bluuebunny/crossref_metadata_2025 huggingface dataset:
Meet the Sac: Endoscopists’ Road Map
Authors: Kurien Mary , Tyagi Amit , Shyam Aparna , Holla Sunil
Published: September 2014

Objectives:

Ideal mucosal incision followed by adequate osteotomy is the key to successful endonasal endoscopic dacryocystorhinostomy. Hence anatomical correlation of intranasal lateral nasal wall landmarks to lacrimal sac and duct was done with secondary computed tomography (CT) correlation.

Methods:

A descriptive study of 10 adult cadaver head sections fixed with 10% formaldehyde solution was done in the anatomy and radiology departments of a tertiary hospital from 2010 to 2011. Following CT scan, these were sagittally sectioned to 10 right and left specimens. Measurement of anatomical landmarks in CT and dissection were taken by metric ruler and digital calipers respectively. With application of paired t test, mean was calculated.

Results:

Maxillary line was clearly identified in 75% of cadavers, the majority overlapping the lacrimal sac. In all cadavers superior end of lacrimal sac was above the axilla, distance between them being 8.88 mm. Length of lacrimal sac was 11.72 mm. These showed positive correlation with CT scan. Distance between anterior edge of lacrimal sac and axilla was 10.58 mm. Genu was at or posterior to nasolacrimal duct in the majority, the length of duct being 10.27 mm. This showed positive correlation with CT.

Conclusions:

Important endonasal landmarks are of middle turbinate—axilla and genu (bony), and maxillary line (mucosal). Mucosal Incision, 9 to 10 mm above axilla, anterior to maxillary line and genu, 10 to 11mm long to just above level of genu, is sufficient to expose lacrimal sac up to its inferior limit. Preoperative CT scan can be reserved for revision or post‐traumatic nasolacrimal sac pathology.
Secondary Nasoseptal Flaps for Endoscopic Skull Base Reconstruction: Proof of Concept and Evaluation of Outcomes
Authors: Choby Garret W. , Mattos Jose L. , Sahu Nivedita , Gardner Paul , Fernandez‐Miranda Juan , Snyderman Carl H. , Wang Eric W.
Published: September 2014

Objectives:

(1) Assess secondary nasoseptal flaps (NSF) as a viable reconstructive option. (2) Evaluate postoperative vascularity of secondary NSFs. (3) Compare cerebrospinal fluid (CSF) leaks and complication rates of secondary NSFs to primary NSFs.

Methods:

This is a retrospective review of patients from 2009 to 2013 undergoing transsellar approaches for skull base tumors at the University of Pittsburgh Medical Center. In cases where the necessity of a vascularized reconstructive flap was made evident only after tumor resection, the NSF was raised after the tumor had been resected and/or CSF leak had developed (secondary NSF). Outcome measures include postoperative magnetic resonance imaging (MRI) findings, CSF leak rates, and complication rates.

Results:

Transsellar approaches were performed in 436 patients during this timeframe. Primary NSFs were used to reconstruct 178 patients while 32 patients had secondary NSFs. Postoperative MRI scans were available in 29 of 32 secondary NSF patients; all maintained vascularity on examination of T1 post‐contrast images (mean time to MRI 4.9 months). There was no significant difference in CSF leak rate between primary NSFs (3.4%) and secondary NSFs (3.1%) (P =. 95). Primary NSFs had a higher overall complication rate (11.7%) compared to secondary NSFs (3.1%), but this was not statistically significant (P =. 142). Logistic regression analysis demonstrated no significant effect of flap type, age, or sex on CSF leak rates.

Conclusions:

Secondary NSFs are a viable reconstructive option for sellar skull base defects. They maintain vascularity as evidenced on postoperative MRI imaging and compare favorably to primary NSFs in regard to CSF leak rates and complication rates.
Sinonasal Outcomes Test‐22 as a Tool to Identify Chronic Rhinosinusitis among Adults with Cystic Fibrosis
Authors: Habib Al‐Rahim , Alsaleh Saad , Manji Jamil , Quon Bradley , Buxton Jane , Javer Amin R.
Published: September 2014

Objectives:

(1) Investigate the ability of a sinus‐specific health‐related quality of life questionnaire (HRQoL) to distinguish clinically significant chronic rhinosinusitis (CRS) among adults with cystic fibrosis (CF). (2) Determine an appropriate cutoff score on the Sinonasal Outcomes Test‐22 (SNOT‐22) with sufficient test sensitivity and specificity, to assist caregivers in identifying adults with CF who may warrant specialist referral and treatment.

Methods:

Participants were enrolled at an adult‐specific CF clinic in a tertiary academic hospital in Vancouver, Canada. Subjects completed the SNOT‐22 followed by endoscopic assessment by otolaryngologists. The Canadian Clinical Practice Guidelines for Chronic Rhinosinusitis were used to confirm diagnosis of CRS.

Results:

To date, 52 of 80 individuals with a confirmed diagnosis of CF have participated in this study. Thirty‐nine (75.0%) individuals were identified with CRS, 12 (30.8%) of whom presented with nasal polyposis. Aggregate SNOT‐22 scores were significantly higher among individuals with CRS compared to non‐CRS counterparts (39.4 ± 20.0 vs 22.7 ± 8.7, P =. 007, 95% confidence interval [CI] for mean difference: 4.7, 28.7). A SNOT‐22 score >26 was found to have a test sensitivity of 74.4% and specificity of 66.7% for diagnosis of CRS (AUC = 0.77, P <. 01). Using SNOT‐22 scores related to rhinological symptoms increased the likelihood ratio of a positive test when compared to aggregate scores (8.3 vs 2.2, respectively).

