Search

Ophthalmic pediatric regional anesthesia has been widely described, but infrequently used. This review summarizes the available evidence supporting the use of conduction anesthesia in pediatric ophthalmic surgery. Key anatomic differences in axial length, intraocular pressure, and available orbital space between young children and adults impact conduct of ophthalmic regional anesthesia. The eye is near adult size at birth and completes its growth rapidly while the orbit does not. This results in significantly diminished extraocular orbital volumes for local anesthetic deposition. Needle-based blocks are categorized by relation of the needle to the extraocular muscle cone (ie, intraconal or extraconal) and in the cannula-based block, by description of the potential space deep to the Tenon capsule. In children, blocks are placed after induction of anesthesia by a pediatric anesthesiologist or ophthalmologist, via anatomic landmarks or under ultrasonography. Ocular conduction anesthesia confers several advantages for eye surgery including analgesia, akinesia, ablation of the oculocardiac reflex, and reduction of postoperative nausea and vomiting. Short (16 mm), blunt-tip needles are preferred because of altered globe-to-orbit ratios in children. Soft-tip cannulae of varying length have been demonstrated as safe in sub-Tenon blockade. Ultrasound technology facilitates direct, real-time visualization of needle position and local anesthetic spread and reduces inadvertent intraconal needle placement. The developing eye is vulnerable to thermal and mechanical insults, so ocular-rated transducers are mandated. The adjuvant hyaluronidase improves ocular akinesia, decreases local anesthetic dosage requirements, and improves initial block success; meanwhile, dexmedetomidine increases local anesthetic potency and prolongs duration of analgesia without an increase in adverse events. Intraconal blockade is a relative contraindication in neonates and infants, retinoblastoma surgery, and in the presence of posterior staphylomas and buphthalmos. Specific considerations include pertinent pediatric ophthalmologic topics, block placement in the syndromic child, and potential adverse effects associated with each technique. Recommendations based on our experience at a busy academic ophthalmologic tertiary referral center are provided.

Otocephaly complex is a rare and usually lethal syndrome characterized by a set of malformations consisting of microstomia, mandibular hypoplasia/agnathia, and ventromedial malposition of the ears. Those cases that have been diagnosed prenatally have used an ex utero intrapartum treatment procedure to establish a definitive airway. However, prenatal diagnosis continues to be challenging, primarily because of poor diagnostic sensitivity associated with ultrasonography. We present a case of a newborn with an unanticipated otocephaly complex requiring emergent airway management. In this report, we discuss the medical and ethical issues related to the care of a newborn with this frequently fatal condition.

Retropharyngeal abscesses are deep neck space infections that can lead to life-threatening airway emergencies and other catastrophic complications. Retropharyngeal abscesses demand prompt diagnosis and early establishment of a definitive airway when there is airway compromise. This can be difficult in an uncooperative patient. We present the case of a 12-year-old girl with mediastinitis and tracheal compression and anterior displacement from a large retropharyngeal and posterior mediastinal abscess secondary to traumatic esophageal perforation, who received successful awake nasal fiberoptic intubation. Anesthesiologists must be prepared for airway emergencies in uncooperative patients, especially children, but there is controversy concerning the use of sedation.

Objective. Papillary squamous cell carcinoma has emerged as a distinct entity from the more common keratinizing squamous cell carcinoma. The basis behind this distinction relates not only to its histologic variation but also to its overall prognosis and survival. The objective of this study was to demonstrate the incidence, demographics, and longterm survival of laryngeal papillary squamous cell carcinoma (LPSCC) and how it relates to other laryngeal malignancies using a population-based database. Study Design. Analysis of a population-based tumor registry. Methods. The United States National Cancer Institute’s Surveillance, Epidemiology, and End Results registry was used to perform a retrospective analysis. Patients diagnosed with LPSCC from 1973 to 2011 were identified. Data endpoints extracted included patient demographics, incidence, and survival. Results. Three-hundred seventy cases of LPSCC were identified, corresponding to 0.5% of all laryngeal tumors. There was a 3:1 male predilection, without a significant racial preference. Most tumors identified were localized (T1) and at stage 1. The 1-year, 5-year, and 10-year disease-specific survival (DSS) for LPSCC was 97.1%, 83.1%, and 73.9%, respectively, compared with 87.9%, 64.5%, and 50.5% for other laryngeal malignancies (P values \.0001). Surgery was associated with a higher overall DSS in both LPSCC (87.4% vs 78.8%) and other laryngeal malignancies (70% vs 59.4%) when compared with other treatment modalities. Conclusion. This analysis of the largest sample of LPSCC demonstrates a better prognosis for this pathology compared with other laryngeal malignancies.

