Negative-pressure pulmonary edema after routine septorhinoplasty: discussion of pathophysiology, treatment, and prevention

OBJECTIVE: To provide rhinologic surgeons with an understanding of acute negative-pressure pulmonary edema (NPPE) and its treatment. DESIGN: Case report and literature review of all published adult cases of NPPE. Patient factors, anesthetic variables, and outcomes are assessed. RESULTS: A total of 146 cases in 45 case reports and series were compiled. There was approximately a 2:1 male-female patient ratio. The average age of the patients was 33 years. Fifty percent of patients had surgery on the upper aerodigestive tract, and 8% had intranasal surgery. No patients received laryngotracheal anesthesia, and 5 of the 146 received intravenous lidocaine prior to extubation. One patient had NPPE following laryngeal mask airway treatment, and 2 patients experienced this complication after conversion from monitored anesthesia care to general endotracheal anesthesia; 33.5% of patients were treated with continuous positive airway pressure alone, while 66.5% required intubation and mechanical ventilation. The average time to resolution was 11.75 hours. Three patients died. CONCLUSIONS: It is known that surgical procedures involving the upper aerodigestive tract have a higher risk of NPPE than other procedures. Rapid diagnosis and treatment is necessary to achieve early resolution and avoid significant patient morbidity. A thorough understanding is integral to the practice of nasal and paranasal sinus surgery, especially with the rising use of outpatient and office-based surgical suites. Therefore, we present a review of pathophysiologic mechanisms, possible risk factors, treatment options, and potential steps that can be taken to minimize this potentially devastating complication of general anesthesia.     

Endovenous Laser Surgery of the Incompetent Greater Saphenous Vein With a 980-nm Diode Laser

BACKGROUND: In recent years, the minimal endoluminal invasive alternatives against surgical ligation and stripping for the treatment of incompetent greater saphenous vein (GSV) have been explored. Endovenous laser surgery is one of these endoluminal alternatives, and its clinical results are being reported at up to 3 years. OBJECTIVE: To evaluate the safety and efficacy of a 980-nm diode laser for the elimination of the incompetent GSV. METHOD: Fifteen limbs in 12 patients with incompetent GSV were treated via an endovenous route with a 980-nm laser under local anesthesia in an outpatient setting. The effects were evaluated clinically along with duplex ultrasound at 1, 4, and 12 weeks after the treatment to determine efficacy and possible complications. RESULTS: Complete occlusion and retraction of treated GSV in all patients were observed during the 12 weeks of the postoperative period. There have been no significant complications to be concerned. CONCLUSION: The endovenous 980-nm diode laser surgery is a relatively simple, safe, office-based procedure that is expected to promise favorable results while a long-term follow-up is awaited.     

Airway Complications from Topical Mitomycin C

OBJECTIVE: Topical application of mitomycin C appears to be a useful adjunct in reducing cicatricial scarring of the airways. Human and animal studies have demonstrated the efficacy and safety of mitomycin C topically in the treatment of airway stenosis at concentrations ranging from 0.4 mg/mL to 10 mg/mL. Although no reports of mitomycin C toxicity have been reported in the otolaryngology literature, the ophthalmologic literature has documented serious, vision-threatening complications resulting from the use of topical mitomycin C. The purpose of this study is to report complications related to mitomycin C use in the treatment of glottic and subglottic stenosis. Risk factors associated with these complications are identified. STUDY DESIGN AND SETTING: A retrospective chart review of all patients treated by the senior author for laryngotracheal stenosis with endoscopic CO(2) laser incisions/dilation and adjuvant topical mitomycin C was performed to determine the incidence of complications. Variables studied included patient age and gender, location and severity of stenosis, medical comorbidities, length of procedure, postoperative instrumentation of the airway, and mitomycin C concentration. RESULTS: Eighty-five cases of adjuvant topical mitomycin C use after CO(2) laser endoscopic treatment and dilation for upper airway stenosis were identified in a total of 44 patients. Complications that were believed to be caused by the local toxicity of mitomycin C occurred in 4 cases out of 85 (or 4.7%), manifested by accumulation of fibrinous debris at the operative site, resulting in partial airway obstruction and the need for emergent airway intervention. CONCLUSIONS: Caution should be exercised when topical mitomycin C is used in the treatment of airway stenosis.     

