RESUMEN
OBJECTIVES: Thyroidectomy and parathyroidectomy using the nerve integrity monitor (NIM) require proper placement of the endotracheal tube with electrodes aligned correctly within the larynx. The purpose of this study is to determine the percentage of patients who require positional adjustments of the endotracheal tube prior to beginning surgery and to understand the value of using the GlideScope to assure proper NIM tube placement within the larynx. METHODS: This prospective study examines operative data from 297 patients who underwent NIM thyroidectomy and parathyroidectomy. After routine orotracheal intubation by an anesthesiologist and positioning of the patient for surgery, a GlideScope was used to check the position of the tube in 2 planes: depth of tube placement and rotation of the tube within the larynx assuring proper placement of the electromyogram electrodes within the glottis. RESULTS: Tube adjustment was required for 66.5% of patients. In 48.1% of cases, tube retraction or advancement to a proper depth was needed. Tube rotation was required for 30.1% of patients, and 11.8% of patients required both adjustment of tube depth and tube rotation to properly align electrodes. CONCLUSIONS: After the anesthesiologist places the NIM endotracheal tube, and the patient is positioned for surgery, additional tube adjustment is often needed prior to the start of surgery. The GlideScope is readily available in the operating suite, its use adds little time to the procedure, and assures proper NIM tube placement. The use of the GlideScope is recommended.
Asunto(s)
Monitoreo Intraoperatorio , Tiroidectomía , Humanos , Tiroidectomía/métodos , Estudios Prospectivos , Monitoreo Intraoperatorio/métodos , Paratiroidectomía , Intubación IntratraquealRESUMEN
The American Academy of Otolaryngology--Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the updated Clinical Practice Guideline: Acute Otitis Externa, as a supplement to Otolaryngology-Head and Neck Surgery. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 8 recommendations developed address appropriate diagnosis of acute otitis externa (AOE) and the use of oral and topical antimicrobials and highlight the need for adequate pain relief. An updated guideline is needed due to new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.
Asunto(s)
Antibacterianos/uso terapéutico , Otitis Externa/terapia , Enfermedad Aguda , Diagnóstico Diferencial , Medicina Basada en la Evidencia , Humanos , Otitis Externa/diagnóstico , Otitis Externa/tratamiento farmacológico , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
OBJECTIVE: This clinical practice guideline is an update and replacement for an earlier guideline published in 2006 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation. This update provides evidence-based recommendations to manage acute otitis externa (AOE), defined as diffuse inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. The variations in management of AOE and the importance of accurate diagnosis suggest a need for updating the clinical practice guideline. The primary outcome considered in this guideline is clinical resolution of AOE. PURPOSE: The primary purpose of the original guideline was to promote appropriate use of oral and topical antimicrobials for AOE and to highlight the need for adequate pain relief. An updated guideline is needed because of new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group. The target patient is aged 2 years or older with diffuse AOE. Differential diagnosis will be discussed, but recommendations for management will be limited to diffuse AOE, which is almost exclusively a bacterial infection. This guideline is intended for primary care and specialist clinicians, including otolaryngologists-head and neck surgeons, pediatricians, family physicians, emergency physicians, internists, nurse practitioners, and physician assistants. This guideline is applicable in any setting in which patients with diffuse AOE would be identified, monitored, or managed. ACTION STATEMENTS: The development group made strong recommendations that (1) clinicians should assess patients with AOE for pain and recommend analgesic treatment based on the severity of pain and (2) clinicians should not prescribe systemic antimicrobials as initial therapy for diffuse, uncomplicated AOE unless there is extension outside the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. The development group made recommendations that (1) clinicians should distinguish diffuse AOE from other causes of otalgia, otorrhea, and inflammation of the external ear canal; (2) clinicians should assess the patient with diffuse AOE for factors that modify management (nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy); (3) clinicians should prescribe topical preparations for initial therapy of diffuse, uncomplicated AOE; (4) clinicians should enhance the delivery of topical drops by informing the patient how to administer topical drops and by performing aural toilet, placing a wick, or both, when the ear canal is obstructed; (5) clinicians should prescribe a non-ototoxic preparation when the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube; and (6) clinicians should reassess the patient who fails to respond to the initial therapeutic option within 48 to 72 hours [corrected] to confirm the diagnosis of diffuse AOE and to exclude other causes of illness.