OBJECTIVE Laryngeal cancer most commonly arises from the glottis. Comparable outcomes in survival have been shown in patients with early glottic squamous cell carcinoma treated with either surgery or radiotherapy. STUDY DESIGN AND SETTING Administrative database study. SUBJECTS AND METHODS The US National Cancer Institute's SEER database (Surveillance, Epidemiology, and End Results) was queried for cases of early glottic cancer (T1-T2N0M0, 1988-2012). We identified 13,312 qualifying cases. Patient demographics, therapeutic measures, and survival outcomes were examined with appropriate univariate and multivariate analyses. RESULTS Early glottic cancer has a mean age at diagnosis of 64.8 ± 11.6 years and a male:female ratio of 6.9:1. The most common treatment modality was radiotherapy alone (51.6%), followed by combination therapy with surgery first (31.5%). Overall, the 5-year disease-specific survival (DSS) rate was 88.4%. When stratified by treatment modality and stage, 5-year DSS for T1 tumors was 93.2% with surgery alone and 89.0% with radiation alone (P < .0001). With combination therapy, the 5-year DSS was 91.3% for surgery first and 84.9% for radiation first (P = .0239). In T2 tumors, 5-year DSS was improved with single-modality therapy versus multimodality therapy (81.1% vs 76.4; P = .0255). CONCLUSION In T1 disease, surgery alone shows improved 5-year DSS versus radiation alone, but this difference was not observed in T2 tumors. Additionally, surgery, rather than radiation, shows improved 5-year DSS when implemented as a first-line therapy. Combination therapy does not show improved 5-year DSS for early glottic cancer.

Laryngeal spindle cell carcinoma (LSpCC) is a rare variant of squamous cell carcinoma. Surgery is the reported mainstay of treatment, but previous analyses failed to demonstrate survival outcomes by therapeutic modality. This study aims to carry out the largest population-based analysis of this histology to determine tumor characteristics, incidence, survival, and prognostic indicators.The National Cancer Institute's Surveillance, Epidemiology, and End Results database was queried for cases of LSpCC diagnosed between 1973 and 2011. Data was analyzed for patient demographics, incidence, treatment, and survival.A total of 312 cases of LSpCC were identified. Males comprised 87.2% of the cases, representing a male-to-female ratio of nearly 7:1. Whites accounted for 83.7% of LSpCC cases, whereas blacks represented 13.1%. Most cases (72.1%) arose in the glottis. The incidence of LSpCC from 2000 to 2011 was 0.023 per 100,000, with an annual percent change of -0.115%. One-, 5-, and 10-year disease-specific survival (DSS) rates for LSpCC were 90.9%, 74.1%, and 57.9%; whereas 1-, 5-, and 10-year relative survival rates were 91.0%, 77.7%, and 64.5%, respectively. Tumors of the glottis had a 5-year DSS of 84.0% compared to 51.9% for nonglottic tumors (P0.0001). High-stage (III/IV) LpSCC had lower 5-year DSS than low-stage (I/II) (36.8% and 91.8%, respectively) (P0.0001). Surgery imparted favorable 5-year survival, whereas radiotherapy did not impact survival rates.Laryngeal spindle cell carcinoma most commonly affects males and has a strong predilection for the glottis. Survival is best for glottic LSpCC. Surgery imparts a favorable prognosis compared to radiotherapy.4.