Mirizzi综合征诊断与治疗10年回顾

目的:总结10年间Mirizzi综合征(MS)的诊治经验,为临床提供借鉴。方法:回顾2004—2013年间收治的27例MS患者临床资料,包括3例保守治疗,24例手术治疗,主要将24例手术患者的术前资料、手术方式、术后恢复及随访情况进行分析与总结。结果:24例手术患者中,术前确诊率为54.2%(13/24),术前MRCP对MS的确诊率高于彩超和腹部CT,23例(95.8%)术后病理诊断为慢性胆囊炎。10例腹腔镜手术患者中,除1例因腹腔粘连严重转为开腹,术后腹痛症状反复外,余未出现术中及术后并发症,远期随访结果良好;14例开腹手术患者中,术后2例出现少量胆汁漏,随访发现1例长期腹痛,1例T管拔除延迟,1例出现切口疝及肠梗阻。结论:MS的术前确诊率低,完善术前检查有助于提高术前确诊率,以便合理选择术式,减少术中并发症。腹腔镜手术治疗MS具有一定的优势。     

Iatrogenic laryngotracheal stenosis. Our therapeutic experience apropos of 25 cases

The authors report 25 cases of iatrogenous laryngotracheal stenosis seen at the university hospital IBN Rochd of Casablanca these stenosis are frequent as well as in infant as (12 cases) as in males (10 cases) they are the consequence of prolonged intubation in cases of coma (12 cases) of traumatic intubation (10 cases) but also after laryngeal irradiation (2 cases) or partial laryngeal surgery (1 case). The seat of stenosis is laryngeal (56%) laryngotracheal (36%) and tracheal (8%). The treatment of these stenosis is difficult; our patients are usually tracheotomised (63.6%) with extensive stenosis. The treatment has used this rilling with laser (12 cases) an endoscopic microsurgery (4 cases) and open surgery 2 times. The dilatation by mean of Montgomery tube or by Traissac tube is often irispensable to avoid relapses. The results are favorable in spite of the length of the treatment (10 days to 30 months) with 15 succesS and 7 partial failures. The authors underline the stenagenous risk of intubations and tracheotomies and on the rules to prevent these iatrogenous laryngo-tracheal stenosis.     

Office-based treatment of laryngeal papillomatosis with percutaneous injection of cidofovir

OBJECTIVE: Our aim was to report our experience with office-based treatment of severe laryngeal papillomatosis with percutaneous injection of cidofovir in a case series of 5 patients. STUDY DESIGN AND SETTING: We conducted a retrospective review of a case series in a tertiary academic care voice disorders clinic. Adult patients with papillomas of the vocal cords and anterior commissure received percutaneous injection using a point-touch technique. Clinical improvement or remission of the papillomatosis was noted. RESULTS: Before initiation of office treatments, patients required direct laryngoscopy and CO(2) laser ablation of papillomas on average every 2.8 months. There were no complications related to the injection technique. During a treatment period of 7 to 16 months (mean 12 months), a significant reduction in the volume of papillomatosis was achieved in all patients. One patient received 2 treatments and another received 1 treatment in the operating room for final clearance of papillomas. CONCLUSION: Office-based treatment of adult patients with anterior laryngeal papillomatosis using percutaneous injection of cidofovir reduces the need for repeated direct laryngoscopy and laser ablation under general anesthesia. SIGNIFICANCE: Percutaneous injection treatment with cidofovir is a useful adjunct to direct laryngoscopy and laser ablation in the treatment of laryngeal papillomatosis.     

Benign tracheal and laryngotracheal stenosis: surgical treatment and results.

