bluuebunny/crossref_metadata_2025 huggingface dataset:
The “Mickey Mouse” Sign
Authors: Manickavasagam Jaiganesh , Mirza Showkat , Sinha Saurabh
Published: February 2015

Objective

In transnasal endoscopic pituitary surgery and transsellar approaches to anterior skull base lesions, a bony sella window is created with the lateral limits being the carotid arteries.

Method

Coronal CT scan of the sphenoid sinuses were reviewed in a tertiary referral hospital and compared with intra operative findings.

Results

Sphenoid anatomy is variable in terms of the degree of pneumatization and bony anatomy around the pituitary gland and internal carotid arteries. We describe a radiological sign ascertained from computerized tomography (CT) that when present indicates whether the carotid arteries can be readily identified endoscopically on entering the sphenoid sinus. On the axial CT the carotid arteries may produce protuberances either side of the sella which together with the bony sella and dorsum sella appear to form the outline of the head of Mickey Mouse or a teddy bear.

Conclusion

When this sign is not present then the junction between the sella and carotids may not be clear and surgeons must be cautious or use neuronavigation.
Utility of Current Sialendoscopes in the Sinonasal Cavity
Authors: Joshi Arjun S. , Singh Ameet
Published: February 2015

Objective

1) To describe the utility of current sialendoscopes in the paranasal sinuses in a cadaveric model. 2) To suggest the novel uses for sialendoscopes and potential improvements in design.

Method

A cadaveric study was performed in a tertiary care hospital setting in October 2011. Currently available sialendoscopes were used for visualization and interventions in the paranasal sinuses. Four cadaver heads were studied pre‐ and postdissection. Outcomes included identification of ostia, cannulation of sinuses, success of mucosal biopsy, and clarity of images.

Results

There were no significant differences in types of scopes. Both Marchal and Erlangen scopes were demonstrated to be effective in both visualizing and cannulating the sphenoid sinuses in pre‐ and postdissected settings (8/8). Neither type allowed for adequate visualization of the maxillary ostia without dissection, but did allow for evaluation and cannulation after antrostomy. Larger diameter scopes were associated with the least distortion of image during assessment of the maxillary ostia. Mucosal biopsy within the sphenoid sinus was possible before dissection, but not in the maxillary sinus.

Conclusion

Sialendoscopes can be used for visualization and interventions in the sinonasal cavity but are limited mainly to the sphenoid sinus. They may be considered as a minimally‐invasive method for drug delivery and/or biopsy in the postoperative setting for all sinuses. The design can be improved somewhat.
Geniotubercle Advancement Effect on Swallow Function
Authors: Rohrer Joseph W. , Eller Robert , Santillan Phyllis , Barrera Jose E.
Published: February 2015

Objective

1) Evaluate swallowing characteristics before and after geniotubercle advancement (GTA). 2) Determine if GTA’s effects on tongue‐base position could be useful for patients who have dysphagia without OSA.

Method

Patients with AHI greater than 10 scheduled for GTA were enrolled consecutively. Video fluoroscopic swallow study (VFSS) was performed preoperatively and 4 months postoperatively. Imagej64 software (National Institutes of Health, Bethesda, Maryland) was used to measure hyolaryngeal elevation and displacement. Video recordings assessed valecular pooling, aspiration, and bolus movement. Studies were reviewed by a speech pathologist and an otolaryngologist.

Results

Preoperative demographics AHI range was 12.4 to 72 with a mean of 51.4 and a median of 65. Postoperatively AHI was 3.8 to 22.4 with a mean of 11.6 and a median of 11.2. There was no reported pre‐ or postoperative dysphagia or aspiration. There was no radiographic evidence of silent aspiration. Hyolaryngeal superior elevation was 0.40, 0.39 (P =. 85), anterior displacement changes were 0.27, 0.17 (P =. 23), and total motion was 0.50, 0.43 (P =. 13).

Conclusion

While geniotubercle advancement surgery was effective at reducing the AHI in all patients in this series, the procedure did not significantly affect the swallowing function of patients. It also did not appear to significantly alter the hyolaryngeal movement, making it unlikely to assist with patients suffering from dysphagia.
Inferolateral Pharyngoplasty
Authors: Tanyeri Hasan M. , Aksoy Elif A. , Serin Gediz M. , Polat Senol , Unal Omer F.
Published: February 2015

Objective

This study describes inferolateral pharyngoplasty (ILP) and its effectiveness as a surgical technique to enlarge pharyngeal air space inferolaterally, which complements submucosal uvulopalatopharyngoplasty (smUPPP) in the treatment of obstructive sleep apnea (OSA).

Method

Fifty‐two patients underwent complete tonsillectomy, including lingual portions of palatine tonsils during smUPPP. Reconstruction included double layer closure, muscle, and mucosa emphasizing inferolateral portions of smUPPP. Pre‐ and postoperative Müller maneuver and respiratory disturbance index (RDI) were analyzed.

Results

The study group consisted of 47 men (90.38%) and 5 women (9.61%). The mean age was 46.6 ± 9.5 years. The pharyngeal collapse varied between 30% and 100% preoperatively. The pharyngeal collapse decreased to values between 20% and 50% postoperatively. Mean RDI levels decreased from 33.3 ± 22.9 to 23.7 ± 22.8 (P =. 027) following surgeries in OSA patients.

