A head and neck cancer patient dies! Why perform an autopsy: for the relatives,for the clinicians or for the pathologists?

It is no secret that autopsy rates at most hospitals worldwide--both teaching and community hospitals--have declined precipitously in recent decades, but is this a desirable state of affairs? This article explores this issue from three viewpoints: that of the family members who grant permission for autopsies; that of the clinicians who seek permission for the autopsy to be carried out; and that of the pathologists who actually perform the post-mortem examination. Family concerns about (the sometimes tangential) matter of organ retention following autopsy have recently been highlighted in Europe, with an accompanying negative overall impression of the autopsy being conveyed by many outlets of the popular media. Clinicians will often concede that they feel somewhat distanced from the whole process of autopsy, and so do not hold it in such high esteem as their predecessors once did decades ago. Pathologists at present often perform autopsies as "additional duties" to be fitted in around their central functions, and so do not see them as a primary task to be accomplished. However, there are reasons why this may be detrimental to patient care, including in particular the fact that clinical/radiographic diagnoses are sometimes not confirmed by the results of a complete autopsy. Suggestions for improving the autopsy rate--in particular amongst head and neck cancer patients--are discussed, and include performance of a more rapid limited autopsy and the designation of specialist pathologists in head and neck cancer to carry out autopsies of these patients as an extension of their clinical duties. One conclusion seems inescapable: to increase autopsy rates, the status of the procedure will necessarily have to be upgraded from that of "afterthought/perfunctory task" to that of "consultation", with all of the shifts in attitude such a modification would entail.     

The posterior ligament of the incus (“white dot”): A reliable surgical landmark for the facial recess

ObjectiveThere is a void in the literature describing reliable surgical landmarks that aid in the dissection of the facial recess in the absence of skeletonizing the mastoid segment of the facial nerve. The posterior ligament of the incus is a readily distinguishable “white dot” along the incus buttress that has been used to guide dissection in a safe and efficient manner. The goal of our study is to describe a surgical approach that utilizes this surgical landmark to drill the facial recess and to take anatomical measurements demonstrating the safety and reliability of this approach.Materials and methodsAfter cortical mastoidectomies were performed in 10 cadaveric temporal bones, the white dot was identified at the junction of short process of the incus and the incus buttress. Using the white dot for anatomical reference, a 2 mm diamond drill bit was used to open the facial recess without first identifying the facial nerve or chorda tympani nerve. After photographs were taken, the facial and chorda tympani nerves were definitively identified and skeletonized to delineate the confines of the facial recess. Photographs were once again acquired in a consistent manner for comparison. Finally, calibrated anatomic measurements were acquired from the 10 distinct image sets.ResultsThe facial recess was successfully drilled in 10 temporal bones using the posterior ligament as a surgical landmark without injury to the chorda tympani or facial nerve. The median angle taken from the axis of the short process of the incus to the facial nerve - chorda tympani junction was 139.2° (IQR 136.8–141). At the widest point in the facial recess, median distances anterior and posterior to an imaginary line connecting the white dot to the facial nerve - chorda tympani junction were 1.6 mm (IQR 1.5–1.7) and 1.6 mm (IQR 1.6–1.7; p = 0.57), indicating at this point, the white dot reference reliably bisects the facial recess width. Similarly, at the level of the round window niche, median anterior and posterior distances from an imaginary line connecting the white dot to the facial nerve - chorda tympani junction were 1.1 mm (IQR 1.1–1.3) and 1.3 mm (IQR 1.1–1.7; p = 0.07), respectively, once again demonstrating the white dot reliably bisecting the facial recess.ConclusionsThe white dot, representing the posterior ligament of the incus, is a reliable surgical landmark that aids in safe and efficient drilling of the facial recess without first skeletonizing the facial nerve.     

Thrombosis of the internal jugular vein in the ENT-department — Prevalence,causes and therapy: A retrospective analysis

