IMPORTANCE:The current coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented needs for invasive ventilation, with 10% to 15% of intubated patients subsequently requiring tracheotomy.OBJECTIVE:To assess the complications, safety, and timing of tracheotomy performed for critically ill patients with COVID-19.DESIGN, SETTING, AND PARTICIPANTS:This prospective cohort study assessed consecutive patients admitted to the intensive care unit (ICU) who had COVID-19 that required tracheotomy. Patients were recruited from March 16 to April 10, 2020, at a tertiary referral center.EXPOSURES:A surgical tracheotomy was performed for all patients following recommended criteria for use of personal protective equipment (PPE).MAIN OUTCOMES AND MEASURES:The number of subthyroid operations, the tracheal entrance protocol, and use of PPE. Infections among the surgeons were monitored weekly by reverse-transcriptase polymerase chain reaction of nasopharyngeal swab samples. Short-term complications, weaning, and the association of timing of tracheotomy (early [≤10 days] vs late [>10 days]) with total required days of invasive ventilation were assessed.RESULTS:A total of 50 patients (mean [SD] age, 63.8 [9.2] years; 33 [66%] male) participated in the study. All tracheotomies were performed at the bedside. The median time from intubation to tracheotomy was 9 days (interquartile range, 2-24 days). A subthyroid approach was completed for 46 patients (92%), and the tracheal protocol was adequately achieved for 40 patients (80%). Adequate PPE was used, with no infection among surgeons identified 4 weeks after the last tracheotomy. Postoperative complications were rare, with minor bleeding (in 6 patients [12%]) being the most common complication. The successful weaning rate was higher in the early tracheotomy group than in the late tracheotomy group (adjusted hazard ratio, 2.55; 95% CI, 0.96-6.75), but the difference was not statistically significant. There was less time of invasive mechanical ventilatory support with early tracheotomy compared with late tracheotomy (mean [SD], 18 [5.4] vs 22.3 [5.7] days). The reduction of invasive ventilatory support was achieved at the expense of the pretracheotomy period.CONCLUSIONS AND RELEVANCE:In this cohort study, with the use of a standardized protocol aimed at minimizing COVID-19 risks, bedside open tracheotomy was a safe procedure for patients and surgeons, with minimal complications. Timing of tracheotomy may be important in reducing time of invasive mechanical ventilation, with potential implications to intensive care unit availability during the COVID-19 pandemic.
IMPORTANCE Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking.OBJECTIVE To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction.EVIDENCE REVIEW Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on head and neck cancer surgery from 1965 through April 2015. Consistent keywords for each topic included "head and necksurgery," "pharyngectomy," "laryngectomy," "laryngopharyngectomy," "neck dissection," "parotidlymphadenectomy," "thyroidectomy," "oralcavityresection," "glossectomy," and "head and neck." The final selection of literature includedmeta-analyses and systematic reviews as well as randomized controlled trials where available. In the absence of high-level data, case series and nonrandomized studies in head and neck cancer surgery patients orrandomized controlled trials and systematic reviews in non-head and neck cancer surgery patients, were considered. An international panel of experts in major head and neck cancer surgery and enhanced recovery after surgery reviewed and assessed the literature for quality and developed recommendations for each topic based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations were graded following a consensus discussion among the expert panel.FINDINGS The literature search, including a hand search of reference lists, identified 215 relevant publications that were considered to be the best evidence for the topic areas. A total of 17 topic areas were identified for inclusion in the protocol for the perioperative care of patients undergoing major head and neck cancer surgery with free flap reconstruction. Best practice includes several elements of perioperative care. Among these elements are the provision of preoperative carbohydrate treatment, pharmacologic thromboprophylaxis, perioperative antibiotics in clean-contaminated procedures, corticosteroid and antiemetic medications, short acting anxiolytics, goal-directed fluid management, opioid-sparing multimodal analgesia, frequent flap monitoring, early mobilization, and the avoidance of preoperative fasting.CONCLUSIONS AND RELEVANCE The evidence base for specific perioperative care elements in head and neck cancer surgery is variable and in many cases information from different surgerical procedures form the basis for these recommendations. Clinical evaluation of these recommendations is a logical next step and further research in this patient population is warranted.
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Otolaryngology–Head & Neck Surgery HomeNew OnlineCurrent IssueFor Authors Podcast Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA Otolaryngology–Head & Neck Surgery journal
OBJECTIVE To compare the real-time diagnostic accuracy of conventional white-light imaging (WLI) endoscopy with that of narrow-band imaging (NBI) endoscopy in patients at high risk for nasopharyngeal carcinoma (NPC). DESIGN Prospective study. SETTING A university tertiary care center. PATIENTS From July 28 through October 27, 2009, a total of 211 consecutive patients at high risk for NPC were enrolled. A high-performance endoscopic system equipped with WLI and NBI modes was used for a detailed examination of the nasopharynx during the same endoscopy. MAIN OUTCOME MEASURES Diagnostic efficacies of WLI and NBI were compared with pathologic findings. Lesions were classified according to the detailed morphologic epithelial microvessel observations during NBI. RESULTS A total of 285 lesions were detected, including 66 cancerous lesions. The sensitivity and negative predictive values of NBI in NPC screening were significantly higher than those of WLI (93.9% vs 71.2%, P = .001; and 98.1% vs 91.7%, P = .003; respectively); specificity and positive predictive value were not significantly different. During NBI, the presence of superficial, distorted, irregularly shaped microvessels indicated malignant lesions; 53 of 55 lesions (96.4%) with type IV intrapapillary capillary loops were confirmed on histologic testing as malignant. The false-negative and false-positive rates for NBI were 4.5% and 3.6%, respectively. CONCLUSIONS Narrow-band imaging endoscopy is a promising tool to differentiate nonmalignant from malignant nasopharyngeal lesions on the basis of the morphologic findings of mucosal capillary vessels in vivo. In addition, NBI may increase the diagnostic value of endoscopy in populations at high risk for NPC.
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Otolaryngology–Head & Neck Surgery HomeNew OnlineCurrent IssueFor Authors Podcast Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA Otolaryngology–Head & Neck Surgery journal
