Annals of Otology Rhinology and Laryngology

Annals of Otology Rhinology and Laryngology

Salivary Clear Cell Carcinoma Clinicopathologic Characteristics and Outcomes: A Population-Based Analysis

30-05-2019 – Daniel D. Sharbel,Aykut A. Unsal,Michael W. Groves,William G. Albergotti,J. Kenneth Byrd

Journal Article

Salivary clear cell carcinoma is an uncommon, low-grade malignancy for which limited data describing predictive clinicopathologic factors and treatment outcomes exist because of rarity. The authors queried the Surveillance, Epidemiology, and End Results database from 1982 to 2014. Multivariate Cox and Kaplan-Meier analyses were performed to determine disease-specific survival (DSS) and predictive clinicopathologic factors. One hundred ninety-eight patients with salivary clear cell carcinoma were included. Overall incidence was 0.011 per 100 000 individuals, with no significant annual percentage change across years (-0.93%, Salivary clear cell carcinoma carries an overall good prognosis. Patients with localized disease and those treated with surgery alone have more favorable prognoses. Male patients and those with regional or distant metastatic disease at time of presentation carry a worse prognosis. N/A.

Revision Stapes Surgery in a Tertiary Referral Center: Surgical and Audiometric Outcomes

04-06-2019 – Esther E. Blijleven,Inge Wegner,Rinze A. Tange,Hans G.X.M. Thomeer

Journal Article

To evaluate pure-tone audiometric results in otosclerosis patients undergoing revision stapes surgery following previous middle ear interventions. A retrospective cohort study was performed in a tertiary referral center. Consecutive otosclerosis patients who underwent revision stapes surgeries, following previous middle ear interventions, for persistent conductive hearing loss, recurrent conductive hearing loss, or vertigo and had available postoperative pure-tone audiometry were included. Mean pre- and postoperative air conduction, bone conduction, and air-bone gap averaged over 0.5, 1, 2, and 3 k
Hz were obtained. Audiometric outcomes were obtained at 7 weeks postoperatively. In total, 63 consecutive otosclerosis patients who underwent 66 revision stapes surgeries were included. Air-bone gap improved significantly with a mean gain of 19 d
B (95% CI, 15-22). Air conduction improved significantly with a mean gain of 18 d
B (95% CI, 14-23). Bone conduction did not change significantly, with a mean deterioration of 0 d
B (95% CI, -2 to 1). Air-bone gap closure to 10 d
B or less was achieved in 38% of cases and to 20 d
B or less in 80% of cases. Indication for surgery, previous type of procedure, primary cause of failure, and current surgical technique were not significantly associated with air-bone gap closure to 10 d
B or less. Indication for surgery and primary cause of failure were associated with one another. Compared to the available literature, a slightly larger gain in air conduction and air-bone gap was achieved in our study. Air-bone gap closure to 10 d
B or less was achieved less often in our study.

Small Cell Carcinoma in the Head and Neck

04-06-2019 – Takahiro Wakasaki,Ryuji Yasumatsu,Muneyuki Masuda,Mioko Matsuo,Akihiro Tamae,Kazuhiko Kubo,Ryunosuke Kogo,Ryutaro Uchi,Masahiko Taura,Takashi Nakagawa

Journal Article

Small cell carcinomas in extrapulmonary sites (ESm
CCs) are very rare. ESm
CCs originating in the head and neck account for approximately 10% of all ESm
CCs, and there are few reports about this disease. ESm
CCs have an aggressive natural history characterized by widespread metastasis. The aim of this study was to investigate the characteristics and outcomes of patients with ESm
CCs of the head and neck. The outcomes of 21 patients with ESm
CCs of the head and neck treated between January 2001 and December 2015 at the authors’ hospital and associated facilities were reviewed. There were 18 men and 3 women, and the median age was 74 years (range, 53-91 years). The tumor site was the larynx in 6 patients; the paranasal sinus in 5; the hypopharynx in 3; the oropharynx in 2; the nasopharynx in 2; and the oral cavity, salivary gland, and primary unknown in 1 patient each. The extent of the disease was staged as follows: stage I or II, 3 cases; stage III, 4 cases; stage IVA, 9 cases; stage IVB, 1 case; and stage IVC, 4 cases. The median observation time was 17 months (range, 1-103 months). Four patients (19%) had distant metastasis at initial treatment, and 13 patients (62%) developed distant metastasis within 3 years. Treatments were administered, including radical surgery (9 patients), radiation therapy (5 patients), chemoradiotherapy (7 patients), and chemotherapy (6 patients). The 1- and 3-year overall survival rates of patients were 56% and 37%, respectively. More than half of the patients died of distant metastasis. ESm
CCs of the head and neck have a poor prognosis, similar to those of carcinomas in many other sites. Control of distant metastasis would contribute to improving the prognosis of ESm
CCs of the head and neck. Further studies are required for better understanding these disease entities and their response to treatment modalities.

eHealth Literacy in Otolaryngology Patients

14-06-2019 – Christopher Eric Bailey,William J. Kohler,Chadi Makary,Kristin Davis,Nicholas Sweet,Michele Carr

Journal Article

The aim of this study was to compare e
Health literacy-one’s perception of one’s ability to use the Internet for health care-among otolaryngology patients in 3 geographic settings of the same department. An academic otolaryngology department. Patients’ opinions and perceptions of their e
Health literacy were assessed with a validated paper survey administered in the summer of 2017. Of 381 asked, 351 people completed the survey, 149 at a university town teaching hospital clinic (group A), 101 at a nearby rural clinic (group B), and 101 at a remote rural clinic (group C). Mean scores were 30.80, 28.97, and 29.03 for groups A, B, and C, respectively. The overall mean was 29.76 ± 5.97. Three surveys reported the minimum score of 8, and 26 reported the maximum score of 40. Results were statistically significantly different among all sites ( Otolaryngology patients in a university town had better e
Health literacy than patients in more rural settings, suggesting that online medical resources and access points are less likely to be useful in rural populations.

Management of Vocal Fold Paralysis and Dysphagia for Neurologic Malignancies in Children

19-06-2019 – Peter Nagy,Nicholas Beckmann,Steven Cox,Anthony Sheyn

Journal Article

To evaluate our experience with a significant number of brain malignancy-related vocal fold paralysis patients and their response to vocal cord-related therapies. Vocal fold paralysis is a potentially devastating complication of various types of pediatric diseases and surgeries that can lead to significant vocal and swallowing difficulties. While there is significant data in the literature on outcomes of children treated for vocal fold paralysis following cardiac or thyroid surgery, there is a scarcity of such information on children following the treatment of neurologic malignancy. Records of 19 patients at a tertiary center who were treated for neurologic malignancies and developed either unilateral or bilateral vocal fold paralysis were reviewed for vocal fold pathology and vocal fold paralysis treatment-related variables, including initial diagnosis, management with observation or speech therapy, duration of therapy, pre- and postintervention swallow studies, and surgical intervention. Bilateral vocal fold paralysis was noted in 26% (5/19) patients. Eighty-four percent (16/19) of patients had stable or improved ability to vocalize and swallow following therapy. There was no statistically significant difference in speech or swallowing improvement after speech therapy alone or speech therapy in combination with injection laryngoplasty ( Patients with vocal fold paralysis secondary to neurologic malignancy can have an improvement in speech and swallowing after a variety of treatments, including speech therapy or early injection laryngoplasty. There was no statistically significant difference in improvement based on the type of intervention utilized. A larger sample size is needed to conclude whether surgical intervention combined with speech therapy leads to more rapid and significant functional improvement than speech therapy alone.

Curved Laryngopharyngoscope With Flexible Next-Generation Robotic Surgical System for Transoral Hypopharyngeal Surgery: A Preclinical Evaluation

21-06-2019 – Kohtaro Eguchi,Jason Y. K. Chan,Ichiro Tateya,Akira Shimizu,F. Christopher Holsinger,Taro Sugimoto

Journal Article

The indication of transoral robotic surgery for hypopharyngeal cancer is limited because of poor accessibility. The aim of this study was to explore the efficacy of a curved laryngopharyngoscope used in combination with a next-generation flexible robotic surgical system for accessing and resecting the hypopharynx. A comparative evaluation of the curved laryngopharyngoscope versus standard straight-blade retractors using the flexible robotic surgical system was conducted on 2 cadavers. End points measured included visualization, accessibility, and ease of dissection for accessing and resecting the hypopharynx. Visualization, accessibility, and dissection were superior with the curved laryngopharyngoscope in all subareas of the hypopharynx. The advantages of accessibility and visualization were much more evident in the cadaver with a high body mass index. These preclinical data suggest that using a curved laryngopharyngoscope in combination with a flexible robotic surgical system may lead to technical innovations concerning transoral surgery of the hypopharynx.

Awareness of European Otolaryngologists and General Practitioners Toward Laryngopharyngeal Reflux

01-07-2019 – Jerome R. Lechien,Francois Mouawad,Geoffrey Mortuaire,Marc Remacle,Francois Bobin,Kathy Huet,Andrea Nacci,Maria Rosaria Barillari,Lise Crevier-Buchman,Stéphane Hans,Camille Finck,Lee M. Akst,Petros D. Karkos

Journal Article

To investigate the current trends in management of laryngopharyngeal reflux (LPR) among young European otolaryngologists and general practitioners (GP). An international survey was sent to European general practitioners and all otolaryngologists under 45 years old from the 2017 IFOS meeting. This survey was conducted by the LPR Study Group of YO-IFOS (Young Otolaryngologists of the International Federation of Otolaryngological Societies). Among the 2500 attendees, 230 European otolaryngologists (response rate = 9%) completed the survey; an additional 70 GPs also completed the survey. GPs did not differentiate between gastroeosophageal reflux disease (GERD) and LPR, overstating GERD-related symptoms (ie, heartburn and regurgitations) in LPR clinical presentation and relying on gastrointestinal endoscopy for LPR diagnosis. Otolaryngologists also believe that GERD-related symptoms are prevalent in LPR. Knowledge of nonacid and mixed LPR and use of multichannel intraluminal impedance-p
H monitoring are still limited in both groups. A therapeutic dichotomy exists between groups: GPs mainly use a 4-week once daily empiric proton pump inhibitors (PPIs) trial, while otolaryngologists use PPIs twice daily for a longer therapeutic period ranging from 8 to 12 weeks. More than 50% of GPs and otolaryngologists believe that they are not adequately knowledgeable and skilled about LPR. The majority of GPs and otolaryngologists do not believe themselves to be sufficiently informed about LPR, leading to different practice patterns and grey areas. The elaboration of international recommendations in the management of reflux is needed to improve practices.

