Considerations for head and neck oncology practices during the coronavirus disease 2019 (COVID‐19) pandemic: Wuhan and Toronto experience

The practices of head and neck surgical oncologists must evolve to meet the unprecedented needs placed on our health care system by the Coronavirus disease 2019 (COVID‐19) pandemic. Guidelines are emerging to help guide the provision of head and neck cancer care, though in practice, it can be challenging to operationalize such recommendations. Head and neck surgeons at Wuhan University faced significant challenges in providing care for their patients. Similar challenges were faced by the University of Toronto during the severe acute respiratory syndrome (SARS) pandemic in 2003. Herein, we outline our combined experience and key practical considerations for maintaining an oncology service in the midst of a pandemic.     

Prone positioning for head and neck reconstructive surgery

Certain head and neck surgical cases require the patient to be positioned prone. Such positioning carries with it an attendant subset of risks and complications not otherwise encountered in more traditional supine positioning. Gaining awareness of these risks and complications, and developing proactive positioning strategies, will enable the surgical team to position the patient optimally for the procedure and provide for every consideration of patient safety. This article consists of a specific literature review of those issues directly related to the anatomical and physiological concerns arising from prone positioning. Particular attention is paid to the cardiopulmonary, renal, ophthalmologic, and neurological vulnerabilities unique to this position. Proper planning by the surgical team and utilization of the correct equipment are a necessity. A tailored approach to the needs of the individual patient and an intimate awareness of the potential pitfalls will contribute to better outcomes when using the prone position.     

Evaluation of deformable models for femoral neck surgery.

OBJECTIVE: Using fluoroscopic images alone, it is difficult to guarantee that screws are positioned within the femoral head and neck. This study evaluates whether the introduction of deformable 3D models limiting the planning and navigation space is a helpful approach to minimizing the incidence of misplaced screws, thereby enhancing patient safety. BACKGROUND: Even though a screw may appear to lie within the femoral head and neck on fluoroscopic images, this may not, in fact, be the case. This is a particular problem for interventions such as fixation of a slipped femoral head or osteosynthesis of the femoral neck, where screws must be set close to the cortical bone without penetrating the joint or injuring the cortex of the femoral neck. METHODS: A system was developed which permits computer-based planning and navigation of screws for femoral neck fracture fixation based on fluoroscopic images. Different approaches were employed which either a) make use of a deformable model adapted to the femoral head/neck, constraining the screw positions within this model; or b) allow the user to position the screws with or without geometrical constraints on the X-rays while maintaining parallelism of the screws. All designs were evaluated and compared by 7 test users using integral projection X-rays calculated from the CT dataset. Results were checked using a 3D model of the bone, also calculated from the CT dataset. RESULTS: Positioning screws using the deformable model resulted in a significantly smaller distribution of screw tip locations and no penetrations into the hip joint, in contrast to the other approaches where up to 11% of screws were misplaced. CONCLUSIONS: Constraining the planning and navigation space by means of a deformable model allows better control of screw positioning and thus increases the chances of a successful intervention. In particular, CAS systems allowing for virtual fluoroscopy should consider supporting this planning approach.     

The influence of head and neck geometry on stability of total hip replacement: a mechanical test study

BACKGROUND: Dislocation after replacement may be caused by poor implant design or positioning, or by the surgical approach taken. We evaluated the influence of head and neck design on range of motion and stability (with respect to risk of dislocation) in total hip endoprostheses. MATERIAL AND METHODS: Using a test device, we determined the stability afforded by different head sizes and neck geometries for various implant positions. RESULTS: Increasing head diameter led to an enhancement of range of motion as well as resistance against subluxation, and thus to improved stability in any movement combination and implant orientation. Smaller femoral heads were associated with increased risk of dislocation, especially in a poor implant position such as retroversion, and steep positioning of the cup. Skirted metal or mushroom-shaped ceramic heads had a reduced range of motion until impingement of approx. 20 degrees, as compared to spherical standard heads. Furthermore, after identical joint loading, skirted heads dislocated more readily than standard heads with corresponding diameters. INTERPRETATION: To obtain sufficient joint mobility and stability, neck geometry and implant position should be considered when choosing the femoral head size.     

