Peer Reviewers—Making the Annals What It Is
08-11-2019 – Richard J. Smith
Thanks to Reviewers – 2018
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
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.
Investigation of Novel Grafts in Use for Pediatric Tympanoplasty
13-07-2019 – Christine Barron,Jordan Lukens,Weston Niermeyer,Amanda Onwuka,Tendy Chiang,Charles Elmaraghy
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
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.
Transoral Tubed Supraglottoplasty: A New Minimally Invasive Procedure for Aspiration
17-07-2019 – Yue Ma,Matthew R. Naunheim,Jill Gregory,Peak Woo
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.
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
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.
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
Case Reports, Journal Article, Review
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.
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
Case Reports, Journal Article, Review
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.
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, Review
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.
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
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.
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
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.
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
Case Reports, 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.
Unsupervised Learning Techniques for the Investigation of Chronic Rhinosinusitis
19-07-2019 – Abigail Walker,Pavol Surda
Journal Article, Review
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
Submental Island Flap: A Technical Update
11-07-2019 – Joseph Zenga,Kevin S. Emerick,Daniel G. Deschler
Case Reports, 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.
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
Case Reports, 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.
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
Case Reports, Journal Article, Review
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.
Open Airway Surgery in a Paraplegic: The Importance of an Adequate Cough
31-07-2019 – Shaunak N. Amin,Jennifer P. Rodney,Alexander Gelbard
Case Reports, Journal Article, Review
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
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
Case Reports, 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.
Efficacy of Multi-Modal Migraine Prophylaxis Therapy on Hyperacusis Patients
02-12-2019 – Mehdi Abouzari,Donald Tan,Brooke Sarna,Yaser Ghavami,Khodayar Goshtasbi,Erica M. Parker,Harrison W. Lin,Hamid R. Djalilian
Vagus Associated Neurogenic Cough Occurring Due to Unilateral Vascular Encroachment of Its Root: A Case Report and Proof of Concept of VANCOUVER Syndrome
02-12-2019 – Christopher R. Honey,Marie T. Krüger,Murray D. Morrison,Baljinder S. Dhaliwal,Amanda Hu
The Usefulness of Respiratory Mechanic Instability in Evaluating the Effect of Continuous Positive Airway Pressure for Obstructive Sleep Apnea
29-11-2019 – Ji Ho Choi,Jae Yeup Jung,Ji Eun Moon,Se-Hwan Hwang
Respiratory mechanics instability (RMI) based on paradoxical movement is correlated with respiratory disturbance such as apnea-hypopnea index (AHI) and reflects the severity of obstructive sleep apnea (OSA). The purpose of this study was to identify RMI as a method for assessing the effectiveness of continuous positive airway pressure (CPAP) in the management for OSA. A total of 71 consecutive OSA patients with CPAP titration were included in this study. We compared sleep (sleep efficiency, arousal index, and sleep stages), respiratory (AHI, oxygen desaturation index ≥3% [ODI3], and lowest oxygen saturation), and RMI parameters (events, index, duration, and % of stage duration) between diagnostic polysomnography and CPAP titration data. All RMI parameters (events [157.5 ± 80.9 vs 80.0 ± 47.1; RMI may be a useful method for evaluating the effect of CPAP in OSA patients.
Experience with Minimally Invasive Ponto Surgery and Linear Incision Approach for Pediatric and Adult Bone Anchored Hearing Implants
27-11-2019 – Aren Bezdjian,Rachel Ann Smith,Nathalie Gabra,Luhe Yang,Marco Bianchi,Sam J. Daniel
To compare intra- and postoperative outcomes between the standard linear incision with tissue preservation and the Minimally Invasive Ponto Surgery (MIPS). A non-randomized retrospective cohort series. Medical files were reviewed of adult and pediatric bone anchored hearing implant recipients. Extracted outcomes included patient characteristics, implant survival, operative time, anesthesia use, intra and postoperative complications, soft tissue tolerability assessed by the Holger’s classification, and implant stability assessed by the Resonance Frequency Analysis (RFA). Outcomes were compared between two surgeries. A total of 59 implants were placed (21 MIPS; 38 linear). Conductive hearing loss was the most common etiology for implantation. Surgery was conducted under local anesthesia in 67% of MIPS patients and 16% of linear patients. No intraoperative complications were reported for both surgical approaches and no implants were lost. Patients undergoing implantation via the MIPS approach displayed less skin reaction postoperatively, however this was not significant ( The MIPS approach seems either similar or superior to the linear approach in all perioperative outcomes evaluated. Outcomes such as surgical duration, anesthesia choice and implant stability measurements support implantation through the MIPS approach for patients meeting eligibility criteria.