Why Central Neck Dissection Works (and Fails) for Recurrent Thyroglossal Duct Remnants

04-07-2019 – Glenn Isaacson,Adam Kaplon,Derrick Tint

Journal Article

To review the patient characteristics and outcomes for children and undergoing central neck dissection for control of recurrent thyroglossal duct cysts and fistula following prior Sistrunk procedures and children requiring surgery for refractory infection. We performed a computerized review of all children who were evaluated for thyroglossal duct cysts during the years 1999-2018 by a single surgeon operating at an urban children’s hospital and an outpatient surgical center. Those requiring a central neck dissection for control of recurrent disease or intractable infection were identified. Age at time of surgery, sex, surgical procedure, and postoperative complications were recorded. These data were combined with similar data from a published report by the same surgeon in the years 1990-1998 to complete a 28-year review. 18 central neck dissections were performed including 13 for recurrent thyroglossal duct remnants after Sistrunk procedures and 5 primary surgeries for intractable infection. Ages ranged from 3 to 19 years (median = 10 years) and 13 of 18 were girls (72%). Four children had their first Sistrunk surgery performed by the senior author. Three children operated elsewhere had intact hyoid bones at the time of revision surgery, suggesting less-than-Sistrunk primary surgeries. Central neck dissection controlled disease in the lower neck in all cases. One child re-fistulized at the level of the hyoid. Central neck dissection in combination with a Sistrunk-type dissection of the tongue base is effective in the control of recurrent infection following unsuccessful Sistrunk surgery and aids in dissection for children with intractable infection. Although this technique reliably controls infrahyoid disease and improves access to the hyoid and posterior hyoid space, it does nothing to address the difficulties of following the thyroglossal tract into the tongue base.

Direct Visualization of Laryngeal Mucociliary Clearance in Adults

04-07-2019 – Luke M. O’Neil,Niall D. Jefferson

Journal Article

Mucociliary clearance is a protective mechanism of the respiratory tract that facilitates the removal of foreign particles and microorganisms. There is a paucity of data on the mucociliary clearance in the adult larynx. Our study aims to visualize and describe the mucociliary clearance of the adult larynx in healthy subjects. Subjects were identified from a volunteer database. Exclusion criteria included laryngeal disease, previous laryngeal surgery, recent upper respiratory infection, and current smoking. A high-definition videolaryngoscope was used to visualize the larynx. The larynx was topicalised with local anesthetic. Methylene blue was placed on both false vocal cords and at the petiole of the epiglottis. Dye clearance was recorded and analyzed. In total, 10 participants participated, 7 men and 3 women, with a mean age of 42 ± 15.7 years (range: 25-71). The average reflux symptom index score was 1.4. Clearance of the dye from the false vocal cords followed a uniform lateral flow, up onto the aryepiglottic folds. The dye from the petiole had minimal vertical movement. Swallowing cleared dye from the aryepiglottic folds. The average time for dye clearance to the aryepiglottic fold was 2.21 ± 1.14 minutes. This is the first study visualizing the mucociliary clearance of the larynx. Ciliary directionality was consistent in the participants studied, with dye moving superolateral from the false cords to the aryepiglottic fold. Swallowing was an effective mechanism for clearance from the endolarynx, when the dye had reached the aryepiglottic fold. Future research can study potential alterations in laryngeal mucociliary clearance in chronic disease states.

Diagnostic Protocol for Detecting Otosclerosis on High-Resolution Temporal Bone CT

10-07-2019 – Lisa A. Brown,Burce Ozgen Mocan,Miriam I. Redleaf

Journal Article

To present a systematic checklist to improve diagnosing otosclerosis (OS) on high-resolution computed tomography (HRCT) of the temporal bones and review this protocol’s efficacy in diagnosing OS on HRCT. A retrospective case series was performed at a University Referral Hospital in urban Chicago, Illinois. High-resolution computed tomographies of the temporal bone were reviewed including 17 ears in the test group with surgically confirmed OS and 21 ears in the control group surgically confirmed to not have OS. Preoperative HRCTs were evaluated by a single neuroradiologist using a systematic protocol created to assist in diagnosing OS. This looked for radiolucency at the fissula ante fenestram and pericochlear region, and new bone formation around the oval and round windows. The radiologist accurately diagnosed OS in all 17 test group ears and ruled out OS in all 21 control group ears using the protocol. All 17 test ears were read to have lucency at the fissula ante fenestram, 9 (53.0%) to have new bone formation, and 8 (47.1%) to have cochlear lucency. The radiologist was more confident in diagnosing OS when cochlear lucency was present with the fissula ante fenestram lucency. This HRCT checklist is a highly accurate tool for evaluating the presence of OS when images are reviewed in the systematic fashion described. Imaging prior to surgery aids in counseling patients, preparing surgically, and excluding other pathologies.

The Genetic and Molecular Determinants of Juvenile Nasopharyngeal Angiofibroma: A Systematic Review

31-05-2019 – Jaime Doody,Eelam A. Adil,Cameron C. Trenor,Michael J. Cunningham

Journal Article

Juvenile nasopharyngeal angiofibroma (JNA) is a rare vascular tumor of unknown etiology. Studies investigating the molecular and genetic determinants of JNA are limited by small sample size and inconsistent approaches. The purpose of this study is to examine all eligible JNA studies in aggregate, applying qualitative analysis to highlight areas of particular relevance, including potential targets for therapeutic intervention. The PubMed, MEDLINE, Embase, Web of Science, Cochrane, and CINAHL databases were screened with inclusion and exclusion criteria applied to all citations. Manuscripts investigating the genetic determinants, histopathogenesis, and heritability of juvenile nasopharyngeal angiofibroma were included. Non-English studies, case reports, and articles focusing on clinical management without original data were excluded. Full text articles were obtained. A qualitative synthesis of data was performed. A total of 59 articles met criteria for inclusion. These were divided into 6 categories based on the primary topic or target discussed, (1) steroid hormone receptors, (2) chromosomal abnormalities, (3) growth factors, (4) genetic targets, (5) molecular targets, (6) Wnt cell signaling, and (7) studies that overlapped multiple of the aforementioned categories. Although relatively low n values prevent definitive conclusions to be drawn, a predominance of certain molecular targets such as vascular endothelial growth factor (VEGF) and Wnt/β-catenin pathway intermediaries is apparent. Although the etiology of JNA remains elusive, contemporary molecular genetic investigation holds promise for risk stratification and could form the basis of a modernized staging system. A multicenter clinical registry and linked tissue bank would further promote the search for JNA specific biomarkers.

Type I Posterior Glottic Stenosis: Natural History and In-Office Management

04-06-2019 – Valeria Silva Merea,Babak Sadoughi

Journal Article

To review the natural history of type I posterior glottic stenosis (PGS-I) and its treatment outcomes through a case presentation and demonstrate the feasibility of in-office management of PGS-I. The case of a middle-aged woman who developed PGS-I after prolonged intubation is presented. A review of the literature on management and treatment outcomes of PGS-I is also performed. Initially presenting with a large granuloma that failed conservative management, the patient deferred surgical intervention and developed unilateral vocal fold hypomobility with posterior glottic synechia. The adhesion was successfully ablated in the office with potassium-titanyl-phosphate (KTP) laser; however, vocal fold hypomobility persisted after treatment. This case illustrates the natural history of the development of PGS-I, demonstrates the feasibility of office-based management of this condition, and provides further evidence that lysis of PGS-I synechia does not uniformly lead to restoration of normal laryngeal function and mobility.

Unusual Nasal Insufficiency in an Infant: What’s Behind the Nostril?

17-06-2019 – Fabian Alzate Amaya,Liliana F. Invencio da Costa,Alejandro Martinez Moran,Roberto Alvarez Rodriguez

Journal Article

Inflammatory myofibroblastic tumor (IMT) is a rare benign lesion, especially in the pediatric age. There are several cases described in pulmonary, digestive and renal localizations, but involvement in head and neck area is infrequent. Case report and review of the literature. A 1 year and 11 months old child, during 2 months had clinical signs of nasal respiratory insufficiency and epistaxis subsequently developing a purulent rhinorrhea and a sleep apnea. His pediatrician previously requested a sinus and cavum X-ray with the finding of an image compatible with an intranasal mass. Endoscopic resection was performed of the mass with further immunohistochemical analysis showing the result of a lesion compatible with IMT. Even though there are very few cases in scientific literature of a tumor with these characteristics in infants, IMT must be present as a differential diagnosis of intranasal masses. The role of the pathologist is essential to reach the definitive diagnosis and the performance of an early surgical treatment decreases aesthetic consequences in this pathology.