Conclusions:

The SNOT‐22 significantly discriminates between CF adults with and CF adults without CRS. Using rhinological symptom scores increases the likelihood of detecting true CRS cases. The use of this questionnaire may assist specialists in identifying individuals who have clinically significant CRS, warranting specialist referral and treatment.
Cleft Repair: Medical Mission Trips versus Empowering Local Surgeons in Developing Countries
Authors: Opsahl Courtney , Sidman James D.
Published: September 2014

Objectives:

Determine whether it is more cost beneficial to partake in a medical mission trip to developing countries to complete cleft repairs or to support medical professionals in providing local care.

Methods:

Retrospective analysis of surgical costs per patient of different types of US‐based charitable organizations. We compared financial information of 3 separate 501(c)(3)s for fiscal years 2011 and 2012. Cost per surgery was determined through expenses and total number of surgeries. Two organizations focus on service‐based missions (typically US‐trained surgeons and other clinicians traveling to developing countries to complete surgeries over a 1‐2 week period). The third organization focuses on funding local surgeons (who are already trained and have proven expertise) to complete cleft repairs. This organization pays local clinicians to complete surgeries, and in return, surgeons upload results to an electronic medical record system so outcomes and progress can be tracked.

Results:

The cost per patient is significantly lower when local surgeons are paid to complete cleft repair cases than when entire teams of clinicians partake in service‐based missions for cleft repairs. While different from country to country, the typical cost for locally provided care is as low as $250/patient. When relying on service‐based missions, the average cost is above $500.

Conclusions:

It is more cost beneficial to empower local surgeons in developing countries to complete cleft repairs.
Sinus Headaches: Otolaryngology Treatment or Neurology Referral: Analysis of Efficacy and Cost‐Effectiveness of Migraine Treatment
Authors: Daraei Pedram , Gross Jennifer H. , Delgaudio John M.
Published: September 2014

Objectives:

Evaluate the efficacy and cost‐effectiveness of empiric treatment of sinus headaches/migraines initiated by an otolaryngologist versus referral to a neurologist for treatment.

Methods:

Retrospective chart review from 1998 to 2013 of patients with ICD‐9 codes for headache or atypical facial pain at an academic medical center. Comparison of cost of workup and treatment initiated by an otolaryngologist was compared with that of patients referred to neurology. Length of delay in treatment was also calculated for patients referred to neurology.

Results:

Of 797 patients reviewed, 57 patients were primarily treated by otolaryngology, and 104 patients were referred to neurology for treatment. Success of patients treated by otolaryngology was 78.9% versus 81.8% for neurology‐treated patients (P =. 77). The average wait for an appointment with a neurologist specializing in headache was 57.9 days. Forty‐two patients had a history of chronic rhinosinusitis, with 18 in the otolaryngology‐treated group and 24 in the neurology referral group (P =. 25). Cost analysis showed that there was a significant increase in health care costs when patients were referred to neurology for diagnosis and treatment, with the referred patients accruing higher health care costs in the form of office visits, medications, and imaging techniques.

Conclusions:

Recognition of sinus headaches as migraines by the otolaryngologist and initiation of treatment allows for earlier improvement of symptoms, improved quality of life, and decreased health care costs, with equal success rates to that of patients treated by neurology.
Transcriptional Activity of HPV in Inverted Papilloma Demonstrated by In Situ Hybridization of HPV mRNA
Authors: Stoddard David G. , Keeney Michael G. , Garcia Joaquin J. , O'Brien Erin K.
Published: September 2014

Objectives:

(1) Demonstrate the incidence of human papillomavirus (HPV) transcriptional activity in inverted Schneiderian papilloma (IP). (2) Evaluate the role of HPV in the pathogenesis of IP and its rare progression to malignancy. (3) Support the consideration of RNAscope in diagnosis and management of IP.

Methods:

Retrospective clinical and histopathologic review of 20 cases of IP who underwent surgical excision at a tertiary referral center between 1995 and 2013. Surgical pathology archival material was re‐examined histopathologically using H&E slides. Formalin‐fixed paraffin‐embedded material from each case was further evaluated using immunohistochemical staining for p16 as well as in situ hybridization (ISH) for HPV E6/E7 mRNA (RNAscope).

Results:

Patients were 40% female with average age 53.7 years (range, 23‐82 years). Three had evidence of malignancy at the time of excision, and 5 demonstrated recurrence of IP. Average follow‐up was 48 months (range, 0‐200 months), and one patient died from squamous cell carcinoma (SCC) arising from the IP. HPV transcriptional activity noted by RNAscope within specimens is reported.

Conclusions:

These data serve to aid in clarification of conflicting prior research attempting to establish a connection between the presence of HPV and development of IP. By demonstrating transcriptional activity of HPV in IP, this connection is rendered more definitive. Further studies are necessary to elucidate the mechanism by which this process occurs, and what, if any, impact HPV status has on progression from IP to SCC.
Adherence to PAP and Subspecialist Referral for PAP Intolerance Following Polysomnogram
Authors: Russell Jonathon O. , Gales Jordan , Bae Charles , Kominsky Alan
Published: September 2014

Objectives:

Obstructive sleep apnea (OSA) is a serious medical condition that adds to patient morbidity and mortality. While treatment with positive airway pressure (PAP) is the standard of care, a significant portion of patients fail to adhere. Little is known about the subsequent management of patients who have refused or failed continuous positive airway pressure. We sought to identify rates of acceptance and adherence to PAP, as well as management and referral patterns of those who failed.