Functional and Aesthetic Outcomes of Extracorporeal Septoplasty: A Systematic Review and Meta-Analyses
25-11-2019 – Amishav Bresler,Roman Povolotskiy,Brandon Nguyen,Giancarlo F. Zuliani,Jean Anderson Eloy,Boris Paskhover,Peter Svider
The safety and efficacy of extracorporeal septoplasty (ECS) has long been debated. Our objective was to determine this technique’s functional and aesthetic outcomes and complications through a systematic review of the literature. PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science databases were evaluated for studies detailing functional or aesthetic outcomes of ECS. Bias was evaluated using the Cochrane Risk of Bias Tool and the Methodological Index for Non-randomized Studies (MINORS) score. Aesthetic and functional outcomes in addition to complications were evaluated using subjective and objective measures. Meta-analyses were performed when appropriate. Seventeen studies encompassing 1418 patients were included. The average MINORS score for observational studies was 9.2. Overall there was a significant improvement in subjective nasal function with a preoperative average Nasal Obstruction Symptom Evaluation (NOSE) score of 75 (±16) decreasing to 19.5 (±16.5) postoperatively for a mean difference (MD) of -55 (95% confidence interval (CI): -60 to -49.5). In terms of objective nasal function, at 6 months postoperatively, there was an improvement of nasal flow measured by rhinometry ranging from 70 to 71% across studies. Anthropometric measurements were utilized for objective aesthetic outcomes. There was a significant improvement in I-shaped deviations (MD: -2.7°, 95% CI: -5.6 to -0.16) and C-shaped deviations improved by 11.9° (95% CI +2.8-+21.2). Complication rates ranged from 0 to 18%. ECS can achieve significant improvements in the subjective and objective function of the nose. The associated complication rate is low but variable between surgeons.
Dexamethasone Use in the Treatment of Pediatric Deep Neck Space Infections
25-11-2019 – James B. Tansey,John Hamblin,Madhu Mamidala,Jerome Thompson,Jennifer Mclevy,Joshua Wood,Anthony Sheyn
Assess the outcome of Intravenous (IV) dexamethasone in the treatment of pediatric deep neck space infections (DNSI) in combination with IV antibiotics. Retrospective chart review of pediatric patients admitted for a DNSI from March 2014 to June 2016. Patient characteristics including demographics, abscess type, antibiotic, dexamethasone, surgery, culture, and length of stay (LOS) were obtained. Patients treated with antibiotics alone versus antibiotics and dexamethasone were compared. Primary outcome measures were rate of surgical drainage and LOS. Overall 153 patients with DNSI were identified, including 62 lateral neck, 18 parapharyngeal, 40 peritonsillar, 32 retropharyngeal, and 1 submandibular. All patients received antibiotics. Dexamethasone was used in 35% of patients. The rate of surgical drainage in the dexamethasone and non-dexamethasone group was 36% and 53% respectively ( Dexamethasone use was associated with a decreased rate of surgical drainage in pediatric patients with DNSI. Further prospective study is needed to determine the role of dexamethasone in treatment.
Comparison of Referral Pathways in Otolaryngology at a Public Versus Private Academic Center
22-11-2019 – Caitlin Bertelsen,Janet S. Choi,Anna Jackanich,Marshall Ge,Gordon H. Sun,Tamara Chambers
Delayed medical care may be costly and dangerous. Examining referral pathways may provide insight into ways to reduce delays in care. We sought to compare time between initial referral and first clinic visit and referral and surgical intervention for index otolaryngologic procedures between a public safety net hospital (PSNH) and tertiary-care academic center (TAC). Retrospective cohort study of eligible adult patients undergoing one of several general otolaryngologic procedures at a PSNH (n = 216) and a TAC (n = 161) over a 2-year time period. PSNH patients were younger, less likely to have comorbidities and more likely to be female, Hispanic or Asian, and to lack insurance. Time between referral and first clinic visit was shorter at the PSNH than the TAC (Mean 35.8 ± 47.7 vs 48.3 ± 60.3 days; Sociodemographic differences between PSNH and TAC patients, as well as differences in referral pathways between the types of institutions, influence progression of surgical care in otolaryngology. These differences may be targets for interventions to streamline care. 2c.
Office-Based Steroid Injections for Idiopathic Subglottic Stenosis: Patient-Reported Outcomes, Effect on Stenosis, and Side Effects
21-11-2019 – Matthew R. Hoffman,David O. Francis,Johnny P. Mai,Seth H. Dailey
Office-based steroid injection has shown promise for idiopathic subglottic stenosis (i
SGS). It is important to understand safety and patient-lived experience. We report patient experience related to airway restriction, voice, and side effects. Sixteen patients (51 ± 14 years) with mild-moderate (20-50%) stenosis undergoing office-based transnasal steroid injections were included; fourteen had prior operations. Patients typically underwent three injections, 1 month apart, followed by transnasal tracheoscopy 1 month later to evaluate outcome; number of injections can vary based on disease severity and response. Outcomes were Dyspnea Index (DI), Modified Medical Research Council (MMRC) dyspnea scale, voice handicap index-10 (VHI-10), and degree of stenosis (estimated from procedural video). At each visit, patients were queried about post-injection airway restriction and side effects. Paired DI decreased ( Steroid injections improved upper airway symptoms. Side effects were mild and transient. Improvement in DI did not correlate with percent stenosis.