Anesthesia mumps and morbid obesity

Parotid gland swelling during/after surgery is a rare but known complication of general anesthesia. It has been found to be associated with patients of all age groups and various surgical procedures. We have found this rare complication to be associated with morbid obesity as well. A forty five year old morbid obese lady (BMI 50.5 kgm-2) was operated for fracture shaft of left humerous after positioning in right lateral position. Intraoperatively, her head was positioned using soft bandage head ring used commonly for such positioning. Postoperatively unilateral painful parotid gland swelling was noted on the dependent (right) side of face. Possible mechanism for such a scenario could be the vulnerable anatomy of short thick neck of morbid obese patient leading to compression of its vessels and compromising perfusion of the area supplied, hence resulting in ischemic sialadenities. Physicians treating these patients should be aware of this condition to avoid misdiagnosis. Minimum turning of neck should be allowed and proper padding of face should be done to avoid occurence of this potentially harmful complication. Also, use of head ring for positioning the head should be discouraged.     

Efficacy of piperacillin-tazobactam in the treatment of surgical wound infection after clean-contaminated head and neck oncologic surgery

BACKGROUND: Although perioperative antibiotic prophylaxis has significantly reduced surgical wound infection rates, this complication is still a frequent complication of head and neck cancer surgery. Because these infections are typically polymicrobial, our study evaluated the safety and efficacy of piperacillin-tazobactam in the treatment of surgical wound infection after clean-contaminated head and neck oncologic surgery. METHODS: In this multicenter, prospective clinical trial, 70 patients with surgical wound infection received piperacillin-tazobactam. RESULTS: Of patients who were evaluable, 92.4% were also clinically cured or improved, and the bacteriologic eradication rate was 80.3%. Of the 70 patients enrolled in the study, six (8.5%) experienced six adverse events: two cases of moderate diarrhea, one allergic skin reaction, and three cases of phlebitis. No deaths were attributable to the study drug. CONCLUSIONS: Piperacillin-tazobactam is a good choice of treatment as monotherapy for surgical wound infection after clean-contaminated head and neck oncologic surgery.     

急性化脓性髋关节炎压力测定及病理检查

探讨急性化脓性髋关节炎的病理过程及其外科治疗。方法选择急性血源性化脓性髋关节炎１９例２２髋,作关节腔、股骨头颈压力和股骨头、颈骨髓涂片及病理检查,并行髋关节切开减压及股骨头颈钻孔减压引流。结果急性血源性化脓性髋关节炎的关节腔压力明显增高,平均为５．４３ｋＰａ,股骨头颈压力高于２．９４ｋＰａ为１３髋。     

Intraoperative somatosensory evoked potential monitoring in achondroplasia

Surgical airway intervention in children with achondroplastic dwarfism poses potential neurological risk secondary to the neck manipulation required for tracheal intubation and operative head positioning. This is particularly true of achondroplastic dwarfs with radiographically documented foramen magnum and spinal canal stenosis. In these children, upper extremity somatosensory evoked potential monitoring establishes the integrity of sensory conduction from peripheral nerve to cortex, providing intraoperative notification of neurologically significant cervicomedullary compression during laryngoscopy and surgical positioning.     

Progressive resistance neck exercises using a compressible ball coupled with an air pressure gauge

Strength training of neck muscles, a potentially important approach to injury prevention and rehabilitation, has been limited by the lack of a convenient means of instituting progressive resistance exercise (PRE) programs. By positioning a compressible ball coupled with an air pressure gauge between the head and a wall, eight men, ranging in age from 21 to 46 years, initially measured the maximum voluntary pressure (MVP) generated within the ball (a measure of neck muscle force), while maximally flexing, extending, and laterally flexing their head into the ball. In accordance with PRE principles, they then performed three sets of 10 repetitions of each motion while maintaining ball pressure at 60-80% of the measured MVP. This training program, consisting of three to five sessions per week for 4-7 weeks: 1) increased the MVPs for flexion [to 156 +/- 9% (SE) pretraining, p < 0.05], extension [to 162 +/- 11% (SE) pretraining, p < 0.05], and lateral flexion [to 173 +/- 12% (SE) pretraining, p < 0.05]; and 2) decreased the disparity between the MVPs for left and right lateral flexion, indicating that the weaker side showed greater improvement than the stronger side (p < 0.05). These findings demonstrate that progressive resistance neck exercises, facilitated by a compressible ball coupled with an air pressure gauge, can markedly increase neck muscle strength and decrease lateral force imbalance. J Orthop Sports Phys Ther 1992;16(6):275-280.     

