bluuebunny/crossref_metadata_2025 huggingface dataset:
Restoration of Recurrent‐Laryngeal‐Nerve Function after Injury in a Rat Model
Authors: Mor Niv , Naggar Isaac , Das Olipriya , Nakase Ko , Silverman Joshua B. , Sundaram Krishnamurthi , Kollmar Richard
Published: August 2013

Objectives:

Recurrent laryngeal nerve (RLN) injury occurs in 4‐10% of thyroid surgeries. Spontaneous RLN regeneration takes months and is often incomplete. Lithium promotes neuronal growth in vitro. We developed methods to objectively detect vocal‐fold impairment in the rat and tested whether systemic lithium enhances recovery after RLN injury.

Methods:

The right RLN was crushed in eight adult rats, and osmotic pumps releasing either lithium or water were implanted. Eight sham‐operated animals were also implanted with either lithium or water pumps. Vocal‐fold motion was captured by microsuspension laryngoscopy and was measured quantitatively by image analysis at the time of surgery and at one and four weeks. Vocalizations, breathing patterns, and laryngeal electromyography were assessed at four weeks.

Results:

Cessation of unilateral vocal‐fold motion was observed simultaneously with every RLN crush. One week after surgery, 50% of “Crush/Water” animals exhibited full vocal‐fold motion, compared to 75% of “Crush/Lithium” and 100% of the sham‐operated animals. In animals with unilateral vocal‐fold immobility, the quantitative analysis also revealed a subtle decrease of vocal‐fold movement on the non‐operated side. At four weeks after surgery, vocalizations, breathing patterns, vocal‐fold motion, and electromyograms were indistinguishable among all groups. Lithium‐treated animals weighed 5% less than water‐treated controls.

Conclusions:

Quantitative endoscopy is a sensitive and efficient tool for detecting vocal‐fold impairment in rats. While our results might suggest enhanced recovery in lithium treated animals, all animals showed a rapid return of vocal‐fold motion. Perhaps more severe nerve injury is necessary to uncover an effect of lithium on nerve regeneration.
Balloon Dilation of the Cartilaginous Portion of the Eustachian Tube
Authors: Silvola Juha T. , Kivekäs Ilkka , Poe Dennis S.
Published: August 2013

Objectives:

Studies of Balloon Eustachian tuboplasty (BET) have shown encouraging results with short follow‐up in small series. We present long‐term results of a prospective study in which subjects act as their own controls. Our pilot study showed patients with prolonged otitis media with effusion (OME) or tendency to atelectatic tympanic membrane (TM) clearly benefit from BET. We chose this patient group for long‐term follow‐up.

Methods:

Out of 80 patients with BET, 42 consecutive adult patients were included. Subjects’ inclusion criteria were OME and/or tendency to atelectasis, type B or C tympanograms, and inability to inflate their middle ears by Valsalva maneuver. All patients had a longstanding ET dysfunction relieved only by repeated tympanostomies. Outcomes included ability to perform a Valsalva maneuver, audiometry, tympanometry, videoendoscopy of the ET with mucosal inflammation rating scores, and otomicroscopy.

Results:

All cases were dilated successfully, without major complications. Follow‐up was 1‐3.5 years. Eighty‐one percent (34/42) of patients were able to do a Valsalva maneuver after balloon dilation. Tympanometry Results showed clear improvement even though many patients have permanent damages in their TMs after longstanding ME ventilation problems. The successful patients did not need new tympanostomy tubes. Also, subjective symptoms were relieved. For 19% (8/42) the ET function did not recover.

Conclusions:

There is accumulating evidence that BET effectively improves ET function in ears with OME or atelectasis. The procedure is well tolerated and without significant complications. The follow‐up continues for these patients, and we investigate possible reasons for negative results.
Does Residual Spiral Ganglion Cell Count Predict Performance in Patients with Bilateral Multichannel Cochlear Implants?
Authors: Seyyedi Mohammad , Nadol Joseph B.
Published: August 2013

Objectives:

Although published reports have not demonstrated a positive correlation between residual spiral ganglion cells (SGC) and word recognition in patients with unilateral multichannel cochlear implants, this study was designed to determine whether word recognition scores after implantation are a function of residual SGCs in patients with bilateral multichannel cochlear implants.

Methods:

Study Design: Retrospective case series. Setting: Temporal bone banks of Massachusetts Eye and Ear Infirmary and House Research Institute. All subjects with bilateral multichannel cochlear implants who were deafened bilaterally by the same etiology were studied. A total of 8 temporal bones from 4 subjects were identified and processed after death for histology. The SGCs were counted by standard techniques. The differences between the better and worse SGC counts as well as the differences in Consonant Nucleus Consonant (CNC) scores were calculated for each subject. Correlation analysis was then performed between the differences of SGC counts and the differences of CNC scores. Statistical power was calculated to illustrate how the results can be used to estimate the sample size as a function of effect size.

Results:

Differences in SGC counts were highly correlated with the differences in CNC word scores (Pearson's correlation = 0.972, P = 0.028) such that with a power of 95% and α = 0.05, only 4 cases were needed to show the same effect size.

Conclusions:

This study suggests the higher residual SGCs predicted better performance after implantation. The results also justify any attempts to reduce the effect of insertional trauma which may adversely affect SGC count.
Ischemic Preconditioning (IPC) with Resveratrol on Epigastric Rat Flap
Authors: Petrone Paolo , Quaranta Nicola , Fiorella Maria‐Luisa , Armenio Andrea , Pascone Michele
Published: August 2013

Objectives:

Investigate the effects of ischemic preconditioning (IPC) plus resveratrol on the viability of epigastric rat flaps for reconstructive microsurgery.

