Barbed reposition pharyngoplasty (BRP) in obstructive sleep apnea treatment: State of the art.

PURPOSE: In this paper, we perform a systematic review that discusses the state of the art and evolution on the barbed reposition pharyngoplasty (BRP) in the velo-pharyngeal surgery. Clinical evidence and published outcomes of this surgical technique are reported and discussed. MATERIALS AND METHODS: We performed a systematic review of the current literature through the analysis of the last 10 years of literature on barbed palate surgery. Study design, number of patients enrolled, inclusion criteria, pre- and posttreatment outcomes (AHI, ODI), surgical success rate, follow-up time and complication has been collected and reported. RESULTS: 15 studies for a total of 1531 patients, out of which 1061 underwent barbed reposition pharyngoplasty. Five trials were uncontrolled prospective studies (215 patients, 14% of total), nine were retrospective studies (1266 patients, 82,6% of total), and one randomized prospective clinical trial (RCT) (50 patients, 3,32% of total). All analyzed studies reported good outcomes after BRP surgery. Average preoperative values of AHI and ODI reduced in all studies considered with a significative statistical difference between preoperative and postoperative values (p < 0.05 in all cases). The postoperative surgical success rate ranged between 65.4 and 93% of cases. There were no significant intra-operative or post-operative complications in all studies considered in this systematic review. CONCLUSIONS: Barbed reposition pharyngoplasty has proven to be an easy to learn, quick, safe and effective new palatopharyngeal procedure, that can be used in a single level surgery or as a part of multilevel procedures.

The effect of the COVID-19 pandemic on non-elective otolaryngology admissions and a positive change in clinical practice.

As the COVID-19 pandemic progressed across the UK and Northern Ireland in March 2020, our otolaryngology department began to make preparations and changes in practice to accommodate for potentially large numbers of patients with COVID-19 related respiratory illness in the hospital. We retrospectively reviewed the number of non-elective admissions to our department between the months of January and May in 2019 and 2020. A significant reduction in admissions of up to 94% during the months of the pandemic was observed. Our practice shifted to manage patients with epistaxis and peritonsillar abscess on an outpatient basis, and while prospectively collecting data on this, we did not observe any significant adverse events. We view this as a positive learning point and change in our practice as a result of the COVID-19 pandemic.

Effects of COVID-19 Pandemic on Otolaryngology Surgery in Italy: The Experience of Our University Hospital.

Otolaryngology and head and neck surgery underwent drastic changes during the COVID-19 pandemic. Since March 10, the first day of the lockdown in Italy, diagnostic and therapeutic procedures were limited to emergency and oncology cases, while outpatient procedures and clinical examinations were temporarily suspended to limit virus diffusion and to reallocate personnel into wards dedicated to COVID-19. In our otolaryngology unit, between March 10 and April 28, 2020, we performed 96 surgical procedures; they mainly consisted in diagnosis and treatment of malignant tumors of the head and neck (77%), management of acute upper airway obstruction in adults and children (14.7%), drainage of abscesses of the head and neck (6.2%), and treatment of nasal bone fractures (2.1%). When comparing these data with those of the same period in 2019 for emergency and oncology procedures, we noticed a drastic reduction of head and neck abscesses and nasal bone fractures, while oncology surgery remained stable.

Epidemiology and incidence of severe respiratory critical events in ear, nose and throat surgery in children in Europe: A prospective multicentre observational study.

