Search Results (42)

Background: Airway management in otolaryngology presents unique challenges due to shared airway access, altered anatomy, and specific procedural requirements. This article examines current techniques and oxygenation strategies across various ENT procedures to provide a guide for otolaryngologists. Methods: A narrative review was performed of the contemporary literature, focusing on airway techniques in ENT surgery, including laryngeal surgery, pediatric bronchoscopy, transoral surgery, and trauma and emergency scenarios. A systematic search for difficult airway guidelines was performed using the EMBASE, Pubmed, and Cochrane databases to examine where guidelines are published. Results: The key areas for specialist airway management included laryngeal surgery in the tubeless field and adjuncts for emergency situations. High-flow nasal oxygen (HFNO), jet ventilation, video laryngoscopy, and specialized tubes emerged as key technological advances, improving safety and outcomes. A systematic search identified 947 difficult airway articles across 82 publishers. These were predominantly in anesthetic journals (n = 301), with limited representation in the otolaryngology literature (n = 8) and limited guidance concerning awake surgical tracheostomies under local anesthetic. Awake tracheal intubation and emergency front-of-neck access were identified as key techniques across multiple publications. Conclusions: Modern ENT airway management requires multidisciplinary planning, advanced equipment familiarity, and procedure-specific techniques. Despite having the expertise to perform the gold standard, the limited otolaryngology literature on difficult airways suggests that guidelines are primarily developed by the anesthetic community. Full article

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are increasingly used in patients with type 2 diabetes, chronic kidney disease, and heart failure. However, their safety and efficacy in patients with congenital or surgically altered urogenital anatomy remains underexplored. Methods: We conducted a narrative review of current evidence regarding the use of SGLT2i in patients with urinary tract malformations, urinary diversions, and functional voiding disorders. Key risks, clinical considerations, and management strategies were synthesized from the existing literature and case reports. Results: Patients with benign prostatic hyperplasia, vesicoureteral reflux, neurogenic bladder, nephrostomies, and ileal conduits may face increased risks of urinary tract infections, fungal colonization, and therapy-related complications due to persistent glycosuria and altered urinary flow. Nevertheless, these patients may still benefit from SGLT2i’s systemic renal and cardiovascular effects. Individualized risk assessment, close monitoring, and multidisciplinary management are essential. Conclusions: Patients with urological abnormalities represent a high-risk but potentially high-reward population for SGLT2i therapy. A cautious, tailored approach is necessary, and future dedicated research is urgently needed to better guide clinical practice. Full article

Background: Total hip arthroplasty (THA) in adult patients with developmental dysplasia of the hip (DDH) presents unique surgical challenges due to altered hip anatomy and biomechanics. One of the most critical factors influencing surgical success is correcting femoral anteversion. This study evaluates the effects of different anteversion corrections (increased, unchanged, and decreased) during THA on clinical outcomes in adult Crowe type 3-4 DDH patients. Methods: A retrospective analysis was conducted on 130 patients who underwent THA with anteversion correction between 2008 and 2017 at a tertiary university hospital. Patients were divided into three groups: Group 1 (increased anteversion), Group 2 (unchanged anteversion), and Group 3 (decreased anteversion). Clinical outcomes were assessed using AOFAS and Lysholm scores, Q-angle measurements, and physical examinations, while radiological evaluations were performed to determine implant stability and complications. Results: Postoperative assessments show that increased anteversion is associated with higher rates of instability, knee dysfunction, and pain. Group 1 had significantly lower AOFAS scores (p < 0.001) and fell due to rotational deformity (25.6%). Group 2 exhibited the best clinical outcomes, with the lowest rates of instability and the highest functional scores. Group 3 had moderate functional improvements but a higher dislocation rate (17.1%) than Group 2. Conclusions: Our findings suggest that excessive changes in femoral anteversion during THA, remarkably increasing it, may negatively impact clinical outcomes by causing instability and pain. Preserving the anteversion angle as much as possible is the most favorable approach for optimizing functional recovery and implant stability. Further large-scale, long-term studies are required to confirm these findings and refine surgical strategies for DDH patients undergoing THA. Full article