Asunto(s)
Antibacterianos/uso terapéutico , Otitis Externa/tratamiento farmacológico , Dolor/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Enfermedad Aguda , Administración Oral , Administración Tópica , Adolescente , Adulto , Analgésicos/uso terapéutico , Niño , Preescolar , Medicina Basada en la Evidencia , Femenino , Estudios de Seguimiento , Humanos , Masculino , Otitis Externa/complicaciones , Otitis Externa/diagnóstico , Otoscopía/métodos , Dolor/etiología , Dolor/fisiopatología , Dimensión del Dolor , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Adulto JovenRESUMEN
A retrospective study of 28 patients who underwent ultrasound-guided fine needle aspiration (FNA) biopsy for thyroid nodular disease was performed to assess the diagnostic accuracy of ultrasound-guided FNA biopsy in detecting malignancy of the thyroid. Sensitivity, specificity, positive predictive value, and negative predicative value were evaluated with respect to final histological surgical pathology. The study's results substantiate those of previous studies: when there is a negative ultrasound-guided FNA, there is high probability that the patient is free of thyroid malignancy and may be followed clinically without the need for surgery.
Asunto(s)
Biopsia con Aguja Fina , Nódulo Tiroideo/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Sensibilidad y Especificidad , Nódulo Tiroideo/patología , Ultrasonografía IntervencionalRESUMEN
To evaluate sports-related ENT injuries regarding demographical trends of patients, location and mechanism of injuries, treatments required, and ability to return to sports activities, an observational study of patients was conducted. Each of the 120 participants in the study was evaluated in a private practice clinic. Males were injured more frequently, and the most common ages affected were 12 to 15-year-olds. Most injuries were the result of collision with other players or from impact of game balls, and most injuries occurred during sporting competitions. The most commonly injured structure was the nose. Most patients were managed medically and able to return to sporting activities quickly. While the most frequent mechanisms for sports injuries are not always preventable, health care providers should be aware of these trends described regarding types of sports commonly producing injuries and the predominant sites of injury to provide optimal care for athletic participants.
Asunto(s)
Traumatismos en Atletas/diagnóstico , Traumatismos Maxilofaciales/diagnóstico , Nariz/lesiones , Accidentes , Adolescente , Adulto , Factores de Edad , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores SexualesRESUMEN
Nasal injuries are among the most common sports injuries. We conducted a prospective, observational study of 91 patients, aged 7 to 60 years (mean: 18.3), who had sustained a nasal injury while engaging in a sport, exercise, or other recreational physical activity. We found that a substantial proportion of these injuries occurred in females (29.7% of cases). A high percentage of injuries (86.8%) occurred in those who had been participating in a noncontact sport; the sport most often implicated was basketball (26.4%). Also, injuries were more common during organized competition as opposed to recreational play (59.3 vs. 40.7%). Of the 91 nasal injuries, 59 (64.8%) were fractures, most of which were treated with a closed reduction. Almost all of the patients in this study (92.3%) were able to return to their sport. We conclude that most sports-related nasal fractures are not preventable.
Asunto(s)
Traumatismos en Atletas/etiología , Traumatismos en Atletas/terapia , Nariz/lesiones , Adolescente , Adulto , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Hueso Nasal/lesiones , Estudios Prospectivos , Fracturas Craneales/etiología , Fracturas Craneales/terapia , Adulto JovenRESUMEN
OBJECTIVES: Review the diagnosis and management of patients with substernal goiter. STUDY DESIGN: Retrospective study of a series of patients treated for substernal goiter. METHODS: Retrospective chart review of patients with substernal goiter (N=16). Records were tabulated for demographics, symptoms, physical and CT findings as well as surgical management and comorbidities. RESULTS: Substernal goiter occurs infrequently. Of the seventeen surgical procedures performed in these sixteen patients, only three required a median sternotomy. All of the patients had multinodular goiter. There were no instances of well differentiated thyroid cancer in this series. Co-morbidities were present in each patient. CONCLUSIONS: Substernal goiters are often quite large at the time of diagnosis as they enlarge slowly. The majority of patients can be managed with a cervical approach. Technological advancements such as the nerve integrity monitor (NIM-2; Medtronic Xomed, Jacksonville, Florida) and Harmonic scalpel as well as team approach to surgery are advantageous for the patient.
