bluuebunny/crossref_metadata_2025 huggingface dataset:
Endonasal Endoscopic Approach to the Orbit (EEAO)
Authors: Karkas Alexandre , Theodosopoulos Philip , Keller Jeffrey T. , Zimmer Lee A.
Published: August 2013

Objectives:

Describe the endoscopic anatomy of medial and inferior orbital walls and present 5 illustrative clinical cases.

Methods:

Two vessel‐injected cadavers (4 sides) were dissected through endoscopic endonasal transethmoid‐sphenoid‐maxillary approach.

Results:

Total ethmoidectomy and maxillary antrostomy were performed. Maxillary sinus roof was removed until reaching the infraorbital canal laterally. Anterior and posterior ethmoidal arteries were identified. Lamina papyracea was removed. Transnasal and transethmoidal sphenoidotomies were made. Periorbita was incised along medial and inferior orbital walls. Cavernous carotid artery was exposed and medialized to show oculomotor (CNIII), trochlear (CNIV), ophthalmic (CNV1), maxillary (CNV2), and abducent (CNVI) nerves in cavernous sinus. In superolateral wall of sphenoid sinus, the optocarotid recess was visualized as well as the optic nerve (CNII) and ophthalmic artery (OphA) entering the orbit. Anteriorly, the annulus tendineus of Zinn (ATZ) was found and incised, showing the insertion of superior, medial, and inferior rectus muscles with CNIII and its branches. CNII, nasociliary branch of CNV1, CNVI, and OphA also enter ATZ. Superior and inferior oblique muscles were seen outside ATZ. The anterior limit of dissection was the eye globe. Five clinical cases of EEAO (lymphoma, aspergilloma, hematoma, abscess, Graves’ disease) will be presented.

Conclusions:

EEAO is ideal for inferior and medial lesions of the orbit. Contrary to craniotomies, EEAO exposes CNII without removing orbital roof and anterior clinoid. Contrary to orbitotomies, EEAO provides excellent visualization with angulated endoscopes. Limits are lesions of superior or lateral part of the orbit or lesions that need manipulation of CNII or a section of medial rectus muscle.
Impact of Increased Postoperative Debridement Frequency following Functional Endoscopic Sinus Surgery
Authors: Manji Jamil , Habib Al‐Rahim , Wang Jay C.C. , Gan Eng C. , Hathorn Iain F. , Javer Amin R.
Published: August 2013

Objectives:

1) Compare sinonasal‐specific quality of life between patients receiving an additional postoperative visit at 14 days compared to a standard of care control group receiving debridements at one, four, and twelve weeks post–functional endoscopic sinus surgery (FESS). 2) Compare endoscopically assessed mucosal edema between the two groups at one and three months post‐FESS to determine if the additional postoperative debridement had an impact on sinus health.

Methods:

Adult chronic rhinosinusitis patients receiving FESS at a tertiary‐level rhinology center between January 2011 and 2012 were included. Records were retrospectively evaluated for sinonasal outcome test (SNOT‐22) and mucosal edema scores (Philpott‐Javer) at one and three months post‐FESS. Treatment subjects receiving additional debridement fourteen days post‐FESS were compared to control subjects receiving the standard of care. Subjects were matched in terms of baseline disease severity and extent of surgery.

Results:

The cohort consisted of 48 subjects equally distributed between study groups. SNOT‐22 scores did not differ between the two groups at one and three months post‐FESS. These findings were not statistically significant (p=0.67, 95% confidence interval [CI]: ‐10.05, 15.47; p=0.63, 95% CI: ‐14.54, 8.96). The treatment group presented with greater reduction in mucosal edema between 1 and 3 months, although this was not statistically significant (3.29 vs. ‐0.26; p=0.40, 95% CI: ‐4.83, 11.93).

Conclusions:

Additional postoperative debridement within the first month following FESS did not provide a significant improvement in quality of life and mucosal edema. However, a clinically significant improvement in mucosal edema was observed with the additional debridement.
Long‐term Outcomes in Sinus Surgery Using New Tools for Measuring Health‐Related Quality of Life
Authors: Remenschneider Aaron K. , D'Amico Laura , Litvack Jamie , Holbrook Eric H. , Gray Stacey T. , Metson Ralph B.
Published: August 2013

Objectives:

Compare pre‐ and post‐operative outcomes at 3 and 12 months using both disease specific (SNOT‐22, Chronic Sinusitis Survey) and general health related quality of life (EQ‐5D) assessments. Describe baseline Health utility values (HUV) in patients with chronic rhinosinusitis, and calculate the impact of sinus surgery on the HUV at 3 and 12 months.

Methods:

From February 2011‐2013, prospective pre‐ and postoperative quality of life data were obtained from patients with chronic rhinosinusitis at Massachusetts Eye and Ear Infirmary. Data obtained pre‐operatively were compared to post‐operative results at 3 and 12 months.

Results:

480 patients enrolled in the study. Three and twelve month response rates have been 73% and 69%, respectively. Patient scores on the SNOT‐22 significantly improved from 48.4 +/‐ 22.0 preoperatively to 22.8 +/‐ 20.3 at 3 months, 95% confidence interval (CI) [22.5, 28.6], and 25.9 +/‐ 20.0 at 12 months, 95% CI [18.8, 26.3]. Patient scores on the CSS similarly fell at 3 and 12 months, with statistically and clinically significant improvement. Baseline health utility values in our population scored at 0.81 +/‐ 0.13, where 0 is a quality of life equal to death and 1 is perfect health. Health utility values improved to 0.89 +/‐0.12, 95% CI [‐0.10, ‐0.06], at 3 months and remained unchanged at 12 months.