Background: Malignant bowel obstruction (MBO) is a common and distressing complication in advanced gastrointestinal cancers, significantly impacting patients’ quality of life. When conservative management fails, palliative decompression is essential to relieve symptoms such as nausea, vomiting, and abdominal distension. Venting gastrostomy is the most established method; however, anatomical challenges may necessitate alternative percutaneous approaches. Objective: This narrative review aims to provide a comprehensive overview of percutaneous gastrostomy techniques for palliative gastrointestinal decompression, including percutaneous endoscopic gastrostomy (PEG), interdisciplinary imaging-guided percutaneous or transhepatic gastrostomy, and percutaneous transesophageal gastrostomy (PTEG). Methods: A literature review was conducted to evaluate the indications, techniques, efficacy, and complications associated with these procedures. The role of a multidisciplinary approach, incorporating radiologic, endoscopic, and palliative care expertise, was also explored. Results: PEG remains the gold standard for venting gastrostomy, achieving symptom relief in up to 92% of cases, with a low complication rate. However, interdisciplinary imaging-guided percutaneous or transhepatic gastrostomy offers a viable alternative for patients with surgically altered anatomy or difficult percutaneous access. PTEG, a newer technique, has demonstrated high technical success and symptom improvement, particularly in patients with extensive peritoneal carcinomatosis or massive ascites, where transabdominal approaches are not feasible. Conclusions: Palliative percutaneous decompression provides effective symptom relief in advanced gastrointestinal cancer. The choice of technique should be individualized based on patient anatomy, clinical condition, and resource availability. A multidisciplinary approach remains crucial in tailoring decompression strategies to improve the quality of life in end-stage malignancies. Full article

Background: Condylar hyperplasia (CH) leads to mandibular overgrowth with anatomical, aesthetic, and functional consequences, particularly affecting facial harmony. It is characterized by severe mandibular prognathism (MP) in bilateral cases. This study aims to propose a therapeutic algorithm for diagnosing and treating bilateral condylar hyperplasia (BCH) based on demographic, clinical, craniofacial growth, and clivus ratio uptake conditions. Methods: Ten patients with severe skeletal Class III by MP, whose alteration was clinically associated with BCH, were consecutively evaluated in a specialized dentofacial deformity center between the period of 2019 and 2024. A detailed protocol was followed to gather clinical history, assess anatomical features, evaluate malocclusion, and identify potential BCH. When suspicion arose, a nuclear medicine test measured condylar scintigraphy uptake. If the result was positive, patients underwent bilateral condylectomy, following one of three treatment protocols. Results: Severe PM, pronounced Class III with excessive negative overjet, elongated condyles of normal anatomy, absence of family history, and accelerated growth since preadolescence and adolescence were common characteristics in these patients. Regarding the treatment protocol chosen according to the characteristics of the patients, five cases followed treatment protocol A: condylectomy and surgical correction of the alteration in two surgical stages. Two cases followed protocol B: bilateral condylectomy and orthognathic surgery in the same surgical time, and three cases followed protocol C: condylectomy and later post-surgical orthopedics and/or orthodontics without a second surgical intervention. Histopathological results confirmed bilateral hyperplastic growth and stability in mandibular size, and occlusion was observed during follow-up. Conclusions: Specialists need to recognize the clinical signs of BCH and use scintigraphy tests to measure condylar metabolic activity when suspected. Early detection of BCH is crucial, as it influences treatment decisions and helps prevent relapses in orthodontic or surgical interventions aimed solely at correcting or compensating for Class III malocclusion caused by MP. Full article