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Bocio/diagnóstico , Bocio/cirugía , Tiroidectomía/métodos , Anciano , Anciano de 80 o más Años , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Estudios Retrospectivos , Esternotomía , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: To determine whether nerve integrity monitor testing during thyroidectomy predicts recurrent laryngeal nerve (RLN) function after surgery. DESIGN: Prospective cohort outcomes study PATIENTS: The study included 210 consecutive patients with thyroid abnormalities who underwent thyroidectomy. METHODS: All patients were intraoperatively monitored with a nerve integrity monitoring system (Xomed NIM II; Medtronic Inc, Fridley, Minnesota), and their vocal cord function was assessed with fiberoptic laryngoscopy before and after surgery. Normal and impaired vocal cord function were compared using an independent t test with respect to postoperative vocal cord mobility, length of the RLN dissection, and the minimum stimulus needed to generate a response at the completion of surgery. RESULTS: There was a statistically significant difference between the stimulus in milliamperes required to stimulate normal vs abnormal functioning nerves at the completion of the procedure at the cricoarytenoid joint (P = .02) and at the distal end of the RLN dissection (P < .01). A greater length of dissected nerve was associated with normal vocal cord function; however, it was not statistically significant (P = .07). CONCLUSION: These data suggest that an RLN that responds at lower-intensity stimulation (
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Nervios Laríngeos/fisiología , Monitoreo Intraoperatorio/métodos , Tiroidectomía , Pliegues Vocales/fisiología , Estudios de Cohortes , Estimulación Eléctrica , Humanos , Laringoscopía , Monitoreo Intraoperatorio/instrumentación , Estudios Prospectivos , Nervio Laríngeo Recurrente/fisiología , Traumatismos del Nervio Laríngeo Recurrente , Enfermedades de la Tiroides/cirugíaRESUMEN
Hypocalcemia as a manifestation of hypoparathyroidism is a well recognized complication of total thyroidectomy. Less well recognized is the possibility of hypocalcemia following subtotal thyroidectomy. A prospective observational series of 107 patients undergoing hemithyroidectomy was evaluated by preoperative serum calcium and albumin determinations as well as serum calcium determinations at one and seven days postoperatively. There was a significant decrease in mean calcium concentration from the preoperative determination (9.1 mg/dL) to postoperative day one determination (8.4 mg/dL) and then a significant mean increase in the calcium concentration from postoperative day one to day seven (9.0 mg/dL). There was no statistical difference between the mean preoperative calcium concentration and the day seven mean calcium concentration. Additional analyses failed to show a significant relationship between repeated calcium determinations and either disease pathology (benign versus malignant), sex, or race. At one week post surgery, patients' serum calcium normalized. Thus the need for calcium replacement or prolonged hospitalization was generally not necessary. The possible exceptions are patient's with low or low normal calcium preoperatively, unknown status of their parathyroid glands (i.e., previous thyroid surgery), devascularization/resection of parathyroid tissue at the time of surgery and patients undergoing completion thyroidectomy.
Asunto(s)
Hipocalcemia/etiología , Tiroidectomía/efectos adversos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Calcio/sangre , Femenino , Humanos , Hipocalcemia/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Enfermedades de la Tiroides/cirugía , Neoplasias de la Tiroides/cirugía , Tiroidectomía/métodos , Adulto JovenRESUMEN
OBJECTIVE: This guideline provides evidence-based recommendations to manage diffuse acute otitis externa (AOE), defined as generalized inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. The primary purpose is to promote appropriate use of oral and topical antimicrobials and to highlight the need for adequate pain relief. STUDY DESIGN: In creating this guideline, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) selected a development group representing the fields of otolaryngology-head and neck surgery, pediatrics, family medicine, infectious disease, internal medicine, emergency medicine, and medical informatics. The guideline was created with the use of an explicit, a priori, evidence-based protocol. RESULTS: The group made a strong recommendation that management of AOE should include an assessment of pain, and the clinician should recommend analgesic treatment based on the severity of pain. The group made recommendations that clinicians should: 1) distinguish diffuse AOE from other causes of otalgia, otorrhea, and inflammation of the ear canal; 2) assess the patient with diffuse AOE for factors that modify management (nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy); and 3) use topical preparations for initial therapy of diffuse, uncomplicated AOE; systemic antimicrobial therapy should not be used unless there is extension outside of the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. The group made additional recommendations that: 4) the choice of topical antimicrobial therapy of diffuse AOE should be based on efficacy, low incidence of adverse events, likelihood of adherence to therapy, and cost; 5) clinicians should inform patients how to administer topical drops, and when the ear canal is obstructed, delivery of topical preparations should be enhanced by aural toilet, placing a wick, or both; 6) when the patient has a tympanostomy tube or known perforation of the tympanic membrane, the clinician should prescribe a nonototoxic topical preparation; and 7) if the patient fails to respond to the initial therapeutic option within 48 to 72 hours, the clinician should reassess the patient to confirm the diagnosis of diffuse AOE and to exclude other causes of illness. And finally, the panel compiled a list of research needs based on limitations of the evidence reviewed. CONCLUSION: This clinical practice guideline is not intended as a sole source of guidance in evaluating patients with AOE. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to the diagnosis and management of this problem. SIGNIFICANCE: This is the first, explicit, evidence-based clinical practice guideline on acute otitis externa, and the first clinical practice guideline produced independently by the AAO-HNSF.
