Purpose The COVID-19 pandemic is placing unprecedented demand upon critical care services for invasive mechanical ventilation. There is current uncertainty regarding the role of tracheostomy for weaning ventilated patients with COVID-19 pneumonia. This is due to a number of factors including prognosis, optimal healthcare resource utilisation, and safety of healthcare workers when performing such a high-risk aerosol-generating procedure. Methods Literature review and proposed practical guideline based on the experience of a tertiary healthcare institution with 195 critical care admissions for COVID-19 up until 4th April 2020. Results A synthesis of the current international literature and reported experience is presented with respect to prognosis, viral load and staff safety, thus leading to a pragmatic recommendation that tracheostomy is not performed until at least 14 days after endotracheal intubation in COVID-19 patients. Practical steps to minimise aerosol generation in percutaneous tracheostomy are outlined and we describe the process and framework for setting up a dedicated tracheostomy team. Conclusion In selected COVID-19 patients, there is a role for tracheostomy to aid in weaning and optimise healthcare resource utilisation. Both percutaneous and open techniques can be performed safely with careful modifications to technique and appropriate enhanced personal protective equipment. ORL-HNS surgeons can play a valuable role in forming tracheostomy teams to support critical care teams during this global pandemic.

Purpose COVID-19 patients requiring mechanical ventilation can overwhelm existing bed capacity. We aimed to better understand the factors that influence the trajectory of tracheostomy care in this population to facilitate capacity planning and improve outcomes. Methods We conducted an observational cohort study of patients in a high-volume centre in the worst-affected region of the UK including all patients that underwent tracheostomy for COVID-19 pneumonitis ventilatory wean from 1st March 2020 to 10th May 2020. The primary outcome was time from insertion to decannulation. The analysis utilised Cox regression to account for patients that are still progressing through their tracheostomy pathway. Results At the point of analysis, a median 21 days (IQR 15-28) post-tracheostomy and 39 days (IQR 32-45) post-intubation, 35/69 (57.4%) patients had been decannulated a median of 17 days (IQR 12-20.5) post-insertion. The overall median age was 55 (IQR 48-61) with a male-to-female ratio of 2:1. In Cox regression analysis, FiO 2 at tracheostomy ≥ 0.4 (HR 1.80; 95% CI 0.89-3.60; p = 0.048) and last pre-tracheostomy peak cough flow (HR 2.27; 95% CI 1.78-4.45; p = 0.001) were independent variables associated with prolonged time to decannulation. Conclusion Higher FiO 2 at tracheostomy and higher pre-tracheostomy peak cough flow are associated with increased delay in COVID-19 tracheostomy patient decannulation. These finding comprise the most comprehensive report of COVID-19 tracheostomy decannulation to date and will assist service planning for future peaks of this pandemic.

We have demonstrated that NIPF does not correlate with the SNOT-22 disease-specific questionnaire, although both outcomes significantly improve postoperatively. At present, we are still lacking a clinically accurate objective measure of nasal function for the evaluation of patients undergoing septorhinoplasty surgery.

ObjectivesTracheostomy for coronavirus disease 2019 pneumonitis patients requiring prolonged invasive mechanical ventilation remains a matter of debate. This study analysed the timing and outcomes of percutaneous tracheostomy, and reports our experience of a dedicated ENT–anaesthetics department led tracheostomy team.MethodA prospective single-centre observational study was conducted of patients undergoing tracheostomy, who had been diagnosed with coronavirus disease 2019 pneumonitis, between 21st March and 20th May 2020.ResultsEighty-one patients underwent tracheostomy after a median (interquartile range) of 16 (13–20) days of invasive mechanical ventilation. Median follow-up duration was 32 (23–40) days. Of patients, 86.7 per cent were successfully liberated from invasive mechanical ventilation in a median (interquartile range) of 12 (7–16) days. Moreover, 68.7 per cent were subsequently discharged from hospital. On univariate analysis, there was no difference in outcomes between early (before day 14) and late (day 14 or later) tracheostomy. The mortality rate was 8.6 per cent and no deaths were tracheostomy related.ConclusionOutcomes appear favourable when patients are carefully selected. Percutaneous tracheostomy performed via a multidisciplinary approach, with appropriate training, was safe and optimised healthcare resource utilisation.

We report the case of a 53-year-old lady who presented with a lump in her left breast. Her initial investigations demonstrated a grade III invasive ductal carcinoma of the breast that was tethered to the pectoralis major; imaging and cytology also revealed metastatic nodes in the left axilla. After undergoing neoadjuvant chemotherapy with evidence of clinical and radiological tumour response, a wire-guided wide local excision and axillary node clearance was performed. When a histological analysis of the specimen was performed, there was no evidence of a viable metastatic tumour in the axillary lymph nodes, but there were several areas of extramedullary haematopoiesis. There are only two other reports in the literature of this finding. This could represent a potential source of false-positive diagnosis of axillary metastasis from breast cancer. It would be prudent to consider biopsy prior to clearance if there are megakaryocytes in axillary node cytology.