Methods:

Retrospective cohort study in an academic hospital. All patients undergoing polysomnogram at a single institution during the months of March and April 2010 (n = 1174) were screened for OSA. Adult patients with apnea‐hypopnea index (AHI) > 15 or 5 < AHI < 15 as well as Epworth Sleepiness Scale (ESS) >10 were included for subsequent analysis. Patients undergoing polysomnography were screened for OSA retrospectively using the electronic medical record (EMR). The subsequent management history including tolerance of PAP and referral to specialists upon failure was collected.

Results:

Of 1174 patients screened, 566 met inclusion criteria. Of 416 patients (74%) with follow‐up information, 237 (57%) were ultimately adherent to PAP. Of 205 nonadherent patients, 86 had refused PAP immediately (42%). Sixty‐one (30%) were referred upon failure or refusal. A total of 139 patients (68%) suffered from untreated OSA without referral to a specialist during a 3‐year follow‐up.

Conclusions:

Despite the known sequellae of OSA, clinicians are neither treating nor referring a significant percentage of patients with OSA. Therapies other than PAP may be warranted in this population.
Comparison of Efficacy and Safety of Intranasal Midazolam with Syrup Chloral Hydrate for Procedural Sedation
Authors: Mathew John
Published: September 2014

Objectives:

Evaluate the efficacy and safety of intranasal midazolam and syrup chloral hydrate for procedural sedation in children.

Methods:

A prospective, randomized, double‐blinded placebo controlled trial, in a tertiary care hospital over 18 months. A total of 82 children, ages 1 to 6 years, undergoing auditory brainstem response testing, were randomized to receive either midazolam nasal spray with oral placebo or syrup chloral hydrate with placebo nasal spray. Midazolam at 0.5 mg/kg delivered as 100 mcg per spray and oral syrup at a dose of 50 mg/kg. Children not sedated at 30 minutes had a second dose at half the initial dose. The primary outcomes measured were safety and efficacy. Secondary outcomes were time to onset of sedation, parental separation, nature of parental separation, parental satisfaction, audiologists satisfaction, time to recovery, and number of attempts.

Results:

There were 41 children in each group. No major adverse events noted. The chloral hydrate group showed earlier onset of sedation (66%) compared with midazolam group (33%). A significant difference in the time to recovery in the chloral hydrate (78 min) group compared with the midazolam group (108 min). Parental and audiologist satisfaction was higher for chloral hydrate (95 % and 75%) than for midazolam (49% and 29%). Overall, sedation with chloral hydrate was 95% compared with 51% with midazolam. Both the drugs maintained sedation.

Conclusions:

Both intranasal midazolam and oral chloral hydrate are safe and efficacious for pediatric procedural sedation. Chloral hydrate was superior to intranasal midazolam with an earlier time to onset of sedation, a faster recovery, better parental and audiologist satisfaction, and successful sedation.
Does OSA in Children with Small Tonsils Improve after Adenotonsillectomy?
Authors: Tang Alice L. , Benke James R. , Ishman Stacey L.
Published: September 2014

Objectives:

There is conflicting opinion regarding the clinical utility of removing small tonsils in children with obstructive sleep apnea (OSA). We sought to (1) determine if OSA improves after adenotonsillectomy (AT) in children with small tonsils; and (2) investigate the relationship between OSA resolution and tonsil size after AT.

Methods:

Retrospective study of 1‐ to 18‐year‐old consecutive nonsyndromic children with OSA who underwent polysomnography before and after AT. Complete response was defined as obstructive respiratory disturbance index (RDI) < 1.5.

Results:

Seventy children (36 female) were included; mean age was 5.9 ± 4.3 years. Tonsils were categorized as 2+ (n = 20), 3+ (n = 36), and 4+ (n = 14). Preoperative RDI, obstructive apnea index (AI), and obstructive hypopnea index (HI) were similar regardless of tonsil size (P >. 05). Overall RDI improved from 18.6 ± 8.6 to 4.0 ± 6.0 with 44% (31/70) complete responders. In the 2+ group, AI and saturation nadir significantly improved (P =. 004‐.033) but HI and RDI did not (P =. 08‐21). All 4 parameters significantly improved for the 3+ (P =. 001‐<.0001) and 4+ (P =. 018‐.003) groups. The mean RDI improvement in the 2+ group was 10.8 ± 5.9 events/hour with 25% (5/20) complete responders, 14.8 ± 2.4 with 56% (20/36) responders in the 3+ and 18.7 ± 5.4 with 43% (6/14) responders in the 4+ group. There was no correlation between OSA severity and tonsil or adenoid size (P >. 32).

Conclusions:

Tonsil size did not correlate with OSA severity. While a larger proportion of patients with 3+/4+ tonsils had complete response after surgery, significant improvement was seen in AI and saturation nadir even in those with 2+ tonsils.
Development of a Clinical Care Pathway for Severe Epistaxis at a Tertiary‐Care Medical Center
Authors: Kass Jason I. , Vosler Peter S. , Wang Eric W. , Snyderman Carl H.
Published: September 2014

Objectives:

(1) Describe the treatment patterns for the management of severe epistaxis at a tertiary‐care center. (2) Develop a clinical care pathway (CCP) for system‐wide management of severe epistaxis.

Methods:

A review of patients admitted for epistaxis from August 2012 to December 2013 was performed using: (1) CPT codes and (2) a digital archive of all medical records. Severe epistaxis was defined as persistent bleeding not controlled using local pressure, vasoconstrictive medication, and anterior packing. A root cause analysis identified factors contributing to the morbidity and mortality of patients with severe epistaxis.

