furthermore, both open and percutaneous surgical techniques may be considered with both techniques showing similar safety and outcome profiles. Additional recommendations with discussion of current evidence are presented. CONCLUSION: These revised recommendations apply new evidence in optimizing patient and health care system outcomes as well as minimizing risks of COVID-19 transmission during aerosol-generating tracheotomy procedures. As previously noted, additional evidence may lead to further evolution of these and other similar recommendations.

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on return to Otolaryngology - Head & Neck Surgery Clinic Practice during the COVID-19 pandemic in Canada.

The novel Coronavirus (COVID-19) has created a worldwide deadly pandemic that has become a major public health challenge. All semi-urgent and elective medical care has come to a halt to conserve capacity to care for patients during this pandemic. As the numbers of COVID-19 cases decrease across Canada, our healthcare system also began to reopen various facilities and medical offices. The aim for this document is to compile the current evidence and provide expert consensus on the safe return to clinic practice in Otolaryngology - Head & Neck Surgery. These recommendations will also summarize general precaution principles and practical tips for office across Canada to optimize patient and provider safety. Risk assessment and patient selection are crucial to minimizing exposure to COVID-19. Controversial topics such as COVID-19 mode of transmission, duration of exposure, personal protective equipment, and aerosol-generating procedures will be analyzed and discussed. Practical solutions of pre-visit office preparation, front office and examination room set-up, and check out procedures are explored. Specific considerations for audiology, pediatric population, and high risk AGMPs are also addressed. Given that the literature surrounding COVID-19 is rapidly evolving, these guidelines will serve to start our specialty back into practice over the next weeks to months and they may change as we learn more about this disease.

Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic.

INTRODUCTION: The performance of tracheotomy is a common procedural request by critical care departments to the surgical services of general surgery, thoracic surgery and otolaryngology - head & neck surgery. A Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force was convened with multi-specialty involvement from otolaryngology-head & neck surgery, general surgery, critical care and anesthesiology to develop a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic. MAIN BODY: The tracheotomy procedure is highly aerosol generating and directly exposes the entire surgical team to the viral aerosol plume and secretions, thereby increasing the risk of transmission to healthcare providers. As such, we believe extended endotracheal intubation should be the standard of care for the entire duration of ventilation in the vast majority of patients. Pre-operative COVID-19 testing is highly recommended for any non-emergent procedure. CONCLUSION: The set of recommendations in this document highlight the importance of avoiding tracheotomy procedures in patients who are COVID-19 positive if at all possible. Recommendations for appropriate PPE and environment are made for COVID-19 positive, negative and unknown patients requiring consideration of tracheotomy. The safety of healthcare professionals who care for ill patients and who keep critical infrastructure operating is paramount.

Squeeze bottle versus saline spray after endoscopic sinus surgery for chronic rhinosinusitis: a pilot multicentre trial.

BACKGROUND: There is a need for controlled trials to guide the perioperative management of patients undergoing endoscopic sinus surgery (ESS). The authors performed a pilot multicenter trial to compare two types of saline delivery devices in this population. METHODS: Patients were randomized to high volume saline irrigation with a squeeze bottle and low volume saline spray after ESS in patients with chronic rhinosinusitis (CRS). Surgeons were blinded to treatment, and one-month postoperative scores for sinonasal outcomes [Sinonasal Outcome Test-22 (SNOT-22)] scale, nasal and sinus symptom score (NSS), and perioperative sinus endoscopy (POSE) scale were compared with preoperative scores. RESULTS: Nine centers provided data for 86 patients. All three outcomes measures improved significantly for both groups. Saline spray: SNOT-22 48.8 versus. 23.7, treatment effect 25.1 (95% confidence interval [CI], 17.9-32.2), POSE 21.1 versus. 8.4, treatment effect 12.7 (95% CI, 9.2-16.1), and NSS 8.2 versus 5.0, treatment effect 3.1 (95% CI, 1.4-4.9) pre- and postoperatively, respectively (all p < 0.0001). Squeeze bottle: SNOT-22 49.5 versus 23.6, treatment effect 25.9 (95% CI, 20.3-31.6), POSE 18.6 versus 9.2, treatment effect 9.3, (95% CI 6.7-12.0), and NSS 9.0 versus 5.7, treatment effect 3.3 (95% CI, 2.3-4.3) pre- and postoperatively, respectively (all p < 0.0001). Analysis of variance did not identify a difference between the two treatment groups. Subgroup analysis based on preoperative disease severity did not change the nonassociation of saline bottle with outcome measures. Post hoc sample size calculation determined that 176 patients is required to detect an 8.9-point difference in SNOT-22 scores. CONCLUSION: In this pilot multicenter trial examining patients with chronic rhinosinusitis undergoing ESS, both squeeze bottle and saline spray showed significant improvement in SNOT-22, POSE, and NSS scores at one-month postoperatively. Because the study was nonpowered, we cannot rule out a potential difference between the two treatment groups.

