Rehabilitación del paciente laringectomizado. Recomendaciones de la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello

Total laryngectomy remains essential treatment for locally advanced laryngeal carcinoma, related to better survival rates. However, it involves changes for the patient, such as the inability to communicate verbally, breathing or aesthetic changes, which affect their quality of life and require comprehensive rehabilitation.This paper was written by the total laryngectomy rehabilitation workgroup of the National Head and Neck and Skull Base working committee of the Spanish Society of Otolaryngology and Head and Neck Surgery. The purpose of the article is to combine materials, surgical procedures and means towards the comprehensive rehabilitation of total laryngectomy patients, so that they can achieve a good quality of life. This paper is aimed at all health care professionals caring for total laryngectomy patients. It is also aimed at the patients themselves, as well as ENT surgeons.We have considered staffing and material needs, all procedures before, during and after surgery and after hospital discharge. There are also detailed recommendations about types of rehabilitation and follow-up, and the need for recording these events.The comprehensive rehabilitation total laryngectomy patients is very important if we want to improve their quality of life. The recommendations we mention aim to help the healthcare professionals involved in the treatment of total laryngectomy patients to help them achieve a good quality of life, as similar as possible to the life they led before surgery.     

Recomendaciones de la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello para la realización de traqueotomías en relación con pacientes infectados por coronavirus COVID-19

The recent COVID-19 (coronavirus) pandemic is causing an increase in the number of patients who, due to their pulmonary ventilatory status, may require orotracheal intubation. COVID-19 infection has demonstrated a high rate of transmissibility, especially via the respiratory tract and by droplet spread. The Spanish Society of Otolaryngology and Head and Neck Surgery, based on the article by Wei et al. of 2003 regarding tracheotomies performed due to severe acute respiratory syndrome (SARS), has made a series of recommendations for the safe performance of tracheotomies.     

Monitorización intraoperatoria del nervio facial durante la cirugía de la glándula parótida en servicios de otorrinolaringología - cirugía de cabeza y cuello

IntroductionFacial nerve injury remains the most severe complication of parotid gland surgery. Due to the increasing evidence about the advantage of the use of intraoperative facial nerve monitoring, a survey was distributed among members of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery with the objective of determining patterns of its use.Material and methodsA questionnaire which included 12 separate questions in 3 sections was distributed via email through the official email of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery. The first section of questions was in relation to demographic characteristics, the second section was related to the pattern of monitoring use and the third section referred to litigation related to facial palsy.Results1544 anonymous questionnaires were emailed. 255 surveys were returned, giving an overall response rate of 16.5%. From these, 233 (91.3%) respondents perform parotid gland surgery. Two-hundred nineteen (94%) respondents use intraoperative facial nerve monitoring. Of the respondents,94% used intraoperative facial nerve monitoring if in their current practice they performed fewer than 10 parotidectomies per year and 93.8% if they performed more than 10 (OR, 1.02; 95% CI, 0.68-1.45; p = .991). With regard to lawsuits, just 3 (1.2%) of the respondents had a history of a parotid gland surgery–associated lawsuit and in just one case the facial nerve monitor was not used.ConclusionOur data demonstrate that most otolaryngologists in Spain use intraoperative facial nerve monitoring during parotid gland surgery. Almost all of them use it to improve patient safety and consider that facial nerve monitoring should be helpful preventing inadvertent injury.     

Recomendaciones sobre el uso de la neuromonitorización en cirugía de tiroides y paratiroides

Introduction

Thyroid and parathyroid surgery (TPTS) is associated with risk of injury to the recurrent laryngeal nerve, superior laryngeal nerve and voice changes. Intraoperative neuromonitoring (IONM), intermittent or continuous, evaluates the functional state of the laryngeal nerves and is being increasingly used. This means that points of consensus on the most controversial aspects are necessary.

Implicación clínica de la lesión iatrogénica de la cuerda del tímpano en la cirugía de la otosclerosis

Introduction: Damage to the chorda tympani nerve is frequent during otologic surgery. This article studies the clinical outcomes of the nerve's section versus its conservation in otosclerosis surgery.Material and method: Retrospective observational study using our department's otosclerosis database and a validated questionnaire on symptoms associated with the chorda tympani nerve. The sample was divided into two groups: section and conservation (patients whose nerve was anatomically conserved). We studied the presence and duration of symptoms, the surgical technique and the audiometric results.Results: 78 patients (88 ears): section group (18 ears; 20 %) and conservation group (70 ears; 80 %). Overall, gustatory symptoms appear in 35 % (39 % section group; 34 % conservation group). Differences between groups are not statistically significant in relation to presence and duration of symptoms, surgical technique or audiometric results. Only 1 patient in each group reports long-term symptoms. Our results suggest there are no major clinical differences following section versus conservation of the chorda tympani nerve. A wide range of factors such as age, presence of previous middle ear pathology, cross innervation and gastronomic culture may play a role in the appearance of symptoms.Conclusions: Symptoms appearing after iatrogenic damage to the chorda tympani nerve have, in general, little clinical relevance, especially in the long term, regardless of whether the nerve is dissected or manipulated to various degrees.     