Conclusion

ILP is a complementary procedure to smUPPP that might increase the effectiveness of the procedure. This effect might originate from double layer closure in particular emphasis on inferolateral portions. We propose that smUPPP in conjunction with ILP is an effective procedure to ameloriate OSA condition.
Manual Dexterity Aptitude Testing: A Soap Study
Authors: Tang Christopher G. , Hilsinger Raymond L. , Cruz Raul M. , Schloegel Luke J. , Byl Frederick M. , Rasgon Barry M.
Published: February 2015

Objective

To determine whether or not manual dexterity aptitude testing in the form of soap carving during otolaryngology residency interviews at Kaiser Permanente Oakland Medical Center predicts surgical skill at the time of graduation from otolaryngology residency programs.

Methods

Over the past 25 years, applicants to the residency program at Kaiser Permanente Oakland were required to carve soap. This study was conducted to determine how applicants with the best and worst soaps compared at the time of graduation with respect to various metrics including visiospatial ability and manual dexterity.

Results

The best and worst soaps from 1990 to 2006 were determined. Sixty‐two individuals qualified for the study and matriculated into otolaryngology residency programs. Surveys were sent to their residency programs to evaluate those individuals on a 5‐point Likert scale in various categories. There was no difference between individuals with the “best soaps” and those with the “worst soaps” in all categories: cognitive knowledge, visiospatial ability, manual dexterity, decision making, and overall score (P >. 1 for all categories). There was a 95% response rate with 35 of 37 residency programs responding, and 59 of 62 surveys returned.

Conclusion

Although further studies need to be conducted to determine the role of manual dexterity and visiospatial aptitude testing in the otolaryngology application process, individuals who have the “best soaps” did not score higher than those with the “worst soaps” in several metrics.
Treatment of Obstructive Sleep Apnea with Multiple Surgeries
Authors: Pinto José A. , Kohler Rodrigo , Godoy Luciana B. M. , Wambier Henrique , Sônego Thiago B. , Mizoguchi Elcio I.
Published: February 2015

Objective

1) Be able to determine the effects of multiple surgeries in the treatment of moderate and severe obstructive sleep apnea. 2) Confirm the importance of identifying the sites of obstruction in the treatment of obstructive sleep apnea.

Method

A retrospective review of a prospective dataset of 40 patients with moderate and severe obstructive sleep apnea who had undergone multiple surgeries. Patients studied underwent palatal surgery with or without nasal and tongue base surgery. Charts between 1997 and 2011 were reviewed and the surgical results were determined.

Results

Thirty‐two patients (80%) underwent UPPP, associated with midline glossectomy in 26 patients (65%). Five patients (12.5%) underwent expansion sphincter pharyngoplasty, associated with midline glossectomy in 1 patient (2.5%). One patient (2.5%) underwent lateral pharyngoplasty. At least some improvement occurred in 4 patients (40%) in the moderate OSAS group (n = 10), but 4 patients (40%) in this group showed a slight (nonsignificant) worsening in mean apnea/hypopnea index. In the severe OSAS group (n = 30) 25 patients (83.3%) showed significant improvement (decrease in mean number of events per hour; P <. 0001). Minimum oxygen saturation improved in the moderate and severe OSAS groups.

Conclusion

In our study, as indicated by the apnea/hypopnea index, the use of multiple procedures appears to have better results in severe OSAS than in moderate OSAS. The results of surgical procedures are difficult to predict. Lack of success is usually due to failure to identify all sites of obstruction.
Upper Airway Dimensions in Snoring: Acoustical and MRI Findings
Authors: Chen Po‐Yueh , Wang Pa‐Chun , Lo Men‐Tzung , Chang Yi‐Chung , Lin Chen , Chen Yunn‐Jy
Published: February 2015

Objective

OSA is caused by soft tissue collapse of the upper airway; treatment strategies can be determined depending on accurately localizing the obstruction sites. Acoustic analysis of snoring might provide a valuable way to localize the obstruction, if the association between the acoustics and the dynamics of the upper airway during OSA can be identified.

Method

Nine PSG OSA patients were enrolled. Dynamics of upper airway and the acoustic manifestations of snore events during natural sleep were recorded with dynamic MRI and a fiber‐optic microphone simultaneously. The Gabor/wavelet transformation was applied to extract the acoustic representation of OSA events by removing the repeated‐appearing MRI scanning background noises.

Results

All of the 9 patients were men (mean age, 48.3 ± 9.9 years, mean BMI, 25.1 ± 1.9). The snore events were categorized into typical (velopharyngeal) and mixed (combined with hypopharyngeal) obstructions. The mean frequency (161 ± 17.4 vs 188 ± 24.1 Hz; P < 10‐16) and high (151~350 Hz)/low(80~150 Hz) frequency power ratio (1.08 ± 0.31 vs 1.55 ± 0.42 Hz; P < 10‐16) of the snore sounds were significantly higher in mixed obstructions. However, the dynamic patterns of the frequency modulation varied with structural changes identified by dMRI. During the snore events, different characteristics of shifts in frequency were found (mean frequency changes: −28.3 ± 21.4 in typical obstruction vs 12.5 ± 22.9 Hz for mixed obstruction; P < 10‐32), which gives better discrimination power.