OBJECTIVES: Benign tracheal stenoses remain the most common indications for tracheal resection. We report lessons learned with surgical management of tracheal stenoses in a consecutive series of 65 patients from the beginning of our experience to date. METHODS: From December 1991 to January 2001 65 patients underwent primary tracheal and laryngotracheal resection and reconstruction for non-neoplastic stenoses. There were 39 males and 26 females with a median age of 33 years (range 14-74 years). There were 58 cases of postintubation and seven of idiopathic stenosis. A cervical approach was used in 60 patients, and a cervical incision with sternal split in four and with sternotomy in one. We performed 45 (69.2%) tracheal resections and 20 (30.8%) laryngotracheal resections. The length of resection ranged between 1.5 and 4 cm (median 2.5 cm). The range of resected rings was two to eight (median five). RESULTS: Fifty-four patients received a preoperative treatment. Preoperative procedures consisted of laser therapy (37), tracheostomy (38) and endotracheal prosthesis (16). We had major complications in eight patients (12.3%) and minor complications in 15 patients (23%). The most frequent complications were: temporary vocal cord dysfunction (eight patients), wound infection (five patients), anastomotic dehiscence (four patients), vocal cord paralysis (two patients), granulation tissue (two patients), deglutition dysfunction (one patient) and restenosis (one patient). Perioperative mortality was 1.5% (one patient). In classifying final results obtained, 54 patients achieved an excellent result, eight a good result and two satisfactory. CONCLUSIONS: The strategy for treatment of airway stenoses is now well established and leads to a high level of success with minimal or no sequelae. Meticulous preoperative assessment and preparation associated with a perfect surgical technique is mandatory to obtain good results. Preoperative treatments (laser and/or endotracheal prosthesis) could increase the extent of injury and the length of stenosis.     

Laryngotracheal resection and reconstruction by Grillo's technic for postintubation stenosis]

BACKGROUND: Tracheal resection and reconstruction is the standard treatment for postintubation stenosis. However, when the stenosis extends proximally to the subglottic larynx surgical treatment is particularly difficult. Specific surgical techniques have to be used in order to preserve the recurrent laryngeal nerves. The aim of this study is to evaluate the results obtained at our Department with laryngotracheal resection and reconstruction with the Grillo technique for postintubation stenosis. METHODS: From January 1984 to December 1997, 83 patients with tracheal and laryngotracheal lesions underwent surgical treatment. Eighteen patients had postintubation stenosis of the upper trachea and subglottic larynx and underwent single-stage laryngotracheal resection and reconstruction. Mean stenosis length was 3.5 cm (range 3-5 cm). Twelve patients underwent anterolateral laryngotracheal reconstruction, and 6 patients had a circumferential laryngotracheal reconstruction. A Montgomery suprahyoid laryngeal release was required in 4 cases. RESULTS: There was no surgical mortality. Surgical results were excellent or good in 17 cases and satisfactory in one case. No recurrence of stenosis has been observed. CONCLUSIONS: Cricoid cartilage involvement in postintubation stenosis should not be considered a contraindication to surgical treatment. However, laryngotracheal resection and reconstruction is technically difficult and should be performed only in selected cases.     

Acute penetrating neck trauma presenting with laryngotracheal injury

Laryngotracheal injuries are serious complications in the case of penatrating neck trauma which may not commonly in Japan. In the last several decades, many authors have discussed method for accurate evaluation and immediate airway management for patient with laryngotracheal injury. But, standardization of the treatment is still controversial about mandatory exploration or selective exploration. We report 4 cases with fresh laryngotracheal injury due to penetrating neck trauma including 3 suicide attempt patients. In these cases, laryngotracheoplasty used by absorbable material was performed within 8 hours after trauma. Two cases of suicide attempt patients underwent tracheostomy at the lower level of the laryngotracheal injury. After these treatment, fiberoptic bronchoscopy was performed to evaluate the airway for 3 cases except 1 who was dead because of hemorrhagic shock on arrival. In 2 cases, the suture filament existed in the lumen of the larynx and trachea, there were no major granulation in the site of repairment and no infection. Three cases were extubated successfully and discharged without major airway problem. Two cases have psychiatric disease such as depression, so we must consider their psychiatric background in the future. In conclusion, penetrating laryngotracheal trauma, we should consider that serious airway injury may be hidden under the superficial small wounds. Also, rapid local wound exploration and laryngotracheoplasty is important for life-saving, and fiberoptic bronchoscopy is effective to prevent early respiratory complications and has value in the evaluation.     