Endoscopic resection of malignant sinonasal tumours: current trends and imaging workup.

INTRODUCTION: Modern advances in endonasal endoscopic surgery have expanded its utility in the management of malignant sinonasal tumours, and the degree to which cases are eligible. Knowledge of the indications, inclusion and exclusion criteria and imaging workup that empowers judicious patient selection is essential. This article discusses the endoscopic resection of malignant sinonasal tumours. CONCLUSION: Studies describing the impact of patient quality of life will surely affect the fate of endoscopic resection, but the current trend suggests that this technique stands to replace an open approach when outcomes are similar. Combined craniofacial/endoscopic and craniofacial-only approaches to sinonasal malignancy remain an important option in the management of complex disease.

Endoscopic sinus surgery in patients with cystic fibrosis: a systematic review and meta-analysis of pulmonary function.

INTRODUCTION: The role of endoscopic sinus surgery (ESS) in patients with cystic fibrosis (CF) is not clearly defined. OBJECTIVE: TO perform a systematic review of subjective and objective outcomes of ESS in CF. METHODS: A systematic review was performed using the keywords 'sinusitis,' 'sinus surgery,' 'nasal polyps' and 'cystic fibrosis.' The quality of papers was assessed using the NICE scoring scale. Outcomes included safety, subjective symptoms, objective endoscopy scores, days spent in hospital, courses of antibiotics, and pulmonary function tests (PFTs). RESULTS: Nineteen studies involving 586 patients were included in the review. There were four prospective cohort trials, and three were rated as good quality. There were no major complications attributable to ESS. There was consistent evidence in four cohort studies of improved sinonasal symptoms, including nasal obstruction, facial pain, headaches, rhinorrhea and olfaction. Three studies reported conflicting results in post-operative endoscopy scores. Three studies showed a decrease in days spent in hospital, and two showed a significant decrease in courses of intravenous antibiotics. A recent study, however, did not show a difference in either days spent in hospital or courses of antibiotics. Pulmonary function tests were not improved by ESS in six cohort trials, and one small study found significant improvement. A meta-analysis of FEV1 scores confirmed no significant difference. CONCLUSION: THE most consistent findings of this review were that ESS in patients with CF is safe, produces symptomatic benefit, and does not consistently improve PFTs. There were more conflicting results with regards to endoscopy scores, days spent in hospital, and courses of intravenous antibiotics. Future prospective studies, utilizing validated quality of life, symptom and endoscopy scales, are needed to further elucidate the role of ESS in the management of chronic rhinosinusitis in CF patients.

Three-week thyroxine withdrawal thyroglobulin stimulation screening test to detect low-risk residual/recurrent well-differentiated thyroid carcinoma.