ObjectiveLess than 5% of deep vein thrombosis is due to thrombosis of the internal jugular vein. Genetic, malignant or inflammatory underlying diseases as well as insertion of venous catheters can be responsible for this pathology. Due to its rare occurrence, it is difficult to find systematic research about thrombosis of the internal jugular vein.MethodsWe performed a systematic analysis of present patient data from our ENT department with the electronic patient record considering the period from 2012-2017. Search terms were “thrombosis” and “jugular internal vein”. We identified 41 patients with the requested diagnosis and performed further analysis of the cases. Internal jugular vein thrombosis was diagnosed in all patients using Duplex sonography and/or CT/MR angiography.ResultsParaneoplastic thrombosis was found in 22/41 patients (54%), in 15 of the 22 (68%), the tumor was located in the ENT region. Two out of seven (29%) of the patients with tumor entities outside the head and neck region had thrombosis of the internal jugular vein as the first symptom of the disease. Another 14/41 patients (34%) had underlying inflammatory diseases – mostly streptococci-associated – for example a cervical abscess. In two patients, insertion of a central-venous catheter was causal, in three patients we could not find any reason for the development of thrombosis.ConclusionTo diagnose the rare and often asymptomatic thrombosis of the internal jugular vein, ultrasound of the cervical region should always include vascular imaging. Thrombosis of the internal jugular vein results mostly paraneoplastic or due to inflammation/abscess. It can be the first symptom of a malignant primary disease and always requires detailed diagnostic clarification.Level of evidence4.     

Patient safety and the annulment of medical clearance exams for hearing aids: Are we “closing the book” too soon?

PurposeTo determine the utility of medical clearance exams by otolaryngologists prior to the distribution of hearing aids to patients with hearing loss.Material and methodsMedical records of 313 consecutive hearing-impaired individuals seeking financial assistance for hearing aids from the Lions Hearing Center of Michigan and who presented for medical clearance exams between January 2014 and May 2017 were retrospectively analyzed. Separate determinations were made for each patient about (1) benefit from the exam and (2) avoidance of significant harm.ResultsMajority (64.2%; n = 201) of patients benefited from medical clearance exams. Furthermore, 5.4% of patients (n = 17) were found to have avoided significant harm due to administration of the medical clearance exam. Finally, 14.4% (n = 45) were offered alternative interventions over conventional hearing aids.ConclusionsMedical clearance exams are beneficial to a majority of patients with hearing loss prior to receiving hearing aids. With the impending arrival of over-the-counter hearing aids in the United States, special consideration should be placed on educating the general public about the importance of the medical evaluation prior to purchasing any type of hearing aid.     

Endoscopic “retrograde” dacryocystorhinostomy: A fast route to the lacrimal sac

Endoscopic Dacryocystorhinostomy (DCR) is an established surgical technique for the management of peripheral nasolacrimal duct (NLD) obstruction. Its main points are the correct identification of the lacrimal sac and the execution of surgical procedures that allow a rapid and accurate healing of the surgical field. The main endoscopic landmarks used for the identification of the lacrimal sac are the middle turbinate and the maxillary line.However, in some cases, this procedure can be difficult due to several factors (e.g. anatomical variations, former surgery).In the present study, a variation of “classic” endoscopic DCR, named “retrograde” endoscopic endonasal DCR (rDCR), is described. rDCR is performed through the quick identification of the NLD at the level of the most anterior insertion of the inferior turbinate in the lateral nasal wall. In most cases, at this level only a very thin shell of bone is present (crack point), easily fractured by using blunt angled dissector. The duct is then followed upward along its course by removing the overlying bone in order to correctly identify the lacrimal sac and unequivocally drill along the lacrimal pathway. This technique proved to be a safe, quick and effective procedure, even in patients with difficult anatomy.     

A new approach for crooked nose: Separated spreader graft “puzzle graft”

IntroductionThe nasal septum takes an important role in nasal shape and function. The term “crooked nose” is commonly used for all of the clinical conditions involving deviation of the nasal axis from the midline. This situation leads to both aesthetic concerns and breathing problems. In this study, we describe a new method in order to nasal dorsum on the midline and improving airway function in crooked nose patients, that will be contribute to the literature.Materials and methodsThis study enrolled 50 (fifty) patients who had undergone open septorhinoplasty operation were included in our study. The puzzle graft, which was prepared as a spreader graft consisting of three separate parts, was used to correct crooked nose in all patients. Anterior rhinoscopic examination, photographs and Nasal Obstruction and Septoplasty Effectiveness (NOSE) scores for the pre-operative and post-operative 1 year were compared and evaluated in this study.ResultsThe new approach was used successfully in all of the patients. Anterior rhinoscopic and 1 year photographic evaluations revealed a significantly correction of external appearance post-operatively. None of the patients had any additional complaints and complications during the post-operative period. We observed that NOSE scores, with which the post-operative nasal obstruction was evaluated, were significantly better in all 50 patients.ConclusionCrooked nose deformity is one of the most difficult problems in rhinoplasty. There is no absolute true technique for solving this situation. Each method works properly in appropriate cases. Sometimes we should use more than one technique in the same operation to correct the pathology. Our purpose is to present a new option to help surgeons in “crooked nose”; to provide a new method that can work safe and effective in convenient conditions.