Methods:

Fifteen Sprague‐Dawley rats were used from September 2011 to December 2011. Superficial epigastric artery‐ and vein‐based island flaps (control flap and resveratrol flap) were used. IPC was applied to both flaps for 60 minutes. Therefore we administered 0.2 cc of resveratrol in the artery of the resveratrol Flap. On day 14, viable flap areas were measured, and taken for histological examinations with hematoxylin‐eosin staining and CD34+ hematopoietic progenitor cells analysis.

Results:

We described destruction of skin and subcutaneous tissues in all control flaps, with hypoxic and ischemic areas and exudative phlogosis. The CD34 analysis was negative. The resveratrol flaps description was completely different. The necrosis and the acute inflammation were minimal. Instead, there was an important angiogenesis. Three rat flaps failed. However, there was angiogenesis also in the failed flaps, although reduced. In all resveratrol flaps there was large lymphoplasmacytic infiltrate, typical of chronic reparative processes, a good indicator of the end of acute inflammatory process.

Conclusions:

The IPC and the resveratrol made a significant contribution to the flap viability. The results of this study will contribute to the literature about the hemodynamics of rat flaps and guide further studies on the issue for the free flap in the reconstructive microsurgery.
Meta‐analysis of Meniett Therapy for Ménière's Disease
Authors: Ahsan Syed F. , Standring Robert T.
Published: August 2013

Objectives:

Evaluate the efficacy of Meniett micropressure treatment for Ménière's disease by performing a meta‐analysis of all relevant treatment studies.

Methods:

Systematic review of the English literature using Medline, Ovid, and Cochrane library from January 1996 to December 2012. We selected all studies for which the Meniett micropressure device was used to treat patients with definitive unilateral Ménière's disease. We did not include isolated case reports and general reviews. Random and fixed models were used to estimate overall effect size.

Results:

Of 80 abstracts screened for relevancy, 18 studies were selected for further review. For hearing, only 9 studies reported pure tone average (PTA) pre‐ and post‐Meniett application. The difference in PTA between pre‐ and post‐micropressure device application was not significant (P = 0.72). Seven studies reported American Academy of Otolaryngology (AAO) functional score pre‐ and post‐treatment. Analysis shows significant improvement of AAO functional score after treatment (P = 0.04). Eight studies reported frequency of vertigo before and after treatment. The treatment was found to be significant in reducing frequency of vertigo (P < 0.0001).

Conclusions:

The Meniett device appears to be a safe, non‐destructive treatment alternative for patients refractory to initial medical therapy for Ménière's disease. The overall body of literature on the efficacy of the Meniett device is sparse and is an obvious limitation of this analysis, yet the data obtained will help to enlighten practitioners on the usefulness of the Meniett device.
Care of Pediatric Tracheostomy in the Immediate Postoperative Period and Timing the First Tube Change
Authors: Lippert Dylan C. , Dang Phat , Kille Tony
Published: August 2013

Objectives:

1) Analyze the impact of a new postoperative care protocol on complications, including skin breakdown. 2) Analyze the safety of performing the first tracheostomy tube change prior to postoperative day 5.

Methods:

Retrospective case series in an academic medical center. Patients: Pediatric patients undergoing tracheostomy from February 2010 to February 2013. Intervention: In 2012 a new protocol was instituted for pediatric tracheostomy care in the immediate postoperative period that included: 1) securing tracheostomy tubes with Velcro straps rather than twill ties, 2) placing a clean drain sponge around the tracheostomy tube daily, and 3) performing the first tracheostomy tube change on postoperative day 3 or 4. Outcome Measures: 1) Rate of complications, including skin breakdown, related to the tracheostomy tube and securing straps. 2) Presence of a mature stoma allowing for a safe first tracheostomy tube change.

Results:

37 patients in the pre‐protocol group and 16 in the post‐protocol group were analyzed. Rate of skin breakdown related to the tracheostomy tube or securing straps was significantly higher in the pre‐protocol group (32.40% vs. 0%, P = 0.01). There was a trend towards a higher overall complication rate change in the pre‐protocol group, but this was not statistically different (18.90% vs. 0%, P = 0.062). In the post‐protocol group, all tube changes were safely performed on postoperative day three or four.

Conclusions:

This new care protocol for pediatric tracheostomies resulted in decreased rates of skin breakdown. In addition, pediatric tracheostomy tubes can be safely changed as early as 3 days postoperatively.
Orbital Fracture Repairs: A 5‐Year Institutional Analysis of Complications
Authors: Connor Matthew P. , Subramanian Meenakshisundar , Novak Joseph , Demartelaere Sheri , Brennan Joseph
Published: August 2013

Objectives:

1) Analyze the complications associated with orbital fracture repair. 2) Recognize the potential benefit of an interdisciplinary approach for complicated cases.

Methods:

Five‐year retrospective chart review of all orbital fractures treated at a military Level I Trauma Center from January 1, 2007, through January 1, 2012. All operative reports, inpatient and clinic notes were reviewed, and a database was created detailing patient demographics, nature of injury, and the surgical service and techniques used for each case. The otolaryngology, ophthalmology, and oral and maxillofacial surgery (OMFS) departments collaborated on the analysis of all cases and complications.