Measurement of serum TSH-stimulated thyroglobulin (Tg) is recognized as a sensitive method for detecting residual/recurrent well-differentiated thyroid carcinoma (WDTC) in patients previously treated by surgery and radioactive iodine (RAI) ablation therapy. WDTC patients who have an undetectable serum Tg on thyroid hormone therapy (THT) in the absence of Tg-antibody interference are considered to be at low risk for residual/recurrent disease. Traditional management has been to withdraw T4 for 4-6 weeks or T3 for 2 weeks to stimulate endogenous TSH. However, this prolonged THT withdrawal induces hypothyroidism and its concomitant morbidity. In the present study, we assess the efficacy of shortening the time of T4 withdrawal to only 3 weeks for detecting residual/recurrent WDTC as a sufficient serum TSH stimulus for obtaining a positive serum Tg result without a routine diagnostic whole body scan (WBS). Additionally, we have evaluated the impact of such a T4 withdrawal interval on quality of life and loss of employment time. A total of 181 patients with WDTC selected for study had previously been treated with a bilateral surgical thyroidectomy followed by RAI ablation therapy (average post-surgery to follow-up interval of 10.8 yr). All of the cohort had an undetectable (< 1 microg/l) serum Tg on THT without Tg-antibody interference. Serum TSH and Tg were measured before and after cessation of T4 therapy for 3 weeks. A serum Tg > or = 2 microg/l was considered positive for residual/recurrent disease. A quality of life questionnaire [Short-Form 36 (SF-36)] was administered before withdrawal, at peak TSH and after resumption of therapy. From the completed SF-36 questionnaires, the overall degree of functional impairment was not severe and did not result in loss of employment time. Moreover, this protocol identified three possible responses to the 3-week T4 withdrawal interval as follows: a) serum Tg undetectable with TSH > or = 25 mIU/l (approximately 75% of total cohort); b) serum Tg > or = 2 microg/l (approximately 10% of total cohort) which will require further investigation and treatment for residual/recurrent disease; c) undetectable serum Tg with inadequate TSH rise (approximately 15% of total cohort), which will require TSH stimulation by either longer T4 withdrawal or recombinant human TSH to exclude residual disease. We conclude that a stimulated serum Tg test performed 3 weeks after T4 withdrawal is a simple and cost-effective first-line screening test with minimal morbidity which is sufficient to evaluate low-risk WDTC patients for recurrent/residual carcinoma.

Carcinoma of the maxillary antrum: a retrospective analysis of 110 cases.

BACKGROUND AND PURPOSE: Cancer of the maxillary antrum is a rare disease with a variety of treatment options. The present study was undertaken to review the outcome of patients with carcinoma of the maxillary antrum managed at a single institution. MATERIALS AND METHODS: A retrospective analysis of 110 cases of carcinoma of the maxillary antrum managed with curative intent during the time period 1976-1993 was performed. There were 33 females and 77 males; the median age was 64 years (range 38-89). The median follow-up time was 4 years (range from 2 months to 17 years). The majority of patients presented with locally advanced disease (78 T4 tumours); nodal involvement was observed in 17/110 cases. Histologic subtypes included in the analysis were limited to squamous cell carcinoma (95 cases) and undifferentiated carcinoma (15 cases). Patients were managed with either primary radiation therapy with surgery reserved for salvage (83/110) or with a planned combined approach with surgery and either pre or postoperative radiation (27/110). RESULTS: The actuarial 5-year cause-specific survival rate was 43%. The 5-year local control rate was 42%. Of 63 patients with local failure, 25 underwent salvage surgery with a subsequent 5-year cause-specific survival of 31%. Multiple regression analysis of patient, disease and treatment related variables identified local disease extent and nodal disease at presentation as the only variables independently associated with cause-specific survival. CONCLUSIONS: This analysis indicates that survival from carcinoma of the maxillary antrum is poor with outcome strongly related to local disease extent. The best treatment strategy for this disease remains undefined. Salvage surgery can result in prolonged survival in selected patients experiencing local failure.

Supraomohyoid neck dissection. Is it diagnostic or therapeutic?

