Dr Anand Suruliraj

Description:Background: The presence of a pseudodiverticulum of the anterior pharyngeal wall, or prominent "pharyngeal bar," is a well-known phenomenon that occurs following total laryngectomy, which can be visualized by nasolaryngoscopy or videofluoroscopy. Among the different techniques of pharyngeal reconstruction, there is higher incidence following primary vertical multilayered closure. It has been postulated to cause dysphagia and lack of dietary progression despite a paucity of data. However, the direct impact of pseudodiverticulum is less clear and anecdotally its presence and severity does not necessarily correlate with dysphagia. Methods: A retrospective case series was performed of all consecutive patients who underwent total laryngectomy or laryngopharyngectomy between 2015 and 2022 at two tertiary head and neck institutions. All patients underwent routine videofluoroscopy postoperatively for swallow assessment. The presence of pseudodiverticulum on postoperative contrast swallow study was recorded to investigate the relationship with patient's ability to tolerate oral intake at 3 months discharge from the hospital. Results: Of 50 laryngectomized patients (mean age 63.8 ± 10.0, 86% male), the main closure techniques were primary vertical (n = 9, 18%), primary T-closure (n = 14, 28%), and flap reconstruction (n = 27, 54%). Pseudodiverticulum was identified in 19 cases (38%). 43 patients underwent primary surgery and 30 had adjuvant radiotherapy. The presence of pseudodiverticulum was significantly associated with vertical primary closure versus non-vertical (T-closure or flap reconstruction) techniques (χ2 (df 1) = 7.4, p = 0.007, OR = 5.7, 95% CI 1.3-24.7). Pseudodiverticulum was not associated with an increased inability to tolerate solid intake or full diet compared to patients without pseudodiverticulum. 26.3% of patients with pseudodiverticulum were on full diet compared to 25.8% of patients without. The vertical closure technique showed no difference in ability to maintain solid intake compared with non-vertical closure; however, no patients were on full diet. Only one patient in the pseudodiverticulum group required surgical management during the study period for retention. Conclusions: The presence of a pseudodiverticulum does not appear to be significantly associated with a need for postoperative dietary modification. The authors postulate that postlaryngectomy dysphagia is multifactorial with sensorimotor aperistalsis of the pharynx and cricopharyngeal stenosis. While a pseudodiverticulum is a common phenomenon, patients did not require modification of diet at higher rates than those without, and they seldom require intervention.

Description:Background: Telehealth programs are important to deliver otolaryngology services for Aboriginal and Torres Strait Islander children living in rural and remote areas, where distance and access to specialists is a critical factor. Objective: To evaluate the inter-rater agreement and value of increasing levels of clinical data (otoscopy with or without audiometry and in-field nurse impressions) to diagnose otitis media using a telehealth approach. Methods: Blinded, inter-rater reliability study. Methods: Ear health and hearing assessments collected from a statewide telehealth program for Indigenous children living in rural and remote areas of Queensland, Australia. Methods: Thirteen board-certified otolaryngologists independently reviewed 80 telehealth assessments from 65 Indigenous children (mean age 5.7 ± 3.1 years, 33.8% female). Methods: Raters were provided increasing tiers of clinical data to assess concordance to the reference standard diagnosis: Tier A) otoscopic images alone, Tier B) otoscopic images plus tympanometry and category of hearing loss, and Tier C) as B plus static compliance, canal volume, pure-tone audiometry, and nurse impressions (otoscopic findings and presumed diagnosis). For each tier, raters were asked to determine which of the four diagnostic categories applied: normal aerated ear, acute otitis media (AOM), otitis media with effusion (OME), and chronic otitis media (COM). Methods: Proportion of agreement to the reference standard, prevalence-and-bias adjusted κ coefficients, mean difference in accuracy estimates between each tier of clinical data. Results: Accuracy between raters and the reference standard increased with increased provision of clinical data (Tier A: 65% (95%CI: 63-68%), κ = 0.53 (95%CI: 0.48-0.57); Tier B: 77% (95%CI: 74-79%), 0.68 (95%CI: 0.65-0.72); C: 85% (95%CI: 82-87%), 0.79 (95%CI: 0.76-0.82)). Classification accuracy significantly improved between Tier A to B (mean difference:12%, p < 0.001) and between Tier B to C (mean difference: 8%, p < 0.001). The largest improvement in classification accuracy was observed between Tier A and C (mean difference: 20%, p < 0.001). Inter-rater agreement similarly improved with increasing provision of clinical data. Conclusions: There is substantial agreement between otolaryngologists to diagnose ear disease using electronically stored clinical data collected from telehealth assessments. The addition of audiometry, tympanometry and nurse impressions significantly improved expert accuracy and inter-rater agreement, compared to reviewing otoscopic images alone.