Results:

A total of 107 cases met inclusion criteria. 54 cases were treated with operative repair. The otolaryngology service performed 20 operations and had 6 complications with 3 patients requiring surgical revision. These complications included 3 cases of entropion and 3 cases of ectropion. The OMFS service performed 19 operations and had 6 complications with 4 patients requiring surgical revision. These complications included 3 cases of entropion and 5 cases of postoperative diplopia. The ophthalmology service performed 5 operations and had 1 complication of diplopia that required surgical revision. A total of 11 cases were treated by the otolaryngology and/or OMFS service in conjunction with ophthalmology as a team approach. None of these cases experienced a postoperative complication.

Conclusions:

Surgical treatment of orbital fractures can have serious complications that often require surgical revision. An interdisciplinary team approach has proved effective at our institution and should be considered for any complicated case.
Impact of Otitis Media Severity on Children's Quality of Life
Authors: Grindler David J. , Blank Sarah I. , Lieu Judith E.C.
Published: August 2013

Objectives:

Children with otitis media suffer sleep disturbances, loss of appetite, earache, and psychosocial and behavioral problems. Our objective was to describe the impact of otitis media severity on infant quality of life (QoL).

Methods:

Study Design: Multi‐institutional prospective cross‐sectional study. Setting: otolaryngology, family practice, and pediatric outpatient clinics. Subjects: Children 6‐24 months of age with and without a primary diagnosis of recurrent otitis media. Data were collected from providers and parents, including relevant patient history, a Family Information Form, the PedsQL Infant quality of life survey, and the 6‐item child with OM QoL survey (OM‐6).

Results:

A total of 2414 patients were enrolled. The average age was 16 months, and 58% were male. The mean OM‐6 score was 3.26, slightly more severe than the reported 2.8 for the average child with OM. The mean PedsQL Infant scores were 77 for children less than 1 year old, and 79 for children >1 year. These values indicate worse QoL compared to the reported average scores for healthy and acutely ill infants, 82.47 and 79.46, respectively. Higher OM‐6 scores were significantly correlated with worse PedsQL Infant scores, Pearson r values ‐0.602 and ‐0.563, P < 0.01. Other factors that correlate with QoL in this population will be discussed.

Conclusions:

Children 6‐24 months of age with recurrent OM had a mean PedsQL score significantly worse than similarly aged healthy children. Worse PedsQL Infant scores were highly correlated with elevated OM‐6 scores, suggesting that severity of OM significantly affects child QoL.
Incidence and Risk Factors for Central Sleep Apnea in Infants with Laryngomalacia
Authors: Tanphaichitr Archwin , Tanphaichitr Pattraporn , Apiwattanasawee Polporn , Rutter Michael J. , Simakajornboon Narong
Published: August 2013

Objectives:

Identify the incidence of and risk factors for central sleep apnea in infants diagnosed with laryngomalacia.

Methods:

We conducted a retrospective study in infants with laryngomalacia. All infants had diagnostic polysomnography (PSG) performed during 2003‐2012. Infants who underwent supraglottoplasty or other upper airway surgery prior to PSG were excluded. Central sleep apnea (CSA) was defined as central apnea index ≥ 5. Demographic data, underlying diseases, and PSG data were reviewed and analyzed.

Results:

Fifty‐four patients met the inclusion criteria. The mean age at the date PSG was performed was 3.35±2.69 months. The incidence of central sleep apnea in infants with laryngomalacia was 46.30%. There was a significantly higher incidence of CSA in patients with the following conditions: underlying neurologic disease or hypotonia (61.11% vs. 38.89%, P = 0.0029), premature infants (62.5% vs. 43.48%, P = 0.0045), history of apparent life threatening events (66.67% vs. 42.22%, P = 0.0006), and age less than 3 months (54.84% vs. 34.78%, P = 0.0068). Severity of obstructive sleep apnea, history of gastroesophageal reflux, pulmonary disease, and symptom severity were not significantly associated with increased risk for CSA. Analysis of sleep architecture revealed a decrease in total sleep time (345.38 ± 70.61 minutes vs. 393.45 ± 68.25 minutes, P = 0.02) and sleep efficiency (67.69 ± 8.93% vs. 75.22 ± 9.28%, P = 0.004) in the CSA group.

Conclusions:

Central sleep apnea is relatively common in infants with laryngomalacia, especially in high risk groups as described above. The presence of CSA can lead to alteration in sleep architecture. In addition to clinical evaluation, polysomnography may be warranted for the evaluation of infants with laryngomalacia and associated complex medical conditions.
Minimally Invasive, Image‐Guided Cochlear Implantation for Pediatric Patients: A Clinical Feasibility Study
Authors: Labadie Robert F. , Reda Fitsum A. , Noble Jack H. , Blachon Gregoire , Dawant Benoit M. , Fitzpatrick J. Michael , Balachandran Ramya
Published: August 2013

Objectives:

Minimally‐invasive, image‐guided cochlear implantation (CI) involves accessing the cochlea via a linear path from the lateral skull to the cochlea avoiding vital structures, including the facial nerve. Herein, we describe and demonstrate the feasibility of the technique for pediatric patients.

Methods:

Thirteen pediatric patients (1.5 to 8 years) undergoing traditional CI in a children's hospital participated in this institutional review board‐approved study. Three fiducial markers were bone‐implanted surrounding the ear, and a computed tomography (CT) scan was acquired. The CT scan was processed to identify the marker locations and critical structures of the temporal bone. A safe linear path was then determined to target the cochlea, avoiding damage to vital structures. A custom microstereotactic frame was then fabricated that would mount on the fiducial markers and constrain a tool to the desired trajectory. After traditional mastoidectomy and prior to cochleostomy, the custom microstereotactic frame was mounted on the bone‐implanted markers to confirm that the achieved trajectory is safe and accurately accesses the cochlea.