Background: Mandibular reconstruction poses challenges in achieving functional and aesthetic outcomes. Effective oral rehabilitation is crucial for restoring function and improving quality of life; however, the altered neomandibular anatomy complicates oral hygiene, increasing the risk of peri-implant complications and making successful rehabilitation more difficult. This study introduces a novel approach combining vestibuloplasty with patient-specific implant-retained splints to enhance oral health and improve rehabilitation outcomes. Methods: Three patients underwent mandibular reconstruction with a free vascularized fibula flap (FFF). After 6 months of osseointegration, vestibuloplasty and soft tissue refinement were performed, with a split-thickness skin graft placed on the FFF periosteum. An implant-retained splint was secured to the abutments for two weeks to support soft tissue healing. Implant survival, bone loss, and peri-implant health were evaluated over a 2-year follow-up. Results: A total of 12 implants were placed, primarily in the neomandible (83.3%), with a 100% survival rate. Implant survival was assessed. Implant survival was assessed based on established criteria for clinical success, including stability, presence of pain, bleeding on probing (BOP), pocketdepth, bone loss and lack of peri-implant radiolucency. Functional outcomes included normal mouth opening, laterotrusion, and protrusion. Pocket depths ranged from 3 to 4 mm, except for one implant in cases 1 and 2. The mean BOP was 51.7%. Conclusions: This case series introduces a surgical technique that combines CAD/CAM and vestibuloplasty to optimize dental rehabilitation in mandibular FFF reconstructions, demonstrating safe thinning of soft tissues for improved oral hygiene and survival. Full article

Supraorbital hollowness and pretarsal fullness, commonly known as the sunken eyelid and charming roll, respectively, are significant anatomical features that impact the aesthetic appearance of the periorbital region. Supraorbital hollowness is characterized by a recessed appearance of the upper eyelid, often attributed to genetic factors, aging, or surgical alterations, such as excessive fat removal during blepharoplasty. This condition is particularly prevalent among East Asians due to anatomical differences, such as weaker levator muscles and unique fat distribution patterns. Pretarsal fullness, also known as aegyo-sal, enhances the youthful and expressive appearance of the lower eyelid, forming a roll above the lash line that is considered aesthetically desirable in East Asian culture. Anatomical-based filler injection techniques are critical for correcting these features, involving precise placement within the correct tissue planes to avoid complications and achieve natural-looking results. This approach not only improves the aesthetic appeal of the eyelid but also enhances the overall facial harmony, emphasizing the importance of tailored procedures based on individual anatomy and cultural preferences. Full article

Introduction: Difficult airway management is a critical challenge in anesthesia, often necessitating advanced techniques to ensure patient safety. A patient presented with a malignant lesion on the epiglottis, significantly altering the airway anatomy. Flexible rhinolaryngoscopy revealed a laryngeal carcinoma affecting the entire epiglottis, causing thickening and displacement, which suggested the potential for difficult intubation. Methods: Given the expected feasibility of bag-mask ventilation and front-of-neck access, an asleep intubation technique was selected. The combined use of a McGrath video laryngoscope and C-MAC video stylet allowed for fast and easy atraumatic intubation on the first attempt. The anesthetic and surgical course was uneventful. Discussion: This case report highlights the successful use of a combined approach involving a video laryngoscope and video stylet for intubation in a patient with known difficulties in airway management, providing insights into the benefits of enhanced visualization and maneuverability. The rigid design and steerable tip of the C-MAC video stylet provide advantages over traditional flexible optics, offering better maneuverability and reducing the need for a second operator. Although this technique was successful in this case, its use in patients with complex airway pathologies warrants careful preoperative assessment and collaboration with an experienced airway management team. Full article

