BACKGROUND:Tracheoesophageal puncture (TEP) with voice prosthesis (VP) insertion is the gold standard of surgical voice restoration in postlaryngectomy patients. The conventional technique involves rigid esophagoscopes and trocar performed by ENT surgeons alone, with technical limitations encountered in patients with cervical abnormalities - in particular those with free or rotational flap reconstructions and postradiotherapy strictures. We report our technique using flexible endoscopy which we show to be feasible and without major safety events, as a possible consideration in the anticipated difficult TEP. METHODS:Our study describes a multidisciplinary approach to secondary TEP involving a combined upper gastrointestinal (UGI) and (Ear, Nose, and Throat) ENT procedure, under the guidance of flexible esophagoscopy, with intraoperative involvement of the speech pathologist to guide VP insertion and placement. The procedure was performed with ease without major complications. RESULTS:We identified nine postlaryngectomy and laryngopharyngectomy patients in our institution who underwent secondary TEP with VP insertion using flexible esophagoscopy and multidisciplinary intra-operative involvement. All patients had pharyngeal reconstruction, including radial forearm free flap (n = 4), pectoralis major rotational flap (n = 3), and anterolateral thigh flap (n = 2). Eight out of nine patients underwent adjuvant radiotherapy. The technique was successfully performed in all patients. There were three cases of early TEP displacement in two patients, of which one patient had a successful repeat procedure. We found the technique advantageous in terms of feasibility and practicality compared to the conventional approach, and without intraoperative difficulties encountered in achieving the desired field of views or navigating the challenging anatomy in a free flap and post-radiotherapy patients. This includes distorted cervical anatomy, the presence of bulky and hair-bearing flap skin, and stricture formation. Minor complications in our cohort included pharyngo-esophageal spasm, TEP displacement, granulation tissue, and peri-prosthetic leaks. CONCLUSION:Our multidisciplinary approach to secondary TEP was performed with flexible esophagoscopy without major related complications. The technique is advantageous in the surgical approach to VP insertion in postlaryngectomy and laryngopharyngectomy patients who have had radiotherapy or pharyngeal reconstruction. It allows for safe anatomical insertion and thorough evaluation of the upper aerodigestive tract for comorbid benign or malignant esophageal pathology.

High-flow nasal oxygen (HFNO) therapy is extensively used in critical care units for spontaneously breathing patients. Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a method of apnoeic oxygenation with continuous nasal delivery of warmed, humidified oxygen at high-flow rates up to 70L/min. THRIVE extends the apnoeic window before desaturation occurs so that tubeless anaesthesia is possible. The advent of THRIVE has had a monumental impact on anaesthetic practice, with a diverse range of clinical applications and it has been incorporated into difficult airway guidelines. THRIVE has many applications in otolaryngology and head and neck surgery. It is used as a pre-oxygenation tool during induction in both anticipated and unanticipated difficult airway scenarios and as a method of oxygenation for tubeless anaesthesia in elective laryngotracheal and hypopharyngeal surgeries and during emergence from anaesthesia. In this scoping review of the literature, we aim to provide an overview on the utility of THRIVE in otolaryngology, including the underlying physiologic principles, current indications and limitations, and its feasibility and safety in different surgical contexts and specific population groups.