Three Cases of Primary Ciliary Dyskinesia Combined With Reduced Exhaled Nitric Oxide

04-07-2019 – Sung Min Han,Chi Sang Hwang,Hyun Jong Jeon,Ho Young Lee,Hyung-Ju Cho,Dong-Joon Park

Journal Article

The diagnosis of primary ciliary dyskinesia (PCD) is often delayed in part related to the limitations of the available diagnostic tests. We present 3 cases of PCD diagnosed using an exhaled nitric oxide (e
NO) measurement. Three cases with a clinical phenotype consistent with PCD were evaluated using an e
NO assay with additional transmission electron microscopy (TEM) and/or genetic panel testing. One male and 2 female patients presented with common symptoms included recurrent respiratory infection from early childhood and a history of neonatal respiratory distress as term newborn. Two of them had situs inversus totalis. Fractional e
NO measurement revealed extremely low NO levels, and subsequently, TEM analysis confirmed ciliary ultrastructural defects in all patients. One patient had compound heterozygous mutation of the PCD-causative gene ( Our report stresses the reliability of e
NO measurement in the diagnosis of PCD, accompanied by clinical phenotypes and additional diagnostic tools, such as TEM analysis and genetic testing.

Spindle Cell Lipomas of the Respiratory Tract: A Case Report and Comprehensive Literature Review

11-07-2019 – Jonathan Reid,Bret Wehrli,Leigh J. Sowerby

Journal Article

Spindle cell lipomas (SCLs) are benign tumors that are characteristically present on the upper back and neck, but in rare cases present throughout the respiratory mucosa, causing hoarseness, stridor, dyspnea, and obstruction. To highlight the importance of considering SCL in the diagnosis of benign respiratory tract tumors, a literature review identified all published cases of respiratory tract SCLs, including 2 from our institution: one case in the nasopharynx and 1 in the nasal valve. All case reports, series and literature reviews from the English literature from 1975 through March 2018 were systematically identified for review in the MEDLINE, EMBASE, and Scopus databases. Two additional cases from our institution were described. In total, 24 cases of SCL in the respiratory tract were identified for review. Two cases from our institution are described here, bringing the total of reported cases to 26. Extensive analyses of oral cavity SCLs already exist, so we excluded this site from our review and focused on sites where SCLs may present with respiratory symptoms. Excluding the oral cavity and oropharynx, the most common location described is the larynx. All 26 cases were treated with excision. One tumor required a second surgery, but there were no other complications nor recurrences. Although rare, SCLs may arise from throughout the respiratory tract and cause dyspnea, hoarseness and stridor. Spindle cell lipoma should be considered in the differential diagnosis of a respiratory tract mass. This diagnosis confers a good prognosis and patients may be reassured that surgery is almost always curative.

Autologous Fat Injection Pharyngoplasty in Adults with Velopharyngeal Insufficiency

14-10-2019 – Kevin J. Contrera,William S. Tierney,Paul C. Bryson

Should Excess Topical Decongestant Use Raise a Red Flag? Rhinitis Medicamentosa and Opioid Use Disorder

04-10-2019 – Aneesh Patel,Jessica R. Levi,Christopher D. Brook

Journal Article

The objective of this study was to determine whether patients with rhinitis medicamentosa (RM) have an increased odds of having an opioid use disorder (OUD) and which characteristics may predict this association. The authors conducted a retrospective case control study of patients 18 years and older who presented to the otolaryngology clinic at an academic medical center from January 2013 through December 2017. Cases, defined as patients who presented with excessive decongestant nasal spray usage based on history, were matched to control patients who presented with chronic rhinitis and did not report regular nasal decongestant usage. The charts were reviewed for patients that carried a problem of opioid abuse, identified using ICD-9 codes 304.
XX or ICD-10 codes F11.
XX. The primary outcome of this study was the odds of having an OUD. Secondary outcomes were assessed by summary statistics. One hundred and thirty-one cases of RM were matched to 1871 controls of chronic rhinitis. Seven cases (5.3%) and 24 (1.3%) controls had a diagnosis of OUD, consistent with an odds ratio of 3.98 for opioid abuse in patients with RM (95% CI: 1.47-9.71). Oxymetazoline was used by 85.5% (n = 112) of patients with RM. Thirty-six patients (27.1%) with RM underwent nasal surgery following a diagnosis of RM, of which twenty patients (55.6%) were prescribed opioids following the procedure. RM is associated with increased odds of having an OUD.

Sterno-omohyoid Free Flap for Dual-Vector Dynamic Facial Reanimation

03-10-2019 – Aurora G. Vincent,Scott E. Bevans,Jon M. Robitschek,Kelly L. Groom,Marc W. Herr,Marc H. Hohman

Journal Article

Dynamic rehabilitation of longstanding facial palsy with damaged, atrophied, or absent facial muscles requires replacement of neural and muscular components. The ideal reconstruction would include a fast-twitch muscle that is small, a reliable donor vessel and nerve, and the potential to provide a natural, synchronous, dentate smile with minimal donor site morbidity. Many flaps have been successfully used historically, but none has produced ideal rehabilitation. To evaluate the novel sterno-omohyoid, dual-vector flap in rehabilitation of chronic facial paralysis. We performed sterno-omohyoid free tissue transfer for smile reanimation in a 39-year-old male with a history of longstanding right facial palsy following resection of a skull base tumor several years previously. We transferred both muscles with the superior thyroid artery, middle thyroid vein, and ansa cervicalis. The patient developed a dynamic smile by 6 months postoperatively, and he had improved objective facial symmetry. Herein, we demonstrate the first use of the sterno-omohyoid flap for successful facial reanimation. Overall, it is a novel flap in facial reanimation with many advantages over traditional flaps, including the potential to produce a more synchronous, dynamic smile while adding minimal bulk to the face. Future series will better elucidate the potential of the sterno-omohyoid flap.

Chronic maxillary atelectasis under the wrappings of an Egyptian mummy

01-10-2019 – Georgios Michailidis,Stavroula Kyriazi,Alicia Maravelia,Eleni Tourna,Constantinos M. Couvaris,Kiriakos Kalampoukas,Ioannis Pantazis,Panagiotis Lazaris,Stefanos Geroulanos,Kleanthi Kalogerakou,Nikos Bontozoglou

Journal Article

In the context of a joint Mummy Research Project of the National Archaeological Museum, the Hellenic Institute of Egyptology and the Athens Medical Centre, an Egyptian mummy of the mid-Ptolemaic Period was transferred to our hospital and was thoroughly investigated with Computed Tomography. The mummy was carefully removed from its coffin and scanned in a 64-detector row computed tomographic scanner. Multiplanar and anthropometric measurements were obtained using advanced software. The mummy appeared to be well-preserved and belonged to a young male adult. Among the findings, the most interesting and uncommon one was the asymmetry of the maxillary sinuses and the orbits. There were no signs of trauma. Computed Tomography revealed in a non-destructive way a rare, based on the published data, facial deformity in an Egyptian mummy attributed to chronic maxillary atelectasis.

Computational Fluid Dynamic Analysis of Different Velopharyngeal Closure Patterns

01-10-2019 – Hanyao Huang,Heng Yin,Yang Wang,Nan Chen,Dantong Huang,Xiangyou Luo,Xing Yin,Qian Zheng,Bing Shi,Jingtao Li

Journal Article

Velopharyngeal (VP) closure has high impact on the quality of life, especially in patients with cleft palate. For better understanding the VP closure, it is important to understand the airflow dynamics of different closure patterns, including circular, coronal, sagittal, and circular with a Passavant’s ridge. The purpose of this study was to demonstrate the airflow characteristics of different velopharyngeal closure patterns. Sixteen adults with no notable upper airway abnormality who needed multislice spiral computed tomography scans as part of their clinical care. Airways were reconstructed. A cylinder and a cuboid were used to replace the VP port in three models of VP port patterns. Flow simulations were carried using computational fluid dynamics. Airflow pressures in the VP orifice, oral cavity and nasal cavity, as well as airflow velocity through the velopharyngeal orifice, were calculated. The airflow dynamics at the velopharynx were different among different velopharyngeal patterns as the area of the velopharyngeal port increased from 0 to 25 mm Airflow dynamics of the velopharynx were correlated to the velopharyngeal closure patterns. Different closure patterns had different largest permitted orifice areas for getting the appropriate oral pressures for normal speech.

Horner Syndrome from a Pediatric Otolaryngology Perspective

28-09-2019 – Kyra N. Folkert,Heather de Beaufort,Nancy M. Bauman

Journal Article

Horner syndrome is described as the clinical triad of miosis, ptosis, and anhidrosis. In pediatric patients the condition may be congenital or acquired from neoplastic, infectious or traumatic conditions, including birth trauma. Most cases of pediatric Horner syndrome present first to a pediatric ophthalmologist however since the neural pathways involve the cervical sympathetic chain otolaryngologists should understand the pathophysiology to avoid delay in management of potentially malignant cases. To aid otolaryngologists in recognizing and managing pediatric Horner syndrome by describing 3 unique cases from malignant, traumatic and/or congenital causes. Case report of 3 pediatric patients with Horner syndrome presenting to our pediatric otolaryngology department. Case #1 is 5-month-old female with ptosis and a left level II 1.5 cm neck mass. Magnetic resonance imaging showed the mass displacing the common carotid artery and excisional biopsy revealed a poorly differentiated neuroblastoma. Case #2 is a 9-year-old female with anisocoria appearing after suffering a severe playground injury. Case #3 is a 3-year-old-male who developed ptosis and anisocoria following re-excision of a recurrent cervical lymphatic malformation. Pediatric Horner syndrome may be a benign finding that is easily overlooked but may reflect a serious underlying condition. Otolaryngologists should be aware of the pathophysiology and differential diagnosis, including malignant causes, to appropriately manage patients.