The Nerve to Thyrohyoid Muscle as a Novel Donor Nerve for Laryngeal Reinnervation
18-11-2019 – M. Elise Graham,Marshall E. Smith
Recurrent laryngeal nerve (RLN) injury may be a consequence of surgical procedures of the skull base, neck, and chest, with adverse consequences to function and quality of life. Laryngeal reinnervation offers a potentially stable improvement in vocal fold position and tone. The classic donor nerve is the ansa cervicalis, but is not always available due to damage or sacrifice during previous neck surgeries. Our objective was to introduce the nerve to the thyrohyoid (TH) muscle as an alternate donor nerve for reinnervation, which has not previously been described. Case series of two patients using the TH nerve for laryngeal reinnervation after RLN injury, with description of surgical harvest. Follow-up results are available for 10 months (one patient) and 3 years (one patient) demonstrating both subjective and objective improvement in function. GRBAS scores were reduced. Maximal phonation time was improved. Patient rating of voice was stable or improved postoperatively. One patient described significant preoperative dyspnea which was significantly improved postoperatively, from a score of 24 to 10 out of 40 on the dyspnea handicap index. VHI was improved in one patient, but scores elevated in the other, despite a change from “moderately severe impairment” to “normal voice” subjectively. Neither patient experienced significant complications from the procedure. Laryngeal reinnervation procedures provide good outcomes in pediatric patients. When ansa cervicalis is not available as a donor nerve, the nerve to TH provides a reasonable alternative.
Identifying Disadvantaged Groups for Cochlear Implantation: Demographics from a Large Cochlear Implant Program
18-11-2019 – Anthony M. Tolisano,Natalie Schauwecker,Bethany Baumgart,Johanna Whitson,Joe Walter Kutz,Brandon Isaacson,Jacob B. Hunter
To identify demographic predictors of patients undergoing cochlear implantation evaluation and surgery. Consecutive adult patients between 2009 and 2018 who underwent cochlear implantation evaluation at a university cochlear implantation program were retrospectively identified to determine (1) cochlear implantation qualification rate and (2) pursuit of surgery rate with respect to age, gender, race, primary spoken language, marital status, insurance type, and distance to the cochlear implantation center. A total of 823 cochlear implantation evaluations were analyzed. Overall, 76.3% of patients qualified for cochlear implantation and 61.5% of these patients pursued surgery. Age was the only independent predictor for cochlear implantation qualification, such that, for each year younger, the odds of qualifying for cochlear implantation increased by 2.5% (OR 0.98; 95% CI: 0.96-0.99). Age, race, marital status, and insurance type were each independent predictors of the decision to pursue surgery. The odds of pursuing surgery increased by 2.8% for each year younger (OR 1.03; 95% CI: 1.01-1.05). Compared to White patients, non-Whites were half as likely to pursue surgery (OR 0.47; 95% CI: 0.25-0.88). Single (OR 0.49; 95% CI: 0.26-0.94) and widowed patients (OR 0.46; 95% CI: 0.23-0.95) were about half as likely to pursue surgery as compared to married patients. Patients with military insurance were 13 times more likely to pursue surgery as compared to patients with Medicare (OR 13.0; 95% CI: 1.67-101.4). Younger age is an independent predictor for a higher cochlear implantation qualification rate, suggesting the possibility for delayed candidacy referral. Rate of surgical pursuit in qualified cochlear implantation candidates is lower for racial minorities, single and widowed patients, and older patients.
Standard Setting of Competency in Mastoidectomy for the Cross-Institutional Mastoidectomy Assessment Tool
16-11-2019 – Thomas Kerwin,Gregory Wiet,Brad Hittle,Don Stredney,Paul De Boeck,Aaron Moberly,Steven Arild Wuyts Andersen
Competency-based surgical training involves progressive autonomy given to the trainee. This requires systematic and evidence-based assessment with well-defined standards of proficiency. The objective of this study is to develop standards for the cross-institutional mastoidectomy assessment tool to inform decisions regarding whether a resident demonstrates sufficient skill to perform a mastoidectomy with or without supervision. A panel of fellowship-trained content experts in mastoidectomy was surveyed in relation to the 16 items of the assessment tool to determine the skills needed for supervised and unsupervised surgery. We examined the consensus score to investigate the degree of agreement among respondents for each survey item as well as additional analyses to determine whether the reported skill level required for each survey item was significantly different for the supervised versus unsupervised level. Ten panelists representing different US training programs responded. There was considerable consensus on cut-off scores for each item and trainee level between panelists, with moderate (0.62) to very high (0.95) consensus scores depending on assessment item. Further analyses demonstrated that the difference between supervised and unsupervised skill levels was significantly meaningful for all items. Finally, minimum-passing scores for each item was established. We defined performance standards for the cross-institutional mastoidectomy assessment tool using the Angoff method. These cut-off scores that can be used to determine when trainees can progress from performance under supervision to performance without supervision. This can be used to guide training in a competency-based training curriculum.
Utility of Audiometry in the Evaluation of Patients Presenting with Dysphonia
16-11-2019 – Justin Ross,William L. Valentino,Alyssa Calder,David Bigly,Sammy Othman,Brian McKinnon,Robert T. Sataloff
Hearing loss has been implicated in dysphonia secondary to voice misuse, although the data supporting this claim are scant. Determining the prevalence of hearing loss in patients with dysphonia and correlating it with self-perception of vocal handicap may help clarify the value of audiometry in evaluation of patients with dysphonia.
This is a retrospective chart review of all new voice patients (n = 405) presenting with dysphonia to the primary investigator between 2015 and 2018. Each new patient routinely undergoes audiometric and voice objective analyses. Main outcomes measured include prevalence, severity of hearing loss, and voice handicap index-10 (VHI-10).