Lateral medullary syndrome after prone position for general surgery

IMPLICATIONS: We describe postoperative lateral medullary syndrome with myoclonic spasm. Improper head rotation during positioning in the anesthetized patient might obstruct the flow of the vertebral artery at the neck and result in diminished perfusion of the associated regions in patients with a history of cervical spinal trauma.     

Dynamic Interaction of Craniofacial Structures during Head Positioning and Direct Laryngoscopy in Anesthetized Patients with and without Difficult Laryngoscopy

Background: We lack fundamental knowledge of the mechanisms of difficult laryngoscopy despite its clinical significance. The aim of this study was to examine how head positioning and direct laryngoscopy alter arrangements of craniofacial structures.

Methods: Digital photographs of the lateral view of the head and neck were taken at each step of head positioning and direct laryngoscopy in age- and body mass index-matched patients with (n = 13) and without (n = 13) difficult laryngoscopy during general anesthesia with muscle paralysis. The images were used for measurements of various craniofacial dimensions.

Results: Both simple neck extension and the sniffing position produced a caudal shift of the mandible and a downward shift of the larynx, resulting in an increase of the submandibular space. Direct laryngoscopy during the sniffing position displaced the mandible and tongue base upward and caudally, and the larynx downward and caudally, increasing the submandibular space and facilitating vertical arrangement of the mandible, tongue base, and larynx to the facial line. These structural arrangements in response to direct laryngoscopy were not observed in patients with difficult laryngoscopy, whereas head positioning produced similar structural arrangements in patients with and without difficult laryngoscopy.     

Perioperative spinal canal narrowing in patients with Down's syndrome.

Two patients with Down's syndrome undergoing intracardiac operations had segmental and generalized myoclonic movements postoperatively and eventual brain death. Electroencephalography in 1 patient showed no seizure despite the presence of the myoclonic movements. Computed tomographic scan showed possible cerebellar hemorrhage. Ultrasound showed cerebral edema when the pupils became fixed and dilated. Because known postoperative neurologic complications could not fully explain the clinical course, and the myoclonic movements suggested spinal origin, we considered the possibility of atlantoaxial instability causing spinal cord damage related to perioperative head and neck positioning. Postmortem study on the second patient revealed 50% reduction of the spinal canal with hyperextension and 90-degree external rotation of the head and neck. In contrast, similar maneuvers in 3 infants without Down's syndrome resulted in only mild spinal canal narrowing. Although the myoclonic movements could be explained by spinal cord compression at the atlantoaxial level, the explanation for the eventual brain death is unclear. However, kinking of the vertebral arteries related to the positioning could have caused cerebellar ischemia, hemorrhage, and increased intracranial pressure. We believe that attention to the problem might bring further answers in the future.     

The association between surgical complications and the POSSUM score in head and neck reconstruction: a retrospective single-center study

The Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) is widely used to predict surgical complications affecting various organs. However, there are few reports about objective evaluation methods for head and neck surgery. In this study, we retrospectively examined the association between POSSUM score and actual surgical complications of head and neck reconstruction surgery. In total, 711 patients who underwent head and neck reconstruction after cancer extirpation between January 2007 and January 2015 were studied. The predicted risk of complications was calculated using the POSSUM score and compared with the actual rate of perioperative complications. Perioperative complications occurred in 178 (25%) patients, comprising systemic complications in 52 (7%) patients, surgical site infection of the head and neck area in 78 (11%) patients and failure of the free flap in 55 (8.8%) patients. When patients were divided into a perioperative complication group and a no-complication group, a significant difference between the two groups was observed in the predicted postoperative rate calculated from the POSSUM score (p?相似文献   