Background/Objectives: Performing endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered gastrointestinal anatomy remains challenging, frequently necessitating the use of forward-viewing endoscopes. Given the challenge in endoscope selection based on the type of altered anatomy, the aim of this study was to examine ERCP success rates by specific endoscopes for different anatomy types. Methods: This single-center retrospective study examined ERCPs performed in patients with surgically altered gastrointestinal anatomy during an 18-year period. Enteroscopy success, cannulation success, and intervention success rates were compared between the different anatomy and endoscope types. Results: This study included a total of 334 adult patients (665 total ERCPs) with altered anatomy. The pediatric colonoscope was most frequently utilized (32.2%), and the majority of procedures were performed for biliary indications. Enteroscopy success was 82.2% in Roux-en-Y gastric bypass (RYGB), 97% in Billroth II, 91.5% in Whipple, and 93.2% in Roux-en-Y hepaticojejunostomy (RYHJ). Cannulation success was 90.5% in RYGB, 90.5% in Billroth II, 83.6% in Whipple, and 90.6% in RYHJ. Intervention success was 88.2% in Billroth II, 65.1% in RYGB, 81.6% in Whipple, and 87.5% in RYHJ. In patients with RYGB and RYHJ, SBE was utilized most frequently, with rotational enteroscopy having the highest success rates. The overall adverse event rate was 5.1%, with the majority of these being mild in severity. Conclusions: This large retrospective study found ERCP with forward-viewing endoscopes to be safe and effective for a variety of surgically altered anatomy types. Despite recent advances seen with endoscopic ultrasound-guided drainage procedures, this study advocates for ERCP as the initial approach for pancreaticobiliary access in surgically altered anatomy. Full article

Endoscopic management of benign pancreaticobiliary disorders encompasses a range of procedures designed to address complications in gallstone disease, choledocholithiasis, and pancreatic disorders. Acute cholecystitis is typically treated with cholecystectomy or percutaneous drainage (PT-GBD), but for high-risk or future surgical candidates, alternative decompression methods, such as endoscopic transpapillary gallbladder drainage (ETP-GBD), and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD), are effective. PT-GBD is associated with significant discomfort as well as variable adverse event rates. EUS-GBD leverages lumen-apposing metal stents (LAMS) for direct access to the gallbladder, providing the ability to treat an inflamed GB internally. Choledocholithiasis is primarily managed with ERCP, utilizing techniques to include balloon extraction, mechanical lithotripsy, or advanced methods such as electrohydraulic or laser lithotripsy in cases of complex stones. Altered anatomy from bariatric procedures like Roux-en-Y gastric bypass may necessitate specialized approaches, including balloon-assisted ERCP or EUS-directed transgastric ERCP (EDGE). Post-operative complications, including bile leaks and strictures, are managed endoscopically using sphincterotomy and stenting. Post-liver transplant anastomotic and non-anastomotic strictures often require repeated stent placements or advanced techniques like magnetic compression anastomosis in refractory cases. In chronic pancreatitis (CP), endoscopic approaches aim to relieve pain and address structural complications like pancreatic duct (PD) strictures and calculi. ERCP with sphincterotomy and stenting, along with extracorporeal shock wave lithotripsy (ESWL), achieves effective ductal clearance for PD stones. When traditional approaches are insufficient, direct visualization with peroral pancreatoscopy-assisted lithotripsy is utilized. EUS-guided interventions, such as cystgastrostomy, pancreaticogastrostomy, and celiac plexus blockade, offer alternative therapeutic options for pain management and drainage of peripancreatic fluid collections. EUS plays a diagnostic and therapeutic role in CP, with procedures tailored for high-risk patients or those with complex anatomy. As techniques evolve, endoscopic management provides minimally invasive alternatives for patients with complex benign pancreaticobiliary conditions, offering high clinical success and fewer complications. Full article