Asunto(s)
Otitis Externa/diagnóstico , Otitis Externa/terapia , Enfermedad Aguda , Diagnóstico Diferencial , Medicina Basada en la Evidencia , Humanos , Otolaringología/métodos , Evaluación de Resultado en la Atención de Salud , Estados UnidosRESUMEN
OBJECTIVE: Establish normative data concerning parotidectomy and facial nerve dissection and determine the relationship between the length of the facial nerve dissected during parotidectomy and subsequent facial nerve paresis. STUDY DESIGN: Prospective mapping of facial nerve during parotidectomy and comparison with postoperative facial nerve function. METHODS: A prospective observational study of 78 patients who underwent 79 parotidectomy procedures. During each procedure, various topographical measurements were recorded. These measurements included the distance from the tragal pointer to the main trunk of the facial nerve, the distance to the pes anserinus, and length of each segmental branch dissected. In addition, a designation of the patient's tumor location was made by drawing a line from the ear canal to the nasal spine. Tumors above this line were designated anatomic zone A and those below the line were designated anatomic zone B. Finally, facial nerve function was quantified at a 1-week follow-up visit using the House-Brackmann Scale. RESULTS: The distance from the main trunk of the facial nerve to the tragal pointer was significantly (P < .000) less than the previously accepted standard of 1 cm. The cervical and marginal mandibular branches had more nerve dissected, whereas the eye and forehead branches were the least dissected. Results of an independent t test and logistic regression (P = .01, both) indicated that patients with temporary facial nerve paresis had a significantly greater amount of nerve dissected than patients without temporary facial nerve paresis. Patients with short-term facial nerve dysfunction had significantly (P < .01) more total nerve dissected (136.73 mm vs. 94.73 mm) than patients without short-term facial nerve dysfunction. Patients with nerve dissection lengths at the third quartile (130.0 mm) were 3.8 times more likely to experience temporary facial nerve paresis than patients with nerve dissection lengths at the first quartile (64.5 mm). CONCLUSIONS: The axiom that the main trunk of the facial nerve is located 1 cm from the tragal pointer may need to be modified to less than 1 cm. The cervical and marginal mandibular branches had more nerve dissected, whereas the eye and forehead branches were the least dissected. Facial nerve paresis after parotidectomy is associated with the length of the facial nerve dissected during the procedure. The greater the length of facial nerve dissected, the higher the chance of facial nerve paresis, albeit temporarily, in this particular series of patients.
Asunto(s)
Nervio Facial/anatomía & histología , Nervio Facial/cirugía , Glándula Parótida/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Procedimientos Quirúrgicos Operativos/métodos , Procedimientos Quirúrgicos Operativos/normasRESUMEN
OBJECTIVE: This Workforce Study re-examined the current scope and geographic distribution of Otolaryngology practice and assessed the otolaryngologists' role in relation to other specialists in the diagnosis and treatment of disorders of the ear, nose, throat, and related structures of the head and neck. Study design A national survey and review of federal, corporate and administrative databases, coupled wih a focus group of otolaryngologists, were analyzed to compile physician manpower figures, state and regional demographic data, and prediction modeling of Managed Care and FFS environments. RESULTS: The current and predicted workforce supply and demographic data support a geographic and proportionate increase in the number of otolaryngologists practicing and entering the workforce. Additional findings involving the role of the specialty specifically identified an increase in the treatment of allergic disease within the Managed Care sector and a diminution of the gatekeeper concept. Demographic findings represent a stable age distribution of 40 to 49 and 50 to 59 year old otolaryngologists, with a noted increase in the number of women entering the field. Empiric data reflects the continuous, diverse and dominant role otolaryngologists maintain in the treatment and care of patients with otolaryngologic and head and neck disease. CONCLUSIONS: This study continues the effort to identify otolaryngology workforce demographic profiles and make recommendations for a future national practice model. Continuous reassessment of the specialty is required.