Results:

For all the 13 patients, it was possible to determine a safe trajectory to the cochlea. Custom microstereotactic frames were fabricated for the desired trajectory and validated successfully on nine patients. Two of these patients had inner ear malformation, and this technique helped the surgeon identify the location for cochleostomy. For patients with normal anatomy, the closest distance of the trajectory to facial nerve and chorda tympani were 1.26 ± 0.32 mm and 0.97 ± 0.40 mm, respectively.

Conclusions:

Minimally‐invasive, image‐guided cochlear implantation is feasible for pediatric patients.
Outcomes of Cricotracheal Resection in Airway Reconstruction for Expanded Indications
Authors: Myer Charles M. , Hart Catherine K. , Tabangin Meredith , Heubi Christine H. , Rutter Michael J. , Cotton Robin T. , de Alarcon Alessandro
Published: August 2013

Objectives:

1) Describe expanded indications of cricotracheal resection (CTR) in airway reconstruction, including revision reconstruction and young age. 2) Define outcomes associated with expanded indications of CTR.

Methods:

Retrospective review of patients undergoing CTR at a tertiary care hospital from January 1, 2005, to December 31, 2011. Primary outcomes included decannulation rates and surgical success, defined as absence of symptoms at last follow‐up. Logistic regression was used to examine age as a predictor of surgical success. Eighty patients were identified, with 68 patients having complete records available for review. Forty‐nine patients were under 21 years of age.

Results:

In pediatric patients, surgical indications included stenosis (n = 43, 87.76%), A‐frame deformity (n = 5, 10.2%), and laryngeal atresia (n = 1, 2%). Patients with subglottic stenosis (SGS) included 4 (9.3%) grade II, 34 (79.07%) grade III, and 5 (11.63%) grade IV. Thirty‐eight patients (77.55%) were tracheostomy‐dependent. Thirty‐one patients (63.27%) had a history of prior airway surgery. Decannulation was achieved in 40 patients (81.63%); 36 patients (73.47%) were asymptomatic at last follow‐up. Eight patients required additional open operation. Logistic regression analysis of pediatric patients showed over‐all surgical success was associated with increased age (P =. 02). Success rates between primary surgery and revisions were similar (67% vs. 77%, Fisher's exact test, P =. 51).

Conclusions:

In our pediatric cohort, we found success of CTR is associated with older age at time of reconstruction. There was no association between success and primary surgery, suggesting CTR remains a viable option in revision cases.
Role of Polysomnography in the Development of an Algorithm for Planning Tracheostomy Decannulation
Authors: Mehta Deepak , Robison Jacob G. , Greenberg Laura , Maguire Raymond , Simons Jeffrey P.
Published: August 2013

Objectives:

Examine the role of polysomnography (PSG) in helping determine readiness of tracheostomized patients for decannulation. Study design: Retrospective medical record review of pediatric patients who underwent PSG with tracheostomy tube in place with the goal of decannulation.

Methods:

Thirty‐three tracheostomized patients who underwent PSG from January 2006 to March 2012 were included. Outcome measures were successful decannulation, PSG results, surgical procedures, and medical comorbidities.

Results:

Of the 33 patients, 23 (69.7%) were decannulated and 10 (30.3%) were not. One (3.0%) patient failed long‐term decannulation. The average apnea‐hypopnea index (AHI) with a capped tracheostomy for those successfully decannulated was 2.75 (range 0.6 to 7.6), while the AHI for those not decannulated was 15.99 (range 3.2 to 62). Factors associated with success or failure to decannulate were assessed and an algorithm was developed to plan for successful decannulation. Laryngotracheal reconstruction was found to be a significant factor in those successfully decannulated. Those who were not decannulated were found to have multiple medical comorbidities and multi‐level airway obstructions.

Conclusions:

PSG is a useful adjuvant study in the process of determining a patient's readiness for decannulation. Our current algorithm for decannulation includes upper airway endoscopy with identification of levels of obstruction followed by surgical correction of those obstructions; capped PSG to determine patency of airway and help assess lung function; overnight admission for capping trial, with decannulation the following day, if well tolerated.
Computed Tomography Scans as an Objective Measure of Disease Severity in Chronic Rhinosinusitis
Authors: Likness Micah M. , Pallanch John F. , Sherris David A. , Kita Hirohito , Mashtare Terry , Ponikau Jens U.
Published: August 2013

Objectives:

A truly objective method of measuring disease severity in CRS does not exist. We evaluated computed tomography (CT) scans of chronic rhinosinusitis (CRS) patients using a novel 3‐D computerized method and compared them to a 2‐D objective computerized analysis of a single coronal slice through the osteomeatal complex (OMC), and subjective methods including Lund‐Mackay and Zinreich's modification of Lund‐Mackay.

Methods:

Forty‐six adults with symptoms and endoscopy confirmation of CRS underwent CT examination and received a triamcinolone injection, followed by CT scan 4‐5 weeks later. Analyze software determined the 3‐D total volume of inflammatory mucosal thickening in all sinuses. The triamcinolone injection served as a tool to determine each method's sensitivity to a treatment intervention.

Results:

The Lin's concordance class correlation (CCC) of the OMC method revealed the best correlation to the 3‐D volumetric computerized values (0.915), followed by the Zinreich (0.904) and Lund‐Mackay methods (0.824). Post‐treatment results demonstrated that both the OMC (0.824) and Zinreich's (0.778) methods had strong agreement with the 3‐D volumetric methods and were very sensitive to change, whereas the Lund‐Mackay (0.545) only had moderate agreement.