Of the 405 subjects reviewed, mean age was 49.0 years (SD = 17.4). 60.7% of subjects were female and 39.3% male. Patients with hearing loss defined as >25 d
B in worse ear with pure tone average (PTA) thresholds at 0.5, 1, 2, and 3 k
Hz (PTA-S) accounted for 18% of the total cohort. The prevalence of previously The prevalence of hearing loss in patients presenting with dysphonia in this cohort is similar to normative population data. This study has also demonstrated that the majority of these patients did not perceive any hearing loss. The reasons behind this may be a result of or associated with the patients’ dysphonia. Furthermore, clinicians should consider performing audiometric evaluation in patients with abnormal VHI-10 scores in the appropriate clinical context.
Pediatric Thyroidectomy: NSQIP-P Analysis of Adverse Perioperative Outcomes
16-11-2019 – Vijay A. Patel,Aliasgher Khaku,Michele M. Carr
This study identifies risk factors and 30-day adverse outcomes of pediatric patients undergoing thyroidectomy. Retrospective analysis utilizing the American College of Surgeons National Surgical Quality Improvement-Pediatric Database (2015-2016). Study population includes pediatric patients (≤18 years) who underwent hemithyroidectomy (HT), total thyroidectomy (TT), and total thyroidectomy with central neck dissection (TT+ND). A total of 720 cases were identified; mean age at time of surgery was 14.1 years, with a female-to-male ratio of 3.4:1. Following hospital discharge, there were 10 related readmissions, with 1 patient requiring reoperation for neck hematoma evacuation. Regression analysis revealed anesthesia time had a significant impact on total length of stay ( Contemporary pediatric thyroidectomy has a low incidence of 30-day general surgical postoperative complications. Future research efforts are necessary once thyroidectomy specific variables are incorporated into ACS-NSQIP-P, which will provide further insights into managing this unique patient population.
Validity and Reliability of the Reflux Sign Assessment
15-11-2019 – Jérôme R. Lechien,Alexandra Rodriguez Ruiz,Didier Dequanter,Francois Bobin,Francois Mouawad,Vinciane Muls,Kathy Huet,Bernard Harmegnies,Sarah Remacle,Camille Finck,Sven Saussez
To develop and validate the Reflux Sign Assessment (RSA), a clinical instrument evaluating the physical findings of laryngopharyngeal reflux (LPR). A total of 106 patients completed a 3-month treatment based on the association of diet, pantoprazole, alginate, or magaldrate with the LPR characteristics (acid, nonacid, mixed). Forty-two asymptomatic individuals completed the study (control group). The RSA results and reflux finding score (RFS) were documented for the LPR patients at baseline and after treatment. Intrarater reliability was assessed through a test-retest blinded evaluation of signs (7-day intervals). Interrater reliability was assessed by comparing the RSA evaluations of three blinded otolaryngologists through Kendall’s W. Responsiveness to change was evaluated through a comparison of the baseline and 3-month posttreatment findings. The RSA cutoffs for determining the presence and absence of LPR were examined by receiver operating characteristic (ROC) analysis. A total of 102 LPR patients completed the study (68 females). The mean age was 53 years. The mean RSA at baseline was 25.95 ± 9.58; it significantly improved to 18.96 ± 7.58 after 3 months of therapy ( The RSA is a complete clinical instrument evaluating both laryngeal and extralaryngeal findings associated with LPR. The RSA demonstrated high intra- and interrater reliabilities and responsiveness to change.
Book Review: The Power of the Voice
15-11-2019 – Victor Hsue,Andrew Lee
Book Review: Patient and Family-Centered Speech-Language Pathology and Audiology
13-11-2019 – Gina L. Palma
Book Review: Laryngeal Manifestations of Systemic Diseases
13-11-2019 – Catherina Yang,John P. Bent
Presentation and Management of Killian Jamieson Diverticulum: A Comprehensive Literature Review
09-11-2019 – Narmien Haddad,Pratima Agarwal,Jessica N. Levi,Jeremiah C. Tracy,Lauren F. Tracy
To examine the clinical presentation, diagnostic evaluation, and management of Killian-Jamieson diverticula (KJD) through literature review. A comprehensive literature review was conducted through December 2018 using keywords Killian-Jamieson diverticula/diverticulum. Data extracted included clinical presentation, imaging characteristics, surgical management, and postoperative care. PubMed and Google Scholar. Sixty-eight cases of KJD in 59 reports (29M:39F; median 58 years old) were identified for review. The most common presentation was dysphagia (n = 39), suspected thyroid nodule (n = 24) and globus (n = 14). The majority of KJD (n = 51) occur on the left, with rare reports of right side (n = 11) and bilateral (n = 5) presentation. Thirty-two cases describe surgical management: 22 utilizing a transcervical approach, with (n = 13) or without (n = 9) cricopharyngeal myotomy; and 10 reported endoscopic surgery. Diverticula managed transcervically averaged 3.8 cm in size in comparison to average 2.8 cm in the endoscopic group. Time to diet initiation after transcervical surgery averaged 4 days versus 2 days after endoscopic surgery. Complications were reported in 2/68 cases; both were diverticula recurrence after endoscopic surgery. Killian-Jamieson diverticula is a rare diagnosis that should be considered in the evaluation of dysphagia, globus, and also suspected thyroid nodule. When patient symptoms warrant intervention, a transcervical approach, with or without cricopharyngeal myotomy, is most commonly utilized. In recent years, an endoscopic approach has been presented as an alternative for smaller diverticula. Further understanding of the optimal treatment and postoperative management for KJD requires larger cohorts. 4.