BACKGROUND: Ear, nose and throat (ENT) surgery, the most frequently performed surgical procedure in children, is a strong predictor for peri-operative respiratory complications. However, there is no clear information about peri-operative respiratory severe critical events (SCEs) associated with anaesthesia management of ENT children in Europe. OBJECTIVE: To characterise the epidemiology and incidence of respiratory SCEs during and following ENT surgery in Europe and to identify the risk factors for their occurrence. DESIGN: A secondary analysis of the Anaesthesia PRactice In Children Observational Trial, a prospective observational multicentre cohort trial. SETTING: The study included 261 centres across 33 European countries and took place over a consecutive 2-week recruitment period between April 2014 and January 2015. PATIENTS: We extracted data from 5592 ENT surgical procedures that were performed on 5572 children aged 6.0 (3.6) years (mean (SD)) from the surgical database and compared these with data from 15 952 non-ENT surgical children aged 6.7 (4.8) years. MAIN OUTCOME MEASURES: The primary outcome was the incidence of respiratory SCEs (laryngospasm, bronchospasm and new onset of postoperative stridor). Secondary outcomes were the differences in epidemiology between ENT children and non-ENT surgical children and the risk factors for the occurrence of respiratory SCEs. RESULTS: The incidence (95% confidence interval) of any respiratory SCE (laryngospasm, bronchospasm and postoperative stridor) was 3.93% (3.46 to 4.48) and was significantly higher than that observed in non-ENT surgical children [2.61% (2.37 to 2.87)], with a relative risk of 1.51 (1.28 to 1.77), P less than 0.0001. Younger age (14% decrease in critical events by increasing year, P < 0.0001), history of snoring, recent upper respiratory tract infection and recent wheezing increased the risk of suffering a SCE by over two-fold (P < 0.0001). There was also some evidence for a positive association with age below 4.6 years and lower surgical volume thresholds (<20 cases/2 weeks). CONCLUSION: The results of this study provide additional evidence for strong associations between risk factors and respiratory SCEs in children having ENT surgery. These observations may facilitate the implementation of good clinical practice recommendations for ENT patients in Europe. TRIAL REGISTRATION: ClinicalTrials.gov, number NCT01878760.

Inferior Turbinate Hypertrophy: A Review of the Evolution of Management in Children.

BACKGROUND: Historically, there has been uncertainty in the treatment of inferior turbinate hypertrophy (ITH) in children. Although management always begins with medical therapy, the decision to offer surgery in resistant cases is becoming more widely practiced. In the pediatric population, turbinate reduction can be achieved with turbinectomy, electrocautery, lasers, submucous microdebridement, and radiofrequency volumetric tissue reduction (RVTR). However, there remains a lack of consensus on the preferred approach to treatment. OBJECTIVE: To compare how the efficacy, duration, and complications of different surgical methods has changed the management of inferior turbinate hypertrophy in children over time. METHODS: In March 2018, a comprehensive literature search was performed in PubMed for all inferior turbinate hypertrophy management-related studies in children. Inclusion criteria included children (age, 1-17 years). Exclusion criteria included reviews and abstracts. RESULTS: Each technique has experienced a period of popularity over the last 30 years in parallel with the technology available at the time as well as evidence from studies in adults. The literature for ITH management in children has largely followed these trends, with a recent improvement in the quality of studies mirroring the overall increase in surgical practice. Of all methods currently used, RVTR and submucous microdebridement offer the least invasive and most efficacious relief of nasal obstruction. CONCLUSION: This review provides an overview of the evolution of ITH management in children and, based on historic and current evidence, proposes the following graduated recommendation to treatment: (1) a 3-month trial of medical management, (2) evaluation for adenoid hypertrophy for consideration of concurrent adenoidectomy, and (3) RVTR or submucous microdebridement as the first-line surgical approach.

Robotics in otorhinolaryngology - head and neck surgery.

A look at the past, present and future.

[Current trends in surgery for benign parotid lesions]. / Gutartige Parotistumore: moderne Therapiekonzepte.

Parotidectomy is the standard procedure for treatment of benign parotid tumors. Nowadays, one of the main objectives of surgery is to minimize morbidity. However, the debate about the appropriate surgical technique in parotid surgery is still ongoing. There is a high level of evidence, that limited parotidectomy techniques are associated with fewer complications and especially with lower prevalence of permanent facial nerve palsy and Frey´s syndrome. However, limited parotidectomy requires an accurate pre-selection of patients and a precise preoperative diagnostic work-up. This manuscript describes the current trends in surgery for benign parotid lesions and illustrates the treatment options for major post-parotidectomy complications.

Updating nasalisation: From concept to technique and results.

