Percutaneous tracheostomy (PT) is an ancient procedure that has recently attracted increasing interest. While there are numerous publications in the literature, there remains confusion due to the large variety of techniques and instruments with which it has been performed and the wide disparity in clinical outcome. This study evaluates the international literature on over 1,500 cases, classifies the techniques that have been used, analyzes the safety of each method, and reports a prospective outcome and cost analysis of 130 cases undergoing what we determined to be the safest method. We found that PT performed with the correct instruments and technique under bronchoscopic surveillance has a lower incidence of complications than open tracheostomy (OT). Cost estimation demonstrated that PT may be significantly more expensive than bedside OT. While we recommend PT as a relatively safe and expedient method of tracheostomy for selected intubated patients in an intensive care unit, it does not offer an advantage for patients who must be taken to the operating room, and should not deprive house officers of necessary experience in OT in this setting.
One hundred fifty‐nine Alaskan natives were nasopharyngoscoped in an attempt to determine the incidence of excessive amounts of adenoid tissue in the nasopharynx. Significant amounts of lymphoid tissue are present in the young Alaskan natives and the incidence is about the same as that of the Caucasian. The amount and incidence of adenoid tissue drops rapidly after puberty. In the opinion of the author, the eustachian orifice of the Eskimo appeared to be more widely patent than that of the Caucasian. In children under age 10, the number of cases in which tonsillectomy and adenoidectomy is indicated is about the same as that of the Caucasian.
If you are like me, you never find time to read all articles in sufficient depth to personally assure the accuracy of the data. I often thumb to the "conclusions" and then review the "discussion." However, the substance of the presentation is contained in the minutia of the "methods and results."The danger of superficial reading is exemplified by the data presentation and analysis contained in the article by Byers et al.' These authors reviewed the M. D. Anderson experience in elective neck dissection (1970)(1971)(1972)(1973)(1974)(1975)(1976)(1977)(1978)(1979)(1980) and indicate a 0% occurrence of histologically positive lymph nodes in the posterior cervical triangle for oral cavity, oropharynx, hypopharynx, larynx, and pharyngeal wall primary sites. However, detailed review of the methods section demonstrates that only 22% of the evaluated operations included a complete dissection of the posterior cervical triangle and only 24% included dissection of the inferior jugular nodes. The prominently displayed figures (1-10) imply that selective neck dissection, excluding the posterior cervical triangle, is appropriate for most primary sites. However, the data cannot support this conclusion since all neck regions were not fully assessed by pathologic analysis.Selective neck dissection remains a controversial and complex issue. Schuller et a1.' prospectively evaluated 50 radical neck specimens and found a 42% incidence of posterior cervical node involvement from a variety of primary sites (tonsil, supraglottic larynx, pyriform sinus). Schuller indicates that 90% of such metastases were in the superior portion of the course of the spinal accessory nerve (above the site of entry of the nerve into the sternocleidomastoid muscle) and that only one case showed metastasis to a node in the inferior chain (posterior to the sternocleidomastoid muscle).2 Byers, in contrast, indicates 0% involvement of the posterior cervical chain for all primary sites except base of the tongue (17%). Skolnick et al.3 in a review of 51 consecutive radical neck specimens, found a 0% incidence of nodes in the posterior cervical trian-gle. However, the majority of the Skolnick cases were laryngeal cancers and thus not likely to have posterior metastases. Schuller et al.4 emphasized the negative impact of metastatic disease in the posterior triangle, showing a 9% survival rate for patients with disease in that location contrasted to a 28% survival for any other site (P < 0.01). Outcome analysis by Jesse et al? and Lingeman et a1.6 provides excellent justification for selective neck dissection in patients with an No and N, neck.Thus, the accumulated evidence in our literature supports Byers contention that the posterior cervical triangle is infrequently involved by head and neck squamous cell carcinoma even though his data do not independently support this conclusion. It is noteworthy that Byers outcome analysis of surgically treated cases can be interpreted as evidence indicating the weakness of selective neck dissection for oral tongue and floor of ...
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