BACKGROUND:The presence of a pseudodiverticulum of the anterior pharyngeal wall, or prominent "pharyngeal bar," is a well-known phenomenon that occurs following total laryngectomy, which can be visualized by nasolaryngoscopy or videofluoroscopy. Among the different techniques of pharyngeal reconstruction, there is higher incidence following primary vertical multilayered closure. It has been postulated to cause dysphagia and lack of dietary progression despite a paucity of data. However, the direct impact of pseudodiverticulum is less clear and anecdotally its presence and severity does not necessarily correlate with dysphagia. METHODS:A retrospective case series was performed of all consecutive patients who underwent total laryngectomy or laryngopharyngectomy between 2015 and 2022 at two tertiary head and neck institutions. All patients underwent routine videofluoroscopy postoperatively for swallow assessment. The presence of pseudodiverticulum on postoperative contrast swallow study was recorded to investigate the relationship with patient's ability to tolerate oral intake at 3 months discharge from the hospital. RESULTS:Of 50 laryngectomized patients (mean age 63.8 ± 10.0, 86% male), the main closure techniques were primary vertical (n = 9, 18%), primary T-closure (n = 14, 28%), and flap reconstruction (n = 27, 54%). Pseudodiverticulum was identified in 19 cases (38%). 43 patients underwent primary surgery and 30 had adjuvant radiotherapy. The presence of pseudodiverticulum was significantly associated with vertical primary closure versus non-vertical (T-closure or flap reconstruction) techniques (χ2 (df 1) = 7.4, p = 0.007, OR = 5.7, 95% CI 1.3-24.7). Pseudodiverticulum was not associated with an increased inability to tolerate solid intake or full diet compared to patients without pseudodiverticulum. 26.3% of patients with pseudodiverticulum were on full diet compared to 25.8% of patients without. The vertical closure technique showed no difference in ability to maintain solid intake compared with non-vertical closure; however, no patients were on full diet. Only one patient in the pseudodiverticulum group required surgical management during the study period for retention. CONCLUSION:The presence of a pseudodiverticulum does not appear to be significantly associated with a need for postoperative dietary modification. The authors postulate that postlaryngectomy dysphagia is multifactorial with sensorimotor aperistalsis of the pharynx and cricopharyngeal stenosis. While a pseudodiverticulum is a common phenomenon, patients did not require modification of diet at higher rates than those without, and they seldom require intervention.

OBJECTIVES:Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) has demonstrated utility in extending the apneic window in the perioperative setting. Its benefits in facilitating tubeless anesthesia are recognized during elective laryngotracheal surgeries. The use of THRIVE and administering higher fractional inspired oxygen concentrations in laser laryngeal surgery (LLS) remains controversial due to the theoretical risk of airway fires. A scoping review of the literature describing institutional experiences with THRIVE during LLS was conducted. DATA SOURCES AND REVIEW METHODS:A systematic scoping review of the literature was performed including PubMed, Medline, Embase, Scopus, JBI EBP Database, and Cochrane Library from inception to April 2023. RESULTS:From the 472 articles identified in our review, nine articles were included representing 271 cases. THRIVE was used for preoxygenation and to maintain apneic oxygenation during LLS. Different institutional practices related to THRIVE parameters and intraoperative modifications during lasing were described in the literature, including cessation of THRIVE, reduction of FiO2 to 30%, and continuous 100% FiO2 oxygenation. One study described a brief ignition of the coating of a KTP laser fiber without injury to the patient. No adverse patient outcomes have been documented in the literature with THRIVE during LLS. CONCLUSION:THRIVE is a safe and effective form of tubeless anesthesia and apneic oxygenation during LLS, with no adverse patient safety events reported in the literature. Key determinants to maintain safety include optimal patient and team selection, effective surgeon-anesthetist cooperation, and institutional protocols that govern intraoperative practice. Laryngoscope, 134:4203-4212, 2024.

A total laryngectomy creates an alternate airway for gas exchange that bypasses the upper aerodigestive tract. The subsequent reduction in nasal airflow, and therefore, reduction in deposition of particles to the olfactory neuroepithelium leads to hyposmia or anosmia. The aim of this study was to assess the quality of life impairment conferred by anosmia following laryngectomy and identify any specific patient-related risk factors that are associated with poorer outcomes. Consecutive patients with a total laryngectomy presenting for review at three tertiary head and neck services (in Australia, the United Kingdom and India) over a 12-month period were recruited. Patient demographic and clinical data were collected, and each subject completed the validated assessment of self-reported olfactory functioning and olfaction-related quality of life questionnaire (ASOF). Dichotomous comparisons were performed using the student's unpaired t-test for continuous variables (SRP), a chi-squared test for categorical variables, and a Kendall's tau-b for ordinal variables (SOC) to assess for a correlation with poorer questionnaire scores. A total of 66 laryngectomees (13.4