Nasalisation is a surgical technique proposed for the treatment of nasal polyposis in 1995. The technique as initially described was based on large opening of the maxillary, sphenoidal and frontal ostia and resection of the middle turbinates, with the aim of resecting the mucosa of the lateral masses of the ethmoid as completely and safely as possible. Recent findings on the evolution and development of the nose and sinuses and sinus physiology allow both the concept and the technique of nasalisation to be updated. According to evo-devo theory, the ethmoid is not a paranasal sinus but the skull-base bone housing the olfactory mucosa. In humans, the olfactory mucosa can be distinguished as functional in the upper recess of both olfactory clefts and vestigial in the rest of the ethmoid bone. Nasal polyposis presents clinically as a specific disease of the vestigial olfactory mucosa of the human ethmoid (and not as a particular kind of chronic rhinosinusitis). The aim of surgery for nasal polyposis is thus maximal resection of the vestigial olfactory mucosa, conserving olfactory function as long as possible. By the production, storage and bolus release of nitric oxide thanks to the sphincter function of the paranasal (maxillary, sphenoidal and frontal) sinus ostia, the paranasal sinuses perform a respiratory function that should be conserved as much as possible. The nasalisation technique has been modified in order for the vestigial olfactory mucosa to be completely resected while sparing the sinus ostia. Middle turbinate surgery still needs to be evaluated: resection is a step toward maximal removal of vestigial olfactory mucosa, while conservation could ensure olfactory cleft integrity. Thus, updating the concept of nasalisation enables the nasalisation technique to be integrated in the evo-devo concept of rhinology.

Trend in otolaryngological surgeries in an era of super-aging: Descriptive statistics using a Japanese inpatient database.

OBJECTIVE: To reveal the age distribution and capture the longitudinal trend in otolaryngological surgeries performed in Japan, where society is rapidly aging. METHODS: Using the Diagnosis Procedure Combination database, we extracted data on patients who were hospitalized and underwent any type of otolaryngological surgery in departments of otolaryngology or head and neck surgery from fiscal year 2007 to fiscal year 2013. Type of surgery, patient's age, and fiscal year were compared. We categorized >200 types of surgeries into eight specialties: ear surgery, functional endoscopic sinus surgery (FESS), other types of paranasal surgery (except for malignancy), head and neck cancer surgery, benign tumor surgery, upper airway surgery (including pharynx and larynx), removal of foreign body, and other. RESULTS: In total, 558,732 patients were included. The proportions of patients in each age category formed two peaks in middle age and in children aged ≤9years. The proportion of all surgeries made up by FESS, other paranasal surgery, benign tumor surgery, and head and neck cancer surgery gradually increased with age, forming a peak in patients in their 60s. The proportion of ear surgery was highest in patients aged ≤9years (34.0% of all surgeries, mostly myringotomy and transtympanic ventilation tube insertion) and formed a gradual peak in patients in their 60s (mostly tympanoplasty). The proportion of upper airway surgery (tonsillectomy and adenoidectomy) was highest in patients aged ≤9years (25.3% of all surgeries). The proportion of foreign body removal was highest in patients aged ≤9years (52.2% of all surgeries) and increased slightly with age. In 2013, compared with 2007, those aged 65-74 years and ≥75years made up a larger percentage of patients undergoing each specific surgery, including tympanoplasty, stapedectomy/stapedotomy, FESS, head and neck cancer surgery, pharyngolaryngectomy, total/subtotal glossectomy, thyroid lobectomy, parotidectomy (for a benign tumor), submandibular gland resection, tonsillectomy, and vocal fold polypectomy. CONCLUSION: The age distribution of otolaryngological surgeries varied by specialty. We found an increased proportion of patients aged 65-74 and ≥75years in most specific surgeries.

Changes in Scope of Procedures Performed by Pediatric Otolaryngologists in the Past Decade.

