Single-session, dual-site robotic surgery for synchronous malignancies is not widely reported. To our knowledge, there are no previous reports of transoral robotic surgery (TORS) and robot-assisted thoracic surgery (RATS) in a single sitting. A 49-year-old male presented with a neck lump. Biopsies and imaging proved synchronous primaries of the tonsil and lung. The morbidity of primary dual-site chemoradiotherapy, or open surgery, presented a management challenge. We therefore opted for sequential robotic resections, in a single sitting. The patient was discharged on Day 6 post-operatively and was able to start radiotherapy less than 3 weeks post-operatively. Undertaking TORS and RATS in a single sitting is feasible and safe. This approach allowed fast-tracking of adjuvant oncological therapy, arguably conveying the greatest chance of cure. We detail the rationale and utility of this novel approach and describe the surgical and anaesthetic challenges of two teams undertaking sequential robotic procedures in a single sitting.

Laryngeal aspergillosis is most commonly seen as a secondary infection that spreads from the lungs and tracheobronchial tree. Primary invasive aspergillosis of the larynx is rare and most likely seen in an immunocompromised patient. We present a case of a 59-year-old woman who presented with progressive dysphonia and subsequently acute stridor. She is a non-smoker with a recent diagnosis of acute myeloid leukaemia. Fibreoptic nasendoscopy revealed a left sided vocal cord lesion ball valving into the glottic space. Histology taken during emergency debulking confirmed Aspergillus fumigatus and the patient was successfully treated with intravenous antifungals. Although there are cases of primary laryngeal aspergillosis discussed in the literature, to the best of our knowledge this is the first reported case to have caused acute airway distress requiring emergency intervention.

Cranial diabetes insipidus (DI), which can cause life-threatening dehydration, is treated with desmopressin, often intranasally. This is challenging in patients whose nasal airflow is altered, such as those requiring tracheostomy. We report the case of a patient, taking intranasal desmopressin for cranial DI, who underwent partial glossectomy, free-flap reconstruction and tracheostomy. Postoperatively, she could not administer nasal desmopressin due to reduced nasal airflow. She developed uncontrollable thirst, polyuria and hypernatraemia. Symptoms were relieved by switching to an enteric formulation. A literature review showed no cases of patients with DI encountering difficulties following tracheostomy. The Royal Society of Endocrinology recommends perioperative planning for such patients, but gives no specific guidance on medication delivery in the context of altered airway anatomy. Careful perioperative planning is required for head and neck patients with DI, particularly for those undergoing airway alteration that may necessitate a change in the mode of delivery of critical medications.

No abstract

Laryngeal neurofibroma is a rare but important differential diagnosis in a patient presenting with stridor. In paediatric patients, these lesions present a management conundrum: complete surgical resection is the established treatment of choice, but an aggressive approach can be detrimental to developing anatomy. We report the case of a plexiform neurofibroma affecting the right hemilarynx of a 3-year-old boy. Endoscopy revealed a large tumour, involving the right aryepiglottic fold and extending into the piriform sinus, ventricle and the false cord. Given the patient’s young age and the challenging tumour location, the lesion was debulked, rather than resected, using coblation (low-temperature plasma radiofrequency ablation). At 30 months follow-up, the neurofibroma has mildly increased in size—in line with expectations that these lesions exhibit slow growth throughout childhood—but there are no significant respiratory symptoms and there is no functional impairment.