Description:Background: Tracheoesophageal puncture (TEP) with voice prosthesis (VP) insertion is the gold standard of surgical voice restoration in postlaryngectomy patients. The conventional technique involves rigid esophagoscopes and trocar performed by ENT surgeons alone, with technical limitations encountered in patients with cervical abnormalities - in particular those with free or rotational flap reconstructions and postradiotherapy strictures. We report our technique using flexible endoscopy which we show to be feasible and without major safety events, as a possible consideration in the anticipated difficult TEP. Methods: Our study describes a multidisciplinary approach to secondary TEP involving a combined upper gastrointestinal (UGI) and (Ear, Nose, and Throat) ENT procedure, under the guidance of flexible esophagoscopy, with intraoperative involvement of the speech pathologist to guide VP insertion and placement. The procedure was performed with ease without major complications. Results: We identified nine postlaryngectomy and laryngopharyngectomy patients in our institution who underwent secondary TEP with VP insertion using flexible esophagoscopy and multidisciplinary intra-operative involvement. All patients had pharyngeal reconstruction, including radial forearm free flap (n = 4), pectoralis major rotational flap (n = 3), and anterolateral thigh flap (n = 2). Eight out of nine patients underwent adjuvant radiotherapy. The technique was successfully performed in all patients. There were three cases of early TEP displacement in two patients, of which one patient had a successful repeat procedure. We found the technique advantageous in terms of feasibility and practicality compared to the conventional approach, and without intraoperative difficulties encountered in achieving the desired field of views or navigating the challenging anatomy in a free flap and post-radiotherapy patients. This includes distorted cervical anatomy, the presence of bulky and hair-bearing flap skin, and stricture formation. Minor complications in our cohort included pharyngo-esophageal spasm, TEP displacement, granulation tissue, and peri-prosthetic leaks. Conclusions: Our multidisciplinary approach to secondary TEP was performed with flexible esophagoscopy without major related complications. The technique is advantageous in the surgical approach to VP insertion in postlaryngectomy and laryngopharyngectomy patients who have had radiotherapy or pharyngeal reconstruction. It allows for safe anatomical insertion and thorough evaluation of the upper aerodigestive tract for comorbid benign or malignant esophageal pathology.

Description:Background: Cervical necrotizing fasciitis is a progressive soft tissue infection with significant morbidity and mortality. Methods: A case review of cervical necrotizing fasciitis managed at our institution (2007-2017) and a systematic review of PubMed, MEDLINE, and EMBASE databases using the algorithm "(cervical OR neck) AND necrotizing fasciitis." Results: There were 1235 cases from 207 articles which were included in our clinical review. Mean age for cervical necrotizing fasciitis was 49.1 years (64.23% men). Etiology was odontogenic (47.04%), pharyngolaryngeal (28.34%), or tonsillar/peritonsillar (6.07%). There were 2 ± 0.98 organisms identified per patient; streptococci (61.22%), staphylococci (18.09%), and prevotella (10.87%). There were 2.5 ± 3.22 surgical debridements undertaken. Descending necrotizing mediastinitis occurred in 31.56% of patients. Mean length of stay in the hospital was 29.28 days and overall mortality was 13.36%. Conclusion: Physicians and surgeons must be vigilant of the diagnosis of cervical necrotizing fasciitis as early clinical findings may be subtle and prompt identification to facilitate aggressive intervention is required to preclude catastrophic local and systemic morbidity and mortality.

Description:Background: One significant side effect of hyperbaric oxygen treatment (HBOT) is middle ear barotrauma (MEBT) may require tympanostomy tube (grommet) insertion by the Ear, Nose and Throat service. Where timely HBOT is needed, routine insertion of grommets under local anaesthesia (LA) is becoming common. Objective: To investigate the differences between patients receiving HBOT and concurrent grommets under LA versus general anesthesia (GA) at The Townsville Hospital (TTH). Methods: A retrospective chart analysis of patients receiving HBOT between 2008 and 2012 and requiring grommets was undertaken. Results: Thirty-one (5%) out of 685 patients treated with HBOT from 2008 to 2012 received grommets. Twelve cases received grommets under LA, and 19 under GA. Twenty out of the 31 cases had grommets following MEBT and the remainder prophylactically. Complications of grommet insertion comprised two cases with blocked grommets. There was a significant difference (P = 0.005) in the time in days from ENT referral to HBOT between the LA group (median 1 day, range 0-13 days) and the GA group (median 8 days, range 0-98 days). Conclusions: A greater number of hyperbaric patients received grommets under GA than LA at the TTH. Insertion of grommets under LA was safe, offering advantages to both the patient and the treating team in the setting of HBOT-associated otic barotrauma.