IMPORTANCE: Monitoring current trends in pediatric otolaryngology will help adjust our training and practice paradigms in a way that ensures the long-term viability of the specialty. OBJECTIVES: To gauge the current scope of pediatric otolaryngology (ORL) practice within and outside of the United States and to identify changes in caseload over the past decade. DESIGN, SETTING, AND PARTICIPANTS: An online survey was sent to pediatric ORL chairs and/or fellowship directors at 42 institutions in the United States and abroad. For 59 procedures, respondents were asked to estimate the percentage of cases performed by their department, determine whether this percentage has changed over the past 10 years (2006-2016), and identify any other specialties performing the procedure. Data were collected during a 2-week period in October 2016, from October 7 through 21, and analyzed from November 2016 through February 2017. MAIN OUTCOMES AND MEASURES: Main outcomes included the percentage of operations currently performed by the respondent's department for each procedure; whether this percentage has decreased, increased, or remained the same over the past decade; other specialties that perform each procedure; and any procedures added to or eliminated from the respondent's practice over the past decade. RESULTS: Respondents from 33 of the 42 academic institutions completed the survey (23 in the United States and 10 international; 79% response rate). Respondents reported the least involvement in procedures pertaining to facial plastic and reconstructive surgery, aerodigestive endoscopy, and congenital anomalies. Conversely, a mean (SD) of 91% (7%) reported performing 90% to 100% of otology, airway, rhinology, and general procedures. A mean (SD) of 82% (11%) reported that their department's involvement in each procedure has remained the same from 2006 to 2016. CONCLUSIONS AND RELEVANCE: The specialty of pediatric ORL has evolved over the past decade. There has been a notable decline in involvement in facial plastic and reconstructive surgery and treatment of vascular malformations and esophageal disorders. The management of thyroid disease is in flux. Monitoring current trends to adjust training and practice paradigms will ensure the long-term viability of the specialty.

New instrumentations in the operating room for sinus surgery.

PURPOSE OF REVIEW: The article reviews the advancements in instrumentation in the operating room that augment the speed, safety or outcomes of endoscopic sinus surgery (ESS). The article aims to update the Rhinologist on recent perioperative instruments that may benefit their practice. RECENT FINDINGS: The greatest advancements in the recent years have been in the field of visualization and optics. The introduction of high definition and ultra high definition 4K camera and screens supported by improvements with three-dimensional and variable angled endoscopes have greatly enhanced the quality and range of the visual information available to the sinus surgeon. This is closely supported by flexibility and enhanced functionality of the powered instrumentation with bipolar, monopolar and malleable blades and ever increasing more powerful burs. SUMMARY: Recent years have seen notable developments in the areas of optics, cameras and powered instruments to support the sinus surgeon. This article summarizes these developments and highlights the major benefits of these developments.

Revisión de nuestra experiencia en fonocirugía infantil / A review of our experience in phonosurgery in children

Introducción y objetivos: La disfonía es un problema frecuente en los niños, especialmente en edad escolar. La exploración de las cuerdas vocales suele ser más difícil y menos precisa que en los adultos. La lesión que más a menudo encontramos en niños con disfonía crónica son los nódulos vocales, seguido de los quistes epidermoides y de las demás lesiones congénitas, como sulcus y puente mucoso. El tratamiento es multidisciplinar y se basa fundamentalmente en rehabilitación vocal. Indicamos tratamiento quirúrgico en niños mayores de 9 años en los que persiste el problema tras la rehabilitación, sobre todo si sospechamos una lesión congénita de la cuerda vocal. Métodos: Presentamos un estudio retrospectivo de la fonocirugía infantil realizada en nuestro hospital durante 9 años (2005-2013). Se incluye a 51 niños, con edades comprendidas entre los 9 y los 16 años. Analizamos la distribución de las diferentes lesiones, tanto congénitas como adquiridas. Evaluamos los resultados mediante la valoración subjetiva de los familiares de los niños intervenidos. Resultados: Obtuvimos una distribución del 76% (n = 39) de lesiones congénitas y un 24% (n = 12) de lesiones adquiridas. Encontramos un porcentaje global de mejoría tras la cirugía del 90%, con mejores resultados en los nódulos vocales, aunque sin alcanzar significación estadística.Conclusiones: La valoración de los resultados de esta cirugía es controvertida y en este estudio se hace con una única pregunta a los familiares. Encontramos un resultado global de mejoría en el 90% de los casos intervenidos, sin ninguna complicación. Tenemos mejores resultados con los nódulos vocales, aunque no alcanzan significación estadística (AU)