Current Opioid Prescribing Patterns after Microdirect Laryngoscopy

27-09-2019 – Molly N. Huston,Rouya Kamizi,Tanya K. Meyer,Albert L. Merati,John Paul Giliberto

Journal Article

The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized. To characterize current opioid-prescribing patterns among otolaryngologists performing MDL. A cross-sectional survey of otolaryngologists at a national laryngology meeting. Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL. In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

Comparing Urban Maxillofacial Trauma Patterns to the National Trauma Data Bank©

27-09-2019 – Jason E. Cohn,Kiara C. Smith,Jordan J. Licata,Alex Michael,Seth Zwillenberg,Tariem Burroughs,Oneida A. Arosarena

Journal Article

We aimed to determine whether certain maxillofacial fracture patterns and injury mechanisms were more prevalent in an urban environment. In addition, we aimed to determine if maxillofacial trauma incidence correlated with income. Data was collected from Einstein Healthcare Network and Temple University Health System. These data were compared to the 2016 National Trauma Data Bank© (NTDB©) using chi-square analysis. Multivariate analysis was used to identify correlations between demographic variables and fracture patterns. Sociodemographic data was further characterized utilizing neighborhood mapping. A total of 252 patients from our urban campuses and 14 447 patients from the NTDB© were identified with facial fractures. Maxillofacial trauma patients in the urban population were more likely to be minorities and less likely to be Caucasian compared to the NTDB© ( Maxillofacial trauma patterns and injury mechanisms were shown to be significantly different in an urban environment as compared to national data.

The Temporoparietal Fascia Flap is an Effective Strategy for Cochlear Implant Wound Coverage

27-09-2019 – Lucas Leonhard,Joseph Roche,Aaron Wieland,G Mark Pyle

Journal Article

To report the rate of major soft tissue complications after cochlear implantation and to describe the use of the temporoparietal fascia (TPF) flap for such complications. Retrospective case series. Tertiary care, University Hospital. Chart review of all patients who underwent cochlear device implantation over a 5-year period to identify patients and to determine the rate of soft tissue complications. Five patients with major soft tissue complications underwent TPF flap with device salvage or explantation/reimplantation. The rate of major skin complications was 6 out of 281 (2.1%) over 5 years, with 5 patients undergoing TPF flap. The average follow-up was 25.8 months (range, 5-58 months). TPF flap represented the definitive, successful solution for all 5 patients. One postoperative hematoma occurred after TPF flap, with no long-term sequelae. The average hospital length of stay was 2.2 nights (range, 1-5 nights). One patient required IV antibiotics for 4 weeks; the remaining patients were treated with a postoperative course of oral antibiotics. The original device remained in place for 4 patients, while one case required device explantation and staged re-implantation. Post-TPF flap hearing results were equal to if not superior to their preoperative results. Major soft tissue complications following cochlear device implantation are rare. The temporoparietal fascia flap is an excellent option for reconstruction of device site soft tissue dehiscences when local wound care and primary closure are not sufficient, and can potentially prevent explantation of a functional implant.

Does Insurance Status Impact Delivery of Care with Upper Airway Stimulation for OSA?

23-09-2019 – Jena Patel,Michael C. Topf,Colin Huntley,Maurits Boon

Journal Article

To understand differences in patient demographics, insurance-related treatment delays, and average waiting times for Medicare and private insurance patients undergoing upper airway stimulation (UAS) for treatment of obstructive sleep apnea (OSA). Retrospective chart review of all Medicare and private insurance patients undergoing upper airway stimulation (UAS) from 2015 to 2018 at a single academic center. Primary outcomes were insurance-related procedure cancellation rate and time from drug induced sleep endoscopy (DISE) and UAS treatment recommendation to UAS surgery in Medicare versus private insurance patients. In our cohort 207 underwent DISE and were recommended treatment with UAS. Forty-four patients with Medicare and 30 patients with private insurance underwent UAS procedure. Patients with Medicare undergoing UAS were older (67.4 ± 11.1 years) than patients with private insurance (54.9 ± 8.1 years). Medicare patients had a shorter mean wait time of 121.9 ± 75.8 days (range, 15-331 days) from the time of UAS treatment recommendation to UAS surgery when compared to patients with private insurance (201.3 ± 102.2 days; range, 33-477 days). Three patients with Medicare (6.4%) and 8 patients with private insurance (21.1%) were ultimately denied UAS. Medicare patients undergoing UAS have shorter waiting periods, fewer insurance-related treatment delays and may experience fewer procedure cancellations when compared to patients with private insurance. The investigational status of UAS by private insurance companies delays care for patients with OSA. 4.

Incidence and Radiological Findings of Incidental Sinus Opacifications in Patients Undergoing Septoplasty or Septorhinoplasty

21-09-2019 – Sung Hee Kim,Jin Seok Oh,Yong Ju Jang

Journal Article

Although the routine use of computed tomography (CT) is controversial, it is employed in the preoperative screening of patients undergoing septoplasty or septorhinoplasty. The aim of this study was to evaluate the incidence and radiological characteristics of incidentally found sinus pathologies on screening CT in patients who underwent elective septoplasty or septorhinoplasty. We retrospectively reviewed the patients who underwent septoplasty and septorhinoplasty performed by a single surgeon (Y.
J.
J.) at Asan Medical Center between January 2016 and December 2017. CT images of 372 patients who had agreed to undergo preoperative CT were reviewed to determine the location and extent of incidental sinus opacifications. Of the 372 patients, 107 (28.8%) showed incidental sinus lesions on CT images. Opacifications were mainly found in the maxillary sinus (73, 68.2%), followed by the ethmoid (34, 31.8%), sphenoid (10, 9.3%), and frontal (3, 2.8%) sinuses. The most common sinus lesion was retention cyst (55, 51.4%), and the second most common one was opacification and mucosal thickening (46, 43%). Other lesions such as osteoma (3, 2.8%), dental cyst (2, 1.9%), and mucocele (1, 0.9%) were rarely found. In patients undergoing septoplasty or septorhinoplasty, the incidence of incidental sinus lesions was approximately 28.8% (107/372). This results indicate that preoperative CT in patients undergoing septoplasty or septorhinoplasty might be helpful to surgeons not only for better understanding the anatomical detail but also for detecting hidden paranasal sinus disease.

Assessment of Tracheostomy and Laryngectomy Knowledge among Non-Otolaryngology Physicians

17-09-2019 – Tsung-yen Hsieh,Leah Timbang,Maggie Kuhn,Hilary Brodie,Lane Squires

Journal Article

Identify knowledge deficits about alternate airways (AAs) (tracheostomy and laryngectomy) among physicians across multiple specialties a tertiary institution and to assess the impact of an educational lecture on improving deficits. : Cross-sectional assessment. Otolaryngology physicians scored an average of 97.8%, while non-otolaryngology physicians scored 58.3% ( The care of patients with AAs requires an understanding of their basic principles. Our findings identify significant knowledge deficits among non-otolaryngologists. Through an instructional lecture, we demonstrated improvement in knowledge among non-otolaryngology physicians and durability of the knowledge after 3 months. Through an instructional lecture, we found tracheostomy and laryngectomy knowledge deficits can be identified and improved upon. Periodic reinforcement of basic principles for non-otolaryngology physicians may be a promising strategy to ensure the proper care of patients with AAs.

Revisit Rates for Pediatric Tonsillectomy: An Analysis of Admit and Discharge Times

17-09-2019 – Sapideh Gilani,Neil Bhattacharyya

Journal Article

To determine the association between intraday timing of outpatient pediatric tonsillectomy and revisit outcomes and complications. Cross-sectional analysis of New York databases. Ambulatory surgery, emergency department and inpatient hospital settings. The State Ambulatory Surgery, State Emergency Department and State Inpatient Databases for 2010-2011 were analyzed for revisits. Outcomes assessed were revisits for any reason, bleeding, acute pain or fever, nausea, vomiting and dehydration. The relationships between the hour of admission for surgery, the hour of discharge and the revisit outcomes were analyzed. The study included 33,611 children (mean age, 6.62 years; 45.7% female) and 62.0% were admitted in the early morning. Discharges were most common in the early afternoon (28.3%). Revisit rates were significantly higher for the early evening discharges (6.0%) versus late morning discharges (3.1%) ( Revisit are significantly higher when the patient is discharged late. Late afternoon surgery is also significantly associated with higher revisit rates. Surgeons may wish to consider these findings when a late tonsillectomy or late discharge is anticipated post-tonsillectomy.

Microlaryngeal Teaching Courses: A National Survey on Prevalence, Value, and Barriers to Implementation

16-09-2019 – Vaninder K. Dhillon,Seth H. Dailey,Lee M. Akst

Journal Article

To assess the prevalence of microlaryngeal teaching course in Accreditation Council for Graduate Medical Education (ACGME)-accredited otolaryngology residency programs in an effort to evaluate the nature, perceived value and barriers to implementation of microlaryngeal courses. A 14-question survey to all ACGME-accredited otolaryngology programs in the United States. Out of 119 ACGME-accredited otolaryngology programs identified on the ACGME Fellowship and Residency Electronic Interactive Database, responses were received from 67 programs (56%). Although 90% of respondents indicated that instruction courses in one discipline or another existed at their institution for their otolaryngology residents, only 33% indicated that their program offers a hands-on instruction course in microlaryngeal surgery. Of those programs that offered a microlaryngeal surgery course, 100% felt the residents appreciated the course; 95% of those programs that did not have a course felt their residents would appreciate a microlaryngeal course at their institution if they were able to offer one. Among programs without a microlaryngeal teaching course, the largest perceived barriers were cost and availability of appropriate equipment. Microlaryngeal courses for otolaryngology residency training are limited in availability in the United States, and there is variability in training across the country. All respondents in our survey indicated the value in these courses for microlaryngeal surgical skill training. There is a clear role for increasing availability of low-cost microlaryngeal stations and courses.