Conclusion

The dynamics of acoustic patterns derived by 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 in combination with instantaneous structural changes of the obstruction sites in OSA patients through dMRI.
Oropharyngeal Syphilis among HIV‐Infected Patients
Authors: Ablanedo‐Terrazas Yuria , Alvarado‐de La Barrera Claudia , Ruiz‐Cruz Matilde , Reyes‐Terán Gustavo
Published: February 2015

Objective

This study was aimed at describing oropharyngeal manifestations of secondary syphilis in HIV‐infected patients. We also sought to determine the clinical risk factors for the development of oropharyngeal syphilitic lesions in patients with HIV and secondary syphilis.

Method

We conducted a case‐control study in HIV‐infected patients at a tertiary referral center in Mexico City. All HIV‐infected patients admitted at our center during the period between November 2009 and February 2012 who fulfilled the CDC criteria for syphilis were included in this case control study.

Results

We identified 35 cases of syphilis; 17 patients had secondary syphilis, and 9 had oropharyngeal manifestations. Lesions involving the anterior tonsillar pillar were the most common, observed in 5 patients; and tongue lesions were observed in 3 patients. Multivariate analysis showed that the development of oropharyngeal lesions was independently associated with age, CD3, CD4, and CD8 cell counts and HIV RNA viral load.

Conclusion

The present work shows that oropharyngeal manifestations of secondary syphilis are frequent in HIV‐infected patients.
Quantitative Assessment of Aspiration: A Novel Porcine Model
Authors: Kanotra Sohit P. , Forte Vito
Published: February 2015

Objective

Develop a porcine model for quantitative assessment of pulmonary aspiration.

Method

The porcine model consists of an endotracheally inserted pH probe with the distal end of the probe at the carina. The pH probe is sutured to the posterior tracheal wall, and the position is verified by a flexible endoscope. An acidic solution of known pH (2.5) is delivered through a catheter attached to the endotracheal tube, with the distal end on the cuff of the tube. The pH probe is connected to a multifunctional data acquisition device (NI USB 6009. National Instruments, USA) with an analogue output signal measuring the voltage generated, which is analyzed on software (Lab View 2011, National Instruments). This continuously provides a quantitative assessment of aspiration by detecting any voltage changes over a period of time indicating leakage of fluid around the endotracheal cuff.

Results

The mean voltage measured with the cuff fully inflated and a column of 10 mL of a solution of known pH on the cuff over a period of 2 hours was 885.74 ± 7.8 mvolts. With deflation of the endotracheal tube cuff a significant drop in voltage (mean voltage drop = 363.24 mvolts, P =. 001) was measured, indicating leakage of the acidic solution across the endotracheal tube cuff.

Conclusion

The model provides a reliable method of quantifying the amount of aspiration. The model can be run for a long period of time and serves as an effective way of analyzing various techniques and devices for reducing aspiration.
Reducing Risks in Tonsillectomy
Authors: de Abajo Jorge , Cervera Javier , Baptista Peter M.
Published: February 2015

Objective

Tonsillectomy is one of the most common procedures performed by the otolaryngologist. Now, many different surgical systems offer advantages related to less pain or postoperative bleeding. In our institution Tissue Welding Starion System (TW) has been used for over 281 patients. We have compared results using TW with bipolar cautery (BC).

Method

Between August 2008 and January 2012, 482 consecutive surgeries were performed in our institution by 2 different surgeons using the clinical guidelines of the AAO‐HNS. Two hundred eighty‐one patients (58.2%) were operated using the TW technology, and 201 (41.8%) were operated using BC. We have evaluated surgical outcomes and complications.

Results

Surgeries performed with TW were significantly faster with less bleeding and carbonization of tissue in comparison with BC. Postoperative pain was significantly lower and patients returned to normal diet faster in the TW group. Eleven patients (2.3%) developed major complications (need for revision surgery, or admission to hospital). Seven of them (1.4%) were from the BC group (3 postoperative bleeding and 4 admissions because of pain). Four of them (0.8%) were from the TW group (3 postoperative bleeding and 1 admission due to persistent fever).

Conclusion

Tonsillectomy with TW proved to reduce by half postoperative bleeding and admissions to hospital compared to BC. These suggest that TW could be an advantageous technique concerning safety.
Smoking Tobacco Use among Operating Room Personnel
Authors: Gonzalez‐Castro Javier , Pascual Jeamarie , Gonzalez‐Aquino Carlos , Tarrats Luisam
Published: February 2015

Objective

To evaluate the prevalence of smoking in operating room (OR) personnel and compare this with that of the general public. Given the first‐hand exposure of these individuals to patients with smoking‐related illnesses, we believe they should have a decreased tendency to smoke.

Method

A survey instrument was given to OR personnel at the University of Puerto Rico in order to learn the prevalence of smoking among other tobacco use related data. Prevalence for the general population and other healthcare‐related populations was investigated using various search engines and compared with our results.