Conclusions:

Computerized CT analysis provides the most comprehensive, objective, and reproducible method of measuring disease severity and is very sensitive to change induced by treatment intervention. A 2‐D coronal image through the OMC provides a valid, user‐friendly method of assessing CRS and is representative of CRS severity in all sinuses. Zinreich's subjective method correlated well overall, but Lund‐Mackay lagged behind in disease representation and sensitivity to change.
The Effectiveness of Diet Control in the Treatment of Food‐Induced Allergic Rhinitis
Authors: Tan Bernard
Published: August 2013

Objectives:

Describe diet control as a novel treatment modality for allergic rhinitis that is likely to be food induced and analyze its efficacy.

Methods:

Prospective study conducted from 1995 to 2010. 449 patients with the diagnosis of allergic rhinitis refractory to conventional treatment (oral antihistamines and/or intranasal steroids) were recruited from the Ear, Nose & Throat & Allergy Clinic. A thorough history and ear, nose, and throat (ENT) examination identified each patient's symptoms of allergic rhinitis, treatment history, and concomitant atopic diseases. IgE mediated allergy to common inhalant allergens was tested by measuring serum specific IgE levels using specific IgE fluorescence enzyme‐labeled assays (ImmunoCAP), while hypersensitivity to common food and inhalant allergens was tested for using intradermal progressive dilution food test (IDPFT). With the help of dieticians, patients underwent 1 month of diet control therapy, and their symptoms after therapy were recorded.

Results:

After 1 month of diet control, 304 (67.7%) patients experienced >50% improvement in their AR symptoms. Patients allergic to malt, Baker's yeast, oyster, tea, tomato, and sesame were more likely to experience symptomatic improvement. Presence of concurrent IgE mediated allergies to common inhalant allergens did not influence the outcome (p=0.418). Addition of conventional therapy to the diet control therapy further improved the likelihood of a therapeutic outcome (p=0.011).

Conclusions:

Diet control therapy for a month can bring symptomatic relief to some patients with food‐induced allergic rhinitis.
Endoscopic Sinus Surgery Provides Effective Relief as Demonstrated by Pre‐ and Post‐operative Healthcare Use
Authors: Benninger Michael S. , Holy Chantal E.
Published: August 2013

Objectives:

Analyze the impact of endoscopic sinus surgery (ESS) on overall healthcare use for treatment of chronic rhinosinusitis (CRS), and evaluate the effectiveness of ESS based on pre‐ and post‐operative healthcare use.

Methods:

A retrospective database analysis was conducted using Marketscan. All patients with ESS (CPT 31254‐31288) in 2008 and at least 5 years continuous medical and drug plan enrollment were included (n=8,827). In‐ and outpatient medical history including prescriptions but excluding pain medication (potentially less disease‐specific) for all sinonasal procedures or diagnoses was analyzed. All costs were determined on a per‐patient, per‐quarter basis, from 4 quarters pre‐surgery to 8 quarters post‐surgery.

Results:

During the 4th quarter pre‐surgery (9‐12 months pre‐operative), healthcare use included ~1.95 prescriptions (95% confidence interval [CI] 1.89‐2.00), 1.92 visits or procedures per patient (95%CI: 1.83‐2.01), and total average cost of US$ 399.10 (95%CI: US$391.24‐US$406.96). These costs increased significantly within 2 months pre‐operatively to $1,523.41, including 3.75 prescriptions (95%CI: 3.68‐3.81). The cost of ESS and related medical care for 90‐day post‐op averaged $8,521.87 (95%CI: $8,505.16‐$8,538.58). By the 15th month post‐operative, healthcare costs dropped to $363.68 (95%CI: $355.77‐371.59), with 1.98 prescriptions (95% CI: 1.93‐2.04) and remained flat for the remainder of the follow‐up period. Cost of all drug categories declined post‐operatively, except for leukotriene modifiers.

Conclusions:

Immediately prior to ESS, patients’ healthcare needs increased approximately 4‐fold. Within 15 months post‐surgery, however, costs were statistically lower than observed 12 months pre‐surgery. These findings suggest that ESS may have provided timely management of a severe and unsustainable disease state.
Interrater and Intrarater Reliability of Philpott‐Javer and Kupferberg Staging following Sinus Surgery Based on Training
Authors: Parhar Harman S. , Thamboo Andrew , Habib Al‐Rahim , Chang Brent , Gan Eng C. , Javer Amin R.
Published: August 2013

Objectives:

The Philpott‐Javer and Kupferberg endoscopic mucosal staging systems for allergic fungal rhinosinusitis have previously demonstrated acceptable inter‐rater reliability among rhinologists. There are, however, numerous learners involved in patient care at tertiary centers. This study aims to 1) Analyze the inter‐rater and intra‐rater reliability of the Philpott‐Javer and Kupferberg scoring systems among otorhinolaryngology learners at different stages in training; 2) Analyze whether the Philpott‐Javer scoring system can be used reliably by learners compared to an experienced rhinologist.

Methods:

This retrospective study examined the endoscopic photographs of patients who had undergone post‐surgical endoscopy at a tertiary sinus center in January 2013. 150 Images (3 images randomly selected from 50 patients) were played twice, one week apart, in a randomized loop and scored according to Philpott‐Javer and Kupferberg criteria by a staff rhinologist, a rhinology fellow, a senior otorhinolaryngology resident, a junior otorhinolaryngology resident, and a medical student.