Introduction and objectives: Dysphonia is a common problem in children, especially those of school age. Exploration of vocal folds is often difficult and less accurate in children. The most frequent lesions found in children with chronic dysphonia are vocal nodules, followed by epidermoid cysts and other congenital lesions, such as sulci and mucosal bridges. The treatment is multidisciplinary and it is fundamentally based on vocal rehabilitation. We indicate surgical treatment in children older than 9 years of age for whom the problem persists after rehabilitation, especially if we suspect a congenital lesion of the vocal fold. Methods: We present a retrospective study of paediatric phonosurgery performed by the Vocal Pathology Unit of our Hospital over a period of 9 years (2005-2013). Fifty-one children were included, ranging in age from 9 to 16 years old. We analyzed the distribution of the different lesions, both congenital and acquired. We evaluated the results by subjective evaluation by the children's relatives. Results: We obtained a distribution of 76% (n = 39) of congenital lesions and 24% (n = 12) of acquired lesions. After surgery, there was a global percentage of improvement of 90%, with better results in cases of vocal nodules, without statistical significance. Conclusions: The evaluation of the results of this surgery is controversial and in this study is done with a single question survey administered to relatives. We found an overall result of improvement in 90% of operated cases, without any complications. We obtained better results in vocal nodules, although not reaching statistical significance (AU)

Recent advances in robot-assisted head and neck surgery.

OBJECTIVE: This article reviews current clinical applications and experimental developments for robotic surgery in the head and neck with special focus on financial challenges, current clinical trials, and the controversial aspect of haptic and tactile feedback. DATA SOURCES: Literature was screened using the pubmed library. Information on clinical trials was excerpted from the National Institute of Health database. Additional data on experimental developments were gathered by personal communication. RESULTS: A steep increase in clinical applications for robotic surgery in the head and neck is determined as possible indications extend. Clinical trials are mostly non-randomized. A wide range of new robotic systems are expected to come into clinical use in the near future. CONCLUSION: As head and neck surgeons become more familiar with robotic surgery some patients evidently benefit from new technologies. Increased competition between the systems will certainly drive technological improvement and decrease the financial burden. Copyright © 2016 John Wiley & Sons, Ltd.

[Computer-aided reconstruction of the facial skeleton : Planning and implementation in clinical routine]. / Computerassistierte Gesichtsschädelrekonstruktion : Planung und Umsetzung in der klinischen Routine.

In computer-aided reconstruction of the facial skeleton, a workflow has been established involving the following steps: > diagnosis → planning and simulation → surgical procedure → validation and quality control <. In addition to clinical findings, the focus of diagnosis is on three-dimensional (3D) imaging, particularly computed tomography. Planning and simulation involves creation of a virtual model of the desired surgical outcome using special planning software. The accuracy of implant fit can be virtually verified before surgery. 3D models and virtual reconstructions can be used for manufacturing patient-specific implants. During the surgical procedure, planning must be transferred to the surgical site as accurately as possible. A number of techniques are available for this purpose, e. g., closed reduction, open reduction with the placement of anatomically preformed or patient-specific implants in combination with surgical guides, and the additional use of navigation. Validation and quality control require postprocedural 3D imaging. After reconstructions of the midface, 3D imaging should be performed even before surgery is completed. Malpositions can thus be directly corrected and unnecessary open reconstructions avoided. Mobile 3D c-arms are particularly useful for intraoperative 3D imaging. Whereas intraoperative imaging makes postoperative imaging after midface reconstruction unnecessary in many cases, postoperative 3D imaging in addition to intraoperative imaging may still be recommended after complex reconstructions of the facial skeleton.

[Robot-assisted surgery in the head and neck region]. / Robotergestützte Chirurgie im Kopf-Hals-Bereich.

Robot-assisted surgery (RAS) in the head and neck region is believed to have a large potential for the improvement of patient care. Several systems with a master-slave setup are already in routine clinical use, particularly for oncologic surgery. Although specific patient groups may benefit from RAS, there is a lack of randomized clinical studies validating the advantages of these new technological systems in comparison to the existing standard procedures. On the other hand, RAS in the head and neck region is being constantly developed. Currently, the main limitations are the technical miniaturization of the tools and the loss of haptic feedback, as well as the high costs for acquisition and maintenance without financial reimbursement. In any case, the current generation of head and neck surgeons will face the technical, scientific, and ethical challenges of RAS.