Reconstruction of circumferential pharyngoesophageal defects with laryngotracheal flap and pectoralis major myocutaneous flap

BACKGROUND: Hypopharyngeal cancer often presents at an advanced stage. Radical surgery has played an important role in the treatment of these cases; however, it always results in a large, or even a circumferential, defect of the pharyngoesophageal segment (PES) that causes some difficulties during reconstruction. MATERIALS AND METHODS: Twelve patients with advanced hypopharyngeal cancer and cervical esophageal invasion received surgery resulting in a circumferential defect of PES, which was reconstructed with the contralateral unaffected laryngotracheal flap and a patch-on pectoralis major myocutaneous flap (PMMCF). RESULTS: The operation time of this method was shorter compared with free flap reconstruction. Only two minor complications and no pharyngocutaneous fistulas were found postoperatively. Nine patients can resume a regular diet. During the follow-up period (median, 38 months), there were no local recurrences and only one contralateral neck recurrence. CONCLUSIONS: The preliminary result shows this technique is a simple and effective method with low morbidity and satisfactory oncologic and functional results.     

The growth of circumferential scars of the major airways from infancy to adulthood

The factors affecting the development and prognosis of scarred airways in children are presented from a long-term follow-up study of 14 cases of tracheobronchial lesions following either injury or operation. Four children managed by endoluminal treatment developed severe stenosis and required treatment, later as adults, by laser resection in 2 cases and by laryngotracheal plastic enlargement and resection with anastomosis in 1 case each. The follow-up of 7 children managed by plastic procedures showed inconsistent results: they were good or excellent in 3 cases but with a decrease in the laryngotracheal diameter of 36%, 28% and 7% respectively. The laryngotracheal calibre decreased in 2 patients to 45% due to partial fibrous stenosis. Resection and anastomosis was required in the remaining 2 patients after 11 and 12 years for severe re-stenosis. The 3 patients who underwent immediate surgical resection all had an excellent clinical and morphological result, with a decrease in the laryngotracheal diameter of only 7%, 13% and 19% after a follow-up of 18, 20 and 15 years, respectively. These results show that the growth capacity of scars in children's airways is closely related to residual sclerosis following the initial treatment. It is thus suggested that primary resection and anastomosis should be performed in as many cases as possible. In the performance of plastic procedures, special attention should be paid to complete resection of the fibrotic tissues. Finally, a very long postoperative follow-up is always required in children in order to assess the development of the airway.     

Thyroid alar cartilage laryngotracheal reconstruction for severe pediatric subglottic stenosis

BACKGROUND/PURPOSE: Laryngotracheoplasty has become an accepted treatment alternative for subglottic stenosis. However, the best autogenous material for laryngotracheoplasty remains controversial. Autogenous superior thyroid alar cartilage (TAC) has been used successfully in single stage laryngotracheal reconstruction in children with subglottic stenosis. METHODS: This is a retrospective study of 6 children (mean age, 16.6 months) undergoing TAC graft laryngotracheoplasty between September 1995, and June 1999. Two children had immediate tracheal intubation for congenital subglottic stenosis. Four others had previous tracheostomy: 3 for severe postintubation subglottic stenosis and 1 for congenital subglottic stenosis. After an anterior cricoid split, a piece of TAC was sutured between the cut ends of the cricoid, with the graft perichondrium facing intraluminally. Endotracheal intubation was maintained postoperatively. RESULTS: Four children underwent successfully extubation 9 to 21 days (mean, 15.5 days) postoperatively. Two required tracheostomy, which was maintained because of severe laryngomalacia and laryngotracheobronchomalacia. One child was treated with CO2 laser because of symptomatic recurrence of the subglottic stenosis 3 weeks after the surgery; another required fundoplication for gastroesophageal reflux 12 months after laryngotracheoplasty. There were no donor site complications in any of the 6 cases. Repeat laryngoscopy and bronchoscopy showed a patent subglottic airway. All of them are without symptoms after a mean follow-up of 26 months. CONCLUSIONS: (1) This preliminary experience indicates that the TAC graft technique is a viable option for laryngotracheal reconstruction; (2) the TAC graft has significant advantages, including a single operative incision and absence of donor-site morbidity.     

