Safety of surgical tracheostomy under continued antithrombotic therapy

Objective: Although various guidelines have been established for the management of antithrombotic therapy during surgical treatments, surgical tracheostomy (ST) under continued antithrombotic therapy (CAT) remains a challenge. We investigated the risk factors for complications after ST by focusing on CAT use during ST. Method: Patients’ medical records from 2009 to 2020 were reviewed in this retrospective study. We selected patients who underwent ST at the Department of Otolaryngology of the University of Tokyo Hospital. Patient demographics, complications, and blood test values were recorded and statistically analyzed to identify the risk factors for postoperative complications. Results: We identified 288 patients (median age: 64 years; 184 men [64%]), among whom 40 (median age: 67 years; 29 men [73%]) underwent CAT. Although the patients undergoing CAT had significantly higher values of activated partial thromboplastin time (p = 0.002) and prothrombin time-international normalized ratio (p = 0.006) than those of antithrombotic naïve patients, no statistically significant intergroup differences were observed in the risks of bleeding, infection, or subcutaneous emphysema. Instead, ST under local anesthesia (p = 0.01) and ST for airway emergency (p = 0.02) significantly increased the risk of early postoperative complications. Conclusion: The results of the present study suggest that ST under CAT can be safely performed without any increased risk of postoperative complications. Nevertheless, surgeons should be extra cautious about early complications after ST under local anesthesia without intubation or ST for airway emergency. Key points: 1. We aimed to investigate the risk factors for complications after ST by focusing on CAT use during ST. 2. Patients undergoing CAT had significantly higher values of APTT and PT-INR than those of antithrombotic naïve patients. 3. ST under CAT can be safely performed without any increased risk of postoperative complications. 4. ST under local anesthesia and airway emergency was a risk factor for complications after ST. 5. Among the complications, subcutaneous emphysema was significantly more frequent in ST under local anesthesia and under airway emergency.

746 COVID-19: Changing the Future of Emergency Epistaxis Management

Introduction Acute epistaxis can be a life-threatening airway emergency. Therefore, the majority of patients in whom conservative management (including cautery) has failed are admitted. However, due to the COVID-19 pandemic, our management has shifted towards a more outpatient centred approach. Method A single centre retrospective study was undertaken of all epistaxis patients managed by the ENT team at our centre over a five-month period from 1st January to 31st May 2020. The first 10 weeks (Pre-COVID-19) were managed using pre-existing guidelines. The following 10 weeks (COVID-19) were managed using the new COVID-19 standard operating procedures which aimed to minimise inpatient admissions. Results 142 patients, with similar demographic data, were seen across the 5-month period. There were significantly more patients aged over 65 presenting in the COVID-19 group (p = 0.04). There was a significantly increased use of local haemostatic agents (Nasopore ® and Surgiflo ®) and decreased use of nasal packing in the COVID-19 group. There were significantly fewer admissions (p < 0.0005) in the COVID-19 group, but similar rates of representation, length of stay and morbidity. Conclusions The COVID-19 pandemic has accelerated the shift towards the use of local haemostatic agents and outpatient management of epistaxis, which is as safe and effective as previously well-established epistaxis management.

Adolescent and adult laryngotracheal stenosis: a review

Background The larynx has multiple composite functions which include phonation, airway protection, and sensory control of respiration. Stenosis of the larynx and trachea were first recorded by O’Dwyer in 1885 and by Colles in 1886, respectively. Initially, the aetiology of laryngotracheal stenosis was predominantly infective. Currently, the leading cause is iatrogenic injury to the laryngotracheal complex secondary to prolonged ventilation in an intensive care unit. Main body Laryngotracheal stenosis is a complex and diverse disease. It poses a major challenge to the surgeon and can present as an airway emergency. Management typically demands the combined involvement of various disciplines including otorhinolaryngology, cardiothoracic surgery, anaesthesiology, interventional pulmonology, and radiology. Both the disease and its management can impact upon respiration, voice, and swallowing. The incidence of iatrogenic laryngotracheal stenosis has reflected the evolution of airway and intensive care whilst airway surgery has advanced concurrently over the past century. Correction of laryngotracheal stenosis requires expansion of the airway lumen; this is achieved by either endoscopic or open surgery. We review the relevant basic science, aetiopathogenesis, diagnosis, management, and treatment outcomes of LTS. Conclusion The choice of surgical procedure in the management of laryngotracheal stenosis is often dictated by the individual anatomy and function of the larynx and trachea, together with patient factors and available facilities. Regardless of how the surgeon chooses to approach these lesions, prevention of iatrogenic laryngotracheal damage remains of primary importance.

Scarlet fever in an adult patient: A challenging diagnosis in an airway emergency

Scarlet fever is essentially a childhood disease, although it may occur in all ages. Early diagnosis and treatment are essential in preventing the spread of infection and progression to life-threatening complications. The case presented describes the clinical difficulty in the diagnosis of scarlet fever in an adult patient with acute involvement of the airway (oedematous laryngitis) and the need for emergent orotracheal intubation and eventually tracheotomy. A high degree of suspicion related to the airway involvement is of utmost importance in an emergency room setting.

Cricothyroidotomy in the emergency setting: indications, techniques and outcomes

Cricothyroidotomy is a lifesaving procedure performed in acute respiratory failure secondary to upper airway obstruction to restore a patent airway. Emergency cricothyroidotomy is considered to be the technique of choice to provide oxygenation to patients in “Can’t Intubate, Can’t Oxygenate” (CICO) scenario. In this study, we describe and discuss indications, different techniques and complications of cricothyroidotomy performed for establishing an airway in the emergency setting from a multidisciplinary point of view.

Nasopharyngeal diffuse large B-cells lymphoma causing acute airway obstruction amid COVID-19 crisis: an anaesthetist’s nightmare

Acute stridor is often an airway emergency. We present a valuable experience handling an elderly woman who was initially treated as COVID-19 positive during the pandemic in November 2020. She needed an urgent tracheostomy due to nasopharyngeal (NP) diffuse large B-cell lymphoma causing acute airway obstruction. Fortunately, 1 hour later, her NP swab real-time PCR test result returned as SARS-CoV-2 negative. This interesting article depicts the importance of adequate preparations when handling potentially infectious patients with anticipated difficult airway and the perioperative issues associated with it.