Atypical Laryngeal Infections: Localized Lesions from Unusual Organisms May Simulate Malignancy

14-09-2019 – Kenneth Yan,Jerome B. Taxy,Ajit Paintal,Aaron D. Friedman

Journal Article

The identification of rare sources of laryngeal infection in immunocompetent patients. Recovered organisms were Single institution retrospective case series of three patients over a 2.5-year period and review of the literature on laryngeal infections by three atypical organisms. Three patients presented with hoarseness and cough; one additionally had throat pain (LTB). Indirect laryngoscopy demonstrated diffuse laryngeal ulceration (LTB, LMF) and an exophytic, contiguous glottic mass (LB). Direct microlaryngoscopic biopsies and cultures established the diagnoses, including a frozen section in one case (LB), which prevented a simultaneously planned surgical resection. Appropriate antimicrobial therapy yielded dramatic laryngeal and corresponding vocal improvement, for which we provide unique photo and audio documentation. In the last 10 years, fewer than 500 cases of LTB have been reported in the English language medical literature, principally outside the United States. To date, there have been reports of only 34 LB and no cases of LMF. Atypical infections of the larynx may be localized and mimic laryngeal cancer on endoscopy. Tissue examination as well as microbiologic samples are diagnostic and complementary.

A Practical Mathematic Method to Predict and Manage Hypocalcemia After Parathyroidectomy and Thyroidectomy

12-09-2019 – Changxing Liu,Liyang Tang,Pedram Goel,Tamara Chambers,Niels Kokot,Uttam Sinha,Dennis Maceri

Journal Article

Prediction and early intervention for hypocalcemia following parathyroidectomy and total thyroidectomy can decrease hospital cost and prevent severe hypocalcemia-related complications. This study aims to predict the severity of hypocalcemia after parathyroidectomy or thyroidectomy and to stratify patients into groups with different levels of risk for developing severe hypocalcemia, so that higher risk patients may be monitored more closely and receive earlier interventions. This was a retrospective cohort study of 100 patients with primary hyperparathyroidism who underwent parathyroidectomy as the primary treatment modality at a tertiary care hospital. Clinical information, including demographic information, perioperative PTH and calcium levels, vitamin D levels, weight of the pathologic glands removed, gland pathology, and re-admission rates, were retrieved. Statistical analysis was performed to analyze the association between collected variables and percentage of calcium drop following parathyroidectomy with statistical significant set at Age, sex, and vitamin D level provided very minimal information to quantify risks of postoperative hypocalcemia. The percentage of decrease from preoperative PTH level to the lowest PTH level after the removal of the abnormal gland(s) is the most significant predicting factor for the severity of postoperative hypocalcemia. There is a mathematic regressional correlation between them. A formula was generated to quantify this linear relationship between them, and the nadir calcium can be calculated as The highest preoperative, lowest postoperative, and change in PTH level can help us reliably calculate the trend of postoperative calcium level. Decision to pursue early interventions can be made based on the calculated result from the formula we obtained.

An Anatomic Variant of the Ansa Cervicalis Precluding Its Use as a Donor Nerve

12-09-2019 – Alexander Zhu,Suresh Mohan,Jeremy D. Richmon,Nate Jowett

Journal Article

The ansa cervicalis is useful for cranial nerve repair, and may be harvested without apparent morbidity. Herein we report an unusual and surgically relevant anatomic variant of the ansa cervicalis. An adult male with left parotid adenoid cystic carcinoma underwent parotidectomy with upper-division facial nerve resection and planned interposition repair using the ansa cervicalis. The ipsilateral hypoglossal nerve was identified, together with a descending branch producing strap muscle contraction when stimulated. This presumed Ansa cervicalis harvest was aborted when its separation from vagus nerve epineurium was not possible. The sural nerve was alternatively harvested. The patient awoke with left vocal fold palsy, which completely resolved within 3 months. Anatomic variants of the ansa cervicalis exist that may preclude graft harvest and place the vagus nerve at risk of inadvertent injury.

Repair of the Protruding Lobule

10-09-2019 – Hermann Raunig,Grant S. Hamilton

Journal Article

In this paper, the author describes a novel step-by-step setback procedure for correcting protruding lobules; the success of correcting protruding lobules depends on the nature and severity of the auricular lobule deformity. Although the auricular lobules occupy small areas on either side of the head, protruding or misshapen lobules exert a significant and sometimes exaggerated disfiguring influence on the otherwise aesthetically pleasing appearance of the ears. Because the lobule is a soft structure without a cartilage skeleton, the correction of a protruding ear and lobule is always a challenge. Protruding lobule abnormalities stem from deformities of the cauda helicis (cartilaginous helical tail) of the auricular lobule, soft tissue, and/or a shortage of anterior skin; however, the abnormalities are usually a combination of all of the above. Therefore, surgical procedures should address all of the causes of lobule deformity and preserve as much tissue and blood supply as possible. Achieving a successful intervention depends on reducing the tension that affects the entire lobule. This is a retrospective analysis of 660 patients who had otoplasty performed by the first author between January 2010 and December 2017. Correction of the ear lobule was needed in 398 (60.3%) patients. Of these, 44.6% patients were male, 55.4% female and the average age was 9 years (range 4-18 years). In this patient cohort, 356 (89.4%) required bilateral and 42 (10.5%) unilateral ear lobule correction. Standardized pre- and postoperative images were recorded for each patient. The goal of a setback procedure is a natural and harmonious auricular lobule appearance that is achieved through simple, optimal surgery that addresses all of the features of the auricular anatomy.

How Pediatric Anesthesiologists Manage Children with OSA Undergoing Tonsillectomy

05-09-2019 – Christopher Roberts,Raihanah Al Sayegh,Pavithra Ranganathan Ellison,Khaled Sedeek,Michele M. Carr

Comments on “Nasolacrimal Duct Management During Endoscopic Sinus and Skull Base Surgery”

05-09-2019 – Diego Cazzador,Daniele Borsetto,Enrico Alexandre,Francesca Angela Chiumenti,Alessandro Pusateri,Fabio Pagella,Enzo Emanuelli

Letter to the Editor Regarding “Sublingual Immunotherapy Attenuates Nasal Symptoms upon Allergen Exposure in Murine Allergic Rhinitis Model via an Induction of IL-10 producing T cells in Submandibular Lymph Node”

31-08-2019 – GuanYang Kang

Journal Article

Response to: Comments on “Nasolacrimal Duct Management During Endoscopic Sinus and Skull Base Surgery”

31-08-2019 – Seth M. Lieberman,Janine M. Rotsides,Alexa Franco,Roy R. Casiano

Journal Article

Validation of Animal Models for Simulation Training in Pediatric Laryngotracheal Reconstruction

30-08-2019 – Saleh Okhovat,Thomas D. Milner,William A. Clement,David M. Wynne,Thushitha Kunanandam

Journal Article

To assess and compare the face (FV) and content validity (CV) of three ex vivo animal models for simulation training in pediatric laryngotracheal reconstruction (LTR). Feasibility of performing LTR was assessed on the head and neck of three different animals (lamb/suckling-pig/rabbit) and laryngeal dimensions and qualitative observations were recorded. A 19-item five-point Likert scale questionnaire was completed for each model to assess FV and CV. Data was prospectively collected and analyzed using descriptive and nonparametric statistics. All three models were suitable for LTR simulation with laryngeal dimensions corresponding to 0-2 years (rabbit), 5-10 (pig) and >10 years (lamb model). Five trainees and five expert pediatric otolaryngologists performed LTR on each model. The overall median FV score was 5 for the lamb model (IQR 4-5), 3 for the rabbit (IQR 2-3), and 4 for the pig (IQR 4-4). The overall median CV score was 5 for the lamb (IQR 5-5), 2 for the rabbit (IQR 2-3), and 4 for the pig model (IQR 4-4). Comparison of the models demonstrated the lamb to be favored as the most realistic and practical model for simulation training in pediatric LTR, with both the lamb and the porcine model attaining validation thresholds. Our study is the first comparative validation assessment of animal models for use in pediatric LTR simulation and it supports the use of ex vivo lamb and porcine models for use in LTR surgical skills training. The lamb model was the favored simulation model while the rabbit was considered inferior for simulation training in pediatric LTR. 3b.

Affordable Rapid Olfaction Measurement Array: A Novel, Essential Oil-Based Test Strongly Correlated with UPSIT and Subjective Outcome Measures

16-08-2019 – Jennifer A. Villwock,Jennifer Li,Chelsea Moore,Alexander G. Chiu,Kevin J. Sykes

Journal Article

Olfactory dysfunction is an important facet of numerous disease states ranging from sinonasal disease to neurocognitive disorders. Due to expense and/or logistical barriers, objective olfactory testing is not common. We describe the creation of a novel, essential oil-based smell test, AROMA was developed for point-of-care olfactory testing and compared to the UPSIT, as well as subjective outcome measures as noted above. About 37 healthy controls were prospectively recruited to assess the reliability of AROMA using a test-retest protocol. An additional cohort of 38 participants with sinonasal disease were prospectively recruited to complete the AROMA and UPSIT, and were compared with a cohort of 30 healthy controls. Spearman correlation correlated AROMA and UPSIT results, patient age, SNOT-22, and perceived loss of smell. AROMA demonstrated good test-retest reliability ( AROMA has a strong correlation with UPSIT and may be more strongly correlated with sinonasal outcomes. Additionally, AROMA is reusable; level of odorant is not static; and AROMA can test both odor detection and identification. 2b.

Rhinotillexomania Manifesting as Empty Nose Syndrome

16-08-2019 – Eve Tranchito,Nipun Chhabra

Journal Article

To highlight a severe case of rhinotillexomania (compulsive nasal picking) and its potential to manifest as empty nose syndrome (ENS). A single case report with the presentation and management of a patient with severe rhinotillexomania who presented with chronic obstructive symptoms. We review the current literature on rhinotillexomania and ENS. This patient’s manifestations mimic the obstructive symptoms of ENS, despite widely patent nasal passages. This is the first report of rhinotillexomania manifesting with features of ENS.