Background: Peritonsillar abscess is the most common deep space infection of the head and neck. It can have life threatening complications if inadequately treated. The study aimed to analyse the workup and management trends of peritonsillar abscess presentations in a tertiary Australian hospital. Methods: A retrospective electronic medical records review was undertaken on all patients who presented with peritonsillar abscess or peritonsillar cellulitis between July 1, 2016 and June 30, 2021, at Nepean Hospital, Sydney, Australia. Data on age, sex, Aboriginal and/or Torres Strait Islander background, length of stay, month of presentation, smoking and alcohol status, microbiology, utilisation of computed tomography (CT) scan, management (medical and/or surgical), tonsillectomy performed, and tonsillar malignancy were extracted and analysed. Results: A total of 291 patients were identified in this 5-year period. The mean age was 34 years with a male predominance (56%). Group A Streptococcus and Streptococcus milleri were the most common pathogens, although 29% of swabs grew normal respiratory flora or no growth at all. CT scans were performed for 26% of patients. Combination intravenous antibiotics and steroids were used as the preferred medical management for 97% of patients. Needle aspiration and incision and drainage as a combination surgical therapy was performed for 40% of cases. Conclusions: There is considerable heterogeneity within the workup and management of peritonsillar abscess presentations in this tertiary Australian hospital. The role of swabs is questionable given it did not change management. CT scans are not recommended routinely. Further studies are warranted to formulate a consensus for the workup and management of peritonsillar abscesses.

Background:Laryngeal paragangliomas (LP) comprise a rare subset of head and neck neoplasms and are an important differential in the patient with a submucosal laryngeal mass.Methods:We discuss an operative technique using coblation assisted excision via laryngofissure in the cases of four confirmed LPs and discuss the current literature with respect to diagnosis and management of these patients.Results:Our case series of four patients demonstrate the laryngofissure approach for LP is safe, provides oncological cure and preserves laryngeal function. This technique with coblation has not been previously discussed in the surgical management of LPs. Patient-reported postoperative voice and swallowing outcomes were excellent in all patients. Whole body imaging techniques were utilized in all patients, with octreotide scintigraphy demonstrating synchronous lesions in two of the four patients-one had a retroperitoneal lesion, whilst another patient had multiple lesions in the skull base, paravertebral region, liver, and adrenal gland.Conclusions:Our cases also highlight the changing clinical paradigms in the diagnostic approach of LPs and an emerging role for octreotide scintigraphy in the workup of these patients. Coblation assisted excision via laryngofissure is efficient and effective in the surgical resection of LP. In patients with multicentric forms of LP, the size, side, and anatomic location of synchronous lesions should be considered in surgical planning to determine feasibility and safety of operative management.Level of Evidence:IV.

Introduction:Early laryngeal carcinomas may be treated by transoral laser microsurgery (TLM) or external beam radiotherapy. We review our experience of surgical treatment of laryngeal pre-malignant and malignant lesions over the past 15 years in a high-volume head neck unit.Methods:A review of a prospective patient database of patients with laryngeal SCC, who were treated with CO2 TLM between 2004 and 2019 was carried out.Results:83 patients with a mean age of 67.7 (SD: 10.6) years underwent primary curative TLM for T1a/b SCC. 5-year overall survival was 93.2% (95%CI 86.9-100%), disease free survival was 86.0% (95%CI 78.1-94.6%), locoregional control was 91.2% (95%CI: 85.1-97.7%) and larynx preservation rate of 95.1% at 5 years.Conclusion:TLM is an excellent treatment modality for T1 early glottic SCC, with excellent locoregional control and disease-free survival. It is minimally invasive, outpatient-based, and cost-effective procedure preserving upper aerodigestive tract dysfunction for all activities of daily living.