Conclusions:

Long term disease specific and general health related quality of life are significantly improved after endoscopic sinus surgery. Defining changes in health utility values after sinus surgery represents an important first step in meaningful comparative quality of life research.
Optimal Endoscopic Management of Sinonasal Inverted Papilloma: Recurrence‐Free Experience with Twenty‐one Patients
Authors: Okhovat Saleh , Taghi Ali S. , Choudhury Natasha , Saleh Hesham , Kuchai Romana
Published: August 2013

Objectives:

1) Explore developments in endoscopic techniques and their application in the management of Sinonasal Inverted Papilloma (SNIP). 2) Describe 0% recurrence rates with aggressive endoscopic resection of complex SNIP.

Methods:

Retrospective single‐center patient cohort analysis of twenty‐one cases of SNIP treated by endoscopic resection at Charing Cross Hospital from December 2002 to September 2012. Pre‐operative assessment included tomography or magnetic resonance imaging and biopsies. The origin and extent of the tumor determined the surgical strategy, and a combination of antrostomy, ethmoidectomy, sphenoidotomy, and endoscopic medial maxillectomy (EMM) with the assistance of angled instrumentation were performed. Sub‐periosteal dissection followed by diamond burr drilling of the underlying bone were performed in all cases. All patients were followed up by regular endoscopic surveillance.

Results:

The study group consisted of 12 (57%) male and 9 (43%) female patients with a mean age of 59 years. Eleven patients (52%) had undergone previous surgery. Association with malignancy was seen in 2 patients (excluded from this study). All patients were treated by pure endoscopic means without adjunctive procedures. Completion surgery was performed on 1 patient with residual disease and histological atypia identified early after the operation. No recurrences were observed after a mean follow‐up of 25 months.

Conclusions:

Our experience is one of the largest single‐center recurrence‐free case series for SNIP treated by pure endoscopic resection. It further supports the efficacy and safety of this technique even in complex recurrent cases and advocates its use as the gold standard first line surgical strategy.
PET/CT Has Greater Diagnostic Utility in Patients with Sinonasal Malignancy
Authors: Nishtala Arvind , Mercier Gustavo , Grillone Gregory A. , Jalisi Scharukh , Truong Minh‐Tam , Subramaniam Rathan , Devaiah Anand K.
Published: August 2013

Objectives:

In sinonasal malignancy, the use of fused positron emission tomography/computed tomography (PET/CT) may help clinicians in decision making more than standard CT +/‐ magnetic resonance imaging (MRI).

Methods:

A retrospective review of sinonasal malignancy patients undergoing PET/CT imaging between 2005 and 2011 at our institution was performed. Eighteen patients met all inclusion criteria: PET/CT performed with treatment and follow‐up at our institution. Histology, staging, imaging data, imaging reports, treatments, follow‐up, and disease status were compiled. A 6‐variable scoring system (tumor involvement, regional disease detection, distant metastases detection, malignant determination, tumor avidity, change in treatment) to examine imaging utility was devised.

Results:

In 12 patients (67%), PET/CT was superior to CT/MRI, while the latter was superior in only 3 patients (16%). Neither modality was superior in 3 patients (16%). PET/CT was able to identify regional or distant disease in 8 patients (44%), while CT/MRI did not (0%). CT/MRI showed more potentially involved tissue than in PET/CT. In 8/18 patients (44%), PET/CT could better distinguish between malignant and non‐malignant tissue; 10/18 patients (56%) were equivocal. The use of PET/CT led to a documented change in the patient's treatment plan in 11/18 patients (61%), compared to 1/18 change for CT/MRI (5%). In looking at overall utility of PET/CT vs CT/MRI in the 6 variables, PET/CT scored significantly higher (Chi‐squared, P = 0.02).

Conclusions:

For sinonasal malignancies, PET/CT better identifies regional and distant involvement, and malignant from non‐malignant tissue. Compared to CT/MRI data, PET/CT has a greater impact on the treatment and management of patients.
SF‐12® for Head‐and‐Neck Keloid Patients: Preliminary Results towards Creating a Keloid‐Specific Scale
Authors: Pattisapu Prasanth , Guy William M. , Brissett Anthony E.
Published: August 2013

Objectives:

1) Compare SF‐12® scores by head and neck keloid patients to U.S. Norms. 2) Contrast SF‐12® scores with keloid symptomatology, including pain, burning, itching, and infection. 3) Discuss the use of keloid‐specific quality of life (QOL) instruments over global health‐related QOL instruments in further research on head and neck keloids.

Methods:

Patients presenting to a keloid clinic in a tertiary referral institution between April 2012 and February 2013 were administered the SF‐12® during their first three appointments. Mental health and physical health composite scores (MCS and PCS) were calculated from SF‐12® surveys and compared with U.S. general population norm SF‐36® scores using two‐sample t‐tests. Associations between SF‐12® scores and symptoms were evaluated using Spearman's Rho.

Results:

First, second, and third visits were completed by 24, 16, and 14 patients, respectively. Median age was 29.5 years (range 15‐56), and 17% (4) were male. Average initial‐visit MCS and PCS scores were 52.9 (±7.8) and 55.1 (±5.1). No significant difference was found between MCS scores and national norms (p=0.08), but PCS scores were significantly higher than the norm (p<0.0001). No association was found between MCS or PCS scores and any symptoms, but negative association between pain scores and MCS and PCS scores approached significance (p=0.076 and 0.057, respectively).