Operative and non-operative treatment of benign subglottic laryngotracheal stenosis.

OBJECTIVE: Surgery is the first line of treatment for laryngotracheal stenosis; Montgomery tube or permanent tracheostomy have been so far the only alternatives. Nd-YAG laser resection and indwelling endotracheal stents have rarely been used in subglottic stenosis for anatomic and technical reasons. We have used the latter approach to optimize the timing of surgery or to achieve palliation without tracheostomy. METHODS: Between 1991 and 2001 we have treated 18 patients with subglottic stenosis (10 males, 8 females; age range 14-78, mean 34). The upper margin of the stricture was 2mm to 1cm below the vocal cords; the stenotic segment extended from 1.5 to 5 cm. Three patients had tracheostomy done elsewhere. Four patients (Group I) had laser and stenting by a Dumon prosthesis as the only treatment; six had laser and stenting (#4) followed after 1-6 months by laryngotracheal resection (Group II); eight had surgery alone (Group III). RESULTS: In Group I, one patient required repositioning of the stent and in two the stent was removed; two patients died of their underlying disease; at a follow-up of 2-9 years all living patients did well but required permanent aerosolized therapy and periodical bronchoscopy. In Group II, we had two wound infections due to airway colonization by staphylococcus aureus. In Group III, two patients developed anastomotic postoperative stenosis, treated by laser (#2) and stenting (#1), and one patient with previous tracheostomy had a wound infection. Overall, in the 14 surgical patients (Groups II and III) stenosis occurred in 14.2% and infection in 21.3%. After a follow up of 15 months to 12 years, all surgical patients breathe and speak well. CONCLUSIONS: Laser resection and endoluminal stenting can be a viable alternative to surgery or optimize the timing of operation in patients with subglottic stenosis.     

Silicone T-tube for complex laryngotracheal problems.

OBJECTIVE: The use of a T-tube to manage complex laryngotracheal lesions, such as tracheal stenosis, tracheomalacia and tracheal injury, has previously been reported by other surgeons in the past. However, further validation of clinical details, including operative management and postoperative care, is needed. METHODS: From January 1991 to May 2000, 53 patients, including 24 with post-tracheostomy stenosis, received 55 silicone T-tubes for transient or permanent stenting of the airway. There were 20 patients for subglottic stenosis; eight for long segment tracheostensis; seven with tracheal stenosis for severe cervicomediastinal fibrosis not amenable for reconstruction; six for complex tracheal injury; four for glottic injury; two each for tracheomalacia, failed tracheal surgery and tuberculotic tracheostenosis; and one each for tracheo-esophageal fistula and necrotizing tracheitis. We retrospectively analyzed these patients. RESULTS: Thirty-eight out of 53 patients (71.8%) with T-tube stenting from 3 to 15 months was considered successful. Fifteen patients' operations failed due to patients' underlining diseases, previous intractable pulmonary infection, poor cognition and/or inadequate tube position. After removal of the tube, three patients (10.7%) developed partial airway obstruction with mild subglottic granulation tissue, which was resolved by carbon dioxide laser therapy. Two patients (7.1%) with prolonged tracheocutaneous fistula were conservatively treated by silver nitrate. CONCLUSION: Silicone T-tube can effectively resolve the complex laryngotracheal lesions with limited complications. Concurrent cardiopulmonary diseases and intractable infection were the two major causes for failure after the T-tube reconstruction.     