Valgus intertrochanteric osteotomy for non-union of femoral neck fracture

In spite of improved surgical techniques and fixation devices, non-union still reportedly occurs in 10-30% of cases of femoral neck fracture. A variety of methods of treatment that preserve the femoral head have been described, yet there are few reports on the results of valgus intertrochanteric osteotomy in cases of femoral neck non-union. We treated 11 such cases with valgus intertrochanteric osteotomy performed at one centre and using a single surgical technique. The cases were evaluated clinically and radiographically at a mean of 4.9 years. All of the non-unions were shown radiographically to have healed by an average of 12.5 weeks. Functional outcome was excellent for nine patients and poor for two who underwent subsequent total hip arthroplasty for avascular necrosis of the femoral head. We conclude that valgus intertrochanteric osteotomy is an effective treatment for femoral neck non-union, but avascular necrosis of the femoral head is a possible complication.     

Dislocation after total hip arthroplasty: implant design and orientation

Implant design and positioning are important factors in maintaining stability and minimizing dislocation after total hip arthroplasty. Although the advent of modular femoral stems and acetabular implants increased the number of head, neck, and liner designs, the features of recent designs can cause intra-articular prosthetic impingement within the arc of motion required for normal daily activities and thus lead to limited motion, increased wear, osteolysis, and subluxation or dislocation. Minimizing impingement involves avoiding skirted heads, matching a 22-mm head with an appropriate acetabular implant, maximizing the head-to-neck ratio, and, when possible, using a chamfered acetabular liner and a trapezoidal, rather than circular, neck cross-section. Computer modeling studies indicate the optimal cup position is 45 degrees to 55 degrees abduction. Angles <55 degrees require anteversion of 10 degrees to 20 degrees of both the stem and cup to minimize the risk of impingement and dislocation.     

Positioning of the patient during shoulder surgery: an inexpensive, safe and easy technique

The knowledge of shoulder pathology has improved tremendously in the last decades, and shoulder surgery is increasingly performed because of new treatment options and better operative results. Nowadays most surgical shoulder procedures are performed in the sitting or semi-sitting (beach chair) position. Stability of the patient and the ability to flex, extend and rotate the shoulder during surgery are crucial to improve exposure of the surgical field and lower the risk of perioperative complications. We developed an easy, safe and inexpensive surgical set-up providing a very good posterior, superior and anterior access to the shoulder in the sitting or semi-sitting position. In this technique, the patient is placed supine with the head at the foot end of the table and the body positioned slightly eccentrically with the back being supported by the leg plate contralateral to the operative side, avoiding any contact with the scapula of the operative side. A neck support is attached on an extra bar at the contralateral side and accommodated to the patient’s lordosis. Next, the leg plate on the operative side is removed, and the head and the body are secured to the table with adhesive dressing. This way a stable positioning of the patient is obtained during the whole procedure, and the shoulder girdle is completely free. The set-up can accommodate patients of different stature and weight without the need to adapt the technique. This position also gives the possibility to provide an excellent radiographic view of the shoulder during operative fracture treatment. Our technique further allows a significant reduction in costs. A surgical table, extra bar, additional arm support and neck support are usually available and can be used in different settings, without the need for a specific shoulder table.     

A review of the surgical and medical treatment of Frey syndrome

Frey syndrome represents a fascinating example of how nerve regeneration can go awry. The syndrome is characterized by profuse facial sweating and flushing that occurs when salivation is stimulated. It can develop following a variety of insults but is most commonly encountered as a complication of parotidectomy. Consequently, it is mainly head and neck surgeons who see and treat this disorder; however, it is important for other clinicians to recognize what these unusual symptoms represent. Diagnosis may be based either on clinical presentation or through objective testing methods. Potential negative social and psychologic implications of this condition can be significant, and treatment ranging from topical agents to local injections of botulinum toxin (Botox) to surgical intervention should be offered to patients. In this article, we present an up-to-date review of the surgical and medical treatment of this syndrome.     