Conclusions:

The goal of disease‐specific QOL measures is to increase measurement range over global health‐related QOL instruments, while increasing specificity to a health problem. We believe our results demonstrate global QOL scales are inadequate for addressing QOL issues faced by keloid patients, highlighting the need for keloid‐specific scales.
The Role of Postoperative Systemic Corticosteroids when Using a Steroid‐Eluting Spacer following Sinus Surgery
Authors: Dautremont Jonathan , Mechor Brad , Rudmik Luke
Published: August 2013

Objectives:

1) Describe the current evidence for middle‐meatal steroid‐eluting spacers in patients with chronic rhinosinusitis (CRS) following endoscopic sinus surgery (ESS) 2) Evaluate the need for postoperative systemic corticosteroids in CRS patients with nasal polyposis when using a steroid‐eluting middle meatal spacer following ESS.

Methods:

CRS patients with nasal polyposis who failed medical therapy and elected ESS (n=36) were enrolled into this randomized, double‐blind, placebo controlled trial. Patients were randomized into either a treatment arm (postoperative prednisone 30 mg once daily for 7 days; n=18) or placebo arm (placebo pill once daily for 7 days =18). Therapeutic outcomes were evaluated at 1 week, 3 weeks, and 2 months postoperatively. Primary outcome was endoscopic grading using the Lund‐Kennedy scoring system. Secondary outcome included disease‐specific quality of life (QoL) using the SNOT‐22 survey.

Results:

Both study arms received significant improvement in endoscopic grading and disease‐specific QoL from baseline compared to the two‐month follow‐up (p0.119).

Conclusions:

Minimizing the use of systemic corticosteroids in patients with CRS may avoid unwanted adverse events. Results from this study suggest that when using a middle meatal steroid‐eluting spacer during ESS for patients with nasal polyposis, postoperative systemic corticosteroids may not significantly improve short‐term endoscopic and disease‐specific QoL.
Topical Triamcinolone Acetonide/Carboxymethylcellulose Foam for Acute Exacerbations of Chronic Rhinosinusitis/Nasal Polyposis
Authors: Chaudhry Ajaz L. , Chaaban Mohamad R. , Woodworth Bradford A.
Published: August 2013

Objectives:

Chronic rhinosinusitis with nasal polyposis (CRS/NP) is a medical disease that is managed more effectively after endoscopic sinus surgery (ESS). Despite topical steroid management, acute inflammatory exacerbations (AEs) are common and typically treated with oral prednisone with well documented side effects. The objective of the current study was to critically evaluate the topical application of triamcinolone acetonide (160mg) in carboxymethylcellulose foam (TA/CMC) for AEs of CRS/NP after ESS.

Methods:

CRS/NP patients managed with ESS by a single rhinologist over a 5 year period were included in the study. Data were reviewed regarding demographics, number of AEs, revision surgery, Sinonasal Outcomes Test‐22 scores (SNOT‐22), frequency of oral prednisone and/or TA/CMC, and notable side effects.

Results:

A total of 371 CRS/NP patients were managed with ESS (49.3 weeks follow‐up, range 2‐249). All patients were managed with topical saline irrigations BID containing budesonide (0.5mg) or mometasone (0.6mg). Revision surgery was required in 8 patients. During this time period, 130 patients (46 years, range 28‐48) developed 267 AEs. Prior to initiating use of TA/CMC in 2010, 66 AEs were treated with prednisone. Subsequently, 116 out of 201 AEs were managed with TM/CMC with a sequential decrease in prednisone use over the last 3 years (77%, 39%, and 32%). SNOT‐22 scores (n=33 within 3 weeks) decreased significantly following TA/CMC instillation (1.69+/‐0.86, pre vs. 1.23+/‐0.8, post; P < 0.01).

Conclusions:

Management of AEs of CRS/NP changed dramatically with the use of TA/CMC in the current evaluation. The treatment appears well tolerated and is a useful tool for CRS/NP AEs in postoperative patient.
Evaluation of Upper Airway in Obstructive Sleep Apnea: Synchronized Imaging and Acoustic Analyses
Authors: Huon Leh‐Kiong , Lo Men‐Tzung , Chang Yi‐Chung , Chen Yun‐Ji , Wang Pa‐Chun
Published: August 2013

Objectives:

Snore signals are produced by soft tissue vibration in the upper airway (UA). To date, there is no gold standard to localize UA narrowing sites in patients with obstructive sleep apnea syndrome (OSAS). In this study, we use a “vocal tract model” to investigate the association between snore acoustic characteristics and UA collapse. Dynamic magnetic resonance imaging (dMRI) was used to provide UA anatomy information.

Methods:

We report data from 44 polysomnography (PSG)‐confirmed snoring episodes. Dynamics of UA and acoustic manifestations of snore events during natural sleep were recorded with synchronized dMRI and fiber‐optic microphone recording. After the deletion of background dMRI noises, the spectrum envelope was reconstructed by applying a vocal tract model to characterize the snoring patterns. The temporal change of spectrum envelope was analyzed using Gabor transformation to correlate with UA dynamics.