Results:

The inter‐class correlation between the 5 raters was 0.7600 (95% CI: 0.6917, 0.8161) and 0.6679 (95% CI: 0.5997, 0.7312) for the Philpott‐Javer and Kupferberg scoring systems respectively, suggesting substantial reliability. Intra‐rater data showed substantial reliability (kappa values between 0.588 and 0.844) among all raters using both systems. There was also moderate to substantial agreement between the learners and the staff rhinologist (kappa values between 0.534 and 0.710).

Conclusions:

Results suggest that both the Philpott‐Javer and Kupferberg staging systems have acceptable intra‐rater and inter‐rater reliability among learners of differing levels of clinical experience and are suitable for evaluating progress following endoscopic surgery.
Porcine Small Intestine Submucosal Grafts for Post‐tumor Resection Orbital Reconstruction
Authors: Phillips James D. , Riley Kristen O. , Woodworth Bradford A.
Published: August 2013

Objectives:

With sinonasal malignancy, removal of the medial orbital wall for tumor involvement is required to obtain complete oncologic resection. However, orbital fat herniation can produce significant morbidity, including enophthalmos and diplopia. The purpose of the current study was to evaluate outcomes following use of porcine small intestine submucosa (SIS) grafts for orbital reconstruction following extirpation of sinonasal malignancies.

Methods:

Review of prospectively collected data regarding orbital reconstruction using SIS was performed. Demographics, tumor histology, size of orbital defect, adjuvant treatment, clinical status, and complications were recorded.

Results:

Seventeen patients (average age 58, range 27‐82) had SIS grafting of the medial orbital wall over a five year period at our tertiary academic institution. Average orbital wall defect size was 1.6 x 2.1 cm (height vs. length). Tumor histopathology included esthesioneuroblastoma (n=5), squamous cell carcinoma (n=4), adenocarcinoma (n=2), sinonasal undifferentiated carcinoma (n=2), melanoma (n=3), and neuroendocrine carcinoma (n=1). Surgical goals were curative intent in all patients. Ten patients had postoperative radiation therapy, while 5 individuals had surgical extirpation following neoadjuvant chemotherapy and radiation. All patients had complete locoregional control at last clinical follow‐up (average 16 months, range 2‐54), although three patients developed distant metastases. The only orbital complications noted were enophthalmos (n=1), periorbital cellulitis (n=1), and orbital wall crusting (n=1).

Conclusions:

SIS reconstruction of orbital wall defects was effective in the current series of patients with only one patient developing noticeable enophthalmos and a low incidence of surgical complications.
Prevalence and Associations of Excessive Daytime Sleepiness in an Asian Multiethnic Adult Population
Authors: Ng Chew Lip , Liu Xuandao , Lim Fiona P. , Liang Fueng H.R.
Published: August 2013

Objectives:

Investigate the prevalence and associations of excessive daytime sleepiness (EDS) in a multi‐ethnic Asian adult population in Singapore.

Methods:

A cross‐sectional study was conducted in an urban town using an interviewer‐administered questionnaire in 2008. 1003 subjects over 40 years of age were selected after randomization. EDS was assessed using the Epworth Sleepiness Scale. A score of 10‐12 indicated mild‐moderate EDS; a score greater than 12 indicated severe EDS. Information on lifestyle, socio‐economic conditions and medical comorbidities were collected.

Results:

The prevalence of EDS was 21.43%. Increased risk of EDS was associated with larger housing types, Prevalence Ratio (PR) 2.21 (95% CI 1.73‐2.82); clinical depression, PR 1.95 (95% confidence interval [CI] 1.07‐3.59); monthly household income higher than US$4846 (S$6000), PR 1.79 (95% CI 1.27‐2.05); desk‐bound vocations, PR 1.77 (95% CI 1.39‐2.25); younger age (40‐49 years old), PR 1.67 (95% CI 1.23‐2.26); alcohol consumption, PR 1.62 (95% CI 1.23‐2.14); employment, PR 1.61 (95% CI 1.27‐2.05); working night shift, PR 1.60 (95% CI 1.09‐2.36); tertiary education, PR 1.50 (95% CI 1.15‐1.93); male gender, PR 1.49 (95% CI 1.13‐1.95); and presence of 2 or more symptoms of depression PR 1.39 (95% CI 1.00‐1.93).

Conclusions:

The prevalence of EDS is comparable to the levels in the United States. EDS was associated with socioeconomic, lifestyle factors, depression, and depressive symptoms. Ethnicity, body‐mass‐index, and waist circumference were not found to be significant.
Role of FOXP3+ CD4+ and FOXP3+ CD8+ T Regulatory Cells in Obstructive Sleep Apnea
Authors: Anderson Martin E. , Buchwald Zachary , Sanford Thomas R. , Aurora Rajeev
Published: August 2013

Objectives:

1) Examine the immune responses which may underlie adenotonsillar hypertrophy (ATH) associated with obstructive sleep apnea (OSA). 2) Discuss the role of effector and regulatory T‐cells in the inflammatory process within the tonsil and its association with apnea‐hypopnea index (AHI).

Methods:

Prospective tonsil specimens were collected from patients undergoing tonsillectomy for OSA at a tertiary‐care pediatric hospital between October 2012 and January 2013. Single cell suspensions of the tonsil samples were stained with fluor‐conjugated antibodies against CD3, CD4, CD8, FoxP3 (a regulatory T‐cell marker), and CD45RO (an activated effector T‐cell marker). The stained cells were then analyzed by flow cytometry. The levels of effector and regulatory T‐cells were then correlated with severity of disease, as quantified by AHI determined from polysomnography.