Significación clínica de la asimetría amigdalina

IntroductionAsymptomatic unilateral tonsillar enlargement is usually treated with systematic tonsillectomy under suspicion of malignancy. Due to the fact that most of the cases are benign pathologies, we set out to study the clinical signs that would help us in the diagnosis in order to avoid unnecessary tonsillectomies.Material and methodsWe reviewed 267 tonsillectomies performed from 1996 to 2006 and 30 of these were indicated because of asymmetry. We evaluated risk factors for malignancy: cervical lymphatic node enlargement, sex, age, tonsillar enlargement noticed by the patient, suspicious appearance, systemic symptoms, history of malignancy and immunocompromise.ResultsHistopathologic study revealed 80 % to be benign and 20 % malignant. The risk factors with the strongest association were enlargement of cervical lymphatic nodes and suspicious appearance of the tonsil.ConclusionsStrict control of a unilateral tonsillar enlargement is possible, but it is mandatory to perform a tonsillectomy when the appearance of the tonsil raises suspicions or there are enlarged lymphatic nodes.     

Doble anomalía de la segunda hendidura branquial

Second branchial cleft anomalies are the most common of this type of neck masses. They can be classified in four types (Bailey/Proctor classification) according to their location. Type II is the most common, and related to vital neck structures such as the carotid artery and jugular vein. Cysts are the most frequent among them. Management consists of surgical excision of the cyst and tract by cervicotomy to avoid recurrence. We present an extremely rare case of a 32-year-old male who presented a sudden appearance of a right lateral neck mass that was identified by an image study as a double branchial cleft cyst. A review of simultaneous branchial cleft cyst in the literature is also made.     

Absceso de cavum y oftalmoplejía secundarios a otitis externa maligna

We present a rare case of ophthalmoplegia, labyrinthitis and abscess of cavum secondary to skull base osteomyelitis by malignant external otitis. Since symptoms persisted in spite of antibiotic therapy, surgical drainage using a transnasal endoscopic approach was performed.     

Impacto de la laringectomía total en la situación laboral

Introduction

Total laryngectomy is one of the most mutilating oncological operations. There are no specific studies evaluating return to work after this surgery.

Evaluación de la disfunción de la trompa de Eustaquio mediante el cuestionario de disfunción tubárica (ETDQ-7) y la tubomanometría

ObjectiveEvaluation of the severity of Eustachian tube dysfunction using the Spanish validation of the Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7) and tubomanometry (TMM).Materials and methodsSpanish validation of the ETDQ-7. Patients: Prospective study with 125 patients, 75 of whom reported symptoms compatible with Eustachian tube dysfunction. Outcome measures: The Spanish version of the ETDQ-7 was administered after translation and back-translation. Internal consistency and reliability were established. Usefulness evaluation of TMM plus ETDQ-7 in the study of Eustachian tube dysfunction.ResultsThe Spanish adaptation of the ETDQ-7 showed high reliability and internal consistency. TMM and ETDQ-7 together showed increased sensitivity and specificity in the diagnosis of Eustachian tube dysfunction.ConclusionsThe Spanish adaptation of the ETDQ-7 is valid, reliable and can be used in a clinical setting to quantify the impact and severity of chronic dysfunction on patients’ lives. A new test formed by combining ETDQ-7 and TMM could be a routine test in the diagnosis of Eustachian tube dysfunction.     

Estudio objetivo de la voz en población normal y en la disfonía por nódulos y pólipos vocales

Astudy of the objetive evaluation of voice was made of 100 voices of healthy adults and 60 with disphonia (nodules and polyps). A laryngostroboscopy and an acoustic analysis was made to everyone. A sustained vowel “a” was carried out and digitalized with Dr. Speech Science software. These parameters were estimated: fundamental frequency (Fo, accourding to gender), Jitter, Shimmer and glottic noise (NNE, HNR, SNR). In the healthy group Fo was 139.72 in men and 267.33 in women, jitter 0.24 and shimmer 2.10. In disphonic patiens (nodules) Fo was 126.96 in men and 240.72 in women, jitter 0.35 and shimmer 3.25. In disphonic patiens (polyps) Fo was 119.75 in men and 218.26 in women, jitter 0.50 and shimmer 4.34. These difference were statistically significant. Glottic Noise in healthy group was: NNE –13.62, HNR 24.07 and SNR 24.49; in disphonic patiens (nodules) was: NNE –10.65, HNR 25.21 and SNR 25.55; in disphonic patiens (polyps) was: NNE –8.24, HNR 29.63 and SNR 28.22. Only the difference in the NNE was statistically significant. We highlight the importance of objetive evaluation of voice disorders.     