Results:

The snore events were categorized into 28 none, 7 typical (velopharyngeal), and 9 mixed (velopharyngeal and hypopharyngeal) obstructions. The snore's dominant frequency of envelop spectrum can differentiate none from typical UA obstructions (82.3±16.4Hz vs 101.9±9.1 Hz, p<0.01); and can differentiate mixed from typical obstructions (131.9±19.8 Hz vs.101.9±9.1 Hz, p < 0.05)

Conclusions:

The dynamics of acoustic patterns derived from the envelope of Gabor spectrogram are unique and characteristics in different types of obstruction with the advantage of low‐cost and easy availability. Therefore, the dynamics of acoustic patterns warrants further investigation to identify the structural changes of the obstruction sites in OSAS patients.
The Impact of Nasal and Sinus Surgery on Obstructive Sleep Apnea
Authors: Friedman Michael , Pott Thomas R. , Cipta Stephanie
Published: August 2013

Objectives:

Evaluate the impact of combined endoscopic sinus surgery (ESS) and nasal surgery on the objective measurements of obstructive sleep apnea (OSA) by comparing polysomnography (PSG) data before and after combined ESS and nasal surgery. Design: Retrospective review of medical records.

Methods:

Fifty‐one OSA patients with chronic sinusitis were identified who underwent combined ESS and nasal surgery as well as pre‐ and postoperative PSG. Clinic charts were reviewed and data collected. Pre‐ and postoperative PSG data were compared to determine whether combined ESS and nasal surgery improved apnea‐hypopnea index (AHI) and oxygen saturation.

Results:

Postoperative AHI did not change significantly following combined ESS and nasal surgery (P > 0.05). Change in AHI ranged from an increase of 51 events/hr to a decrease of 52.1 events/hr. 43% of patients had an improvement or worsening in postoperative AHI within 5 events/hr, and 80% had a change in AHI within 20 events/hr. There was no significant correlation between preoperative AHI, body mass index (BMI) and change in AHI (p > 0.05). Combined ESS and nasal surgery did not cure any of the patients’ OSA.

Conclusions:

There does not appear to be a significant change in AHI following combined ESS and nasal surgery in patients with chronic sinusitis and OSA. Combined ESS and nasal surgery can lead to an improvement, worsening, or lack of change in AHI. This study showed that BMI and preoperative AHI cannot be used to determine whether combined ESS and nasal surgery will impact their sleep apnea.
A Simplified Approach to Microvascular Head and Neck Reconstruction: A 17‐Year Experience with 1416 Cases
Authors: Seth Rahul , Nabili Vishad , Blackwell Keith E.
Published: August 2013

Objectives:

Free flap failure is a dreaded complication that significantly affects both patient postoperative morbidity and surgeon anguish. This presentation aims to 1) familiarize the audience with a simplified and highly reliable approach to microvascular head and neck reconstruction; and 2) discuss the surgical principles and perioperative management fundamental to achieving flap success greater than 99%.

Methods:

Retrospective chart review performed at a tertiary care academic center. 1416 consecutive free flaps were performed for head and neck defect reconstruction between 1995 and 2012. Patient demographics, defect and free flap characteristics, and postoperative flap survival were examined.

Results:

Fibula, radial forearm, subscapular system, anterolateral thigh, and rectus abdominis flaps accounted for 99% of procedures performed. Since 2005, the anterolateral thigh flap largely replaced the rectus abdominis flap. The rate of successful free flap transfer was 99.5%, with only 8 flap failures. Increased risk of free flap failure was encountered in fibula flaps (8 out of 614, 1.8%) versus all others (0 out of 802, 0%), p<0.01. Flap failures occurred more frequently in women (7 out of 478, 1.5%) than in men (1 out of 938, 0.1%), p<0.01.

Conclusions:

A simplified approach to microvascular reconstruction of the head and neck facilitates success rates in excess of 99%. Surgical principles attentive to selecting reliable flap donor sites, large caliber recipient vessels, non‐redundant and kink‐free pedicle geometry, and use of simple perioperative care measures enable high success. These principles are paramount in reducing flap loss, associated patient morbidity, and microvascular surgeon burnout.
Usefulness of Sleep Endoscopy in Predicting Positional Obstructive Sleep Apnea
Authors: Victores Andrew J. , Hamblin John S. , Gilbert Janet , Takashima Masayoshi
Published: August 2013

Objectives:

1) Evaluate the ability of drug‐induced sleep endoscopy (DISE) to identify patients with positional obstructive sleep apnea (OSA) and 2) assess the effects of body position on the upper airway during sleep. Study Design. Prospective, controlled study. Setting. Academic tertiary care center.

Methods:

Twenty patients with OSA were enrolled. They were equally divided into two groups depending on presence of positional OSA on polysomnogram. Positional OSA was defined by non‐supine 50% reduction in apnea‐hypopnea index. Patients were placed in both lateral and supine sleep positions and DISE performed. Upper airway collapse was compared between the sleep positions and between the two groups.

Results:

Most patients (80%) demonstrated multilevel obstruction on DISE. All positional OSA patients demonstrated at least a partial improvement in collapse while in the lateral sleep position. Most of the reduction in collapse involved the tongue base and epiglottis (P <. 05). Sleep position did not alter the upper airway morphology of patients without positional OSA. Tongue base and epiglottic obstruction while supine was significantly greater in positional as compared to non‐positional OSA patients (P <. 05). Apnea‐hypopnea index and body mass index were not significantly different between the two groups.

Conclusions:

Sleep position changes the upper airway morphology of positional OSA patients on DISE. Hypopharyngeal collapse was the primary site that improved with change in position. DISE in multiple sleep positions should be considered as part of a minimally invasive approach to surgical therapy of OSA.
Temporalis Tendon Transposition for Dynamic Facial Reanimation following Radical Oncologic Resection
Authors: Nagel Thomas H. , Howard Brittany E. , Donald Carrlene B. , Crujido Lisa R. , Hayden Richard E.
Published: August 2013

Objectives:

Report a patient series in which a temporalis tendon transposition was performed for facial paralysis following radical oncologic resection. 1) Describe the modifications in technique of temporalis tendon transfer associated with concurrent cancer resection. 2) Evaluate the effect of complex defects and their reconstruction on facial reanimation outcomes.