Results

A total of 113 individuals completed the survey; 6.19% were found to be current smokers, and 7.96% were found to be past smokers. Data from the Centers for Disease Control show that the prevalence of cigarette smoking among US adults is 20.9%, which is significantly higher than what we found in our population (P =. 01). In Puerto Rico, the prevalence of smoking is 10.6%, which is also significantly higher than our study population (P =. 05). Among current smokers, (n = 7), 85.7% have tried to quit at least once (P =. 02), and all claimed to have knowledge of the possible complications associated with smoking.

Conclusion

Smoking tobacco remains the number one cause of preventable death in the United States despite many efforts to educate the general public on the dangers associated with its use. A more visual or hands‐on encounter with the effects of smoking may help decrease tobacco burden in the general population.
The Acute Loss of Weight in Eustachian Tube Function
Authors: Pascoto Gabriela R. , Abreu Cassiana B. , Silva Maria Laura S. , Weber Raimar , Pignatari Shirley S.N. , Stamm Aldo E.C.
Published: February 2015

Objective

To evaluate the frequency and intensity of auditory tube dysfunction related to obese patients before and after bariatric surgery.

Method

Nineteen patients with a formal indication for bariatric surgery underwent surgery prior to a hearing evaluation (otoscopy, tonal and vocal audiometry, and impedanciometry) and a questionnaire on hearing; and in 3 and 6 months after surgery. Patients with disease or a history of ear surgery were excluded.

Results

We found that 5 (26.3%) patients showed symptoms related to dysfunction of the Eustachian tube at the first postoperative evaluation. After 6 months of follow‐up, 9 (47.3%) patients presented symptoms of tubal dysfunction.

Conclusion

This study suggests that bariatric surgery can cause symptoms of Eustachian tube dysfunction, probably due to rapid weight loss and the consequent loss of peritubal fat.
Ultrasound Assessment after Parotid Sialolithotomy
Authors: Joshi Arjun S. , Sood Amit J.
Published: February 2015

Objective

1) To demonstrate the utility of ultrasound in the assessment of residual parotid sialoliths or fragments after endoscopic‐assisted or purely open sialolithotomy. 2) To discuss limitations of using ultrasound for detection of sialolithiasis of the parotid glands.

Method

From August 2009 to January 2012, 5 adult patients with symptomatic parotid sialolithiasis underwent endoscopic‐assisted or purely external sialolithotomy in a tertiary‐level hospital setting. Pre‐and intraoperative post‐sialolithotomy ultrasound was performed. Outcomes included presence of residual stones/fragments and proximal ductal dilatation.

Results

Five patients with symptomatic parotid sialolithiasis refractory to sialendoscopic extraction underwent either endoscopic‐assisted sialolithotomy or pure open sialolithotomy. Four of 5 patients demonstrated proximal ductal dilatation on ultrasound. One of 5 (20%) demonstrated residual sialolithiasis on ultrasound immediately after sialolithotomy. That patient underwent re‐exploration at the time of the procedure and was demonstrated to have residual sialolithiasis with successful delivery of the fragments. There were no instances of infection, ductal stenosis, loss of glandular function, or permanent buccal facial nerve paralysis, with follow‐up ranging from 6 months to 1 year.

Conclusion

After cases of endoscopic‐assisted or purely external parotid sialolithotomy, there is no widely used method to assess for residual stones. As a first, and in this small cohort of patients, we propose that ultrasound is effective and should be considered for the assessment of residual stones after external parotid sialolithotomy.
Ultrasound Localization during Parotid Sialolithotomy
Authors: Joshi Arjun S. , Sood Amit J.
Published: February 2015

Objective

1) To describe a novel operative technique that has been demonstrated to be successful in stone localization and subsequent retrieval in patients with parotid sialolithiasis. 2) To demonstrate feasibility of the technique and discuss its indications.

Method

From August 2009 to January 2012, patients with symptomatic parotid sialolithiasis underwent ultrasound needle localization and open sialolithotomy in a tertiary‐level hospital setting. Outcomes included success of delivery, presence of infection, ductal stenosis, loss of glandular function, or facial nerve paralysis. Independent variables included size of and location of sialoliths.

Results

Five patients were treated using transcutaneous ultrasound‐guided needle placement and injection of methylene blue prior to external sialolithotomy in the operating room. Patients were chosen if they had failed prior sialendoscopic extraction. Postoperative outcomes and long‐term follow‐up results were obtained. Follow‐up ranged from 6 to 12 months. Mean operative time from skin incision to closure was 52 minutes (range, 43‐85 minutes). Five of 5 (100%) cases were successful for stone retrieval. Stents were placed in 4 of 5 cases. The average stone size was 5.3 mm. There were no complications of infection, ductal stenosis, loss of glandular function, or permanent buccal facial nerve paralysis. No patients had salvage parotidectomy.

Conclusion

After failing a purely endoscopic approach, sialoliths of the parotid gland pose a problem for precise localization and treatment. Ultrasound has been demonstrated to be reliable for identifying sialoliths. We propose a novel technique and assert that ultrasound‐guided needle localization is a reliable aid to effective external parotid sialolithotomy.
Advanced Juvenile Nasopharyngeal Angiofibroma
Authors: Ceylan Alper , Yılmaz Metin , Ataç Mustafa , Üstün Selin
Published: February 2015

Objective

The aim of this study was to describe a case of advanced juvenile nasopharyngeal angiofibroma from our practice and discuss the controversies of surgical treatment.