Objectives: To propose the optimal timing to consider tracheostomy insertion for weaning of mechanically ventilated patients recovering from coronavirus disease 2019 pneumonia. We investigated the relationship between duration of mechanical ventilation prior to tracheostomy insertion and in-hospital mortality. In addition, we present a machine learning approach to facilitate decision-making. Design: Prospective cohort study. Setting: Guy’s & St Thomas’ Hospital, London, United Kingdom. Patients: Consecutive patients admitted with acute respiratory failure secondary to coronavirus disease 2019 requiring mechanical ventilation between March 3, 2020, and May 5, 2020. Interventions: Baseline characteristics and temporal trends in markers of disease severity were prospectively recorded. Tracheostomy was performed for anticipated prolonged ventilatory wean when levels of respiratory support were favorable. Decision tree was constructed using C4.5 algorithm, and its classification performance has been evaluated by a leave-one-out cross-validation technique. Measurements and Main Results: One-hundred seventy-six patients required mechanical ventilation for acute respiratory failure, of which 87 patients (49.4%) underwent tracheostomy. We identified that optimal timing for tracheostomy insertion is between day 13 and day 17. Presence of fibrosis on CT scan (odds ratio, 13.26; 95% CI [3.61–48.91]; p ≤ 0.0001) and Pao 2:Fio 2 ratio (odds ratio, 0.98; 95% CI [0.95–0.99]; p = 0.008) were independently associated with tracheostomy insertion. Cox multiple regression analysis showed that chronic obstructive pulmonary disease (hazard ratio, 6.56; 95% CI [1.04–41.59]; p = 0.046), ischemic heart disease (hazard ratio, 4.62; 95% CI [1.19–17.87]; p = 0.027), positive end-expiratory pressure (hazard ratio, 1.26; 95% CI [1.02–1.57]; p = 0.034), Pao 2:Fio 2 ratio (hazard ratio, 0.98; 95% CI [0.97–0.99]; p = 0.003), and C-reactive protein (hazard ratio, 1.01; 95% CI [1–1.01]; p = 0.005) were independent late predictors of in-hospital mortality. Conclusions: We propose that the optimal window for consideration of tracheostomy for ventilatory weaning is between day 13 and 17. Late predictors of mortality may serve as adverse factors when considering tracheostomy, and our decision tree provides a degree of decision support for clinicians.

COVIDTrach is a UK multidisciplinary collaborative project that aims to evaluate the outcomes of tracheostomy in COVID-19 patients. It also examines the implementation of national guidance in COVID-19 tracheostomies and the incidence of COVID-19 infections amongst those health care workers involved in the procedure. An invitation to participate in an online survey tool (REDCap) was disseminated to all UK NHS departments involved in tracheostomy in mechanically ventilated COVID-19 patients via the Federation of Surgical Specialty Associations, it's subsidiary organisations and the Intensive Care Society. To date 78 hospitals have submitted 564 COVID-19 tracheostomy cases. Fifty-two percent (n=219/465) of patients who had undergone tracheostomy and were still alive, had been successfully weaned from mechanical ventilation at the point of completing the survey. The all cause in-hospital mortality following tracheostomy was 12% (n=62/530), with 3% of these (n=2/62) due to tracheostomy related complications and the remaining deaths due to COVID-19 related complications. Amongst 400 cases submitting data two weeks after the tracheostomy, no instance of COVID-19 infection amongst operators was recorded. FFP3 masks or Powered Air Purifying Respirators were used by operators in 100% of tracheostomies and a face visor or hood with face shield was available in 99% of cases. This interim report highlights early outcomes following tracheostomy in mechanically ventilated COVID-19 patients. Future reporting from COVIDTrach will include more detailed analysis at later timepoints using comparator groups in order to provide a more comprehensive assessment of tracheostomy in COVID-19.

Background: There has been a great expansion in patient-based outcome measures to face the ever-increasing demand to demonstrate surgical efficacy. However, surgeons have not adopted until now any systematic outcome instrument. The 22-item Sino-Nasal Outcome Test (SNOT-22) is a validated sinonasal outcome score in sinonasal and septorhinoplasty surgery but does not measure aesthetic outcome. The aim of this paper is to validate a modification to the Sino-Nasal Outcomes Test-22 (SNOT-22) with a new question regarding the shape of the nose (SNOT-23). Methodology: We conducted a prospective cohort study on 69 consecutive patients undergoing septorhinoplasty and a control group of healthy volunteers. Reproducibility, responsiveness to treatment, known group differences and validity of the SNOT-23 were analysed. Scores were compared to visual analogue scales, nasal obstruction symptoms evaluation (NOSE) score and nasal inspiratory peak flow. Results: SNOT-23 has good test-retest reliability and is a valid outcome measure for assessing response to surgery especially with regards to shape of the nose and nasal obstruction when compared to other patient reported measures. Conclusion: SNOT-23 is a valid and reliable tool that can be easily used in routine clinical practice to assess the functional and aesthetic outcomes from septorhinoplasty surgery. The SNOT-23 could be adopted as a universal, easy to use tool in rhinology clinics for the assessment of response to septorhinoplasty and sinus surgery.