Verrucous carcinoma of the larynx (VCL) is a rare entity with reportedly favorable prognosis. Current analyses are limited primarily to case reports and case series, thus making a population-based analysis useful in characterizing frequency, incidence, and survival trends to guide clinical diagnosis and decision making.Analysis of the National Cancer Institute's SEER (Surveillance, Epidemiology, and End Results) database.Cases of VCL diagnosed between 1973 and 2011 were searched in the SEER database. Analysis was carried out with respect to patient demographics, tumor characteristics, incidence, treatment modality, and survival.In sum, 516 patients with VCL were identified. Males composed 88.4% of cases. Whites accounted for 88.4% of cases, with 8.1% of cases occurring in black patients. Most cases (79.7%) arose in the glottis, a statistically significant predilection when compared with other laryngeal malignancies (P.0001). Incidence of VCL decreased from 2000 to 2011, with an annual percent change of -5.4%. Overall 1-, 5-, and 10-year disease-specific survival for VCL was 97.5%, 88.0%, and 77.4%, while 1-, 5-, and 10-year relative survival was 98.1%, 85.5%, and 74.2%, respectively. Surgery seemed to confer better prognosis when compared with other treatment modalities.This large population-based analysis of VCL demonstrates that this entity has a good prognosis, arises in the glottis, and is decreasing in incidence. Five-year survival seems highest when surgery is utilized. However, this finding may be subject to selection bias in high-stage lesions.

Sinonasal extramedullary plasmacytoma (SN-EMP) is a rare plasma cell neoplasm. Published literature on this tumor largely consists of case reports and case-series with small sample sizes. This study analyzed population-based data on SN-EMP patients to understand demographic and clinical features as well as incidence and survival trends.The Surveillance, Epidemiology, and End Results (SEER) database was queried for SN-EMP and other head and neck EMP (HN-EMP) cases from 1973 to 2011. Cases were analyzed to determine patient demographics, initial treatment modality, and survival outcomes.Of 778 patients identified with EMP in the head and neck region, 367 patients had SN-EMP and 411 had other HN-EMP. There was a strong male predilection found, with a male-to-female ratio of 3.65:1 in the SN-EMP group and 1.87:1 in the other HN-EMP group. The majority of the patients presented with localized disease in both SN-EMP (84.4%) and other HN-EMP (81.0%) groups. The most common treatment modality reported in this database was surgery with adjuvant radiotherapy in both SN-EMP (46.3%) and other HN-EMP (38.9%) groups, followed by radiotherapy alone (SN-EMP: 40.7%; other HN-EMP: 34.2%). Five-year and 10-year disease-specific survival rates were comparable between SN-EMP (88.2% and 83.3%, respectively) and other HN-EMP (90.0% and 87.4%, respectively) (p = 0.6016 and p = 0.4015, respectively).This study analyzed the largest cohort of SN-EMP patients to date. There was no statistically significant survival advantage found for any 1 particular treatment modality over other treatment modalities in both SN-EMP and other HN-EMP.

Purpose: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Methods: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). Results: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Conclusion: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

The management of trauma patients has become increasingly nonoperative, especially for solid abdominal organ injuries. However, the Residency Review Committee (RRC) still requires an operative trauma experience deemed essential for graduating general surgical residents. The purpose of this study was to review the trauma volume and mix of patients at two trauma centers and determine the major operative trauma cases available to residents involved in the care of these patients.A retrospective chart review was conducted at the two trauma centers used by the Michigan State University surgery residency. Both of the trauma centers are American College of Surgeons verified. Surgical residents are involved with the care of every trauma patient at each of the hospitals. Cumulative data were collected and analyzed from January 1, 1997, through December 31, 1999. Age, gender, mechanism of injury (blunt vs. penetrating), Injury Severity Score, length of stay, operative interventions, and patients managed nonoperatively were reviewed.There were 434 patients selected for this study from 2,340 patients admitted to the trauma services. Male patients accounted for 66% of patients and female patients accounted for 34% of patients. Blunt trauma was the mechanism in 89% of patients, with penetrating trauma accounting for the other 11% of patients. Of the total number of patients, motor vehicle crashes accounted for the majority of cases, 325 of 434 (75%). Overall, 85% (370 of 434) of patients were managed without an index trauma surgical procedure according to RRC guidelines. Only 14.7% (64 of 434) of patients underwent operative intervention that qualified as index trauma surgical cases identified by the RRC. The spleen and small bowel were the two most commonly injured organs found at laparotomy. Nonoperative intervention of many patients with solid abdominal organ injuries did not meet the operation requirements expected by the RRC.Our residency program had 10 graduating chief residents over the 3-year time period. With only 64 operative trauma cases, this yields an average of 6.4 trauma cases per resident. This falls significantly short of the 16-case minimum requirement in trauma surgery established by the RRC. The operative trauma requirements established by the RRC for graduating residents may be unattainable in many residency programs because of the high incidence of blunt trauma and the changing patterns of trauma management.