BACKGROUND: The supraomohyoid neck dissection (SOHND) is often performed in patients with cancer of the oral cavity, where there is no clinical or radiologic evidence of regional metastases. When on pathologic examination positive neck nodes are found, however, some consider it a curative operation, whereas others regard it as a staging procedure only. METHODS: We retrospectively reviewed 43 patients with cancer of the oral cavity who had a SOHND during the period from 1991 to 1994. All patients were staged as having N0 disease and had a total of 48 SOHNDs (38 unilateral, 5 bilateral). The follow-up period was at least 2 years. RESULTS: Seven of 48 N0-staged necks showed occult metastasis (15%). Two of these patients received postoperative radiotherapy. One of 7 (14%) patients with pathologic node-positive disease on the SOHND side developed recurrent ipsilateral neck disease during the follow-up period, whereas 4 (10%) recurrences developed in 41 necks that were pathologically staged as N0. Survival was 88% for patients with pathologically N0 necks versus 86% for patients with pathologically N+; disease. CONCLUSION: Supraomohyoid neck dissection is an effective staging procedure; however, in this group of patients, neck recurrence and patient survival after SOHND appear not to be related to pathology N stage. Also, SOHND with or without adjuvant radiotherapy appears to control the neck in the majority of patients, attesting to therapeutic efficacy. A prospective study is needed, however, to see if a "wait and see" policy does not achieve similar long-term outcome.

An objective analysis of the impact of lateral rhinotomy and medial maxillectomy on nasal airway function.

OBJECTIVE: The lateral rhinotomy and medial maxillectomy procedure, while known to interrupt nasal valve supports, has not previously been reported to adversely affect nasal airway function. The purpose of this study was to utilize state-of-the-art techniques to objectively analyze the impact of this procedure on nasal airway function. DESIGN: The study design was retrospective and subject controlled. METHODS: The study population was derived from an academic, tertiary-referral, otolaryngology-head and neck surgery department with an estimated catchment population of 4 million people. Subjects included 21 consecutive, long-term postoperative patients who had undergone lateral rhinotomy and medial maxillectomy for inverted papilloma. Objective measures included vestibular cephalometric measurements, airflow rhinomanometry, and acoustic rhinometry. RESULTS: Statistically significant results reveal that although lateral rhinotomy and medial maxillectomy are associated with alar collapse, both overall nasal airflow and valve areas are increased. CONCLUSION: Lateral rhinotomy and medial maxillectomy does not adversely affect nasal airway function. This appears to be the result of concomitant resection of the functionally dominant inferior turbinate. This suggests that lateral rhinotomy performed in conjunction with operations not requiring inferior turbinectomy, such as anterior craniofacial resection, may adversely affect nasal airway function.

Outcome analysis of Zenker's diverticulectomy and cricopharyngeal myotomy.

BACKGROUND: The optimal management of Zenker's diverticula is controversial in part because of the method of categorizing treatment success or failure. Subjective and objective radiologic tests have been used to evaluate the various treatment modalities. There seems to be poor correlation between subjective and objective findings, and we tested this hypothesis in a group of patients undergoing one form of therapy (diverticulectomy and cricopharyngeal myotomy [CPM]). METHODS: Eighteen consecutive patients underwent Zenker's diverticulectomy and CPM. Postoperative symptoms and abnormalities detected by barium esophagrams were evaluated after a mean follow-up of 30.3 months (range, 7-74 months). RESULTS: Three of 18 patients (17%) complained of dysphagia (2 occasional and not bothersome; 1 bothersome and affecting dietary intake). Postoperative static contrast esophagrams were interpreted without knowledge of the subjective symptoms. Small diverticula were identified in 8 patients (44%). There was poor correlation between symptoms and objective radiographic abnormalities with agreement of 56% and a kappa statistic of 0.23. CONCLUSIONS: Objective radiographic abnormalities are far more common than subjective complaints following diverticulectomy and CPM. Postoperative static contrast radiography is not routinely required and may be misleading because of the poor correlation between symptoms and radiographic findings. The value of dynamic videofluoroscopy needs to be evaluated.

Continuing medical education interests of Canadian otolaryngologists.

A questionnaire was sent to Canadian otolaryngologists to assess their continuing medical education interests. One hundred and eighty-seven completed questionnaires were returned, a response rate of 28.5%. The categories of highest interest were nose/sinus, otology/vestibular, and general otolaryngology. Lower overall ratings were found for head and neck surgery and facial plastic/reconstructive surgery topics.

Incidence and types of non-palpable thyroid nodules in thyroids removed for palpable disease.