Methods:

Retrospective review of 10 patients who underwent orthodromic temporalis tendon transposition for dynamic facial reanimation of their facial paralysis following radical cancer resection from January 2010 through February 2013. Data was collected for parotid malignancy, defect composition, reconstructive details, postoperative course, complications, and outcomes.

Results:

All patients underwent radical parotidectomy with facial nerve sacrifice and resection of adjacent soft and/or bony tissue for parotid malignancy. Complex defects included cutaneous loss necessitating concurrent flap reconstruction (n=5), partial or total temporal bone resection (n=6), and mandibulectomy (n=2). All patients underwent dynamic reanimation with temporalis tendon transposition through a nasolabial incision. Facial reanimation was performed at the same time as the resection in 6 cases and in a delayed setting in 4 cases. There was no difference in outcomes in these two patient groups. Due to tumor involvement, six resections included sacrifice of the internal maxillary artery without resultant compromise of the temporalis transfer. During the follow‐up period, all patients had improved facial symmetry at rest and developed voluntary motion with post‐procedure facial training therapy.

Conclusions:

Temporalis tendon transposition is a reliable, straightforward option for dynamic facial reanimation in the oncologic patient. Radical resection does not prohibit using this technique.
Tension Pneumocephalus after Endoscopic Sinus Surgery: A Technical Report of Multiportal Endoscopic Skull Base Repair
Authors: Bly Randall A. , Morton Ryan , Kim Louis , Moe Kris S.
Published: August 2013

Objectives:

Large skull base defects and cerebrospinal fluid (CSF) leak repairs are traditionally performed through a transnasal endoscopic approach or an open craniotomy approach. While this is often successful, when the defect is adjacent to the crista galli it can be very difficult to seal the medial portions of the defect. Our objective is to report our experience using a novel multiportal (transnasal and transorbital) endoscopic technique to repair large, bilateral anterior cranial fossae defects using an intracranial “brain sling.”

Methods:

Reviews of the literature and medical records were performed.

Results:

Endoscopic transnasal and transorbital repair of large bilateral anterior cranial fossae skull base defects was performed using acellular radiated cadaver dermis and collagen matrix through a multiportal approach. The visualization and surgical access through transorbital portals permitted an intracranial extradural/intradural repair using a single, large section of reconstruction material. It was introduced through a portal distant to the site of injury to avoid enlarging the region of damage, and fashioned so that forces of gravity maintained its proper position. All leaks were repaired successfully with one surgical procedure, and there were no surgical complications in the cohort.

Conclusions:

The “brain sling” technique is applicable to the reconstruction of large skull base defects of any etiology and may be important for oncologic reconstruction. By using a multiportal approach, instrumentation could be performed without blocking the endoscopic view, and multiple viewing angles of the pathology could be used to improve the surgical efficacy.
Transoral Endoscopic Assisted ORIF of Orbital Rim Fractures
Authors: Brickman Todd M. , Jeyakumar Anita S.
Published: August 2013

Objectives:

1) Evaluate the feasibility of a purely transoral approach to infraorbital rim fractures using endoscopic assistance. 2) Analyze the patient outcomes of cosmesis and the success rate of reduction and fixation.

Methods:

A retrospective review was conducted in 16 midface facial fracture patients that presented to a level one trauma center in 2011‐2012 involving orbital rim fractures that did not require orbital floor exploration. All patients had open reduction internal fixation (ORIF) of midface facial fractures (medial and lateral buttress, and orbital rim) through a transoral approach utilizing endoscopic assistance. The zygomatic‐frontal (ZF) suture line fractures were repaired through a superior blepharoplasty incision. Orbital rim ORIF was accomplished with modified curved and ladder plates from stock midface vendor plating systems. The plates were fabricated to be positioned laterally on the orbital rim and then course inferiorly to the inferior orbital nerve (ION) and medially fixated to the medial buttress bridging the orbital rim fracture.

Results:

All patients had acceptable reduction and fixation of orbital rim fractures with cosmetically acceptable results. There was no plate extrusion or infection or worsening of ION parasthesias, with six patients having immediate post‐operative improvement in their ION parathesia. No post‐operative enophthalmos or diplopia was noted and no revision surgery was needed.

Conclusions:

A transoral endoscopic approach for carefully selected midface fractures involving the orbital rim is feasible with acceptable results. Future work is needed to develop a prefabricated plate that can be stocked in mid‐face plating systems.
Validated Assessment Tools for Reconstructing Facial Defects in Simulation
Authors: Sajan Javad A. , Hilger Peter A. , Sidman James D. , Walsh William E. , Chaffin Phillip L. , Reihsen Troy , Sweet Robert
Published: August 2013

Objectives:

1) Create a 3D functional organosilicate model for assessing facial reconstruction that is valid and has high inter‐rater reliability. 2) Perform a prospective blinded study using 3D and 2‐dimensional (2D) models for evaluating facial reconstruction.

Methods:

A 3D organosilicate model of a human adult face was built with a corresponding 2D paper model. Surgical subspecialty trainees from six institutions prospectively drew a z‐plasty on the paper model and the organosilicate model. Next, the subjects each performed a z‐plasty on the organosilicate model with surgical instruments and suture. Three blinded reviewers rated two drawings and one scar revision per subject.