2μm激光分层汽化切割膀胱术治疗膀胱肿瘤

目的 分析应用2 μm激光汽化切割术治疗膀胱肿瘤的临床疗效.方法 采用骶管麻醉,经尿道膀胱镜2μm激光汽化切割术治疗56例膀胱肿瘤患者,共切除肿瘤68个.术中分层汽化切割膀胱壁,逐层切除标本并分别送病理检查.观察手术时间,术中出血情况,术中及术后并发症.肿瘤病理分期以及术后随访等情况.结果 56例患者均可耐受手术;单个肿瘤平均治疗时间为7 min.本组患者手术时间4～15 min,平均(8.8±3.3)min;术中出血量极少,无闭孔神经反射,术后亦无继发出血,膀胱穿孔1例;术后肿瘤病理分期:T1期40例患者,共47个肿瘤,T2期16例患者,共21个肿瘤;术后随访12～17个月,平均14.5个月,复发3例,1例复发两次,总复发率5.3%.无原位复发.结论 2μm激光汽化切割术治疗膀胱肿瘤是一种安全有效的新方法.由于2μm激光可以做到对膀胱壁全层进行精细的分层汽化切除,不仅可以有效地治疗浅表性膀胱肿瘤,也适用于治疗部分浸润性膀胱肿瘤.     

Anastomotic complications after tracheal resection: prognostic factors and management

OBJECTIVE: We sought to identify risk factors for anastomotic complications after tracheal resection and to describe the management of these patients. METHODS: This was a single-institution, retrospective review of 901 patients who underwent tracheal resection. RESULTS: The indications for tracheal resection were postintubation tracheal stenosis in 589 patients, tumor in 208, idiopathic laryngotracheal stenosis in 83, and tracheoesophageal fistula in 21. Anastomotic complications occurred in 81 patients (9%). Eleven patients (1%) died after operation, 6 of anastomotic complications and 5 of other causes (odds ratio 13.0, P = .0001 for risk of death after anastomotic complication). At the end of treatment, 853 patients (95%) had a good result, whereas 37 patients (4%) had an airway maintained by tracheostomy or T-tube. The treatments of patients with an anastomotic complication were as follows: multiple dilations (n = 2), temporary tracheostomy (n = 7), temporary T-tube (n = 16), permanent tracheostomy (n = 14), permanent T-tube (n = 20), and reoperation (n = 16). Stepwise multivariable analysis revealed the following predictors of anastomotic complications: reoperation (odds ratio 3.03, 95% confidence interval 1.69-5.43, P = .002), diabetes (odds ratio 3.32, 95% confidence interval 1.76-6.26, P = .002), lengthy (> or =4 cm) resections (odds ratio 2.01, 95% confidence interval 1.21-3.35, P = .007), laryngotracheal resection (odds ratio 1.80, 95% confidence interval 1.07-3.01, P = .03), age 17 years or younger (odds ratio 2.26, 95% confidence interval 1.09-4.68, P = .03), and need for tracheostomy before operation (odds ratio 1.79, 95% confidence interval 1.03-3.14, P = .04). CONCLUSIONS: Tracheal resection is usually successful and has a low mortality. Anastomotic complications are uncommon, and important risk factors are reoperation, diabetes, lengthy resections, laryngotracheal resections, young age (pediatric patients), and the need for tracheostomy before operation.     

会厌在外伤性喉气管狭窄整复中的应用

目的探讨会厌在外伤性喉气管狭窄整复中的应用及术后疗效。方法1988年1月～2002年2月，收治外伤性喉气管狭窄42例，其中喉狭窄33例，喉气管狭窄9例。年龄9～48岁，平均28．2岁。病程1～26个月，平均10．2个月。均采用手术治疗，方法：①会厌下移 胸骨舌骨肌肌筋膜瓣整复术；②会厌下移 胸骨舌骨肌肌筋膜瓣 胸锁乳突肌锁骨膜瓣整复术。结果术后37例10～75d拔除气管套管，拔管率为88．1％，5例戴管，占22．9％；42例均于术后9～24d拔除胃管，其中5例轻度误吸，经练习后1周内均恢复正常进食；25例放置扩张子，拔除时间为9～19d；42例中5例术后2～5个月有肉芽组织生长，经支撑喉镜下激光治疗1～3次治愈；术后均获1年～3年4个月随访，37例拔管者喉功能完全恢复，5例戴管者部分恢复喉功能。结论会厌用于整复喉气管狭窄，具有取材简便、抗感染能力强、成活率高及结构稳定等优点，与双肌蒂胸骨舌骨肌肌筋膜瓣联合应用能修复较大范围的缺损。胸锁乳突肌锁骨膜瓣其骨膜面光滑而致密，不易发生萎缩，是修复气管壁缺损的理想材料。     

Mitomycin-c application in airway stenosis surgery: analysis of safety and costs.

