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OBJECTIVE - The primary aim of this study is to evaluate the safety, efficacy, and execution of major open laryngotracheal operations for patients in the advanced decades.
STUDY DESIGN - Case series with chart review.
SETTING - Multidisciplinary clinic at a tertiary care academic hospital.
SUBJECTS AND METHODS - Patient characteristics, operative course, and postoperative outcomes were retrospectively recorded for all airway reconstruction operations performed between 1999 and 2016 on patients aged ≥60 years Long-term success was defined as prosthesis-free survival at last follow-up. Descriptive statistics were performed.
RESULTS - Twenty-nine patients met inclusion criteria, and the median age was 71 years (interquartile range, 63-74). Tracheal resection was the most common procedure (13 patients), followed by laryngotracheal reconstruction (7 patients). Fifteen patients began their operation with a tracheostomy, 6 of whom underwent decannulation prior to leaving the operating room. Three additional patients underwent decannulation at follow-up appointments and were prosthesis-free at most recent follow-up. The mean time to decannulation among these patients was 3 months. Of the 14 patients beginning their procedure without a tracheostomy, only 2 required permanent airway prosthesis. The overall long-term rate of prosthesis-free survival was 72.4% (21 of 29 patients). Factors suggestive of long-term success include lower McCaffrey grade and lack of pulmonary disease, hypertension, or diabetes, as well as decreased red blood cell distribution width on preoperative complete blood count.
CONCLUSION - Through careful patient selection, preoperative workup, and meticulous postoperative care, airway reconstruction procedures in patients aged ≥60 years are reasonably successful. Of 29 patients, 21 (72.4%) were successfully breathing long-term without airway prosthesis.
Importance - Airway reconstruction for adults with laryngotracheal stenosis (LTS) is directed toward improving airway caliber to mitigate the patient's dyspnea and achieve prosthesis-free breathing (ie, without tracheostomy, intraluminal stent, or T-tube). Despite the importance of preoperative risk stratification to minimize postoperative complications, consensus on an objective predictive algorithm for open airway reconstruction is lacking.
Objective - To determine whether the ability to achieve a prosthesis-free airway in adults after open airway reconstruction is associated with red blood cell distribution width (RDW) at the time of surgery.
Design, Setting, and Participants - Case series study investigating 92 consecutive patients 18 years and older with laryngotracheal stenosis who underwent open airway reconstruction at a US tertiary care hospital from January 1, 2006, to January 1, 2017.
Main Outcomes and Measures - The main outcome was a prosthesis-free airway (absence of tracheostomy, intraluminal stent, or T-tubes) at last follow-up. Multivariate logistic regression modeling was used to identify independent factors associated with this outcome.
Results - Of the 92 patients who met inclusion criteria, the median (interquartile range) age was 44 (33.0-60.3) years; 50 (53%) were female, and 82 (89%) were white. In all, 74 patients (80%) were prosthesis free at the last follow-up (mean, 833 days; 95% CI, 10-4229 days). In multivariate analyses, airway decannulation was significantly correlated with reduced RDW (odds ratio [OR], 0.40; 95% CI, 0.19-0.84) and the absence of posterior glottic stenosis (OR, 0.12; 95% CI, 0.04-0.37).
Conclusions and Relevance - These data suggest that surgical success in open airway reconstruction is significantly associated with RDW and whether the patient had posterior glottic stenosis. The RDW is a routine laboratory parameter that may provide some insight to the preoperative probability of prosthesis removal, facilitate risk stratification, promote informed patient decision making, and optimize health care resource management.
Inhalation injury is an independent risk factor in burn mortality, imparting a 20% increased risk of death. Yet there is little information on the natural history, functional outcome, or pathophysiology of thermal injury to the laryngotracheal complex, limiting treatment progress. This paper demonstrates a case series (n = 3) of significant thermal airway injuries. In all cases, the initial injury was far exceeded by the subsequent immune response and aggressive fibroinflammatory healing. Serial examination demonstrated progressive epithelial injury, mucosal inflammation, airway remodeling, and luminal compromise. Histologic findings in the first case demonstrate an early IL-17A response in the human airway following thermal injury. This is the first report implicating IL-17A in the airway mucosal immune response to thermal injury. Their second and third patients received Azithromycin targeting IL-17A and showed clinical responses. The third patient also presented with exposed tracheal cartilage and underwent mucosal reconstitution via split-thickness skin graft over an endoluminal stent in conjunction with tracheostomy. This was associated with rapid abatement of mucosal inflammation, resolution of granulation tissue, and return of laryngeal function. Patients who present with thermal inhalation injury should receive a thorough multidisciplinary airway evaluation, including early otolaryngologic evaluation. New early endoscopic approaches (scar lysis and mucosal reconstitution with autologous grafting over an endoluminal stent), when combined with targeted medical therapy aimed at components of mucosal airway inflammation (local corticosteroids and systemic Azithromycin targeting IL-17A), may have potential to limit chronic cicatricial complications.
© American Burn Association 2018. All rights reserved. For permissions, please e-mail: email@example.com.