Results:

Of 332 cases of epistaxis, 48 met criteria for severe epistaxis. Of these, 64.6% (31/48) presented via the Emergency Department and 35.4% (17/48) as an inpatient. All were packed initially. Average duration of packing was 3.02 ± 1.88 days. Nearly half (45.8%) failed packing and had either sphenopalatine artery ligation (37.5%) or embolization (8.3%). Intubation was required in 16.7% (8/48) for airway protection. Nearly half (48.9%) were inappropriately admitted to a location where key resources (operating room and interventional radiology) were unavailable after hours. A CCP was then devised in conjunction with emergency medicine that minimizes the duration of nasal packing and length of hospitalization and reduces the total cost of care. Implementation of the pathway required changes in the electronic medical record and educational programs.

Conclusions:

Implementation of a CCP requires evaluation of current practices and the standard of care followed by input from institutional decision makers. Quantifying improvement requires retrospective normative data with ongoing review of compliance with the CCP.
Functional Outcomes and Quality of Life Associated with Cricopharyngeal Myotomy for Cricopharyngeal Dysfunction: A Prospective Study
Authors: Van Abel Kathryn M. , Moore Eric J. , Kasperbauer Jan L. , Hinni Michael L. , Lott David G. , Baron Todd H. , Ekbom Dale C.
Published: September 2014

Objectives:

(1) Evaluate cricopharyngeal myotomy (CPM) for cricopharyngeal dysfunction (CPD) including Zenkers diverticulum (ZD) and cricopharyngeal bar/hypertrophy (CPB). (2) Analyze functional outcomes and quality of life associated with CPD following CPM.

Methods:

A prospective multicenter study performed from January 1, 2012, to July 1, 2014, included patients presenting with CPD undergoing CPM. Standardized questionnaires including the 10‐item Eating Assessment Tool (EAT‐10), Functional Outcome of Swallowing Scale (FOSS), and the Reflux Symptom Index (RSI) were completed preoperatively, at 3 and 6 months postoperatively.

Results:

Thirty‐two patients were included (18F; mean 71 years; range, 53‐86 years). Primary CPD included ZD (17/32; 53.1%), CPB (6/32; 18.8%), and ZD+CPB (9/32; 28.1%). The most common comorbidities included GERD (11/32; 34.4%), hiatal hernia (6/32; 18.8%), and an underlying neurologic disease (5/32; 15.6%). Twenty‐six patients (81.3%) underwent rigid‐endoscopic, 3 (9.4%) underwent flexible‐endoscopic, and 3 (9.4%) underwent open‐transcervical CPM. One patient developed a leak on postoperative day 3. There were no deaths. Three patients experienced treatment failure at 7, 14, and 14 months postoperatively, requiring revision surgery. Mean preoperative RSI was 24.7 (range, 10‐40), FOSS was 2.2 (range, 0‐4), and EAT‐10 was 20.7 (range, 2‐34). The 3‐month questionnaire (32/32, 100%) demonstrated an improved mean RSI of 7.2 (range, 0‐30), FOSS of 0.6 (range, 0‐3), and EAT‐10 of 4.6 (range, 0‐24). A total of 63% (20/32) completed the 6‐month questionnaire, demonstrating a stable/improved mean RSI of 4.95 (range, 0‐17), FOSS of 0.55 (range, 0‐2), and EAT‐10 of 3.1 (range, 0‐15).

Conclusions:

This represents one of the first prospective studies to demonstrate a significant improvement in functional outcome and quality of life in patients with CPD undergoing CPM.
Human Parafollicular Cancer Cells: A Neuronal Model for Novel Drug Identification to Treat Neuropathic Pain
Authors: Masterson Caleb , Durham Paul L.
Published: September 2014

Objectives:

This study was conducted to identify the types of functional voltage‐gated calcium channels expressed by the neuronal‐like human parafollicular (CA77) cancer cell line.

Methods:

CA77 cells were grown in culture and the expression of functional calcium channels studied using Fura‐2 am during live cell imaging to measure changes in intracellular calcium levels in response to stimulation with potassium chloride (KCl) alone and in combination with several voltage‐gated calcium channel blockers. These included: nifedipine, funnel spider toxin (FTX), and ω‐conotoxin, which inhibit L‐type, P/Q‐type, and N‐type voltage‐gated calcium channels, respectively. To investigate transcriptional expression, primers for L‐, N‐, and P/Q‐type channels were used in reverse transcriptase polymerase chain reaction (RT‐PCR).

Results:

Significant increases in intracellular calcium levels were measured in response to KCl (P <. 001, n = 45), which was not repressed by nifedipine or ω‐conotoxin (P =. 893, n = 34, P =. 957, n = 31). However, KCl‐mediated intracellular calcium increase was repressed by FTX (P <. 001, n = 42). Using RT‐PCR, mRNA for P/Q‐type receptor was detectable but not the mRNA for the N‐ and L‐type voltage‐gated channels.

Conclusions:

Taken together, our results provide evidence that CA77 cells express functional P/Q (CaV2.1) calcium channels, which are known to promote increased neuronal excitability, inflammation, and nociception. Thus, CA77 cells can provide an efficient and cost‐effective means to screen novel therapeutics to treat migraine and other neurological diseases of the head and neck that involve P/Q channel activation in the underlying pathology.
Medical Malpractice in Sinonasal Disease: An Analysis of Litigation over the Last Ten Years
Authors: Winford Tyler W. , Wallin Jordan L. , Clinger John D. , Graham Aaron M.
Published: September 2014

Objectives:

(1) Review past literature on medical malpractice in rhinology and sinonasal disease in the Unites States of America. (2) Analyze otolaryngology malpractice litigation related to sinonasal disease in the last 10 years. (3) Discuss ways to prevent future malpractice litigation in this area of otolaryngology.