Book Review: Textbook of Vertigo: Diagnosis and Management
09-11-2019 – Sean Mooney,John Bent
Five-year Survival Data on the Role of Endoscopic Endonasal Nasopharyngectomy in Advanced Recurrent rT3 and rT4 Nasopharyngeal Carcinoma
08-11-2019 – Eugene Hung Chih Wong,Yew Toong Liew,Siow Ping Loong,Narayanan Prepageran
Endoscopic endonasal nasopharyngectomy (EEN) for recurrent nasopharyngeal carcinoma (r
NPC) is being increasingly used due to the added high magnification, reduced morbidities associated with open procedures and good survival outcomes. Most studies looked at usage of EEN in patients with lower recurrent staging (r
T1 and r
T2) although more and more surgeons are studying the outcome of EEN in advanced r
T3 and r
T4). The aims of this study were to report the long-term 5-year survival outcome of EEN performed in patients with advanced r
NPC, and to determine any prognostic factors for patients’ survival. All patients who underwent EEN for advanced r
NPC between January 2003 and December 2015 inclusive were analyzed. All surgeries were performed in University Malaya Medical Centre in Kuala Lumpur and Queen Elizabeth Hospital in Sabah. We reported the 5-year overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) and any related complications and significant prognostic factors. Twelve patients with r
NPC (2 r
T3 and 10 r
T4) were followed-up over a mean duration of 44.8 months (range, 40-440 weeks). The 5-year OS was 50.0% (mean 44.75 months), DFS was 25.0% (mean 35.25 months) and the DSS was 58.3% (mean 43.33 months). No severe operative complications were encountered and no independent prognostic factors for survival outcome were identified. This is the first report in English that exclusively described the long-term 5-year survival data in patients with both r
T3 and r
T4 recurrent NPC after EEN. The data suggest that EEN is a feasible treatment to improve survival with minimal morbidities in patients with r
T3 and r
T4 recurrent NPC. However, more studies with larger patient size is recommended.
Quality and Readability of Online Information on In-Office Vocal Fold Injections
08-11-2019 – Grace S. Yi,Amanda Hu
Vocal fold injection augmentations are increasingly being performed in the office setting on awake patients, as opposed to the operating room. These procedures thus require patient cooperation and education. As the Internet is a widely-used resource for patients, our aim was to assess the quality and readability of online resources on in-office awake vocal fold injections. An online Google search using the terms “office vocal fold injection medialization” and “awake vocal fold injection” was conducted. The first 50 English-language websites were categorized into professional- and patient-targeted, and major and minor sources. They were analyzed using the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL) test, and DISCERN quality score. Fifty websites were evaluated, and the overall DISCERN score was 2.60 ± 1.01, the mean FRES was 32.16 ± 19.10, and the mean FKGL was 13.76 ± 4.12. Between the 25 professional-targeted and 25 patient-targeted websites, professional-targeted sites had significantly higher DISCERN ( Our study shows that half of the top Google results for our topic were not written for patient education, but rather for health care professionals. The reading level of this information exceeds the recommended grade level for patient education materials, and may be less comprehensible than intended. While patient-targeted materials are easier to read than professional-targeted sites, they are of lower quality. The quality of the available online information on this topic is suboptimal for both patients and health care providers. This research highlights the need for more appropriate patient education materials given low health literacy rates.
“In-Office Balloon Sinus Ostial Dilation with Concurrent Antiplatelet and Anticoagulant Therapy for Chronic Rhinosinusitis without Nasal Polyps”
06-11-2019 – Thomas S. Higgins,Bülent Öcal,Ridwan Adams,Arthur W. Wu
Functional endoscopic sinus surgery (FESS) and balloon sinus ostial dilation (BSD) are well-recognized minimally invasive surgical treatments for chronic rhinosinusitis without nasal polyps (CRSs
NP) refractory symptoms to medical therapy. Patients on antiplatelet and anticoagulant therapies (AAT) usually are recommended to discontinue their medications around the period of endoscopic sinus surgery. The goal of this study is to assess the clinical experience of BSD in CRSs
NP patients with concurrent anticoagulant or antiplatelet therapy. A review of prospectively-collected clinical data from October 2012 to March 2017 were used to perform a cohort study of subjects with CRSs
NP who met criteria for surgical intervention while on antiplatelet and anticoagulant therapy. Data were collected on demographics, details of the procedures, type of AAT used, pre- and postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores, and complications. Thirty-five patients underwent in-office BSD while on antiplatelet and/or anticoagulant therapy. The mean difference in pre- and postoperative SNOT-22 scores of 9.9 (SD 14.4, In-office BSD appears to be a safe alternative to endoscopic sinus surgery in select patients who cannot discontinue antiplatelet and anticoagulant therapy. IV.