Results:

CD4 effector T‐cells (CD4 T‐eff) were significantly upregulated in pediatric patients with an AHI 5 relative to those with AHI < 5. This result, calculated by Mann‐Whitney two‐tailed test, indicates that the fraction of activated T‐cells increased with elevated AHI (P < 0.0095). FoxP3+ CD8 T‐cells (CD8 TcReg) were present at lower levels in patients with an elevated AHI. When these data were plotted as the ratio of CD8 T‐eff to CD8 TcReg versus AHI, a correlation coefficient of 0.67 was observed.

Conclusions:

The significant upregulation of CD4 T‐eff and the increased ratio of CD8 T‐eff to CD8 TcReg in relation to elevated AHI both suggest a immunologically‐driven response that is contributing to ATH and the development of OSA.
ZPPP Combined with Endoscopic Coblator Open Tongue Base Resection for Severe OSAHS
Authors: Lin Hsin‐Ching , Friedman Michael
Published: August 2013

Objectives:

Retrospectively investigate the safety and outcomes of Z‐palatopharyngoplasty (ZPPP) combined with endoscopic coblator open tongue base resection (ECO‐TBR) for the treatment of severe obstructive sleep apnea/hypopnea syndrome (OSAHS).

Methods:

Thirty‐five consecutive patients with severe OSAHS who had multilevel obstruction, failed continuous positive airway pressure therapy, and then underwent ZPPP combined with ECO‐TBR were enrolled in this study. The subjective symptoms and objective PSG parameters were collected preoperatively and at a minimum of 3 months postoperatively. Statistical analysis was determined by Wilcoxon signed rank test.

Results:

Three female and 32 male patients (mean, 42 years) had a minimum follow‐up of 3 months and complete data available for analysis. None of the patients had perioperative or postoperative complications. No long‐term obvious velopharyngeal insufficiency was encountered. The classical success rate was 62.9% (22/35). Three months postoperatively, the Epworth sleepiness scale decreased from 11.0 ± 4.2 to 8.7 ± 4.3 (p = 0.0006). The apnea/hypopnea index (/hr.), lowest oxygen saturation (%), and bed partner evaluation of patient's snoring visual analog scale (0‐10) decreased from 50.6±16.6 to 26.5 ± 23.5, 70.4 ± 9.9 to 80.1 ± 11.3, 9.86 ± 0.69 to 3.27 ± 1.96, respectively (all p<0.0001).

Conclusions:

This study shows the significant benefits of ZPPP plus ECO‐TBR in severe OSAHS patients.
Submandibular Gland Transfer in the Treatment of Refractory Xerophthalmia
Authors: Quintanilla‐Dieck Lourdes , Pittman Amy , Wax Mark K.
Published: August 2013

Objectives:

Dry eye syndrome is a very common condition characterized by ocular irritation due to a deficient tear film. In mild cases, patients present with an annoying foreign‐body sensation in the eyes. In its most severe form, it can cause ulceration of the cornea with spontaneous perforation and loss of the eye. There exists a small subpopulation of patients who suffer from extremely dry eyes. In these patients, routine surgical measures or medical management do not suffice to prevent complications. Submandibular gland transfer as a treatment for xerophthalmia has been studied and shown to be effective in other countries; however, the procedure is rarely used in the United States.

Methods:

We describe the procedure of microvascular submandibular gland transfer and discuss the outcomes in cases of submandibular gland transfer that have been performed at our institution to date.

Results:

In the series of patients reported from our institution, four procedures in three of the patients were successful, with improvement in epithelial defect on slit‐lamp examination and/or improvement in tear production. Two procedures in the fourth patient were unsuccessful; the first was complicated by scarring of the submandibular duct, which was unsalvageable with revision surgery. The gland was removed and replaced with the opposite submandibular gland, but the transplanted gland proved non‐viable.

Conclusions:

The technical expertise required for the transfer is readily available in almost all academic centers. The microvascular reconstructive surgeon has expertise in the harvesting of the flap, as well as in the transfer. When used, this technique provides an effective way to treat patients with refractory xerophthalmia.
Use of the Supraclavicular Artery Island Flap for Reconstruction of Cervico‐facial Defects
Authors: Kokot Niels C. , Mazhar Kashif , Reder Lindsay , Lee Peng Grace , Sinha Uttam K.
Published: August 2013

Objectives:

Describe the supraclavicular artery island (SAI) flap as an alternative flap for reconstruction of cervico‐facial defects.

Methods:

Retrospective chart review in an academic, tertiary referral center of our first 18 consecutive patients undergoing SAI flap reconstruction for cervico‐facial defects between 2010‐2012. Outcome measures included size and location of the defect, time to raise the flap, flap size and viability, and complications. Statistical analysis was performed using SAS 9.1.

Results:

Defects of the temporal bone (n=5), and cervical skin (n=13) were reconstructed. Mean flap width was 6.1cm (range 5‐9cm). Mean flap length was 21.7 cm (range 16‐28cm), with the proximal portion of the flap de‐epithelialized to match the defect resulting in a mean skin paddle length of 10.3 cm (range 5‐18cm). Minor donor site dehiscence occurred in 2 patients. Partial skin flap necrosis occurred in 2 patients, while 1 patient had complete loss of the skin paddle. There was a significant correlation between flap length greater than 22 cm and flap necrosis (chi‐sq p=0.01). No significant correlation between flap location and flap necrosis or dehiscence was found. 17 patients were happy with the cosmetic outcome of the flap.