Morphometric Differences in the Recurrent Laryngeal Nerve in Patients with Vocal Fold Paralysis

14-08-2019 – Melissa R. Chao,Katherine A. Howe,Jennifer L. Pierce,Amanda C. Stark,Marshall E. Smith,Michael B. Christensen

Journal Article

Injury to the recurrent laryngeal nerve (RLN), if severe enough, can result in vocal fold paralysis. Reinnervation surgery can improve patient outcomes, but previous studies have reported a negative correlation between time since onset of paralysis and surgical outcomes. The ability of the paralyzed nerve to serve as a conduit for donor nerve fibers may be a factor in the success of reinnervation; however, changes in RLN composition after paralysis have not been well studied. Therefore, we investigated the morphometric composition of explanted RLN sections from patients who had experienced vocal fold paralysis for varying length of times. Nine nerve sections from unilateral vocal fold paralysis (UVP) patients and seven control nerve sections were analyzed for morphometric parameters including fascicular area, fiber count, fiber density, fiber packing, mean g-ratio, and fiber diameter distribution. Nerves from UVP patients were also compared as a function of time since UVP onset. In comparison to control nerves, paralyzed nerves were found to have significantly lower fiber densities and fiber packing, higher mean g-ratio values, and a shift in diameter distributions toward smaller diameter fibers. With respect to paralysis duration, no significant differences were observed except in fiber diameter distributions, where those with paralysis for >2 years had distributions that were significantly shifted toward smaller diameter fibers. The morphometric data presented here suggest that correlations between the time since onset of vocal fold paralysis and reinnervation outcomes may be due to fiber size changes in the paralyzed nerve over time.

Attitudes of Clinicians about Screening Head and Neck Cancer Survivors for Lung Cancer Using Low-Dose Computed Tomography

14-08-2019 – Kimberly Dukes,Aaron T. Seaman,Richard M. Hoffman,Alan J. Christensen,Nicholas Kendell,Andrew L. Sussman,Miriam Vélez-Bermúdez,Robert J. Volk,Nitin A. Pagedar

Journal Article

National guidelines recommend lung cancer screening (LCS) using low-dose computed tomography (LDCT) for high-risk patients, including survivors of other tobacco-related cancers like head and neck cancer (HNC). This qualitative study investigated clinicians’ practices and attitudes toward LCS with LDCT with patients who have survived HNC, in the context of mandated requirements for shared decision making (SDM) using decision aids. Thematic analysis of transcribed semi-structured clinician interviews and focus group. Clinicians recognized LCS’ utility for some HNC survivors with smoking histories. However, they identified many challenges to SDM in diverse clinic settings, including time, workflow, uncertainty about guidelines and reimbursement, decision aids, competing patient priorities, unclear evidence, potentially heightened patient receptivity and stress, and the complexity of discussions. They also identified challenges to LCS implementation. While clinicians feel that LDCT LCS may benefit some HNC survivors, there are barriers both to implementing LCS SDM for these patients in primary care as currently recommended and to integrating it into cancer clinics. Challenges for SDM across settings include a lack of decision aids tailored to patients with cancer histories. Given recommendations to broaden LCS eligibility criteria, more research may be required before refinement of current guidelines.

Causative Factors for Complications in Transpalatal Advancement

14-08-2019 – Lyndon Chan,Leon Kitpornchai,Stuart Mackay

Journal Article

Transpalatal advancement (TPA) is a procedure that is used when modern variants of uvulopharyn-gopalatoplasty are unable to provide enough anterior traction. Although successful in reduction of obstructive sleep apnea (OSA) parameters, it also comes with procedure-specific risks. Formation of an oro-nasal fistula (ONF) is a complication that results in significant morbidity and a protracted treatment course. After approval from the University of Wollongong Health Research Ethics Committee, a retrospective chart review of all cases undergoing TPA performed by a single surgeon over a 10-year period from 2008 to 2018 was performed. Patients underwent pre- and postoperative level 1 or 2 polysomnography. Factors potentially contributing to palatal complications, as well as pre- and postoperative polysomnographic parameters, subjective sleep questionnaires, and body mass index (BMI) were statistically analyzed where a A total of 59 patients were included. Overall palatal complication rate was 25.4% (15/59), with the most common being transient velo-palatal insufficiency (VPI) (8/59, 13.6%). ONF developed in 4/59 (6.8%) of patients. None of the analyzed contributing factors for palatal complications were statistically significant, except the presence of a high-arched palate and development of ONF. All analyzed sleep parameters, as well as BMI, were significantly different when comparing pre- to postoperative results. This study suggests that TPA has a role in current sleep surgery paradigms and can significantly improve both objective and subjective outcome measures of OSA. Surgeons contemplating TPA on patients with high-arched hard palates should do so with caution.

Validation of the Maxillary Sinus Roof as a Landmark for Navigating the Pediatric Skull Base

09-08-2019 – Sean S. Evans,Catherine Banks,Joshua Richman,Audie Woolley,Do Yeon Cho,Bradford Woodworth

Journal Article

To define a new anatomic relationship in pediatric sinus surgery, assessing the maxillary roof as a constant safe landmark to avoid skull base injury in the pediatric population. Retrospective analysis. Tertiary care children hospital. A retrospective analysis was performed of all computed tomography scans of the sinuses and facial bones at the emergency department of a tertiary children’s hospital over the course of a year. Radiographic measurements included the lowest cribriform plate and planum sphenoidale (PS) heights, or posterior skull base when not yet pneumatized, as well as the highest maxillary roof height. The nasal floor was used for reference. Statistics were performed via Shapiro-Wilks test with a Three hundred and seven unique scans were reviewed (38.9% female; n = 122; Despite variation in sinus growth and development in children, the current study demonstrated the validity of the maxillary sinus roof as a constant safe landmark in the pediatric population, offering a novel anatomic relationship for teaching safety in performing pediatric sinus surgery. 4.

Intranasal Septal Splints: Prophylactic Antibiotics and Nasal Microbiology

08-08-2019 – Amit Ritter,Uri Alkan,Dafna Yahav,Ethan Soudry,Ella Reifen

Journal Article

Intranasal septal splints are often used in nasal septal surgeries. Routine use of postoperative antibiotics is an accepted practice, although data regarding its efficacy in preventing postsurgical complications are limited. This study aimed to examine bacterial colonization on septal splints following prophylactic antibiotic therapy and the association with postoperative infections. Fifty-five patients underwent septoplasty by a single surgeon between March 2015 and April 2016. All had intranasal septal splints and were given antibiotic prophylaxis for 7 days until removal of splints. Nasal cultures were taken before surgery, and septal splints were examined for bacterial colonization following their removal. Thirty-six patients (65%) had positive nasal culture prior to surgery. The most common isolates were Increased bacterial growth and emergence of resistant strains were observed on intranasal septal splints despite prophylactic antibiotic treatment. Nonetheless, this did not translate into clinical infection. Thus, considering antibiotics overuse and increasing bacterial resistance, further research is needed to determine the role of antibiotic prophylaxis in the setting of intranasal splints.

Caudal Septal Division and Interposition Batten Graft: A Novel Technique to Correct Caudal Septal Deviation in Septoplasty

07-08-2019 – Shin Ae Kim,Yong Ju Jang

Journal Article

Correction of caudal septal deviation is a challenging task that may require multiple surgical approaches. To introduce a novel technique – caudal septal division and interposition batten graft – and evaluate its surgical outcomes in patients undergoing correction of caudal septal deviation. The surgical procedure includes a division of the deviated caudal L-strut preserved after resection of the deviated quadrangular septal cartilage at the central portion. A batten graft made of septal cartilage or bone is interposed between the cut ends of the caudal L-strut, the upper part of which mobilized toward the more concave side of the nasal cavity, and then sutured. The medical records of 29 patients with caudal septal deviation who underwent septoplasty using caudal L-strut division and interposition batten graft technique between January 2016 and March 2018 were retrospectively reviewed. Patient satisfaction and symptom improvement were evaluated by using the Nasal Obstruction Symptoms Evaluation scores. Endoscopic assessment of deviation correction was performed and postoperative complications were analyzed. Of the 29 patients, 19 (65.5%) answered the telephonic interview. Mean Nasal Obstruction Symptoms Evaluation scores were 62.1 preoperatively and 9.2 postoperatively, exhibiting significant improvement ( Caudal septal division and interposition batten graft can serve as an alternative surgical approach with acceptable surgical outcomes for managing severely deviated caudal septum. 4.

Clinical Analysis of Pediatric Thyroid Cancer: A Single Medical Institution Experience of 18u2009Years

03-08-2019 – Hyung Kwon Byeon,Sang Bin Kim,Hyeon Seok Oh,Hong Kyu Kim,In Hak Choi,Hyunjung Kim,Jae-Gu Cho,Kyung Ho Oh,Seung-Kuk Baek,Jeong-Soo Woo,Soon-Young Kwon,Hoon Yub Kim,Kwang Yoon Jung

Journal Article

The incidence of pediatric thyroid cancer is relatively low compared to the disease in adults. This study aims to present the data in our institution on pediatric thyroid cancer patients, with particular emphasis on the risk factors of recurrence together with treatment outcomes. Between January 2000 and July 2018, patients 1 cm showed higher rate of lymph node metastasis and extrathyroidal extension than tumors ≤1 cm. All patients survived with nine PTC patients who displayed treatment failure. Age, tumor size, multifocality, lateral lymph node metastasis, and postoperative thyroglobulin levels were significant prognosticators for disease recurrence. Pediatric thyroid cancer is relatively rare and should be considered a specific disease entity with respect to the thyroid cancer in adults, since there are several distinctive characteristics.