Endoscopic Transoral Hybrid Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy
01-11-2019 – Meijin Nakayama,Ryan K. Orosco,F. Christopher Holsinger,Giuseppe Spriano,Giovanni Succo,Armando De Virgilio,Nobuhiko Oridate
The hybrid supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCPL-CHEP, that is, open partial horizontal laryngectomies OPHL Type IIa) has been described using a flexible next generation robotic surgical platform for manipulation. We sought to evaluate the feasibility of performing this procedure using endoscopic transoral (Endo
T) surgical techniques without robotics. Preclinical cadaveric study using two human cadavers. Hybrid SCPL-CHEP was performed with a flexible endoscope for visualization and hand-held instruments for manipulation (SILS Hook monopolar and Dissect, HAVAS Laryngo
FIT malleable straight jaw instruments, and Stratafix 4-0 spiral knotless barbed suture). Endo
T hybrid SCPL-CHEP was successfully performed. The hand-manipulated rigid instruments allowed for transoral incisions and mucosal suturing. We provide the procedural steps of Endo
T hybrid techniques. Endo
T hybrid SCPL-CHEP was technically feasible in the preclinical cadaveric laboratory setting and appeared comparable to the hybrid SCPL-CHEP via transoral robotic surgery (TORS). Selected handheld instruments and flexible endoscopy appear to facilitate minimally invasive surgery of the larynx. This novel procedure and technique warrant further clinical study for consideration of feasibility, applicability, and patient benefit.
Book Review: Key Topics in Otolaryngology
01-11-2019 – Samia F. Nawaz
Risk of Mortality between Untreated and Treated Papillary Thyroid Cancer: A Matched Cohort Analysis
29-10-2019 – Jonathan K. Lin,Lori C. Sakoda,Jeanne Darbinian,Melissa Socarras,Whitney Chiao,Nathaniel Calixto,Charles Quesenberry,Deepak Gurushanthaiah,Kevin H. Wang,Megan Durr
To examine the association between treatment status and mortality risk among patients with papillary thyroid cancer (PTC). We identified 3,679 adults with PTC. Thirty-one untreated patients were matched to 155 treated patients. Hazards ratios (HR) and 95% confidence intervals (CIs) were calculated to estimate all-cause and disease-specific mortality. A low-risk subgroup was analyzed for differences in all-cause mortality. The adjusted HRs (95% CIs) for all-cause mortality at 5 and 10 years were 4.2 (1.7-10.3) and 4.1 (1.9-9.4) and for disease- specific mortality were 14.1 (3.4-59.3) and 10.2 (2.9-36.4), respectively, for untreated versus treated patients. The adjusted HRs (95% CIs) for all- cause mortality was 0.7 (0.1-6.4) for low-risk untreated versus matched treated patients. Compared to treated patients, untreated PTC patients were at higher risk of death while low-risk untreated PTC patients had comparable rate of metastasis and no increased risk of all-cause mortality.
Neck Surgery with Hypnosis: An Evaluation Based Upon Patient’s Self Assessment
29-10-2019 – Marie Jaouen,Valentine Parent,Maxime Codet,Véronique Gerard,Anita Chatellier-Miras,Cécile Chaize,Olivier De Crouy Chanel,Franck Jegoux
Surgery with hypnosis avoids the use of general anesthesia (GA). It also shortens hospitalization and promotes outpatient surgery. The objective of this study has been to assess the satisfaction of operated patients. No previous study has focused on patient satisfaction in a prospective design. In this prospective, non-randomized, observational study, all patients operated with hypnosis between 2009 and 2017 in the Ear, Nose, and Throat department of a tertiary care hospital were selected. All patients were asked to fill a questionnaire based on a previously validated questionnaire incremented with complementary questions. Questionnaires were completed immediately after surgery for 31 patients and after 6 months for 20 patients. Global Satisfaction Index (GSI) was self-assessed on a scale ranging from 1 to 10. Patients were asked; whether they felt comfortable during the operation, whether hypnosis helped them, whether the experience matched their expectations, whether they would revisit or recommend it to someone else and whether they considered to have been sufficiently informed before the procedure. The data was analyzed using a linear regression model with During the inclusion period, no patient required conversion to GA. A total of 48 questionnaires were evaluated. The median of the GSI was 8/10. GSI significantly correlated with patient comfort ( This study reveals that patients’ global satisfaction after hypnosis is high. This is significantly related to the quality of preoperative information and to the experience of the surgical team. It also suggests that patients are more likely to benefit from hypnosis if the surgery is longer.
Gene Expression Analysis to Investigate Biological Networks Underlying Nasal Inflammatory Dysfunctions Induced by Diesel Exhaust Particles Using an In Vivo System
24-10-2019 – Hyun Soo Kim,Byeong-Gon Kim,Sohyeon Park,Nahyun Kim,An-Soo Jang,Young Rok Seo,Moo Kyun Park
Diesel exhaust particles (DEP)s are notorious ambient pollutants composed of a complex mixture of a carbon core and diverse chemical irritants. Several studies have demonstrated significant relationships between DEP exposure and serious nasal inflammatory response
In the present study, we identified DEP-induced gene expression profiles under short-term and long-term exposure, and identified signaling pathways based on microarray data for understanding effects of DEP exposure in the mouse nasal cavity.