Method

We present a 13‐year‐old boy who underwent external resection of advanced juvenile nasopharyngeal angiofibroma at the Gazi University medical faculty otorhinolaryngology department, in 2012.

Results

No complication was seen after surgery. Postoperative radiotherapy was given for small residual tumor.

Conclusion

Surgical treatment is the basic tactics in management of advanced juvenile nasopharyngeal angiofibroma. Stage of the tumor is the main factor contributing to the choice of the appropriate surgical approach.
Approaches to Parapharyngeal Space Tumors
Authors: Duggal Prahlad
Published: February 2015

Objective

Parapharyngeal tumors, owing to diversity of pathologies and the close proximity to vital structures, pose both a diagnostic enigma as well as a therapeutic challenge. The present study is an attempt to present our past 4 years experience in the surgical management of parapharyngeal tumors using various approaches.

Method

A retrospective analysis of records of 22 patients who were operated for parapharyngeal tumors during the past 4 years was done. Only those cases where the primary neoplasm was of parapharyngeal space were included. The data so collected was analyzed for clinical presentation, radiological findings, surgical management and outcome.

Results

The most common pathology found was salivary gland tumors (9) followed by neural origin tumors (5), carotid body tumor (2), and miscellaneous (6). Of the recommended approaches for parapharyngeal tumors, transcervical, trans‐cervical transparotid, and transcervical with mandibular swing approaches were used in the present study, while trans‐oral approach was not used. Transcervical transparotid approach was the most commonly used approach followed by transcervical approach. Transcervical with mandibular swing approach was used in cases with large tumors going to skull base. Size and extent of tumor along with type of pathology and vascularity were the main factors determining the approach selected.

Conclusion

Transcervical transparotid and transcervical approaches are the most frequently used approach in the present study providing adequate exposure depending upon the extent of tumour in parapharyngeal space. Mandibular swing approach should be used for huge tumors where dissection under vision is not possible and vascular control is compromised otherwise.
Endoscopic Transnasal Approach for Orbital Floor Fracture
Authors: Omura Kazuhiro
Published: February 2015

Objective

In recent years, we developed a more minimally invasive technique of endoscopic transnasal approach to repair orbital floor fractures (OFF) with preserving and repositioning the fractured bones. This study reviews our technique of endoscopic transnasal approach to OFF patients.

Method

OFF patients treated with endoscopic transnasal approach were reviewed in a retrospective fashion. Type of fracture, locations, period from injury to surgery, surgical outcomes including patient’s subjective symptom and objective examinations, and complications were collected from patient charts. Preoperative and postoperative (>6 months) CT scans were also evaluated.

Results

A total of 5 patients were treated with endoscopic transnasal approach. The subjective symptoms were recovered in all patients. Hess screen test showed no limitation of eye movement after surgery. Postoperative CT scan also showed that the fractured bone of the orbital floor was identified in the almost original anatomic location 6 months after surgery. No complications or bone absorption were found after surgery.

Conclusion

The novel technique of endoscopic transnasal approach to OFF patients resulted in excellent outcomes. It allows more minimally invasive surgery for the patients without any incisions and graft placement. We still have to watch for late complications and the presence/absence of the fractured bone absorption.
Isolation and Characteristics of Human Muscle Stem Cells
Authors: Wei Yan
Published: February 2015

Objective

To establish the methods for purification, culture, and identification of adult human skeletal muscle stem cells in vitro and to explore the biological properties of the cells.

Method

Muscle stem cells were obtained from the consenting donors and cultured in serum‐free medium. Phenotypic characteristics of the cells and expression of cell‐specific markers were determined using RT‐PCR and immunocytochemistry. The cells were analyzed for their multi‐lineage differentiation potential into osteoblastic, adipocyte, and smooth muscle cell lineages.

Results

Primary cultured human skeletal muscle stem cells proliferated and formed the big spheres when cultured with serum‐free medium. Immuno‐fluorescent staining displayed PaX7 and ALDH1 positive expression in the cell spheres. Furthermore, Myod and Desmin showed positive expression in the monolayer cells derived from the spheres. The gene expressions of 0ct3/4, Nanog, Sox2, and Pax7 in the cells were determined by RT‐PCR. The cell clones formed from single cells grew well. In addition, they were capable of spontaneous differentiation into myotubes in the differentiation medium and into other mesodermal cell lineages in induction medium.

Conclusion

Human muscle stem cells with properties of self‐renewal capacity and multidifferentiation could be successfully isolated and expanded in vitro.
Cervicoscopic Coblation Thyroid Surgery
Authors: Rao‐Merugumala Srinivasa
Published: February 2015

Objective

1) To evaluate the efficacy and safety of cervicoscopic and coblation assisted surgery (CCAS) of thyroid. 2) To present a rare case of myofibroblastic nodule with focal embryonal tissue in a 72‐year‐old woman. 3) To understand these rare presentations for effective management.

Method

To evaluate the safety and efficacy of outcomes CCAS and conventional thyroid surgical procedures from October 2008 to September 2010. Arthrocare EVac 70 Xtra Plasma Wand was used for hemostasis and subcapsular dissection.