Cochlear-Vestibular Impairment due to West Nile Virus Infection

01-08-2019 – Daniela Parrino,Giuseppe Brescia,Maria Vittoria Trimarchi,Giulia Tealdo,Lolita Sasset,Anna Maria Cattelan,Roberto Bovo,Gino Marioni

Journal Article

West Nile virus (WNV) has been spreading over the last 20 years. Human infection is asymptomatic in most cases. When the disease becomes clinically manifest, it may involve a range of issues, from a mild infection with flu-like symptoms to a neuroinvasive disease. Albeit rarely, WNV-associated sensorineural hearing loss (SNHL) has also been reported. Here we describe two new cases of SNHL and balance impairment caused by WNV infection. The patients were investigated with repeated audiometric tests and, for the first time, videonystagmography was also used. Unlike findings in the few other published cases, an improvement in audiometric thresholds and vestibular function was documented in both of our patients. In the light of our findings, a prospective study would be warranted on a large series of patients with WNV infection in order: (i) to better define the epidemiology of the related cochlear-vestibular involvement; and (ii) to elucidate the virus-related changes to peripheral and central auditory and vestibular functions.

Blast-Induced Cholesteatomas After Spontaneous Tympanic Membrane Healing

01-08-2019 – Omer J. Ungar,Shahaf Shilo,Wengier Anat,Oren Cavel,Ophir Handzel,Yahav Oron

Journal Article

To characterize blast-induced cholesteatomas (BIC) in terms of symptoms, presentation, and location within the middle ear cleft (MEC). A search for all English language articles in “MEDLINE” via “PubMed” and “Google Scholar” was conducted. A total of 67 ears with BIC were included. Fifty-eight ears in which the traumatic perforation failed to spontaneously close were excluded, leaving seven case reports (eight patients, nine ears) for statistical analysis. Time between blast exposure to spontaneous tympanic membrane (TM) closure was 16 days to 10 months. Time between blast exposure and cholesteatoma diagnosis was 5 months to 4 years. The cholesteatomas were diagnosed due to symptoms in two ears, as asymptomatic finding on physical examination in one ear and as asymptomatic finding in axial imaging in three ears. BICs can develop behind intact tympanic membrane or along with TM perforation. Based on the current review, when a TM perforation and spontaneous healing were documented, after blast exposure, MRI scan is an integral component of the follow-up. The optimal timing for MRI performance after blast exposure, is yet to be identified.

Open Airway Surgery in a Paraplegic: The Importance of an Adequate Cough

31-07-2019 – Shaunak N. Amin,Jennifer P. Rodney,Alexander Gelbard

Journal Article

To describe a case of open airway surgery with postoperative respiratory complications in a paraplegic woman and to review the unique respiratory physiology seen in patients with a history of cervical or thoracic spinal cord injury (SCI). Case report and literature review. We describe the case of a 25-year-old paraplegic who developed tracheal stenosis after tracheotomy, eventually requiring tracheal resection and re-anastomosis. Her postoperative course was complicated by mucus plugging and severe atelectasis, necessitating reintubation. After extubation, the patient reported difficulty expectorating secretions ever since her SCI, requiring manual abdominal pressure from her family members to assist her when she needed to cough. This first report of cricotracheal resection in a patient with paraplegia following SCI highlights the importance of an

Clinical Approach After Complicated Ear Mold Fitting: A Case Series of Six Patients and Evaluation of Literature

31-07-2019 – Cindy van den Boer,Erik van Spronsen,Carlijn T. Q. Holland,Fenna A. Ebbens,Jérôme J. Waterval

Journal Article

Insertion of mold material into the middle ear is a complication of molding procedure for ear impression. These cases are referred to an ENT specialist. There is no standardized approach to this problem. Literature shows different clinical strategies. The aim of this study is to share our experience and to analyze the adverse outcome of different clinical approaches. A case series of six patients with molding material inside the middle ear after complicated molding procedure for swimming earplugs are described. Additionally, available literature was reviewed to analyze results of the clinical approach after iatrogenic molding procedures. Forty-nine ears were included. In-office removal of the material is associated with a significant risk of adverse outcome if the eardrum cannot be examined. This also accounts for ossicular involvement. Temporal bone CT is advised in patients after complicated ear mold fitting if the tympanic membrane cannot be examined completely or the middle ear is involved. Blind removal should be avoided. Retroauricular transcanal tympanotomy or transmastoidal tympanotomy with facial recess approach is best practice in case the mold material has entered the middle ear. A clinical treatment algorithm is presented.

Anterior Skull Base Reconstruction following Ablative Surgery for Osteoradionecrosis: Case Report and Review of Literature

27-07-2019 – Katya Chapchay,Jeffrey Weinberger,Ron Eliashar,Neta Adler

Journal Article

Osteoradionecrosis is one of many potentially severe complications of radiotherapy for nasopharyngeal carcinoma. Osteoradionecrosis of the skull base is life-threatening due to the critical proximity of the pathological process to vital structures, for example, the intracranial cavity, the upper spine, and major blood vessels. Reconstructive options following surgical debridement of the anterior skull base and upper spine osteonecrosis have been scarcely described in the literature. We present a rare case of osteoradionecrosis of the clivus and cervical vertebrae C1-C2 in a patient previously treated with chemoradiotherapy for nasopharyngeal carcinoma, presenting as severe soft tissue infection of the neck. Aggressive surgical debridement and reconstruction with a two-paddle free anterolateral thigh flap was performed using a combination of transcervical and transnasal endoscopic approaches. A novel endoscopic procedure in the sphenoid sinus enabled flap anchoring in this complex area. Surgical modalities for osteoradionecrosis of the skull base and upper spine are discussed and review of the literature is presented. Reconstruction of the anterior skull base with a well-vascularized free flap following ablative surgery should be considered in management of life-threatening osteoradionecrosis of the area. Endoscopic opening of the sphenoid sinus and creating a funnel-shaped stem is a newly described technique that guarantees precise placement of the flap and is a valuable adjunct to the reconstructive armamentarium.

Acellular Dermal Matrix Mistaken as Recurrence of Malignancy Following Surgery on Positron Emission Tomography/Computed Tomography: A Case Report

27-07-2019 – Seokhwan Lee,Soo-Keun Kong,Seong Hwan Bae,Kyoungjune Pak,Se-Joon Oh

Journal Article

To report a rare clinical presentation of an acellular dermal matrix (ADM) used during lateral temporal bone resection mimicking recurrence of cancer of external auditory canal (EAC) on positron emission tomography/computed tomography (PET/CT) 9 months after surgery. Case report and literature review. A 71-year-old woman underwent lateral temporal bone resection 9 months earlier for management of squamous cell carcinoma of the EAC. She exhibited recurrence of the tumor on Care should be taken when using an ADM during malignant tumor surgery if the site of surgery is not conducive for fine needle aspiration or biopsy.

Ectopic Thymus: An Unusual Case of Subglottic Mass

19-07-2019 – Irene Paraboschi,Federica Fati,Francesca Rizzo,Oliviero Sacco,Nicola Stagnaro,Girolamo Mattioli,Alessandro Simonini,Oscar Mazzei,Michele Torre

Journal Article

The aim of our study is to report a case of a child with subglottic thymus that was suspected during diagnostic work-up for severe airway obstruction, excised surgically and confirmed with final histopathological examination. Moreover, we performed a narrative literature review to outline clinical and diagnostic features of this rare condition and to report suggestions for the management of subglottic masses. We report the case of a 7-month-old boy who was admitted to our Pediatric Airway Team Unit due to a history of worsening biphasic stridor and recurrent episodes of upper airway obstruction. The successful diagnostic work-up and a narrative literature of analogous cases of subglottic thymus were reported. Ectopic thymus is a very rare condition in which thymic tissue is found outside the normal pathway of its embryonic migration. It usually presents as a cystic or, more rarely, solid mass, showing an indolent course toward spontaneous involution. In some cases, however, it becomes symptomatic exerting compression on surrounding vital structures. Due to its rarity, the initial diagnosis is normally mistaken with inflammatory diseases or malignancies and the definitive diagnosis is only achieved after histological examination of the excised specimen. To our knowledge, only four other cases of subglottic ectopic thymic tissue have been reported in the English literature so far and the diagnosis has never been suspected preoperatively. It is mandatory to consider ectopic thymic tissue in the differential diagnosis in children presenting with airways obstruction in order to prevent unnecessary, extensive, and exploratory surgery.