Methods:

The study is a case series with review of court records pertaining to litigation of otolaryngologic treatment of sinonasal disease using the Westlaw and Lexis Nexis legal databases. The phrase medical malpractice was searched with terms related to sinonasal disease involving court cases in the last 10 years, yielding 26 cases. The cases were analyzed for pertinent data regarding plaintiffs, presenting complaint, practice setting, type of malpractice, resulting injury, result of verdict, and amount of reward or settlement.

Results:

Chronic sinusitis was the most common presenting symptom. Many cases included multiple types of alleged malpractice with the most common being negligent technique and lack of informed consent. The most common alleged injuries included cerebrospinal fluid leak, meningitis, nasal obstruction, and orbital trauma. Defendants prevailed in 13 of the 18 cases in which outcomes were known, with mean award of $225,000 and mean settlement of $212,500. The cases won by plaintiffs were all in a private practice setting.

Conclusions:

Otolaryngologists should be aware of the causes of malpractice litigation as it relates to treatment of sinonasal disease and ensure informed consent is obtained and well‐documented. A unified and complete database of medical malpractice cases is needed to allow for further analysis of specialty‐related claims.
The Quality of Economic Evaluations in the Otolaryngology Literature
Authors: Liu C. Carrie , Lui Justin T.H. , Oddone‐Paoluccu Elizabeth , Rudmik Luke
Published: September 2014

Objectives:

(1) Identify factors that may predict the quality of economic evaluations in the otolaryngology literature. (2) Identify current weaknesses in published economic evaluations for the purposes of improving the quality of future studies.

Methods:

This is a retrospective quality review of published economic evaluations using the validated Quality of Health Economic Studies (QHES) instrument. A systematic review of the Medline, Embase, PubMed, and NHS economic evaluation databases was performed using otolaryngology key terms combined with the terms cost and effectiveness. A manual search of 33 otolaryngology journals was also performed to prevent missed studies. Included studies were graded using the QHES instrument, a 16‐item checklist providing a total quality score of 100.

Results:

Fifty studies were identified, and the mean QHES rating was 54.7 (SD: 31.0). Higher quality economic evaluations were associated with a higher journal impact factor (correlation coefficient r 0.62, P <. 01), having an author with a PhD in health economics (r 0.56, P <. 01), and having authors who have published prior economic evaluations (r 0.46, P <. 01). The most commonly omitted methodology was lack of defining the cost perspective and lack of a robust sensitivity analysis.

Conclusions:

The quality of economic evaluations is important to properly inform efficient allocation of scarce health care resources. Our study investigated the overall quality of economic evaluations in the otolaryngology literature and demonstrated that there is potential to improve the quality of published studies. Future studies should follow published methodology guidelines and consider collaborating with authors who have experience with economic evaluation.
Racial Disparities in Incidence of Human Papillomavirus–Associated Oropharyngeal Cancer in an Urban Population
Authors: Ramer Ilana , Varier Indu V. , Zhang David Y. , Demicco Elizabeth , Posner Marshall , Misiukiewicz Krzysztof , Sikora Andrew G.
Published: September 2014

Objectives:

(1) Determine whether there is a difference in the incidence of human papillomavirus (HPV)–associated oropharyngeal carcinoma (OPC) between non‐Hispanic Caucasians and minorities in an institutional series drawn from the highly urbanized population of New York City.

Methods:

Several recent studies suggest that rates of HPV‐associated OPC are higher in Caucasians than in minorities. We hypothesized that this difference would be lower in the highly diverse, urban population of New York City. This is a retrospective chart review of 240 patients with surgically treated OPC at the Icahn School of Medicine at Mount Sinai (ISMMS) between 1999 to 2013. Researchers determined age, sex, race, ethnicity, and tumor site of study participants. Polymerase chain reaction (PCR) was used to detect the presence of oncogenic HPV‐DNA in paraffin tumor blocks. Incidence of HPV‐positive cancers was compared between Caucasians and minorities (defined as African Americans, Asians, and Hispanics) using Fisher's exact test.

Results:

We found a higher incidence of HPV‐positive OPC HPV in Caucasians than racial minorities within the ISMMS population (P =. 010). HPV incidence detected by PCR was 149 out of 192 (77.6%) for Caucasians and 28 out of 48 (58.3%) for minorities. Specifically, there was a higher incidence in Caucasians compared with African Americans (P =. 024), but no significant difference between Caucasians and Hispanics (P =. 218). There were no significant differences between the 2 cohorts in sex or age.

Conclusions:

The incidence of HPV‐positive OPC is higher in non‐Hispanic Caucasians than in minorities in New York City. This observation is consistent with previously reported trends from study populations in less urbanized areas.
Ten Steps to Develop Patient Education Videos for Individuals of All Health Literacy Levels
Authors: Saffarzadeh Areo G. , Verma Sunil P.
Published: September 2014

Objectives:

(1) Create a protocol for developing educational videos for patients of all health literacy levels. (2) Describe National Institutes of Health (NIH) guidelines, evidence‐based principles of instructional design, and industry best practices related to creating educational videos for patients.

Methods:

Utilizing (1) NIH guidelines for patient education materials, (2) evidence‐based principles of instructional design, and (3) industry best practices, a 10‐step protocol was developed for creating video‐based patient education materials. As a proof‐of‐concept, these 10 steps were used to create a short video to help patients understand flexible laryngostroboscopy.