OBJECTIVE: This study describes a large series of patients receiving topical mitomycin-c (MMC) during airway surgery, including complications, and carries out a cost analysis for its use in laryngotracheal stenosis. STUDY DESIGN AND SETTING: Retrospective review, tertiary center. Airway patients receiving MMC are reviewed for demographics, stenosis characteristics, and MMC usage. A basic cost analysis is carried out. RESULTS: Fifty patients underwent 93 MMC applications (mean = 50.8 years, 25 male, 25 female). In 89 of 93 applications (96%), the concentration of MMC was 0.4 mg/ml. One major complication occurred (1.1%). The expense for MMC is $455; the mean cost for airway surgery is $7,840. It is estimated that if 1 of 17 MMC treated patients requires one less operation, the cost ratio is favorable. CONCLUSIONS: This large series contributes to literature that MMC is a safe adjunct to laryngotracheal surgery. The marginal cost for MMC application is favorable based on our basic cost analysis and existing efficacy data. SIGNIFICANCE: Mitomycin-c seems to be safe and cost-effective in endoscopic airway surgery. EBM rating: C-4.     

Facial Laser Resurfacing with the Propofol-Ketamine Technique: Room Air, Spontaneous Ventilation (RASV) Anesthesia

BACKGROUND: Multiple anesthetic approaches exist for full-face laser resurfacing. The propofol-ketamine technique is reviewed as a reasonable alternative to providing adequate anesthesia for full-face laser resurfacing in the office environment. OBJECTIVE: To report outcomes using propofol-ketamine opioid avoidance, room air, spontaneous ventilation monitored anesthesia care (MAC). METHOD: A retrospective chart review of 95 consenting adult patients receiving propofol-ketamine anesthesia in a private practice, office-based setting. RESULTS: An average of 6 (200 mg) ampules of propofol, including waste, were used per patient. All patients received adequate anesthesia as evidence by a lack of movement during surgery. There were no hallucinations, no postoperative nausea or vomiting (PONV), no cardiovascular instability or seizures (clinical signs of lidocaine toxicity), and no hospital admissions for either PONV or pain. CONCLUSION: The propofol-ketamine technique appears to be an excellent alternative anesthetic approach to EMLA cream, tranquilizer-opioid regimens, or general inhalational anesthesia for facial laser resurfacing.     

Long-term results of laryngotracheal resection for benign stenosis.

OBJECTIVE: We report the long-term results of our 16-year experience with laryngotracheal resection for benign stenosis. METHODS: Between 1991 and 2006, 35 consecutive patients (19 males, 16 females) underwent laryngotracheal resection for subglottic postintubation (32) or idiopathic (3) stenosis. Mean age was 43 years (range 14-71). At the time of surgery 13 patients presented with tracheostomy and 7 with a Dumon stent. The upper limit of the stenosis was from 0.6 to 1.5 cm below the vocal cords. The length of airway resection ranged between 1.5 and 6 cm. Suprahyoid release was performed in two patients and pericardial release in one. Nine patients had psychiatric and/or neurological post-coma disorders. Mean follow-up is over 5 years (61 months; range 3-194). RESULTS: There was no perioperative mortality. Thirty patients (85.7%) had excellent or good anatomic and functional results. Four patients (11.4%) presented restenosis at a distance of 25-110 days from the operation. Restenosis was successfully treated by endoscopic procedures in all four patients. One patient (2.9%) presented anastomotic dehiscence that required temporary tracheostomy closed after 1 year with no sequelae. Three patients (8.4%) had wound infection. Long-term follow-up was uneventful also in patients who had early complications. CONCLUSIONS: Long-term follow-up confirms that laryngotracheal resection is the definitive curative treatment for benign subglottic stenosis. Surgical complications can be successfully managed by non-operative procedures. Despite the occurrence of early complications, excellent and stable results can still be obtained at long term.