Results:

Forty‐three trainees encompassing 3 PGY1, 10 PGY2, 13 PGY3, 11 PGY4, 3 PGY5, and 3 PGY6 (fellows) completed the study. Subjects were placed into three groups, novices (PGY1+PGY2), intermediates (PGY3+PGY4), and experts (PGY5+PGY6). Experts performed better than intermediates and intermediates better than novices for performing the z‐plasty and drawing on the organosilicate model. This statistically significant difference between groups was determined by one‐way ANOVA (p =<.05) and Tukey post‐hoc test p=<.05 and showed substantial inter‐rater reliability agreement among the three raters with an average Cohen's Kappa=0.76. On the 2D paper model the experts performed better than novices (p=<.05); however, there was no difference between experts and intermediates (p=0.98).

Conclusions:

We have created a 3D organosilicate model for facial reconstruction that is valid and shows high inter‐rater reliability. The 3D model was able to detect a difference between experts and intermediates where the 2D model could not.
The Clinical Evaluation of a Tonsil Patch Using Biodesign Tissue Grafts
Authors: Melder Patrick C.
Published: August 2013

Objectives:

The current study is a follow‐up to a previous study determining the efficacy of a truly novel material for use during tonsillectomy to improve post‐operative pain. The goal of the current study is to further evaluate its use and analyze possible post‐operative pain reduction using the material.

Methods:

This is a prospective single blinded evaluation of Biodesign tissue grafts (COOK Medical) with patients serving as self‐controls. This study involved adult patients undergoing tonsillectomy for chronic tonsillitis or as part of Uvulopalato‐pharyngoplasty (UPPP) for sleep apnea surgery. Biodesign was fashioned and then sutured into the right tonsillar fossa using a combination of 2.0 polysorb (Covidien) and 2.0 chromic suture. The left tonsil was closed without Biodesign. If a palatoplasty was performed, it was left to granulate with secondary intention. Post‐operatively, the patients filled out a diet and narcotic log for 14 days and a visual analog pain scale for 10 days. A total of 25 patients were studied in this prospective, single blinded study.

Results:

Closure technique is important in reducing post‐operative pain with Biodesign. Closure of the tonsillar fossa resulted in higher pain than without closure. Further, time for placement remains a barrier for wide‐spread adoption. The tissue grafts integrated well into the native tissue, and there were no incidents of aspiration.

Conclusions:

The tissue handles well and would be amenable for coverage of other soft‐tissue defects in the upper aerodigestive tract.
The Effect of Duty Hour Regulation on Resident Surgical Case Volume in Otolaryngology
Authors: Curtis Stuart H. , Miller Robert H. , Weng Cindy , Gurgel Richard K.
Published: August 2013

Objectives:

Evaluate the effect of duty hour regulation on graduating otolaryngology resident surgical case volume and to analyze trends in surgical case volume for each of the Accreditation Council for Graduate Medical Education (ACGME) key indicator cases from 1996‐2011.

Methods:

Operative logs were obtained from the American Board of Otolaryngology and ACGME for otolaryngology residents graduating in the years 1996‐2011. Key indicator volumes before and after resident duty hour regulations (2003) were compared. A paired t‐test was performed to evaluate the overall difference in operative volume. The Wilcoxon signed rank test evaluated differences between individual procedures per time period. Linear association of the average volume of each key indicator per year was performed using linear regression.

Results:

The average total number of key indicator cases per graduating resident was 441 in 1996‐2003 compared to 500 cases in 2004‐2011, and the average number of key indicator cases (total key indicator cases/number of key indicators) was 31.5 in 1996‐2003 compared to 36.2 in 2004‐2011 (P = 0.0012). The linear association for the change in average number of key indicator cases per year was not statistically significant (P = 0.1990). Sub‐analysis of individual key indicators showed a statistically significant (P < 0.05) increase in volume between pre‐ and post‐duty hour regulation for bronchoscopy, ethmoidectomy, mastoidectomy, parotidectomy, and thyroid/parathyroidectomy and a decrease in flaps and stapes/ossiculoplasty.

Conclusions:

Implementation of the 2003 duty hour regulations has not reduced the total volume of key indicator cases for graduating otolaryngology residents. Overall and many specific key indicator operative volumes have increased.
Endoscopic Endonasal Management of Nonfunctioning Pituitary Adenomas with Cavernous Sinus Invasion: Our Experience
Authors: Ferreli Fabio , Turri‐Zanoni Mario , Gallo Stefania , Bignami Maurizio , Tomei Giustino , Locatelli Davide , Castelnuovo Paolo
Published: August 2013

Objectives:

1) Review the management of Non‐Functioning Pituitary Adenoma (NFPA) invading the cavernous sinus (CS), currently in balance between radiotherapy, surgical decompression of neural structures, and wait‐and‐see policy. 2) Report our experience in the surgical removal of these lesions through an endoscopic endonasal trans‐sphenoidal approach (EETSA).

Methods:

From 1999 to 2010, 56 cases of NFPA with CS invasion were treated through an EETSA. The Knosp classification was used to describe CS involvement as evidenced by preoperative magnetic resonance imaging (MRI) and intraoperatively. Extent of resection was evaluated on postoperative contrast‐enhanced MRI, as well as the surgical and visual outcomes. Endocrinological remission was defined according to the most recent consensus criteria.

