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BACKGROUND: During the early part of the COVID-19 pandemic, the Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force published recommendations on performance of tracheotomy. Since then, our understanding of the virus has evolved with ongoing intensive research efforts. New literature has helped us better understand various aspects including patient outcomes and health care worker (HCW) risks associated with tracheotomy during the COVID-19 pandemic. Accordingly, the task force has re-evaluated and revised some of the previous recommendations. MAIN BODY: Based on recent evidence, a negative reverse transcription polymerase chain reaction (RT-PCR) COVID-19 swab status is no longer the main deciding factor in the timing of tracheotomy. Instead, tracheotomy may be considered as soon as COVID-19 swab positive patients are greater than 20 days beyond initial symptoms and 2 weeks of mechanical ventilation. Furthermore, both open and percutaneous surgical techniques may be considered with both techniques showing similar safety and outcome profiles. Additional recommendations with discussion of current evidence are presented. CONCLUSION: These revised recommendations apply new evidence in optimizing patient and health care system outcomes as well as minimizing risks of COVID-19 transmission during aerosol-generating tracheotomy procedures. As previously noted, additional evidence may lead to further evolution of these and other similar recommendations.

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INTRODUCTION: The performance of tracheotomy is a common procedural request by critical care departments to the surgical services of general surgery, thoracic surgery and otolaryngology - head & neck surgery. A Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force was convened with multi-specialty involvement from otolaryngology-head & neck surgery, general surgery, critical care and anesthesiology to develop a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic. MAIN BODY: The tracheotomy procedure is highly aerosol generating and directly exposes the entire surgical team to the viral aerosol plume and secretions, thereby increasing the risk of transmission to healthcare providers. As such, we believe extended endotracheal intubation should be the standard of care for the entire duration of ventilation in the vast majority of patients. Pre-operative COVID-19 testing is highly recommended for any non-emergent procedure. CONCLUSION: The set of recommendations in this document highlight the importance of avoiding tracheotomy procedures in patients who are COVID-19 positive if at all possible. Recommendations for appropriate PPE and environment are made for COVID-19 positive, negative and unknown patients requiring consideration of tracheotomy. The safety of healthcare professionals who care for ill patients and who keep critical infrastructure operating is paramount.

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Endoscopic percutaneous dilatational tracheostomy is at least as safe as standard open tracheostomy in the operating room (OR). Recently, a single dilator was introduced to accomplish dilatation of the tracheal aperture in one step, thus obviating the need for multiple graduated dilators. Experience with endoscopic percutaneous tracheostomy (PCT) using the single dilator in 40 patients to date supports the premise that the procedure is safe, rapid, and technically simple. In the study by Añon et al, two very different techniques, are compared: the Ciaglia percutaneous dilatational tracheostomy technique using multiple dilators and the Griggs percutaneous technique using guidewire-dilating forceps. Although relative complication rates for the two techniques are not significantly different, both procedures are performed in a 'blind' fashion, without the benefit of a bronchoscope. The reported incidence of serious complications in this study is high, and almost certainly avoidable with the addition of direct bronchoscopic visualization. Operative time is reported to be shorter with the Griggs technique, but this finding is unlikely to hold true for the single dilator technique, which reduces procedure time to less than 15 min. This author's experience with bedside endoscopic PCT using the single dilator indicates that it is a safe, rapid and cost-effective procedure with a low complication rate.

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Cranial base chrodoma, a rare, usually slow-growing tumour of bone thought to arise in notochord remnants, presents itself when its growth in the spheno-occiput results in cranial nerve compression or an obvious nasopharyngeal mass. The present review of 11 cases of cranial base chordoma encountered at three McGill University teaching hospitals from 1979 until 1992 examines presentation, radiologic findings, pathology, treatment, and outcome. A literature review surveys chrodoma with regard to epidemiology, diagnosis, efficacy of medical and surgical modalities on tumor control, and survival. Discussion focuses on current therapeutic options relative to histopathologic characteristics of chordoma, and whether or not these may be used to predict course of disease and outcome.

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Although tracheostomy is an ancient technique, disagreement continues concerning the complication rate associated with the procedure. A retrospective review of 281 consecutive tracheostomies was undertaken to evaluate the current risks of tracheostomy in tertiary care teaching hospitals. In addition, we sought to identify factors associated with increased morbidity. The intraoperative and postoperative complications were analyzed regarding indication and comorbidity factors. The majority of cases (56%) were performed on ICU patients. The total complication rate was 24%. A statistically significant increased risk of complications was found both in emergency situations and in ICU patients. Delaying tracheostomy was associated with prolongation of ICU stay. Despite the relatively large number of patients studied, there were no deaths.

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Laryngeal plasmacytomas are rare neoplasms that present difficulties in diagnosis, both clinically and pathologically. Lymph node metastases are found in up to 25% of patients but do not alter the prognosis. Systemic dissemination occurs in 17-35% of cases and significantly shortens survival. Radiotherapy plays a major role in the primary treatment of these lesions, but the optimum dose is not yet known. Chemotherapy is reserved for locally advanced or disseminated disease. Survival at five years is approximately 50%, but the known risk of late recurrences or disseminated disease makes life-long follow-up mandatory.

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Disc batteries represent a distinct type of pediatric foreign body because of their potential for severe morbidity and mortality. We present the case of an 18-month-old boy who ingested a lithium battery and, despite a delay in diagnosis, had a favorable outcome. Button batteries are being used with increasing frequency in a variety of devices including hearing aids, watches and calculators. Most contain a heavy metal such as mercury, and an alkaline electrolyte. Esophageal impaction results in a corrosive esophagitis leading to perforation with the attendant sequelae. Injury may occur by four mechanisms: (1) electrolyte leakage from batteries; (2) alkali produced from external currents; (3) mercury toxicity, and (4) pressure necrosis. Early diagnosis and urgent removal are required for esophageal impaction. More distal sites can be managed conservatively with spontaneous passage occurring in the majority of cases. Prevention should be directed at placing the cells out of reach and child-proofing battery-powered appliances.

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