Background: Mediastinal mass syndrome represents a major threat to respiratory and cardiovascular integrity, with difficult evidence-based risk stratification for interdisciplinary management. Methods: We conducted a narrative review concerning risk stratification and difficult airway management of patients presenting with a large mediastinal mass. This is supplemented by a case report illustrating our individual approach for a patient presenting with a subtotal tracheal stenosis due to a large cyst of the thyroid gland. Results: We identified numerous risk stratification grading systems and only a few case reports of regional anesthesia techniques for extracorporeal membrane oxygenation patients. Clinical Case: After consultation with his general physician because of exertional dyspnea and stridor, a 78-year-old patient with no history of heart failure was advised to present to a cardiology department under the suspicion of decompensated heart failure. Computed tomography imaging showed a large mediastinal mass that most likely originated from the left thyroid lobe, with subtotal obstruction of the trachea. Prior medical history included the implantation of a dual-chamber pacemaker because of a complete heart block in 2022, non-insulin-dependent diabetes mellitus type II, preterminal chronic renal failure with normal diuresis, arterial hypertension, and low-grade aortic insufficiency. After referral to our hospital, an interdisciplinary consultation including experienced cardiac anesthesiologists, thoracic surgeons, general surgeons, and cardiac surgeons decided on completing the resection via median sternotomy after awake cannulation for veno-venous extracorporeal membrane oxygenation via the right internal jugular and the femoral vein under regional anesthesia. An intermediate cervical plexus block and a suprainguinal fascia iliaca compartment block were performed, followed by anesthesia induction with bronchoscopy-guided placement of the endotracheal tube over the stenosed part of the trachea. The resection was performed with minimal blood loss. After the resection, an exit blockade of the dual chamber pacemaker prompted emergency surgical revision. The veno-venous extracorporeal membrane oxygenation was explanted after the operation in the operating room. The postoperative course was uneventful, and the patient was released home in stable condition. Conclusions: Awake veno-venous extracorporeal membrane oxygenation placed under local anesthetic infiltration with regional anesthesia techniques is a feasible individualized approach for patients with high risk of airway collapse, especially if the mediastinal mass critically alters tracheal anatomy. Compressible cysts may represent a subgroup with easy passage of an endotracheal tube. Interdisciplinary collaboration during the planning stage is essential for maximum patient safety. Prospective data regarding risk stratification for veno-venous extracorporeal membrane oxygenation cannulation and effectiveness of regional anesthesia is needed. Full article

Background: The rise in bariatric surgeries, particularly Roux-en-Y gastric bypass (RYGB), has added complexity to diagnostic evaluations in post-transplant patients. Case Presentation: We present a rare case of metastatic jejunal adenocarcinoma in the biliopancreatic limb of a patient with a history of RYGB, diagnosed three months after simultaneous liver–kidney transplantation. Despite multiple advanced imaging modalities, the primary malignancy eluded detection during pre-transplant evaluation. The patient developed progressive anemia and persistent liver enzyme elevation, which led to a comprehensive diagnostic workup. After failed initial endoscopic and radiological attempts, a multifaceted approach combining PET-CT, targeted open liver biopsy, and repeat endoscopy via a G-tube site enabled the discovery of a 5 cm partially obstructing jejunal mass. Histopathological analysis confirmed moderately differentiated adenocarcinoma. Conclusions: This case underscores the challenges in diagnosing gastrointestinal malignancies in patients with altered anatomy, particularly following RYGB. It highlights the need for modified cancer screening protocols before organ transplantation, especially for those with complex post-surgical gastrointestinal anatomy, to prevent the development of metastatic disease post-transplant. Further research is warranted to refine screening strategies and improve early malignancy detection in this high-risk population. Full article