Results

One representative case includes a 72‐year‐old Afro‐Caribbean woman who presented with 3‐year history of progressive exertional dyspnea and hoarse voice due to diffuse multinodular goiter with a dominant solid nodule on ultrasound and a thy2 on needle aspirate. She was refused general anaesthesia. CCAS of thyroid under cervical block as a day case, revealed moth‐eaten appearance thyroid follicles with areas of hemorrhage and cholesterol clefts with focal embryonal thyroid tissue and a prominent myofibroblastic nodule formation. In contrast the third patient in this series showed areas of fibrotic hemorrhagic nodules with cystic degeneration.

Conclusion

This study illustrates that CCAS of thyroid provides a minimally invasive technique with less morbidity and has good cosmetic outcome and is amenable to be performed under cervical block in selected patients. Myofibroblastic proliferation commonly reported in papillary carcinoma was contrary to association with benign pathology in this case.
Changes in Tumor Size and Margins due to Specimen Processing
Authors: Mills Jonathan C. , Critchlow William A. , Renner Gregory J.
Published: February 2015

Objective

1) Identify and quantify changes that occur in tumor size and tumor‐free margins between surgical resection and gross pathologic analysis of oral cavity squamous cell carcinoma specimens. 2) Determine the extent to which these changes occur before or after tissue fixation in formalin.

Method

Preliminary analysis of this ongoing prospective study is presented. Patients with oral cavity squamous cell carcinoma undergoing surgical resection were included. Mucosal reference points were marked with sutures, representing tumor diameter and 2 separate resection margins. Measurements were recorded immediately before resection, after resection, and after fixation in formalin.

Results

Specimens from 16 patients were examined. From before resection to after formalin fixation, tumor size decreased by a mean of 3.05 mm (95% CI 0.54‐5.56 mm), an 11.2% reduction, P =. 02. Most of this decrease (mean, 1.94 mm, 95% CI 0.04‐3.84 mm) occurred between the pre‐ and postresection measurements (before formalin fixation), P =. 046. Margins decreased by a mean of 0.84 mm (95% CI 0.12‐1.57 mm) from preresection to postfixation, an 11.2% reduction, P =. 025. All of this decrease occurred prior to formalin fixation.

Conclusion

Preliminary analysis suggests that mucosal dimensions of both tumor and tumor‐free margins in oral cavity squamous cell carcinoma specimens decrease between surgical resection and gross pathologic analysis. Most of this decrease occurs prior to fixation, especially for margins, and may be due to intrinsic tissue properties rather than formalin effects.
A Comparative Analysis of Immune Infiltrating Lymphocytes in a Murine Model of Oral Cancer
Authors: Judd Nancy P. , Allen Clint T. , Uppaluri Ravindra , Winkler Ashley E.
Published: February 2015

Objective

1) Understand types of infiltrating immune cells that contribute to the tumor microenvironment. 2) Understand the relative difference in immune infiltrates between aggressive and indolent tumor phenotypes in a new syngeneic model of OSCC.

Method

This research is a preclinical scientific study focusing on mouse derived oral cavity squamous cell carcinoma that was conducted over 6 months at Washington University in St Louis. This study analyzed tumor infiltrating immune cells by flow cytometry and identified individual infiltrating populations associated with either aggressive or indolent growth.

Results

Indolent growing mouse oral cancer (MOC) lines were associated with increased expression of increased MHC class I expression and increased CD8+ T‐cell infiltration into the tumor microenvironment. However, aggressive and metastatic MOC lines were associated with decreased class I expression and increased FOXP3+ CD4+ T‐cell infiltration and targeting these regulatory T‐cells delayed tumor growth in vivo.

Conclusion

These data validate that key infiltrating immune cells identified here parallel findings in human head and neck cancer, making this newly developed syngeneic model a critical platform for the continued dissection of tumor‐host interactions in head and neck cancer.
Lateral Pterygoid Fracture Can Predict a Mandible Fracture
Authors: Truong Anh Q. , Strong E. Bradley , Dublin Arthur B.
Published: February 2015

Objective

Isolated lateral pterygoid plate fractures on head CT imaging can serendipitously be associated with mandible fractures on subsequent maxillofacial imaging. Our objective is to understand the mechanism and to establish a protocol for the radiographic evaluation for this phenomenon.

Method

We performed a retrospective case series of 7 maxillofacial trauma patients with evidence of isolated lateral pterygoid fractures noted on CT images between 2006 and 2012 at our tertiary care institution. Subsequent maxillofacial CT images with coronal, axial, and sagittal views allowed for complete evaluation of maxillofacial trauma.

Results

Seven patients between 2006 and 2012 who sustained facial trauma were found to have isolated lateral pterygoid plate fractures. Subsequent evaluation via maxillofacial CT showed associated mandible fractures. All the patients were men with an average age of 37 years. Seven patients had an ipsilateral subcondylar fracture, 2 had a symphyseal fracture, 2 had a body fracture, and 1 had a coronoid fracture.