PURPOSE - To compare the cost-effectiveness of various treatment strategies in the management of pelvic fracture urethral injuries using decision analysis.
METHODS - Five strategies were modeled from the time of injury to resolution of obstructed voiding or progression to urethroplasty. Management consisted of immediate suprapubic tube (SPT) placement and delayed urethroplasty; primary endoscopic realignment (PER) followed by urethroplasty in failed patients; or PER followed by 1-3 direct vision internal urethrotomies (DVIU), followed by urethroplasty. Success rates were obtained from the literature. Total medical costs were estimated and incremental cost-effectiveness ratios (ICERs) were generated over a 2-year follow-up period.
RESULTS - PER was preferred over SPT placement in all iterations of the model. PER followed by a single DVIU and urethroplasty in cases of failure was least costly and used as the referent approach with an average cost-effectiveness of $17,493 per unobstructed voider. The ICER of a second DVIU prior to urethroplasty was $86,280 per unobstructed voider, while the ICER of a third DVIU was $172,205. The model was sensitive to changes in the success rate of the first DVIU, where when the probability of DVIU success is expected to be less than 32% immediate urethroplasty after failed PER is favored.
CONCLUSIONS - Management of pelvic fracture urethral injuries with PER is the preferred management strategy according to the current model. For those who fail PER, a single DVIU may be attempted if the presumed success rate is >32%. In all other cases, urethroplasty following PER is the preferred approach.
PURPOSE OF REVIEW - This article summarizes the indications and surgical techniques for the reconstructions of anterior skull base defects.
RECENT FINDINGS - There is increasing popularity of the vascularized pedicled flaps in endoscopic skull base surgery for the successful reconstruction of anterior skull base defects, compared with the use of free-tissue grafts. The location and size of the defect as well as the rate of cerebrospinal fluid (CSF) flow are important considerations for selection of the most appropriate reconstructive approach. Recent literature provides evidence suggesting that pedicled flaps may be more effective for clival defects and high-flow CSF leaks, potentially reducing the incidence of postoperative CSF leaks. Although the nasoseptal flap (NSF) continues to be the mainstay of endoscopic skull base reconstruction, alternative vascularized flaps exist when the NSF is impractical or unavailable, and new surgical approaches continue to evolve.
SUMMARY - Vascularized pedicled flaps, and especially the NSF, have greatly reduced complications associated with endoscopic skull base surgery. Multiple considerations should be taken into account during closure of skull base defects, and several options are available to accommodate different needs.
OBJECTIVE - To investigate the association between perioperative patient characteristics and treatment modalities (eg, vasopressor use and volume of fluid administration) with complications and failure rates in patients undergoing head and neck free tissue transfer (FTT).
STUDY DESIGN - A retrospective review of medical records.
SETTING - Perioperative hospitalization for head and neck FTT at 1 tertiary care medical center between January 1, 2009, and October 31, 2011.
SUBJECTS AND METHODS - Consecutive patients (N=235) who underwent head and neck FTT. Demographic, patient characteristic, and intraoperative data were extracted from medical records. Complication and failure rates within the first 30 days were collected
RESULTS - In a multivariate analysis controlling for age, sex, ethnicity, reason for receiving flap, and type and volume of fluid given, perioperative complication was significantly associated with surgical blood loss (P=.019; 95% confidence interval [CI], 1.01-1.16), while the rate of intraoperative fluid administration did not reach statistical significance (P=.06; 95% CI, 0.99-1.28). In a univariate analysis, FTT failure was significantly associated with reason for surgery (odds ratio, 5.40; P=.03; 95% CI, 1.69-17.3) and preoperative diagnosis of coronary artery disease (odds ratio, 3.60; P=.03; 95% CI, 1.16-11.2). Intraoperative vasopressor administration was not associated with either FTT complication or failure rate.
CONCLUSIONS - FTT complications were associated with surgical blood loss but not the use of vasoactive drugs. For patients undergoing FTT, judicious monitoring of blood loss may help stratify the risk of complication and failure.
© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.
PURPOSE OF REVIEW - To discuss the current applications and indications for the use of pedicled flaps in the reconstruction of endoscopic skull base defects.
RECENT FINDINGS - Current trends in endoscopic skull base surgery include the use of vascularized pedicled flaps rather than free tissue grafts (autograft or allograft) for the repair of anterior cranial base defects. In particular, recent evidence-based algorithms for skull base reconstruction suggest that use of pedicled flaps for clival defects and high-flow cerebrospinal fluid (CSF) leaks may reduce the incidence of postoperative CSF leaks. The primary workhorse continues to be the nasoseptal flap (NSF); however, other options exist in cases wherein this flap is unavailable because of prior sacrifice or unable to reach the area of interest (e.g., defects adjacent to the frontal recess).
SUMMARY - Adoption of vascularized pedicled flaps over the last decade, particularly the recently popularized NSF, has greatly reduced complications associated with endoscopic skull base surgery. The need for vascularized flap reconstruction is governed primarily by defect size and location, and by the presence of a high-flow CSF leak. Additional vascularized flaps can be used in conjunction with the NSF, or as an alternative when the NSF is unfavorable or unavailable.