Results:

Using NIH guidelines, a script was created with text designed for the sixth‐grade reading level using the SMOG Readability Formula. Evidence‐based principles of instructional design that were incorporated into the video included: the Personalization Principle, Multimedia Principle, Coherence Principle, Contiguity Principle, and Practice Principle. A video was recorded with a high definition camera, and audio narration was recorded separately. A short video describing laryngeal anatomy and showing actual footage laryngostoboscopy was edited on Camtasia Studio 8.0 and produced for optimized viewing on the iPad. The video was pilot tested on patients prior to undergoing flexible laryngostroboscopy at an outpatient otolaryngology–head and neck surgery clinic.

Conclusions:

There is currently no protocol for creating educational videos for patients with limited health literacy. This 10‐step protocol was created to help those creating educational videos incorporate NIH guidelines, evidence‐based principles of instructional design, and industry best practices into their projects.
Are Patients Undergoing Thyroidectomy in Montreal, Canada, during Winter at Increased Risk for Postoperative Hypocalcemia?
Authors: Mascarella Marco A. , Nhan Carol , Payne Richard J.
Published: September 2014

Objectives:

(1) Review the rate of postoperative hypocalcemia in patients undergoing thyroidectomy in the summer and winter. (2) Identify the association between the season when surgery was completed and the risk of postoperative hypocalcemia.

Methods:

A retrospective chart review of 436 patients undergoing thyroidectomy at the McGill University Thyroid Cancer Centre from 2006 to 2014 was performed. Patients undergoing total or completion thyroidectomy in the winter months (December to February) and summer months (July to September) were included in the study. Parathyroid hormone (PTH) and serum corrected calcium were recorded according to the McGill post‐thyroidectomy protocol. Preoperative PTH and 25‐hydroxyvitamin D (25‐OHD) were measured. Hypocalcemia was defined as a corrected calcium level <1.9 mmol/L.

Results:

The rate of postoperative hypocalcemia was 8% for patients operated on in the winter and 1.8% for those in the summer (P =. 01). Patients undergoing surgery in the winter were 4.3 times more likely to develop postoperative hypocalcemia than those in the summer (P =. 01, 95% confidence interval [1.5 to 1 5]). Surgery during the summer months showed a higher preoperative 25‐OHD level (P =. 04). Preoperative PTH levels were significantly greater in the winter months as compared with the summer (5 pmol/L and 4.5 pmol/L, respectively; P =. 01). Patients with 25‐OHD deficiency (≤70nmol/L) were not found to have a higher rate of postoperative hypocalcemia (5.2% and 13.8%, respectively; P =. 22).

Conclusions:

In this study, patients undergoing thyroidectomy during the winter months were 4.3 times more likely to develop postoperative hypocalcemia when compared with patients operated in the summer.
The Diagnostic Accuracy of Fine‐Needle Aspiration for Parotid Malignancy
Authors: Stein Andrew P. , Britt Christopher J. , Hartig Gregory K.
Published: September 2014

Objectives:

Determine the sensitivity and specificity of fine‐needle aspiration (FNA) in the diagnosis of parotid malignancy and analyze those histologies most often associated with false negative and false positive results.

Methods:

A retrospective chart review was performed for all patients who had a parotidectomy at the University of Wisconsin from 1994 to 2013. Patients who underwent preoperative FNA were identified, and FNA results were categorized as benign, malignant, or indeterminate. Surgical pathology was utilized as the gold standard.

Results:

A total of 771 patients underwent parotidectomy from 1994 to 2013, and 280 patients (36.3%) had a preoperative FNA. Based on surgical pathology, 178 (63.6%) patients had benign disease and 102 (36.4%) had malignant parotid neoplasms. 174 (62.1%) FNAs were benign, 94 (33.6%) were malignant, and 12 (4.3%) were indeterminate. Excluding indeterminate cases, the sensitivity and specificity for FNA in the diagnosis of parotid malignancy were 83.7% (95% confidence interval [CI]: (74.8%, 90.4%)) and 93.0% (95% CI: (88.0%, 96.3%)), respectively. Moreover, FNA correctly categorized malignancy in 83.7% (n = 82) and benign in 92.9% (n = 158) of cases. There were 16 false negatives (16.3%) with mucoepidermoid carcinoma having a diagnostic accuracy of 60% and acinic cell carcinoma 50%. Both were most commonly mistaken for pleomorphic adenoma. There were 12 false positives (7.1%), most commonly pleomorphic adenoma (n = 4) and warthins (n = 3).

Conclusions:

This study demonstrates that FNA has high sensitivity (83.7%) and specificity (93.0%) for the diagnosis of parotid malignancy. However, mucoepidermoid carcinoma and acinic cell carcinoma are more commonly associated with a false negative FNA.
Epithelial‐Myoepithelial Carcinoma of the Salivary Glands: An Analysis of 246 Cases
Authors: Vazquez Alejandro , D'Aguillo Christine M. , Farver William , Abdou Rami Y. , Baredes Soly , Eloy Jean A. , Park Chan W.
Published: September 2014

Objectives:

Epithelial‐myoepithelial carcinoma (EMC) is a rare neoplasm of the salivary glands. In this study we aim to analyze the clinical features of EMC using national registry data.

Methods:

Retrospective cohort study. The Surveillance, Epidemiology, and End Results (SEER) database was queried. Data were analyzed with respect to various demographic and clinicopathologic factors. Survival was analyzed using the Kaplan‐Meier and Cox proportional hazards models.