Alteration in gene expression due to DEP exposure provokes an imbalance of the immune system via dysregulated inflammatory markers, predicted to disrupt protective responses against harmful exogenous substances in the body. Several candidate markers were identified after validation using q
RT-PCR, including S100A9, CAMP, IL20, and S100A8. Although further mechanistic studies are required for verifying the utility of the potential biomarkers suggested by the present study, our
The Impact of Medical Scribes on Patient Satisfaction in an Academic Otolaryngology Clinic
23-10-2019 – Katherine R. Keefe,Jessica R. Levi,Christopher D. Brook
Evidence shows that scribes can improve provider efficiency and satisfaction in several settings, but is mixed on whether scribes improve patient satisfaction. We studied whether scribes improved patient satisfaction in an academic otolaryngology clinic. The authors performed a retrospective review of patient responses to the Press Ganey survey between 12/2016 and 12/2017. Their responses about satisfaction with the provider and wait times were examined. Three providers worked with scribes during this year; each spent six months with a scribe and six without. The authors compared survey responses from periods with and without scribes using the Fischer exact test. Average overall provider ratings were compared using the Student’s A total of 87 patients filled out Press Ganey surveys for the 3 providers over the year: 54 for visits without scribes, and 33 for visits with scribes. Fischer exact analysis demonstrated no significant difference in satisfaction with providers and wait times for both individual providers and all providers combined (all Patient satisfaction with wait times and providers was high overall and was not affected by the presence of a medical scribe.
Yolk Sac Tumors of the Head and Neck in Aicardi Syndrome
23-10-2019 – Madison V. Epperson,Hayley L. Born,Dehua Wang,Charles M. Myer
To understand that yolk sac tumors (YSTs) of the head and neck (H&N) are exceedingly rare and typically carry a poor prognosis. To acknowledge the possibility of increased incidence in patients with Aicardi Syndrome and the ramifications this has on early diagnosis and treatment in this population. To date, four germ cells tumors of the H&N have been reported in patients with Aicardi Syndrome. This report presents the second known case of a H&N YST in a patient with Aicardi syndrome. In both cases, the patient was initially misdiagnosed given unconvincing radiologic evidence. However, tissue diagnosis and elevated alpha-fetoprotein (AFP) levels were suggestive of a YST. In contrast to the poor prognosis previously described, both patients with Aicardi syndrome had an excellent chemotherapeutic response exhibited by normalization of AFP levels and imaging. Rare germ cell tumors of the H&N, such as YSTs, have now been documented in several patients with Aicardi syndrome, indicating a possible association given the rarity of these tumors in the population. YSTs should be considered in the differential diagnosis of H&N masses in these patients, with emphasis on early tissue diagnosis and treatment.
Surgical Management of Vestibular Schwannoma: Practice Pattern Analysis via NSQIP
22-10-2019 – Vijay A. Patel,Mitchell Dunklebarger,Kalins Banerjee,Tom Shokri,Xiang Zhan,Huseyin Isildak
Characterize current perspectives in the surgical management of vestibular schwannoma (VS) to guide otolaryngologists in understanding United States practice patterns. A retrospective analysis of ACS-NSQIP database was performed to abstract all patients from 2008 to 2016 who underwent VS resection using ICD-9/10 codes 225.1 and D33.3, respectively. The specific surgical approach employed was identified via CPT codes 61520, 61526/61596, and 61591, which represent retrosigmoid (RS), translabyrinthine (TL) and middle cranial fossa (MCF) approaches, respectively. Analyzed outcomes include general surgical complications, total length of stay, and reoperation. A total of 1671 VS cases were identified, 1266 (75.7%) were RS, 292 (17.5%) were TL, and 114 (6.8%) were MCF. The annual number of cases increased over the study period from 15 to 375, which is chiefly attributed to increased institutional participation in ACS-NSQIP. Perioperative variables including BMI ( There is increased employment of RS approach for the operative management of VS, which likely is the result of increased reliance on both stereotactic radiosurgery and observation as alternative treatment strategies.
Detection of Pepsin in Oral Secretions of Infants with and without Laryngomalacia
21-10-2019 – Miles J. Klimara,Tina L. Samuels,Nikki Johnston,Robert H. Chun,Michael E. McCormick
Laryngomalacia is a common cause of stridor in infants and is associated with laryngopharyngeal reflux (LPR). Although pepsin in operative supraglottic lavage specimens is associated with severe laryngomalacia, detection of pepsin in oral secretions has not been demonstrated in an outpatient setting. Children <2 years old with laryngomalacia diagnosed by flexible laryngoscopy and children without stridor were selected. Oral secretion samples were obtained in clinic from all subjects. Pepsin, IL-1β, and IL-8 enzyme-linked immunosorbent assays were performed to determine presence of LPR. Sixteen laryngomalacia and sixteen controls were enrolled. Pepsin was detected more frequently in oral secretions of patients with laryngomalacia (13/16) than in controls (2/16; Pepsin in saliva appears to be associated with laryngomalacia, suggesting a role for salivary pepsin as a noninvasive marker of LPR in patients with laryngomalacia. Future studies will determine the utility of this test in laryngomalacia.