Conclusion

Isolated lateral pterygoid fractures noted on head CTs are suggestive of associated mandibular fractures. The proposed mechanism is an acute force on the mandible that is traduced through the pterygoid muscles. A dedicated maxillofacial CT may reveal an associated mandibular fracture even in the setting of negative clinical exams.
Distribution of FDG PET and CT Imaging Results after Radiation
Authors: Patel Sapna A. , Mendez Eduardo , Rajendran Joseph , Weiss Noel S.
Published: February 2015

Objective

Both FDG PET and CT imaging can evaluate for persistent or recurrent malignancy after radiation treatment. Currently, there is a paucity of information about the discrepancy rates with these modalities. We want to determine the distribution of the results of posttreatment FDG PET/CT scans and their level of concordance.

Method

We reviewed the records of 486 patients with head and neck squamous cell carcinoma who underwent a postradiation FDG PET/CT scan between 2000 to 2011. PET and CT positivity were defined as a standardized uptake value (SUV) of ≥ 3.0 and a lymph node size of ≥1 cm, respectively.

Results

Sixty‐four patients in whom 80 PET/CT scans were performed were eligible. A total of 62.5% (50) of the scans were both PET and CT negative. Scans that were PET positive and CT negative comprised 16.2% (13), while 11.3% (9) were PET negative and CT positive. The remaining 10.0% (8) had positive PET and CT scans. Among those with a positive CT scan (17), 47% (8) had a positive PET scan, yet among those with a negative CT scan (63), only 20.6% (13) had a positive PET scan. The results of the 2 imaging modalities showed a fair level of agreement (kappa = 0.24).

Conclusion

There is a moderate level of concordance between PET and CT imaging modalities in the postradiation setting.
Effects of Ketorolac after Free Tissue Transfer
Authors: Schleiffarth Jack R. , Pagedar Nitin A. , Van Daele Douglas J. , Bayon Rodrigo , Chang Kristi E.
Published: February 2015

Objective

1) Describe the effect on postoperative pain and narcotic requirements in patients receiving ketorolac as an antiplatelet agent after head and neck free tissue transfer. 2) Assess for bleeding complications in patients receiving ketorolac.

Method

We identified patients who underwent head and neck free tissue transfer procedures at the University of Iowa between July 2010 and December 2011. A subset of patients received ketorolac as an antiplatelet agent at the discretion of the attending surgeon. Postoperative analgesic use, pain scores, and bleeding complications were compared.

Results

We identified 88 free tissue transfers, with 25 procedures in the ketorolac cohort. Patients in the nonketorolac group received a higher dose of aspirin (198.7 mg/d vs 26.2 mg/d, P <. 0001). In the first 10 postoperative days, patients in the ketorolac and nonketorolac cohorts received equivalent narcotic doses (morphine equivalents, 49.4 mg/d vs 44.4 mg/d, P =. 45). The ketorolac group reported higher pain scores (2.9 vs 2.1, P =. 002), still significant after correcting for the effect of bone flaps. Ketorolac use was not associated with need for transfusion (P =. 66). Reexploration rates, length of hospitalization, and days with neck drains were not different.

Conclusion

Ketorolac did not demonstrate a significant analgesic effect in this group of patients. However, there also was no evidence to suggest a higher likelihood of bleeding complications or prolonged need for suction drains. Ketorolac may be safely used as an antiplatelet agent, with narcotic requirements unchanged.
Endoscopic Benign Neck Mass Excision without Cervical Scar
Authors: Koh Yoon Woo , Lee Hyoung Shin , Kim Won Shik , Shin Yoo Seob , Hong HyunJun , Choi Hong‐Shik , Choi Eun Chang
Published: February 2015

Objective

Conventional transcervical approach leaves a visible scar on the neck, regardless of the size of the incision. The aim of this study was to determine the safety and feasibility of a transaxillary or retroauricular approach for the excision of benign neck masses by comparing it to the conventional open approach.

Method

We prospectively compared the outcomes of endoscopic removal of benign neck lesions with the outcomes of conventional open surgery. Transaxillary approach was chosen for lesions mainly located in level III to V and the perithyroidal area and retroauricular approach was chosen for those located in level I or II area.

Results

Operation was successful in all patients in endo group without any significant intraoperative complications or conversion to open surgery. The operating time in the endo group was longer than in the conventional group (P =. 010). The total amount (P =. 689) and duration (P =. 325) of drain between the 2 groups showed no significant difference. The mean duration of hospital stay was also comparable between the groups (P =.129). No significant difference was observed in the overall perioperative complications between the 2 groups. Cosmetic satisfaction evaluated with the graded scale showed much better results in the endo group (P =. 000).

Conclusion

Endoscopic resection via the transaxillary or retroauricular approach is safe and feasible for various benign cervical lesions with excellent cosmetic results.
Do Residency Applicant Measures Predict Future Performance?
Authors: Shonka David C. , Christophel John J. , Kesser Bradley W.
Published: February 2015

Objective

To determine if residency applicant measures are predictive of resident performance.

Method

A retrospective review of the residents graduating from 2006‐2012 was performed. Residency applicant measures including board scores, medical school grades, and applicant rank were recorded. These were compared to measures of resident performance including otolaryngology training exam (OTE) scores and composite 360° evaluation scores obtained during the final year of residency.