Results:

A total of 246 cases were available for frequency analysis and 189 for survival analysis. Mean age at diagnosis was 63.8 (±15.4) years. EMC affected females more frequently (57.3%). Distant metastases were present in only 4.5% of cases. Overall disease‐specific survival (DSS) at 15 years was 80.2%. Patients with low‐grade histology had better DSS at 10 years than those with high‐grade tumors (96.2% vs 71.0%, P =. 0124). Tumors >4 cm exhibited the worst DSS at 15 years (64.5%, P =. 0009). In the survival analysis cohort, all but 6 patients underwent surgery, and a total of 78 (41.3%) received adjuvant radiation therapy (RT). However, no survival benefit was noted for patients who received RT when compared with those who did not (P =. 4594). Although a trend toward higher survival with RT (97.1% vs 83.5% without) was observed when high tumor grade and size >4 cm were excluded, it was not statistically significant (P =. 2058).

Conclusions:

This report represents the largest series of EMC to date. Despite being regarded as a low‐grade, indolent tumor, a significant fraction of our cohort underwent RT in addition to surgery, with no apparent added survival benefit.
Evaluation of Lymph Node Metastasis in Oropharyngeal Squamous Cell Carcinoma
Authors: Durmus Kasim , Boyce Brian J. , Ozer Enver
Published: September 2014

Objectives:

(1) Examine the association between histopathologic variables and neck metastasis. (2) Analyze the effect of human papillomavirus (HPV) status on lymph node (LN) metastasis.

Methods:

Medical records of 93 patients who underwent transoral robotic surgery (TORS) with concurrent neck dissection for oropharyngeal squamous cell carcinoma (SCC) between 2008 and 2013 were reviewed.

Results:

At the time of presentation, 60 (64.5%) patients had tonsil cancer, 14 (15%) had base of tongue, and 19 (21%) had carcinoma of unknown primary. High risk types of HPV and p16 positivity were 74.4% and 85.4%, respectively. Mean primary tumor size was 2.3 cm (range, 0.3‐5.1 cm). Nodal status based on pathologic examination were N0 in 7 (7.5%) patients, N1 in 12 (12.9%), N2a in 25 (26.9%), N2b in 37 (39.8), N2c in 5 (5.4%), and N3 in 7 (7.5%). Average positive LN number was 2.56 (range, 0‐37). Extracapsular spread (ECS) was identified in 29.1% of all patients. Primary tumor size had no effect on positive LN size, number or ECS. HPV positivity (rs = 0.25, P =. 021), p16 overexpression (rs = 0.36, P =. 001), and lymphovascular invasion (rs = 0.34, P =. 001) were significantly associated with increased positive LN number. Positive LN number correlates with ECS (rs = 0.28, P =.009).

Conclusions:

HPV positivity, p16 overexpression, and lymphovascular invasion increase the risk of cervical lymph node metastasis. Increased primary tumor size does not necessarily mean advanced neck disease.
Larynx Replacement by a Device after Total Laryngectomy: Initial Clinical Experience, Future Steps
Authors: Dupret‐Bories Agnès , Schultz Philippe , Vrana Nihal Engin , Hémar Patrick , Vautier Dominique , Lavalle Philippe , Debry Christian
Published: September 2014

Objectives:

To present the first cases of laryngeal rehabilitation by an artificial larynx performed after a total laryngectomy. The prosthesis aims at proposing an alternative to laryngeal transplantations and to techniques of tissular engineering and/or transplants by free fragments, used essentially in tracheal reconstructions.

Methods:

The artificial larynx was developed thanks to fundamental biomaterial research and long‐term animal experiments. The insertion is a 2‐stage procedure. The first step, performed immediately after the total laryngectomy, consists of connecting the trachea with a hollow titanium tube. After a 6‐week period of healing, or 3 months after radiotherapy, a swallowing valve is fixed over the integrated titanium tube (second step).

Results:

Four patients have been treated (2 whole prosthesis, 2 partial prostheses) from June to December 2012. Two patients were able to talk in a whispering fashion while the tracheostomy was temporarily closed; their functioning in the relevant postoperative problem areas, such as swallowing, breathing, and smelling were significantly improved.

Conclusions:

Our clinical trials demonstrated that a temporary closure of the tracheostomy opening can be achieved. Potential improvements of this larynx replacement open real perspectives of complete rehabilitation after total laryngectomy. The artificial larynx, which does not require immune‐suppressor treatment, would avoid the definitive tracheostomy, considered by most patients as a loss of physical and psychological integrity.
Facial Fractures Secondary to Bicycle Accidents
Authors: Orb Quinn T. , Taggart Michael , Williams Bryce , Ward Preston D.
Published: September 2014

Objectives:

(1) Determine the incidence of facial fractures. (2) Characterize the type of craniofacial injuries due to bicycle trauma.

Methods:

Using CPT codes, we completed a query of facial fractures treated at a tertiary medical center between 1999 and 2012. Individual chart review of 1108 patients revealed 28 patients who were treated for facial fractures secondary to bicycle accidents.

Results:

Of the 28 patients identified, 86% (n = 24) were male and 14% (n = 4) were female. The median age was 27.5 with a range from 4 to 78 years. Male patients between the ages of 13 and 39 showed the highest incidence of injury. Alcohol was involved in 18% (n = 5) of cases. A total of 18 (64%) patients were hospitalized, with 28% (n = 5) of hospitalized patients admitted to the intensive care unit. The most common injury type was nasal fracture (46%, n = 13), and the craniofacial region most commonly injured was the mid‐face (50%, n = 14), with tripod fractures (36%, n = 5) and Le Fort I fractures (29%, n = 4) as the most likely injuries. Ejection from the bicycle was the most common mechanism of injury cited (50%, n = 14). Though only 18% (n = 15) of patients were involved in a collision with a motorized vehicle, all of these patients required hospitalization. Complex surgery was required in 54% (n = 15) of patients. Nine patients (32%) required closed reduction of a fracture and 4 (14%) underwent maxillomandibular fixation.