Results:

EETSA was performed using direct para‐septal, trans‐ethmoidal, or trans‐ethmoidal‐pterygoidal approach. The surgical procedure was well tolerated by all patients. At discharge, visual disturbance was improved in 30 (81%) patients who had complained of visual impairment preoperatively. Normalization or improvement of previous hypopituitarism was obtained in 55% of cases. A gross‐total or subtotal resection was reached in 51/56 patients. The recurrence‐free survival was 87.5%, with a mean follow‐up of 61 months. No major intraoperative or postoperative complications occurred.

Conclusions:

Surgical removal using an EETSA is a minimally‐invasive, safe, and effective procedure for the management of NFPA invading the CS, able to solve the mass effect, preserving or restoring visual function, and obtain an adequate long‐term tumor control. However, close screening of pituitary function and appropriate neuroradiological follow‐up should be performed after surgery for early detection of tumor recurrence or regrowth.
Errors in Otolaryngology Revisited
Authors: Shah Rahul , Boss Emily F. , Brereton Jean , Roberson David W.
Published: August 2013

Objectives:

1) Know the areas of risk for errors in otolaryngology. 2) Be able to discuss the implications of errors in otolaryngology. A decade ago, a survey study of errors in otolaryngology identified areas of risk and proposed a classification schema for errors. This study used a similar methodology to obtain current data for comparison.

Methods:

An anonymous online survey was distributed via the AAO‐HNS weekly email. Respondents were asked to describe any event in their practice that they felt should not have happened. Events were classified using the prior schema.

Results:

445 (66%) of 681 respondents reported an event within the past six months. Mean age of affected patients was 41±24 years. An adverse consequence occurred in over half of events with corrective action taken in 82.8%. 68% of respondents subsequently changed their practice patterns. Domains with the most reported errors were technical (27.9% of all events, 71% with major morbidity), administrative (12.2%, 3.7%), errors in testing (10.8%, 8.3%), and surgical planning (9.9%, 45.5%). There were 8 wrong site surgeries, 23 cranial nerve injuries (91.3% major morbidity), and 9 errors during endoscopic sinus surgery (55.6% major morbidity). There were 4 deaths.

Conclusions:

Otolaryngologists remain vulnerable to error‐related adverse events. The domains with the greatest risk for error‐related major morbidity have changed little and include errors in surgical planning, equipment‐related errors, and technical errors (surgery near cranial nerves and endoscopic sinus surgery). Awareness of high‐risk areas may help us focus more preventive efforts in these domains.
Impact of the Gene Expression Classifier on Surgeon‐Patient Decision Making in Indeterminate Thyroid Nodules
Authors: Parker Charles A. , Steward David L.
Published: August 2013

Objectives:

1) Describe the impact the gene expression classifier has on management of indeterminate thyroid nodules. 2) Define patient and nodule characteristics which influence further testing with the gene expression classifier (GEC) versus diagnostic thyroidectomy (DT).

Methods:

A retrospective chart review was performed on 273 patients who underwent fine‐needle aspiration (FNA) for thyroid nodules from November 2011 to January 2013. We further analyzed 68 patients with cytological indeterminate aspirates. These patients were offered serial observation with repeat FNA, GEC testing, or DT. Demographic data, cytologic and histologic findings, and management outcomes will be discussed.

Results:

In 68 patients with indeterminate cytology, 47% underwent GEC testing, 52% chose DT, and 1% elected for continued observation. The mean age in patients who underwent GEC testing was 57 years and 49 years in those who elected DT (p<0.05). Patients with a Bethesda classification of suspicious for malignancy were more likely to undergo DT, whereas those with a diagnosis of atypical of undetermined significance (AUS) or follicular neoplasm (FN) were more likely to obtain the GEC test (p<0.05). Those factors not found to be statistically significant were gender and size of the nodule (p>0.05). Thirty‐seven percent of patients with an AUS or FN diagnosis who obtained the GEC test underwent a DT. However, of those patients with an AUS or FN diagnosis who did not obtain the GEC test, 97% underwent a DT (p<0.0001).

Conclusions:

Use of the GEC significantly reduced the surgical rate among patients with a Bethesda classification of AUS or FN.
Laser‐Assisted Lithotripsy in the Minimally Invasive Treatment of Sialolithiasis
Authors: Phillips James D. , Withrow Kirk
Published: August 2013

Objectives:

In the minimally invasive treatment of sialolithiasis, lasers can be used to fracture stones, allowing for the endoscopic extirpation of larger lesions. The purpose of the current study was to evaluate outcomes following the use of the holmium YAG laser for intracorporeal salivary lithotripsy.

Methods:

Review of prospectively collected data regarding patients who underwent interventional sialoendoscopy for sialolithiasis was performed, recording patient demographics, surgical findings, and clinical outcomes. Patients who were treated with intracorporeal laser lithotripsy were compared with those who had simple basket retrieval or endoscopic assisted open removal. Patients were surveyed by phone for current symptom follow‐up.

Results:

Thirty‐one patients (average age 56, range 14‐84) were treated for sialolithiasis with endoscopic techniques at our academic institution from 2011‐2012. Sialoliths averaged 5.9 mm in size (range 2‐20mm), arising from the submandibular ducts (n=20), parotid (n=10), or both (n=1). The holmium YAG laser was used in 16 patients. Of these cases, 6 patients required additional maneuvers to open the duct to allow for stone extraction compared to 10 cases in which the laser was not used. At last follow‐up, 77% of patients who had laser assistance reported improvement of symptoms compared with 56% of the non‐laser group. Complications in all patients included ductal stenosis (n=1), residual stone fragments (n=2), salivary fistula (n=1), and the need for additional procedures (n=6).