Background: Laryngeal paragangliomas (LPs) comprise a small subset of head and neck paragangliomas (HNPGLs), arising from the superior or inferior laryngeal paraganglia. Multicentric forms of LP are rare and should raise suspicion for hereditary disease. A systematic review of the literature was performed to identify all reported cases of multicentric LP and discuss the unique diagnostic and management paradigms in these situations.Methods: A literature search was performed using an advanced search algorithm of the Medline, PubMed, SCOPUS, and EMBASE databases using the keywords "head and neck", "larynx", "paraganglioma", "multicentric", "synchronous", and "metachronous", which were combined with Boolean ("and" or "or") operators. Further articles were identified using Google Scholar and the references of selected articles. The authors included all article types within the published literature from 1975 to 2022, without exclusion based on language, that reported on LP with multifocal disease.Results: A total of 11 articles were included, which reported 12 patients who had multicentric cases of LP. Eighteen synchronous lesions were identified and involved the carotid body (n=10), skull base (n=4), jugulotympanic cavity (n=1), parapharyngeal space (n=1), paravertebral space (n=1), and retroperitoneum (n=1). The skull base and parapharyngeal space lesions may represent carotid or vagal paragangliomas. Two patients had cervical lymph node involvement, and 1 patient had multiple cutaneous nodules, each with biopsy confirmed paraganglioma. Three studies reported genetic testing, which revealed succinate dehydrogenase (SDH)-B mutation, confirming a hereditary component.Conclusions: Synchronous lesions in patients with LP are uncommon and should prompt suspicion of hereditary disease. Multicentricity is an important consideration in surgical planning and has prognostic implications requiring stricter surveillance and genetic workup. The increasing popularity of whole-body octreotide scanning in the diagnostic workup of paragangliomas is likely to discover more synchronous or metachronous lesions. Multicentricity in LP introduces complexities in surgical management and may alter treatment paradigms and prognosis. Diagnostic modalities should include whole-body scanning to detect synchronous lesions.

In the last decade, the introduction of continuous intraoperative recurrent laryngeal nerve (RLN) monitoring (C-IONM) has enabled the operator to verify the functional integrity of the vagus nerve-recurrent laryngeal nerve (VN-RLN) axis in real-time. We aim to present the current evidence on C-IONM utility for thyroid surgery by conducting the first meta-analysis on this technique. A systematic review of literature was conducted by two independent reviewers via Ovid in the Medline, EMBASE, and Cochrane reviews databases. The search was limited to human subject research in peer-reviewed articles of all languages published between Jan 1946 and April 2020. Medical subject headings (MeSH) terms utilized were thyroid surgery, thyroidectomies, recurrent laryngeal nerve, vagal nerve, monitor, and stimulation. Thirty-eight papers were identified from Ovid, another six papers were identified by hand-search. A random effect meta-analysis was performed with assessment of heterogeneity using the I-2 value. A total of 23 papers that investigated the use of continuous vagal nerve monitoring during thyroid surgery were identified. The proportion of nerves at risk (NAR) with temporary RLN paralysis postoperation was 2.26% (95% CI: 1.6-2.9, I-2 = 37). The proportion of NAR with permanent RLN palsy postoperation was 0.05% (95% CI: 0.08-0.2, I-2 = 0). In this meta-analysis, there is one case of temporary vagal nerve paralysis secondary to VN electrode dislodgement, and a case of hemodynamic instability manifested in bradycardia and hypotension in the initial phase of surgery shortly after calibration. C-IONM is a safe and effective means by which RLN paralyses in thyroid surgery can be reduced.

Branchial clefts are most often associated with the pediatric population but can also affect adults. The adult population undergoing branchial cleft excision is poorly described. This study sought to describe the population and outcomes of those undergoing branchial cleft excision.