Unsupervised Learning Techniques for the Investigation of Chronic Rhinosinusitis

19-07-2019 – Abigail Walker,Pavol Surda

Journal Article

This article reviews the principles of unsupervised learning, a novel technique which has increasingly been reported as a tool for the investigation of chronic rhinosinusitis (CRS). It represents a paradigm shift from the traditional approach to investigating CRS based upon the clinically recognized phenotypes of “with polyps” and “without polyps” and instead relies upon the application of complex mathematical models to derive subgroups which can then be further examined. This review article reports on the principles which underlie this investigative technique and some of the published examples in CRS. This review summarizes the different types of unsupervised learning techniques which have been described and briefly expounds upon their useful applications. A literature review of studies which have unsupervised learning is then presented to provide a practical guide to its uses and some of the new directions of investigations suggested by their findings. The commonest unsupervised learning technique applied to rhinology research is cluster analysis, which can be further subdivided into hierarchical and non-hierarchical approaches. The mathematical principles which underpin these approaches are explained within this article. Studies which have used these techniques can be broadly divided into those which have used clinical data only and that which includes biomarkers. Studies which include biomarkers adhere closely to the established canon of CRS disease phenotypes, while those that use clinical data may diverge from the typical “polyp versus non-polyp” phenotypes and reflect subgroups of patients who share common symptom modifiers. Artificial intelligence is increasingly influential in health care research and machine learning techniques have been reported in the investigation of CRS, promising several interesting new avenues for research. However, when critically appraising studies which use this technique, the reader needs to be

The Effects of Endoscopic Sinus Surgery on Voice Characteristics in Chronic Rhinosinusitis Patients

18-07-2019 – Danny B. Jandali,Ashwin Ganti,Inna A. Husain,Pete S. Batra,Bobby A. Tajudeen

Journal Article

Functional endoscopic sinus surgery (FESS) is a standard treatment modality for patients with chronic rhinosinusitis (CRS) who have failed appropriate medical therapy. However, FESS entails modification of the upper airway tract that may alter phonatory resonance and produce voice changes. The effects of FESS on postoperative voice characteristics in patients with CRS have yet to be quantitatively assessed. Patients with severe CRS who underwent FESS at a tertiary care referral center between May and October 2017 were prospectively enrolled. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and the Voice Handicap Index (VHI) were used to quantitatively evaluate voice characteristics and quality of life, respectively. Preoperative and postoperative CAPE-V and VHI scores were compared with postoperative scores for each patient. Sino-Nasal Outcome Test (SNOT-22) scores were also obtained to assess changes in patient symptoms. 18 CRS patients undergoing FESS were enrolled. The average preoperative Lund-Mackay score was 14, indicating baseline severe CRS. Postoperative assessments demonstrated a statistically significant decrease in CAPE-V (45-27, Patients with CRS experience a significant improvement in voice characteristics and vocal quality of life following FESS. Furthermore, this appears to correlate with a significant decrease in self-reported disease severity. These findings may augment the discussion of potential benefits of FESS to a new potential domain for voice quality.

Transoral Tubed Supraglottoplasty: A New Minimally Invasive Procedure for Aspiration

17-07-2019 – Yue Ma,Matthew R. Naunheim,Jill Gregory,Peak Woo

Journal Article

We describe a new procedure for aspiration called tubed supraglottoplasty (TS). TS is a transoral procedure that approximates the aryepiglottic (AE) folds and arytenoids. This narrows the laryngeal inlet. This procedure has been used to improve swallowing and reduce aspiration in patients with vocal fold paralysis. We describe the technical aspects of TS and report on 11 patients. TS is done by oral intubation followed by suspension laryngoscopy. An incision is made along the AE fold into the posterior commissure and then continued to the opposite AE fold. Dissection within this incision creates two mucosal flaps, one based on the laryngeal surface and the other on the pharyngeal surface. Two 1-cm releasing incisions are made at each end of the AE fold. The laryngeal mucosal flap is approximated using a 3-0 self-locking running suture. The pharyngeal mucosal flap is approximated as a second layer. This double-layered mucosal V-Y advancement flap builds up the posterior laryngeal height. It narrows and “tubes” the supraglottis. All patients tolerated TS without airway complications. Ten of the 11 patients reported improved swallowing function with less aspiration. Six of the 8 patients with prior G-tubes had their gastrostomy tube removed. Postoperative laryngoscopy showed a narrowed “tubed” supraglottis with a higher posterior wall preventing spillover and aspiration. An improved Functional Oral Intake Scale was recorded in ten of eleven patients. TS is a minimally invasive procedure that can improve swallowing and reduce aspiration.

Investigation of Novel Grafts in Use for Pediatric Tympanoplasty

13-07-2019 – Christine Barron,Jordan Lukens,Weston Niermeyer,Amanda Onwuka,Tendy Chiang,Charles Elmaraghy

Journal Article

To evaluate the impact of allograft and xenograft in pediatric tympanoplasty on patient outcomes. A retrospective cohort study of 50 pediatric patients undergoing tympanoplasty at a single tertiary pediatric hospital system that received either autograft, allograft, or xenograft. Patients were evaluated for persistent perforation, recurrent perforation, revision surgery, and postoperative infection. Hearing outcomes, operative charges, and operative time were also evaluated. Statistical analyses included chi-square and Fisher exact tests for categorical data and Wilcoxon-Mann-Whitney tests for continuous data. Half of the cohort received autografts, whereas 38% received xenografts and 14% received allografts. Although there was not a significant difference in charges associated with these procedures, xenografts had the shortest mean operative time (mean: 39 vs 68 minutes in autografts, Similar rates of complications were observed among autografts, xenografts, and allografts, providing preliminary evidence that they are safe to use in pediatric tympanoplasty.

Detection of Microbiota in Post Radiation Sinusitis

13-07-2019 – Timothy J. Stoddard,Varun V. Varadarajan,Peter T. Dziegielewski,Brian J. Boyce,Jeb M. Justice

Journal Article

A shift in the microbiota of chronic rhinosinusitis has been described after radiotherapy to the sinonasal cavity and skull base. There is a paucity of literature characterizing the bacteriology of post radiation sinusitis using next-generation gene sequencing techniques. This study aims to describe and compare the microbial flora of rhinosinusitis after radiotherapy using both culture and molecular techniques for microbial DNA detection. The medical records of patients treated with external beam radiation for sinonasal, nasopharyngeal, or skull base malignancy were reviewed at a tertiary care facility. Patients’ sinonasal cavities were swabbed for routine culture or brushed for molecular gene sequencing. Swab specimens were processed for standard microbial culture, and brush specimens were sent for gene sequencing at Micro Gen
X Laboratory (Lubbock, Texas, USA). Twenty-two patients were diagnosed with chronic sinusitis after undergoing radiotherapy. The bacteriology of post radiation sinusitis appears to resemble the microorganisms responsible for chronic sinusitis in healthy adults. Next generation gene sequencing techniques may reveal additional organisms responsible for sinusitis and provide complementary results that may impact the medical treatment of post radiation sinusitis.

Quality of Voice and Prognostic Markers for the Recovery of Vocal Fold Paralysis After Thyroid Surgery

12-07-2019 – Rudolf Reiter,Adrienne Heyduck,Thomas Karl Hoffmann,Sibylle Brosch,Maria Anna Buchberger,Katharina Schorer,Theresa Weber,Anja Pickhard

Journal Article

This study is set to analyze clinicopathological factors predicting the recovery of unilateral vocal fold paralysis (UVP) in patients after thyroid gland surgery. The quality of voice was additionally assessed in these patients. The charts and videolaryngostroboscopy (VLS) examinations of 84 consecutive patients with a complete UVP after surgery of the thyroid gland were retrospectively reviewed. Patients were divided into 2 groups: patients who fully recovered from vocal fold paralysis and those who failed to recover after a follow-up of 12 months. The quality of voice was analyzed among other things by determining the Voice Handicap Index (VHI). The UVP fully recovered in 52 of 84 (61.9%) patients. Positive mucosal waves (p
MWs) on the paralyzed side, a minimal glottic gap <3 mm seen at the first postoperative VLS, age ≤50 years, and surgery duration ≤120 minutes were associated factors for a complete recovery of nerve function. The voice parameters improved independently from recovery of the paralysis in 90% of the patients. For patients with a poor prognosis of a UVP, early intervention may be beneficial. Thus, predicting factors for a full recovery of vocal fold motion would be a valuable tool. In our cohort, about 60% of recoveries could have been predicted using the above-mentioned parameters. Good quality of voice was independently reached in 90% of the cases.

Submental Island Flap: A Technical Update

11-07-2019 – Joseph Zenga,Kevin S. Emerick,Daniel G. Deschler

Journal Article

In recent years, the submental island flap has demonstrated decreased cost and morbidity as compared with free tissue transfer and has been widely applied to a range of head and neck defects. Several studies, however, continue to report a high rate of submental flap complications including partial necrosis and venous congestion. The object of this report is to describe a technical modification to the submental flap harvest which increases efficiency and reliability. Single institutional case series with chart review. The essential technical details and technique modifications of the submental flap harvest are described, and a case example is discussed. Between January 2018 through January 2019, 24 submental island flaps were performed. All flaps included the mylohyoid muscle which was delineated with manual blunt dissection. Reconstructive indications included oral cavity and oropharyngeal wounds as well as facial cutaneous and lateral skullbase defects. There were no flap-related complications. Manual blunt dissection of the mylohyoid muscle and its inclusion in the submental island flap increases efficiency and reliability.

Outcomes Using a Postoperative Protocol in Pediatric Single-Stage Laryngotracheal Reconstruction

15-02-2019 – Prasad John Thottam,Taylor Gilliland,Nicholas Ettinger,Rahul Baijal,Deepak Mehta

Journal Article

The aim of this study was to evaluate single-stage laryngotracheal reconstruction (ss
LTR) outcomes before and after the implementation of a postoperative care protocol in pediatric patients. A case-control study with chart review was conducted at 2 tertiary academic centers from 2010 to 2016. Pediatric patients who underwent ss
LTR with a postoperative care protocol were compared with those who did not receive care under this protocol. Data regarding perioperative management were collected and compared using χ Nineteen patients completed ss
LTR after the protocol was initiated, and 26 prior patients were used as control subjects. Planned extubation failed in 9 patients (35%) in the control group compared with 1 patient (5%) in the protocol group ( P < .05). Using a structured protocol demonstrated a decrease in delayed extubation and intensive care unit stay ( P < .05). Despite more postprotocol patients' requiring posterior graft placement, preprotocol patients were less likely to be extubated within 7 days ( P < .05). The authors propose an intensive care unit protocol that uses a combination of pharmacologic agents to optimally reduce the risk for adverse events that delay time to extubation and thus decannulation. Timely extubation was more likely with the use of this postoperative care protocol using a multidisciplinary approach involving otolaryngologists, pharmacists, intensivists, and anesthesiologists.