Isolated Congenital Middle Ear Malformations: Comparison of Preoperative High-Resolution CT and Surgical Findings
21-10-2019 – Na Zhang,Yi Li,Xiaobo Ma,Danni Wang,Shuling Li,Fei Yan,Shouqin Zhao
To compare preoperative temporal bone high-resolution computed tomography (HRCT) readings to intraoperative findings during exploratory tympanotomy for suspected cases of isolated congenital middle ear malformations (CMEMs) and summarize the malformations that can and cannot be diagnosed with HRCT. A retrospective study was conducted. All cases were confirmed as isolated CMEMs during surgery. Detailed clinical records were reviewed, with a focus on imaging and surgical findings. One hundred and thirty-two patients and 145 ears were reviewed. Ninety cases (62.1%) could be identified as isolated CMEMs and at least one as middle ear anomaly using preoperative HRCT. Fifty-five cases (37.9%) were reported to be completely normal and the patients underwent exploratory tympanotomy to determine the final diagnosis. Stapes fixation, either alone or associated with other ossicular chain anomalies, contributed to 53.1% of the cases. Most cases of aplasia or dysplasia of the ossicular chain, for example, aplasia/dysplasia of the long process of the incus, aplasia of the stapes’ superstructure, and atresia of the oval window were easily identified in preoperative HRCT. However, fixation of the ossicular chain can be elusive in HRCT, and exploratory tympanotomy is needed for a definitive diagnosis. HRCT provides helpful preoperative clinical information in CMEM and may obviate the need for middle ear exploration in some cases. The negative findings (anomalies that are difficult to identify through preoperative HRCT) and the positive findings (anomalies that are relatively easy to identify through preoperative HRCT) were summarized.
Preoperative Maxillary Sinus Imaging and the Outcome of Sinus Floor Augmentation and Dental Implants in Asymptomatic Patients
21-10-2019 – Amit Ritter,Noa Rozendorn,Gal Avishai,Eli Rosenfeld,Ilan Koren,Ethan Soudry
Preoperative maxillary sinus imaging findings have been suggested to be associated with complications and outcomes of sinus lift and dental implant procedures; nonetheless the evidence is controversial. The aim of this study was to examine the association between preoperative maxillary sinus imaging findings and outcomes of sinus lift and dental implant procedures in asymptomatic patients. We included all patients who underwent maxillary sinus lift and dental implant procedures between 2014 and 2017. Maxillary sinus imaging findings were extracted from pre-procedural dental computed tomography scans, and outcomes of the procedures were assessed. A total of 145 procedures were included. No sinonasal symptoms were reported preoperatively. In 46% of cases maxillary sinus imaging was abnormal. The most common imaging finding was peripheral mucosal thickening (38%). Sinus floor cyst/polyp was identified in 13% of the cases, of which 47% occupied more than 50% of the sinus volume. Partial or complete opacification of the maxillary sinus was documented in 3% of cases. The sinus ostium and ostiomeatal complex were obstructed in 7% and 1%, respectively. Mucosal perforation was documented in 22% of cases and was inversely related to mucosal thickening ( Incidental maxillary sinus imaging findings such as mucosal swelling, cysts or polyps, regardless of their severity or size, and maxillary ostial obstruction may not need to be addressed prior to sinus augmentation and dental implant procedures in asymptomatic patients. Patients with complete sinus opacification should be referred to an otolaryngologist prior to surgery. Further controlled trials, in larger cohorts, are needed to corroborate our findings.
Electronic Consults in Otolaryngology: A Pilot Study to Evaluate the Use, Content, and Outcomes in an Academic Health System
18-10-2019 – Sapideh Gilani,Krishna Bommakanti,Lawrence Friedman
To categorize the primary reasons for electronic consults (e
Consults) to otolaryngology from primary care physicians (PCPs). To determine how many patients avoided subsequent in-person otolaryngology office visits. This is a retrospective analysis of a pilot study that took place between 2016 and 2017 regarding e
Consults to adult otolaryngology placed by primary care physicians at the University of California, San Diego (UCSD) Medical Center. The complaints were categorized as related to the following: ear, nose, throat or neck. Initial recommendations were classified as (1) providing education only (no intervention), (2) suggesting medical therapy provided by the PCP, or (3) suggesting surgical intervention. Univariate statistics and multinomial logistic regression were used to analyze the association of problem type with the need for follow-up in the otolaryngology offices. The data was analyzed for differences in patient age and gender. The study population included 64 patients (average age 54.6 years, 60.9% male). Within this group, 41% of consults were for ear complaints, 15% for nose complaints, 28% had throat-related complaints, and 16% had neck-related complaints. In-person follow-up was not required for 82.8% of the consults. Overall, 76.9% of ear, 100% of nose, 88.9% of throat, and 70.0% of neck complaints did not require in-person visits. e
Consults to otolaryngology were primarily for ear concerns. Of the e
Consults, 82.4% did not require in-person follow-up. We therefore conclude that the use of e
Consults prevented substantial office visits that would not otherwise be necessary. Efforts should be made to promote the widespread use of e
Consults, which may to the more efficient use of resources.
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
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
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.
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
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
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
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
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
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
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
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.) 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
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
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.