Conclusions:

The SAI flap is a viable alternative to microvascular reconstruction of cervico‐facial defects in select cases. This flap is reliable, easy to harvest, and versatile. It provides a good color match in the region. Flap complications and donor site morbidity were minimal and resolve with conservative measures. Flaps longer than 22 cm have a higher risk of skin necrosis.
Venous Anastomosis with Microvascular Coupler in Head and Neck Reconstruction: Experience in 200 Consecutive Procedures
Authors: Robb Philip , Tulunay‐Ugur Ozlem E. , Suen James Y. , Moreno Mauricio A.
Published: August 2013

Objectives:

There is a scarcity of data on outcomes when GEM microvascular coupler is used for head and neck reconstruction. We sought to review our experience in a large, contemporary series.

Methods:

Retrospective chart review of 201 consecutive flaps performed in 193 patients between September 2009 and January 2013 in a tertiary academic setting.

Results:

The cohort consisted of 125 males with a mean age of 64 years (range 3‐83). A double free flap was performed in 8 cases. The most common defect locations were mandible (n = 62, 30.8%); oral cavity (n = 27, 13.4%), and cutaneous (n = 24, 11.9%). Flaps included anterolateral thigh (n = 85, 42.3%); fibula (n = 53, 26.4%); radial forearm (n = 37,18.4%); scapula, latissimus, and rectus (n=5, 2.5% respectively); iliac crest and vastus (n = 4, 2% respectively); and other (n = 3, 1.5%). A double venous anastomosis was performed in 26 flaps. The entire range of couplers (1‐4mm) was used, but the 2.5mm was the most commonly used (n = 83, 36.6%) followed by the 2.0mm (n = 47, 20.7%). Facial (n = 134, 59%), External jugular (n = 32, 14.1%), and superficial temporal (n = 22; 9.7%) were the most common recipient vessels. Seven cases underwent microvascular revision yielding arterial thrombosis in 1 case, pedicle torsion in 1 case, and venous thrombosis in 5 cases. The flap was successfully salvaged in 3 cases. A delayed failure in another patient yielded an overall flap success rate of 97.5%. None of the tested variables reached statistical significance for venous thrombosis or flap survival.

Conclusions:

The microvascular coupler is a reliable alternative for venous anastomosis in head and neck flaps. Given the low failure rate, a multi‐institutional study could help elucidate outcome predictors in this setting.
Cost‐Effective Management of Patients with Sinus Headache, Facial Pain, and Pressure: A Decision Analytic Approach
Authors: Ewbank Clifton , Dodick David W. , Lal Devyani
Published: August 2013

Objectives:

1) To study patients presenting to a tertiary otolaryngology clinic with primary complaints of sinus headache, facial pain, and/or pressure. 2) To perform a computer‐based decision analysis of these patients to maximize treatment effectiveness and minimize cost.

Methods:

A computer‐based decision analytic approach was used to model cost‐effectiveness (CE) of treatment of 253 adult patients presenting to a tertiary ear, nose, and throat (ENT) clinic over a two‐year period. Chief complaints were sinus headache and/or facial pain/pressure. Analysis of demographics and treatment data was performed. Management was classified into three categories: 1) maximal medical therapy (MMT) alone, 2) MMT followed by endoscopic sinus surgery (ESS) due to refractory disease, and 3) referral to neurology for pain without apparent sinus etiology. Established treatment algorithms were integrated with CPT based treatment costs to create a 66‐point decision tree that provides a comprehensive picture of CE of various modes of treatment for facial pain.

Results:

For patients without evidence of sinus disease, referral to neurology for facial pain saved $33.61 per patient for pain management. ESS resulted in a significant improvement in CE only with demonstrable sinus disease (C/E=26.37; p=0.027). Other trends observed include a non‐significant reduction in cost and effectiveness of using MMT first in patients without clinical evidence of sinus disease (C/E=12.98; p=0.064).

Conclusions:

Our model demonstrates favorable CE of determining the etiology of facial pain as early as possible and proceeding with MMT or with referral to neurology, accordingly. ESS should only be offered to patients with true sinus disease refractory to MMT.
Development and Validation of a Health‐Related Quality‐of‐Life Comorbidity Index
Authors: Levine Corinna G. , Weaver Edward M.
Published: August 2013

Objectives:

Comorbidity indexes adjust for comorbidity confounding on a specific outcome, but no index is designed specifically for a quality of life (QOL) outcome. The Functional Comorbidity Index was previously designed to predict physical function. The goals of this study: 1) Develop a Quality of Life Comorbidity Index (QOLI) designed specifically to predict QOL (measured using SF‐36 component scores) in sleep apnea patients; 2) Compare the ability to predict QOL between the QOLI, the Functional Comorbidity Index, and another commonly used index.

Methods:

A random sample of 300 subjects, selected from prospectively enrolled sleep apnea patients between 2004‐07, was split into a model‐development cohort (n=200) and a validation cohort (n=100). Additional comorbidities suspected to impact QOL were selected as candidate variables to add to the Functional Comorbidity Index. Multivariate linear regression using predictive stepwise modeling was applied to determine which candidate variables maximized the ability to predict QOL (adjusted R2). The resultant QOLI was tested in the validation cohort, and the ability to predict QOL was compared to other comorbidity indexes.

Results:

The QOLI model that best predicted QOL added smoking, illicit drug use, migraine, fibromyalgia, allergies, and sinusitis to the Functional Comorbidity Index. The ability to predict QOL (adjusted R2) was better in the QOLI by 10% compared to the Functional Comorbidity Index and by 18% compared to the Charlson Comorbidity Index.

Conclusions:

The QOLI is useful to predict quality of life and is a more robust predictor of QOL than other comorbidity indexes in obstructive sleep apnea patients.