Mucormycosis results in non-enhancement of infected tissues on contrast enhanced MRI due to angioinvasion and subsequent ischemia. Non-enhancement of the nasal turbinate is termed the ‘Black Turbinate’ (BT) sign. We report the case of a 75-year old man who presented with facial pain and the BT sign on MRI. This case highlights the importance of obtaining MRI in patients with suspected mucormycosis and reiterates the significance of the BT sign to clinicians in prompt recognition and treatment of mucormycosis.

Objective: Cadaveric experiments and more recently clinical data have demonstrated that patients with vertical height discrepancy between their arytenoids experience poorer voice outcomes in patients with unilateral vocal cord palsy (UVP) after medialisation laryngoplasty. However, the presence or severity of height discrepancy in normal patients without UVP has not yet been clearly defined. Study design: Case-control study. Setting: Tertiary Australian hospitals. Subjects and methods: A retrospective review was performed on patients who underwent high computed tomography imaging of the neck. Scans were assessed for discrepancy in arytenoid vertical height discrepancy and compared to a cohort with known UVP. Results: 44 normal patients (50% female, mean age 57.6 +/- 14.8 years) were compared to 23 patients with UVP (43.4% female, mean age 52.3 +/- 14.9 years.) Normal patients were found to have a smaller height discrepancy compared to UVP patients (student's t-test,2.00 mm +/- 0.00 vs 2.39 mm +/- 0.72, p < .001.) Conclusion: This study suggests that discrepancy is pathologic, and it is plausible that this results in acoustic consequences.

Background: A long-term tracheostomy tube has the potential to cause significant morbidity and mortality in both hospitalised patients and those in the community. This study aims to assess the rates of microbial colonisation and infection of tracheostomy tubes. Materials and methods: Consecutive patients were enrolled from both inpatient and outpatient settings during their routine tracheostomy changes. During changes, culture swabs were taken from the cuff/outer-cannula and inner-cannula. Analysis were performed to compare culture results with risk factors. Results: 65 patients were enrolled in the study. Inpatients (65.9% vs 38.1%, chi(2) 4.48, p = 0.03), increasing acuity of care (from outpatient; ward; HDU; and ICU in increasing acuity) (tau(b) = 0.289, p = 0.012), cuffed tracheostomy tubes, (66.7% vs 39.1%; chi(2) 4.59, p = 0.032); diabetics (64.6% vs 35.3%; chi(2) 4.39, p = 0.036); and males were associated with increased colonisation (72.4% vs 44.4%; chi(2) 5.12, p = 0.024). Conclusion: Factors associated with an increase in colonisation and infection of tracheostomy tubes were location, and in males, diabetics and in cuffed tubes.

Introduction Narrowband imaging (NBI) is a special endoscopic optical enhancement setting allowing better visualization of mucosal microvasculature compared to white light endoscopy. This study evaluates the validity of NBI using the Ni classification in the detection and differentiation of severe dysplasia (SD) and glottic squamous cell carcinoma (SCC). Methods Patients with suspicious vocal cord lesions underwent conventional white light endoscopy followed by clinically indicated biopsy. At the same time, NBI images were obtained and graded independently. Lesions were graded from I to V according to the Ni classification and compared to histopathological findings. Results Fifty-two patients were included in this study (40 SCC and 12 SD). The sensitivity and specificity of NBI in diagnosing laryngeal cancer was 95.0% (CI, 83.9%-99.4%) and 83.3% (CI, 51.6%-97.9%), respectively. The negative likelihood ratio was 0.06. Higher Ni grades correlated very strongly with more advanced disease. Conclusions NBI using the Ni classification is a sensitive diagnostic tool for the detection and differentiation of early neoplastic and preneoplastic glottic lesions. As higher Ni classification correlates strongly with advanced disease, it serves as a useful adjunct to white light endoscopy in the diagnosis of laryngeal cancer. Level of Evidence: Level IV.