Evaluación de la vía aérea mediante laringoscopia indirecta en pacientes con hipertrofia de la amígdala lingual

Introduction and objectivesPrevalence of the lingual tonsillar hypertrophy is unknown but it is believed that its presence is associated with the difficult airway. To investigate this, indirect laryngoscopy was performed on patients in the preoperative evaluation and this pathology was diagnosed. The relationship with difficulty of viewing the larynx, intubation and ventilation, under general anaesthesia and using direct laryngoscopy, was then studied.MethodsWe performed the demographic variable checks and tests for predicting difficult intubation (mouth opening, thyromental distance, cervical flexion-extension, neck thickness and Mallampati test), in the preoperative step on 300 patients who were going to be submitted to general anaesthesia. We then performed indirect laryngoscopy on them using a 70° rigid laryngoscope to ascertain the frequency of appearance of lingual tonsillar hypertrophy. Next, under general anaesthesia, we carried out direct laryngoscopy to verify whether there was difficulty in viewing the larynx and intubation and ventilation. We then investigated the association of demographic predictors of difficult intubation, including indirect laryngoscopy, with the presence of this condition.ResultsPrevalence of lingual tonsillar hypertrophy was 2%. No relationship between the appearance of this entity and the difficulty of viewing the larynx, intubation and ventilation was found. Only indirect laryngoscopy was linked to the appearance of this pathology.ConclusionsLingual tonsillar hypertrophy is a relatively frequent disorder, whose presence is not usually associated with difficult airway.     

Aplicación de la biopsia por endoscopia flexible en el diagnóstico de la patología tumoral en otorrinolaringología

Introduction and objectives

Interventional endoscopy allows us to act on the pathology of the patient with minimal discomfort, low costs and high efficiency. We assessed the validity of flexible endoscopic biopsies in our hospital, in lesions suspected of malignancy in the rhino-pharyngo-laryngeal space.

Fístulas de LCR tras la cirugía de tumores del ángulo pontocerebeloso y su relación con el índice de masa corporal

IntroductionThe most frequent complication after vestibular schwannoma surgery is cerebrospinal fluid (CSF) fistula.Material and methodsRetrospective study of 170 patients who had vestibular schwannoma (163) or other tumours in the cerebello pontine angle (CPA) (7). Resection was carried out using different approaches: retrosigmoid (66%), translabyrinthine (24%), middle cranial fossa (5%) and others (5%). We studied the day of onset, location and treatment of the CSF leaks, and the influence of demographic, radiological and clinical variables, including Body Mass Index.Results27 patients developed a CSF fistula (15.9%): 15 were incisional (8.8%), 8 patients developed CSF rhinorrhea (4.7%), 1 CSF otorrhea (0.6%) and 3 a combination of the above (1.8%). We controlled 11 CSF fistulae with bed rest and compressive dressings (6.5%), 7 required lumbar drainage (4.1%), 2 lumbar drainage and wound closure with local anaesthesia (1.2%) and 7 patients required returning to the operating room under general anaesthesia (4.1%). There was not a significant relationship between the apparition of CSF and tumour size, type of approach, age or body mass index (BMI).ConclusionsDespite the great development and new surgical techniques, CSF fistulae are still a frequent complication after VS surgery. There might be other aetiological factors such as intracranial pressure. There was no significant relationship between CSF fistula and BMI. Adequate management and early conservative measures led to reduced reintervention rates of less than 5% in all patients.     

Tratamiento quirúrgico del síndrome de apneas obstructivas durante el sueño: de la cirugía palatofaríngea a la reconstrucción quirúrgica multinivel de la faringe. bases,resultados y perspectivas futuras

In this paper is evaluated the effectiveness, as a function of the morphologic structure of the Upper Airways (UA) -evaluated by vigil ENT exploration plus cephalometrics- in the treatment of Obstructive Sleep Apnea Syndrome (OSAS) of the UPPP with or without Nasal Surgery (NS), performed on 33 OSAS patients, and the Multilevel UA Reconstruction (MUAR), performed on 13 patients with multilevel UA obstruction. 10 patients of this group were also evaluated by UA Pressure Measurements during Sleep (PMS). UPPP shows an effectiveness of 60% in cases of favourable UA topography: Predominant palatal obstruction (Type I: euthopic palate with no hypopharyngeal obstruction and Type IIa: palate of low implantation with no hypopharyngeal obstruction, either N+ (nasal obstruction present) or N- (nasal obstruction obsent) and 0% in cases of unfavourable UA structure: Extrapalatal obstruction (Type IIb: palatal and hypopharyngeal obstruction and Type III: hypopharyngel obstruction, either N+ or N-). The maximum UPPP effectiveness is achieved in UA topography IN+ (80%), followed by IIaN- (60%), IIaN+ (57%) and IN- (47%). MUAR, applied on failures of UPPP and patients with UA topography unfavourable to UPPP (Types IIb and III) that rejected CPAP therapy, shows a success rate of 50% in IIaN+ UA type (allowing the recuperation of the 50% of the UPPP failures having this UA topography), 80% in type IIbN+ (where UPPP is contraindicated) and 0% in types IIaNand IIbN-. PMS shows UA multilevel obstruction during sleep. The role of UPPP, NS and MUAR in the treatment of SAOS is are discussed.     