Conclusions:

Bicycle accidents can cause significant craniofacial injuries with many patients requiring hospitalization and surgery, especially when a motor vehicle is involved.
Interpretation of Incidental Head and Neck Uptakes on PET/CT in Patients with Lung Cancer
Authors: Gobel Yves , Abgral Ronan , Potard Gael , Salaun Pierre‐Yves , Marianowski Remi , Valette Gerald
Published: September 2014

Objectives:

Smoking is the major risk factor for lung and head and neck cancer. The purpose of this study is to determine the clinical impact of the incidental head and neck positron emission tomography (PET)/computed tomography (CT) findings in patients undergoing investigation for lung cancer.

Methods:

The reports from PET/CT studies for patients with lung cancer from September 2005 and April 2012 were retrospectively reviewed. The incidental head and neck findings were interpreted as suggestive of second primary malignancy. These incidental findings were compared with the final diagnosis obtained from clinical and histological investigations.

Results:

A total of 592 patients were investigated for lung cancer in the study period. Head and neck PET/CT positive lesions suggestive of second primary malignancy were found in 65 (11%) patients. Twenty‐three patients had nasoendoscopy, and a biopsy was done in 10 patients. In 4 (0.68%) patients, these lesions were proven of second primary malignancy: 2 squamous cell carcinoma (larynx and oral cavity), 1 undifferenciated carcinoma (parotid), 1 osteosarcoma (mandible). At a median follow‐up of 13 months, 3 of 4 patients with a second primary died from a malignancy and 1 had no evidence of disease. Metastasis from lung adenocarcinoma was found in 2 (0.34%) patients.

Conclusions:

PET/CT detected unexpected head and neck primary malignant tumors in at least 0.68% of patients with lung cancer. Among patients who underwent clinical investigations, 26.1% had a head and neck malignant tumor.
Invasion of the Thyroid Gland in Advanced Laryngeal and Hypopharyngeal Squamous Cell Carcinoma
Authors: Mangussi‐Gomes João , Leonhardt Fernando D. , Moussalem Guilherme F. , Ahumada Nicolas G. , Oliveira Cleydson L. , Hojaij Flávio C.
Published: September 2014

Objectives:

(1) Evaluate the frequency of invasion of the thyroid gland in patients with laryngeal or hypopharyngeal squamous cell carcinoma (SCC) submitted to total laryngectomy (TL) or pharyngolaryngectomy (TPL) associated with thyroidectomy. (2) Determine whether clinico‐pathological characteristics can predict glandular involvement.

Methods:

A retrospective study was conducted in an academically affiliated tertiary care referral center. Charts and anatomopathological reports of surgical specimens of 93 patients treated in the period from January 1998 to July 2013 were reviewed. All patients presented with laryngeal or hypopharyngeal SCC and underwent TL or TPL in association with thyroidectomy. Adjuvant therapy was indicated when tumor or neck conditions required it. Sociodemographic data, frequency of thyroid gland invasion, and other clinico‐pathological variables were analyzed.

Results:

Tumor was staged as T2 in 10 patients, T3 in 26 patients, and T4 in 53 patients. Five patients had initial stage II and 88 had advanced stage III‐IV disease. The overall frequency of invasion of the thyroid gland was 16.1%. Carcinomas that invaded the thyroid gland were more advanced (P =. 005) and more frequently staged as T4a (P =. 001). Glandular involvement was associated with invasion of the anterior commissure (odds ratio [OR] = 5.9; confidence interval [CI]–95% 1.2‐27.7), subglottis (OR = 12.0; CI‐95% 1.5‐95.8), thyroid cartilage (OR = 4.2; CI‐95% 1.1‐16.1), and cricoid cartilage (OR = 18.7; CI‐95% 5.0‐70.2).

Conclusions:

Invasion of the thyroid gland is uncommon in the context of laryngopharyngeal SCC. Clinico‐pathological features such as advanced tumors, T4a tumors, anterior commissure, subglottis, thyroid cartilage, and cricoid cartilage involvement are more associated with glandular invasion. Indications for thyroidectomy should be refined in order to reduce morbidity of the surgical treatment.
Need for Level V Neck Dissection in T3‐T4 Oral Squamous Cell Carcinoma
Authors: Marfani Muhammad S.
Published: September 2014

Objectives:

(1) Recognize the frequency of level V neck node involvement in T3‐T4 oral squamous cell carcinoma. (2) Analyze the need of level V neck dissection with N0 ‐ N1 neck in T3‐T4 oral squamous cell carcinoma (SCC).

Methods:

Noninterventional, descriptive study from January 2011 to August 2012 at Dow University of Health Sciences & Civil Hospital Karachi, Pakistan, a tertiary care teaching hospital. Sampling was nonprobability and purposive. Histopathologically proven cases of squamous cell carcinoma of oral cavity with T3‐T4 lesion and N0‐N1 neck on basis of clinical examination and computed tomography scan findings were included in this study. All patients underwent modified radical neck dissection type‐I along with excision of the primary growth.

Results:

Forty‐nine patients fulfilling selection criteria were assessed on the basis of histopathological reports. At level I, metastatic lymph nodes were positive in 12 patients; 4 had positive nodes at level II and 2 each at level III and IV. However, none were positive at level V. Primary lesion was involving cheek in 40 and tongue in 9 cases. Histopathology revealed moderately differentiated SCC in 33 and well‐differentiated SSC in 16 patients.

Conclusions:

Our study suggests that level V neck dissection is not needed in oral SCC with N0‐N1 neck even in T3‐T4 lesions. However, as the sample size is small, further study with a larger number of cases is required to establish future guidelines for the extent of neck node clearance in oral cancer.