Endoscopic ultrasound (EUS)-guided interventions have revolutionized the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), providing minimally invasive alternatives with improved outcomes. These procedures have significantly reduced the need for high-risk surgical interventions or percutaneous alternatives and have provided effective palliative care for patients with advanced gastrointestinal and bilio-pancreatic malignancies. EUS-guided biliary drainage (EUS-BD) techniques, including hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and antegrade stenting (EUS-AS), offer high technical and clinical success rates, with a good safety profile particularly when Endoscopic Retrograde Cholangiopancreatography (ERCP) is not feasible. EUS-HGS, which allows biliary drainage by trans-gastric route, is primarily used for proximal stenosis or in case of surgically altered anatomy; EUS-CDS with Lumen-Apposing Metal Stent (LAMS) for distal MBO (dMBO), EUS-AS as an alternative of EUS-HGS in the bridge-to-surgery scenario or when retrograde access is not possible and EUS-guided gallbladder drainage (EUS-GBD) with LAMS in case of dMBO with cystic duct patent without dilation of common bile duct (CDB). EUS-guided gastroenterostomy (EUS-GE) has already established its role as an effective alternative to surgical GE and enteral self-expandable metal stent, providing relief from GOO with fewer complications and faster recovery times. However, we do not yet have strong evidence on how to combine the different EUS-guided drainage techniques with EUS-GE in the setting of double obstruction. This comprehensive review aims to synthesize growing evidence on this topic by randomized controlled trials, cohort studies, and case series not only to summarize the efficacy, safety, and technical aspects of these procedures but also to propose a treatment algorithm based essentially on the anatomy and stage of the neoplasm to guide clinical decision-making, incorporating the principles of personalized medicine. This review also highlights the transformative impact of EUS-guided interventions on the treatment landscape for MBO and GOO. These techniques offer safer and more effective options than traditional approaches, with the potential for widespread clinical adoption. Further research is needed to refine these procedures, expand their applications, and improve patient care and quality of life. Full article

Background: Head and neck reconstruction following ablative surgery results in alterations to maxillofacial anatomy and function. These postoperative changes complicate dental rehabilitation. Methods: An innovative modular, stackable guide system for immediate dental rehabilitation during mandibular reconstruction is presented. The virtual surgical planning was performed in Materialise Innovation Suite v26 and Blender 3.6 with the Blenderfordental add-on. The surgical guides and models were designed and manufactured at the point of care. Results: The duration of the surgery was 9 h and 35 min. Good implant stability (>35 Ncm) and a stable occlusion were achieved. After 9 months of follow-up, the occlusion remained stable, and a mouth opening of 25 mm was registered. The dental implants showed no signs of peri-implant bone loss. Superposition of the preoperative planning and postoperative position of the fibula parts resulted in an average difference of 0.70 mm (range: −1.9 mm; 5.4 mm). Conclusions: The in-house developed stackable guide system resulted in a predictive workflow and accurate results. The preoperative virtual surgical planning was time-consuming and required extensive CAD/CAM and surgical expertise. The addition of fully guided implant placement to this stackable guide system would be beneficial. More research with longer follow-ups is necessary to validate these results. Full article

Endometriosis is a chronic, estrogen-dependent inflammatory disease characterized by the presence of endometrial tissue outside the uterus, causing pelvic pain and infertility. Infertility arises mainly due to inflammatory mediators in the peritoneal fluid, contributing to local hypoestrogenism, which appears to exacerbate chronic inflammation and sensitize pelvic nerves. Local hypoestrogenism within endometriotic lesions contrasts with the systemic estrogen-dependent nature of the disease. This localized reduction in estrogen levels, resulting from an altered hormonal response, can contribute to the altered immune response and inflammation characteristic of endometriosis, potentially exacerbating tissue damage, promoting fibrosis, adhesions, and endometrioma formation that distort pelvic anatomy, and affecting fertility. Chronic pelvic pain and dyspareunia further complicate conception in affected women. In vitro fertilization (IVF) and laparoscopic surgical excision of endometriotic lesions are the two primary management options for endometriosis-related infertility, although current data provide limited guidance on when to prefer one approach over the other. It is generally accepted that treatment strategies must be individualized according to the patient’s wishes, symptomatology, age and the preferences of the woman and the couple. Timely intervention and structured follow-up for symptomatic women wishing to conceive may maximize conception rates within two years post-surgery, while minimizing the need for repeated interventions, which should be avoided. On the other hand, first-line IVF is particularly viable in cases of unoperated deep infiltrating endometriosis in asymptomatic women, or for those ineligible for or opposed to surgery. This review aims to evaluate the most recent data on endometriosis-related infertility to identify evidence-based key points that can enhance tailored management in clinical practice. Full article