Miotomía del cricofaríngeo en el tratamiento de la distrofia muscular oculofaríngea

Oculopharyngeal muscular dystrophy (OPMD) is an autosomal dominant myopathic disease which provokes oropharyngeal dysphagia, palpabral ptosis and proximal limb weakness. It is the abnormal expression of the GCG triplet in the PABPN1 gene on chromosome 14 that causes this disease. The study of the oropharyngeal dysphagia that these patients suffer from should include upper gastrointestinal endoscopy, barium video-radiology and oesophageal manometry. Genetic study confirms the diagnosis. We report 6 patients (3 of whom were siblings) referred to our department with a confirmed diagnosis of OPMD, who underwent cricopharyngeal myotomy to achieve normal swallowing.     

Aportación al estudio de la otosclerosis y del síndrome de van der hoeve

Morphological and microchemical changes that effect to the otosclerotic stape in the Van der Hoeve’s syndrome were examined with a scanning electron microscope equipped with an energy dispersive X-ray fluorescence. Using the Ca/P ratio as criterion –measured by the characteristic x-ray fluorescence– it was shown that the Van der Hoeve stape had a higher Ca/P ratio (2.6:1) as compared to the normal stape (2:1). The Van der Hoeve’s syndrome lesions as poorly mineralized, with low calcium salt and apparent increase of phosphates. This finding indicates a possible change from hydroxyapatite (or apatite) to brushite, which imply an acidification of bone.     

Caracterización de la enfermedad por reflujo faringolaríngeo en pacientes de edad avanzada y ancianos

ObjectivesTo characterize laryngo-pharyngeal reflux (LPR) in patients over 60 years of age.MethodsRetrospective review of patients over 60 years of age with symptoms suspicious of LPR, seen from 2005 to 2014 at an ENT Department of an academic hospital. Eighty-five consecutive patients (54 females, 31 males) who had completed a dual-sensor 24-hour pH-metry were included (considered “gold-standard” in LPR diagnosis).Body mass index, and reflux information and interventions were revised. pH-metries were evaluated according to DeMeester & Johnson's criteria. Symptoms were assessed according to the Reflux Symptom Index (RSI) and classified as abnormal if score was ≥13. A naso-fibro-laryngoscopy enabled findings to be documented according to the Reflux Finding Score (RFS), and they were classified as abnormal if the score was ≥7.ResultsThe patients’ mean age was 67 years. A positive pH-metry was present in 70 patients (82.5%). Fifty patients (59%) had abnormal body mass index, and almost 90% of them had an abnormal pH-metry. Mean RSI score was 9.8, with abnormal results in 24 patients (28%). Only 20 patients (23%) with abnormal RSI had a positive pH-metry. Posterior commissure hypertrophy was the most common finding (90% of patients). Mean RFS score was 9.07, with abnormal results in 69 patients (81%). Sixty-one patients (70%) with abnormal RFS had a positive pH-metry. Only 18 patients (20%) had coincidental abnormal pH-metry, RSI, and RFS.ConclusionsIn ageing patients, abnormal body mass index is strongly associated with abnormal pH-metry. RSI is a weak indicator of LPR, whereas RFS has a moderate value.     

Lista de verificación de tomografía computarizada de hueso temporal y base de cráneo lateral

Computed tomography scan of the temporal bone is a fundamental imaging modality for both the diagnosis and treatment of a wide range of pathologies affecting this complex structure. Temporal bone computed tomography scan provides a more detailed depiction of bone structures, compared with magnetic resonance imaging and, for this reason computed tomography scan is the imaging modality of choice in the planning of otological surgery.The aim of this article is to present a checklist to allow the otolaryngologist to assess systematically and in an organized manner the main anatomical landmarks, anatomical variants, as well as the most common postoperative surgical changes, which can be identified before any safe otological surgery.This revision was promoted by the Spanish Society of Otolaryngology and elaborated in a checklist template divided into the different areas of the temporal bone and the lateral skull base.