Four different airway-management strategies in patient with Launois-Bensaude syndrome or Madelung's disease undergoing surgical excision of neck lipomatosis with a complicated postoperative course

Launois-Bensaude syndrome, otherwise known as Madelung's disease, is a rare disorder characterized by fatty accumulations of the upper trunk, neck and head, causing serious cosmetic deformity and neck immobility. We report a case of a patient with Launois-Bensaude syndrome who required 4 different airway management strategies during his hospitalization for postoperative complications after an elective surgical excision of a severe neck lipomatosis. Anesthesiologists who treat patients with Madelung's disease should be aware of 2 major problems: difficult airway and increased frequency of postoperative bleeding. A proper choice of airway management technique is therefore necessary, including a safe intubation and extubation plan to reduce the consequences of airway complications.     

Head and neck position for direct laryngoscopy

The sniffing position (SP) has traditionally been considered the optimal head position for direct laryngoscopy (DL). Its superiority over other head positions, however, has been questioned during the last decade. We reviewed the scarce literature on the subject to examine the evidence either in favor or against the routine use of the SP. A standard definition for the position should be used (e.g., 35° neck flexion and 15° head extension) to avoid confusion about what constitutes a proper SP and to compare the results from different studies. Although several theories were proposed to explain the superiority of the SP, the three axes alignment theory is still considered a valid anatomical explanation. Although head elevation is needed to achieve the desired neck flexion, the elevation height may vary from one patient to another depending on head and neck anatomy and size of the chest. In infants and small children, for example, no head elevation is needed because the size and shape of the head allow axes approximation in the head-flat position. Horizontal alignment of the external auditory meatus with the sternum, in both obese and non-obese patients, indicates, and can be used as a marker for, proper positioning. Analysis of the available literature supports the use of the SP for DL. To achieve a proper SP in obese patients, the "ramped" (or the back-up) position should be used. The SP does not guarantee adequate exposure in all patients, because many other anatomical factors control the final degree of visualization. However, it should be the starting head position for DL because it provides the best chance at adequate exposure. Attention to details during positioning and avoidance of minor technical errors are essential to achieve the proper position. DL should be a dynamic procedure and position adjustment should be instituted in case poor visualization is encountered in the SP.     

Positioning immobile critically ill patients who are at risk of pressure injuries using a purpose‐designed positioning device and usual care equipment: An observational feasibility study

The prevalence of pressure injuries in the intensive care unit (ICU) setting is high with rates ranging from 13.1% to 45.5%. Evaluation of interventions to prevent pressure injuries should be informed by preliminary research to identify factors that should be considered during the design of future trials. The study objectives were to evaluate the process of participant recruitment and monitoring in the ICU; measure the maintenance of body angle (in the side‐lying lateral tilt position) and head and neck alignment angle (in the supine position) among immobile critically ill patients when using a purpose‐designed positioning device and usual care equipment, and; ascertain the time required to position patients with the purpose‐designed positioning device and the usual care equipment. A prospective, observational, feasibility study was conducted in an ICU in Victoria, Australia. The sample was immobile critically ill adults at high‐risk of developing pressure injuries. The usual care interventions were pillows, foam wedges, and rolled towels, and the intervention device was the Z‐Flo Fluidized Positioner. The body angle and head and neck alignment were measured on six occasions (at baseline, 1 hour, and 2 hours). The time required for positioning was also measured. The sample was predominately male (n = 5, 62%) with a mean age of 59 years. The majority of patients (n = 106, 92.2%) were not immobile and therefore were ineligible to participate. A total of 48 turning and positioning interventions were observed. For the side‐lying lateral tilt position, the degree of difference from baseline to 2 hours was no more than three degrees for all the devices (the Fluidized Positioner 25°‐26°, the foam wedge 29°‐27°, and the pillow 23°‐21°). For the head and neck position, the degree of difference from baseline to 2 hours was the greatest for the pillow and rolled towel (78°‐71°, a difference of 7°) and the pillow alone (79°‐74°, a difference of 5°). The degree of difference was the lowest for the Fluidized Positioner (84°‐86°, a difference of 2°). Future research to evaluate positioning equipment in the ICU should consider patient eligibility characteristics, particularly immobility. The conduct of preliminary studies to inform the design of larger pressure injury prevention trials is recommended.