This systematic review and meta-analysis evaluates the validity of narrowband imaging (NBI) in differentiating between low-risk leukoplakia and high-risk leukoplakia. Medline, EMBASE, Scopus, Cochrane Database of Systematic Reviews and Database of s of Reviews of Effects were searched. Studies evaluating the diagnostic accuracy of NBI in the assessment of laryngeal leukoplakia were included. Pooled sensitivity, specificity and diagnostic odds ratio were calculated. Seven studies met the inclusion criteria assessing a total of 586 lesions with laryngeal leukoplakia. In differentiating between low-risk and high-risk leukoplakia, NBI had a pooled sensitivity and specificity of 85.4% (95% CI [76-99.9]) and 94.9% (95% CI [91.1-97.2]) respectively. Pooled diagnostic odds ratio was 99.2 (95% CI [38.28-257.18]). NBI is a useful imaging modality in differentiating between low-risk leukoplakia and high-risk laryngeal leukoplakia. The high sensitivity, specificity and diagnostic odds ratio make NBI a useful tool in the workup of laryngeal leukoplakia.

Tracheostomy‐tube change protocols are implemented primarily due to concern regarding infections. Currently changes vary from within 4 weeks post‐insertion to 3 monthly thereafter. However, currently no evidence‐based guidelines exist to justify these protocols. This study aims to assess the colonization of tracheostomy‐tubes associated with the frequency of changes.

INTRODUCTION: Purastat is a novel haemostatic agent that has recently been used effectively in nasal procedures, specifically in functional endoscopic endonasal surgery in the prevention of post-operative epistaxis while minimising adhesion formation. This study presents a case of successful application of Purastat following division of a nasopharyngeal/palatal stenosis following radiotherapy. PRESENTATION OF CASE: A 49-year-old male developed severe nasopharyngeal stenosis following concurrent chemoradiotherapy with curative intent a HPV positive base of tongue squamous cell carcinoma. Following treatment, while the patient experienced excellent metabolic response, he began to progressive nasal obstruction which he reported to be significantly affecting his quality of life. Following multidisciplinary team discussion, division of the stenosis was considered appropriate. Under general anaesthesia, the patient was positioned lying supine with the neck extended. A Boyle-Davis gag with lip and teeth protection was placed and a Y-suction catheter inserted to lift the palate from the posterior pharyngeal wall. Coblation using a PDW wand was used to divide the area of fibrosis bilaterally toward the superior tonsillar pillar until palatopharyngeus musculature was visible. Injection of 4 mg of Dexamethasone with a hypodermic needle was then performed followed by application of 4 ml of topical Purastat onto the raw surfaces after haemostasis was confirmed. The patient was discharged the same day on simple analgesia and instructions to avoid exertion for two weeks. He attended follow-up in the outpatient department two months later and reported persisting resolution of his nasal obstructive symptoms. No evidence of recurrence or residual adhesion tissue was noted. (C) 2020 The Author(s). Published by Elsevier Ltd on behalf of US Publishing Group Ltd.

Background: Laryngeal chondrosarcoma (LC) is a rare malignant tumour with a favorable prognosis. Treatment options are varied with many patients receiving a total laryngectomy. We present a series of patients advocating a conservative management paradigm.

Background The elderly represents one of the most rapidly growing subsets of the population. This population experiences a higher incidence of thyroid pathology. However, there are concerns that the elderly also experiences increased perioperative complications and are poor candidates for thyroidectomy. Methods Patients who underwent thyroidectomy over the age of 80 years at three tertiary head and neck units were included. Data regarding age, sex, presenting symptoms, comorbidities, preoperative investigations, type of surgery, postoperative complications, and final thyroid pathology were retrieved from hospital records. Results Of a total of 39 patients (69% women, mean age 83.1), the majority (40.1%) presented with a combination of symptoms: shortness of breath, feeling of pressure in the neck, dysphagia, or tiredness. Two (5.1%) were asymptomatic. Low rates of postoperative complications were encountered and were minor (n = 5). No intensive care unit admissions or mortality was experienced. Conclusion Thyroid surgery in octogenarians carries an acceptable complication profile.