Conclusions:

The results of our series indicate that intracorporeal laser assisted lithotripsy is an effective addition to the armamentarium of sialoendoscopy.
Post‐discharge Complications Predict Reoperation and Mortality after Otolaryngology Surgery
Authors: Chen Michelle M. , Roman Sanziana A. , Sosa Julie A. , Judson Benjamin L.
Published: August 2013

Objectives:

1) Determine procedure‐specific rates of post‐discharge complications and their risk factors in the first 30 days following inpatient otolaryngology surgery. 2) Evaluate association between post‐discharge complications and risk of reoperation.

Methods:

A retrospective cohort study of the ACS‐NSQIP database (2005‐2011) was used to identify 48,028 adult patients who underwent one of eight groups of inpatient otolaryngology procedures and examine demographic and clinical characteristics. Outcomes of interest included postoperative complications, unplanned reoperation, and mortality in the first 30 days following surgery. Statistical analysis included chi‐square tests, student's t tests, and multivariate logistic regression.

Results:

Laryngectomy, lip, and tongue/floor of mouth surgery had the highest post‐discharge complication rates (8.0%, 7.4%, and 4.1%, respectively). The most common complications were surgical site infections (46.4%), other infections (33.4%), and venous thromboembolic events (7.4%). Multivariate analysis demonstrated that increasing age (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00‐1.02), longer operative time (OR, 1.64; 95% CI, 1.34‐2.01), hospital stay >1 day (OR, 1.49; 95% CI, 1.20‐1.86), and American Society of Anesthesiologists (ASA) class >3 (OR, 1.46; 95% CI, 1.19‐1.79) were independently associated with post‐discharge complications. Patients with complications were more likely to die (0.9% vs 0.1%, P<. 001) or have a reoperation (10.4% vs 1.2%, P<. 001). On multivariate analysis, post‐discharge complications were independently associated with reoperation (OR, 6.55; 95% CI, 3.94‐10.87).

Conclusions:

This is the first study of overall post‐discharge events after otolaryngology surgery. Post‐discharge complication rates in otolaryngology are procedure‐specific and associated with reoperation. Targeted procedure‐specific triage and follow‐up plans for high‐risk patients could improve outcomes.
Role of Intraoperative Ropivacaine in Post‐tonsillectomy Pain Control: Randomized Control Trial Using a Paired Design
Authors: ChiaChing Yao William , Corbitt Christian A. , Bender Melissa E. , Takashima Masayoshi
Published: August 2013

Objectives:

1) Evaluate the efficacy of ropivacaine in post‐tonsillectomy pain management in adults using a paired design. 2) Evaluate the timing of intraoperative ropivacaine administration in post‐tonsillectomy pain control.

Methods:

A prospective double‐blinded randomized control trial with a paired design was performed on 25 consecutive adults undergoing a tonsillectomy. One side was injected with saline and the other side with ropivacaine. Patients were also pre‐randomized into those receiving injections immediately before or after the tonsillectomy. Laterality of the injection was alternated and all surgery performed by the senior author. Patient responses were obtained via telephone interview and written questionnaire.

Results:

3/25 patients were excluded from the study. 16/22 patients had pain lateralize to one side during recovery. There was no statistically significant difference in pain control between ropivacaine and normal saline. Local anesthetic decreased pain in 7/22 patients while more pain was experienced on the side with local anesthetic in 9/22 patients. 6/22 patients had no difference in pain. The time to equalization of pain based on laterality was 8.8 and 6.8 days, respectively, in the pre‐ and post‐tonsillectomy group.

Conclusions:

Multiple studies have examined the role of local anesthetic in controlling post‐tonsillectomy pain with equivocal results. This is the first study examining the role of local anesthetic in tonsillectomies using a paired design. Administration of ropivacaine does not affect post‐tonsillectomy pain. Moreover, timing of injection does not have an effect on postoperative pain. We recommend against the use of intraoperative ropivacaine for pain control in patients undergoing tonsillectomy.
Surgical Variation in Tonsillectomy and Adenoidectomy Procedures
Authors: Sethi Rosh , Leslie Jessica , Bannos Cassandra , Roberson David W. , Lee Gi Soo
Published: August 2013

Objectives:

Identify potential sources of variation in tonsillectomy/ tonsillotomy and adenoidectomy procedures that may impact operating room (OR) efficiency and cost. Background: Surgeons display substantial variability in use of equipment and technique for same procedure. Examination of process variability may lead to valuable insights about potential improvements in efficiency and cost.

Methods:

Observational quality improvement initiative conducted at an academic inpatient children's hospital and a satellite site in 2012. One author (RS) observed 65 procedures consisting of tonsillectomy/tonsillotomy with or without adenoidectomy; an additional 50 cases were included by review of patient records. Over 100 variables were measured for each case, including patient demographics, indication, and technique used. Univariate and multivariate analysis was used to determine predictors of OR times and total charges.

Results:

Multivariate analysis showed: Significantly lower charges at satellite location compared to main campus (34.1% reduction, P < 0.0001). Longer total OR time is associated with higher total charges. Anesthesia time did not vary between the two sites. Individual surgeons’ operating time varies up to two‐fold. Factors with a statistically significant association with shorter total OR time are location (satellite vs. main campus, P = 0.0233), deep vs. awake extubation (P < 0.0001), and identity of surgeon (P = 0.0016).

Conclusions:

Results of this study suggest substantial opportunities for increased efficiency by identification of those process steps associated with shorter OR time and lower total charges, including satellite location, deep extubation, and possibly by using the more efficient surgeons as exemplars of most efficient techniques.