The purpose of this study was to determine the number, size and types of non-palpable and ultrasound undetected thyroid nodules in thyroid glands removed for a single palpable nodule. Twenty patients undergoing partial (hemi- and subtotal) thyroidectomy and 40 patients having a total thyroidectomy were analyzed. Patients had no more than one palpable nodule, no cervical adenopathy and no history of previous thyroid surgery. An ultrasound was performed routinely within four months of surgery. Forty-six nodules were detected by final pathology in the partial thyroidectomy group but only 42% were detected by palpation and 59% by ultrasound. The median diameter of non-palpable and ultrasound undetected partial thyroidectomy nodules was 0.5 cm and all were benign except for one case of lymphoma. Pathology detected 186 nodules in the total thyroidectomy group although palpation only detected 22% of these and ultrasound 42%. The median diameters of the benign and malignant non-palpable nodules were 0.4 cm and 0.25 cm respectively. Most of the undetected nodules in the total thyroidectomy group were benign but there were 20 non-palpable and 18 ultrasound undetected papillary carcinomas.

Observations on the natural history of a parotid epithelial-myoepithelial carcinoma of intercalated ducts.

A case report of a parotid epithelial-myoepithelial carcinoma (EMC) of intercalated ducts is presented. There were no changes in clinical characteristics or growth over a four-year period as documented by repeated clinical examination and serial ultrasounds. This neoplasm may be mistaken for an adenoid cystic carcinoma on fine needle aspiration and is believed to represent an adenocarcinoma of low malignant potential. The imperceptible growth of this epithelial-myoepithelial carcinoma is in accord with a low malignant potential.

Nonpalpable occult and metastatic papillary thyroid carcinoma.

The results of palpation, ultrasound, and detailed pathology were compared in 50 patients undergoing total thyroidectomy. Of the 211 nodules recognized by pathology, palpation detected 24% and ultrasound detected 43%. There were 14 patients with palpable papillary carcinomas, and 12 of these 14 had metastatic foci in other portions of the gland. Metastatic foci would have been left in 10 patients if only a lobectomy had been performed and would have been left in 6 patients if only a subtotal thyroidectomy (as defined in this report) had been performed. Of the 33 patients with benign palpable nodules, 5 had occult papillary carcinomas. In 2 of those 5 patients, the occult carcinomas would not have been removed if a less-than-total thyroidectomy had been performed. The significance of these occult and metastatic papillary carcinomas is discussed.

Prevalence of human papillomavirus in sinonasal papillomas: a study using polymerase chain reaction and in situ hybridization.

Inverted and fungiform papillomas of the sinonasal cavity share a common origin from the Schneiderian membrane, but they differ widely in their rates of recurrence and progression to carcinoma. To determine the role of human papillomavirus in the etiology of these lesions, 15 inverted papillomas, five fungiform papillomas, and two squamous cell carcinomas associated with inverted papilloma were examined for the presence of HPV by in situ hybridization (ISH) and polymerase chain reaction (PCR). ISH was carried out on formalin-fixed, paraffin-embedded material using HPV types 6/11, 16/18, and 31/33/35 DNA probes. Tissue DNA was amplified by PCR with HPV L1 consensus primers, and the product was detected by gel electrophoresis, Southern blotting, and hybridization with type specific probes (HPV types 6/11, 16, 18). Three of 15 inverted papillomas and two of five fungiform papillomas were positive for HPV 6/11 by ISH, whereas PCR detected HPV 6/11 sequences in two of 15 inverted and three of five fungiform papillomas. Biopsies from two patients who had serial resections contained HPV 6/11 in the original lesions and all recurrences. No HPV was detected in the carcinomas by ISH, whereas PCR detected HPV 16 in one carcinoma. These findings confirm the presence of HPV DNA sequences in both inverted and fungiform sinonasal papillomas as well as in an associated squamous carcinoma. This would suggest a role for HPV in the pathogenesis of Schneiderian membrane lesions. Furthermore, our data indicate that ISH and PCR are equally sensitive in detecting HPV in sinonasal papillomas.