Results

Data was available on 20 residents. Residency applicant board scores were minimally predictive of resident OTE scores during the final year of residency (r2 = 0.377). There was no significant correlation between board scores and performance on evaluations (r2 = 0.10). Grade received during the surgical clerkship had an inverse correlation with performance on the OTE (r2 = 0.13). The surgical clerkship grade also had no correlation with evaluation score (r2 = 0.04). Most notably, applicant rank had minimal correlation with final resident performance as measured by composite evaluation score (r2 = 0.06).

Conclusion

Commonly used measures of applicant quality are minimally predictive of ultimate resident performance. Further studies are indicated to identify better predictors of resident performance.
Effects of a Reward System on Resident Academic Productivity
Authors: Mills Jonathan C. , Chang C. W. David
Published: February 2015

Objective

1) Implement a reward system that positively promotes academic productivity amongst otolaryngology residents. 2) Evaluate outcomes of the reward system with regards to resident academic output.

Method

Residents earn points for completing various steps of a research project. Points may be redeemed for academic endeavors, including books, equipment, and travel expenses. Resident publications submitted between 7/1/1997 and 6/30/2011 were reviewed. This timeframe included equal periods before and after implementation of the reward system, which occurred in 2004.

Results

The reward system was well‐utilized, with median annual points earned per resident of 850 (range 0‐3670). Forty‐nine resident authors on 40 unique publications were identified. Mean resident publications per year increased from 1.67 prior to the reward system to 5.57 after implementation of the reward system, P =. 01. After implementation of the reward system, a significantly higher percentage of resident publications were of the case report type (10% before and 85% after, P <. 001).

Conclusion

The reward system is well‐utilized by otolaryngology residents at our institution. One measure of academic achievement—number of publications—increased after implementing the reward system. These data suggest that this system may be effectively encouraging resident research, but may have the unintended effect of skewing publication output toward case reports.
Are Those Who Seek Rhinoplasty Really More Depressed?
Authors: Naraghi Mohsen
Published: February 2015

Objective

1) To study whether the prevalence of depression in rhinoplasty candidates is more than the patients of non‐cosmetic surgeries. 2) To define the importance of depression screening as a factor in rhinoplasty patient selection.

Method

The Beck depression inventory has been used to screen the state of depression in both patients seeking rhinoplasty and those who were supposed to undertake routine non‐cosmetic otorhinolaryngologic surgeries in the same hospital. 45 patients in each group were evaluated, and the results were analyzed through chi‐square and Student t tests.

Results

Overall 54.4% of patients were female and 45.6% were male, among which 62% of females were in the rhinoplasty group (p:0.02). The mean age in the rhinoplasty group was at least 1 decade younger than the patients undertaking non‐cosmetic surgeries (24.89 vs 36.27). Six rhinoplasty patients and 3 non‐cosmetic surgery patients were categorized in the mild depression group (P: 0.39). None of the patients seeking rhinoplasty were scored as having moderate and severe depression, while 2 patients of noncosmetic surgeries were categorized in these groups.

Conclusion

Despite the existing social image of a large prevalence of depressive symptoms in rhinoplasty seekers, which would lead to the terms of concern about the operation result, patients undertaking rhinoplasty, both males and females, seem to be as depressed as other patients of the same socioeconomic status.
Systemic Chemotherapy with Loco‐regional Radiotherapy
Authors: Chen Ming‐Yuan
Published: February 2015

Objective

Systemic chemotherapy is the basic palliative treatment for metastatic nasopharyngeal carcinoma at diagnosis (mNPC), but radiotherapy for primary tumor and its regional lymph nodes (loco‐regional radiotherapy, LR‐RT) is not routinely advocated. In current study, we evaluate the impact of LR‐RT on survival of patients with mNPC.

Method

A retrospective review of 385 mNPC patients at diagnosis recorded at San Yat‐Sen University Cancer Center between 2001 and 2009. We compared mortality risks between patients who underwent different anticancer treatments including systemic chemotherapy, LR‐RT, and local treatment of metastasis, alone or in combination, adjusted these risks for prognostic factors.

Results

However, it presented a 50% reduced risk of death compared to those without any anticancer treatment (HR, 0.5; 95% CI, 0.2 to 1.0; P =. 044) and 140% increase of death risk compared with those who underwent combination treatment of systemic chemotherapy and LR‐RT (HR, 2.4; 95% CI, 1.3 to 4.5; P =. 004). With analysis in the subgroup of patients who received combination treatment (n = 176), induction chemotherapy and LR‐RT with high dose (≥66Gy) showed significant lower risk of death compared to concurrent and adjuvant chemotherapy (HR, 0.4; 95% CI, 0.3 to 0.7; P =. 001) and low‐dose radiation (<66Gy) (HR, 0.6; 95% CI, 0.3 to 1.0; P =. 033).

Conclusion

LR‐RT, particularly combined with systemic chemotherapy, improves survival of patients with mNPC at diagnosis. High dose LR‐RT combined with induction chemotherapy is advocated based on current data. However, well‐designed prospective studies are expected to further evaluate the impact of LR‐RT.
The Esophageal Branches of the Recurrent Laryngeal Nerve
Authors: Espinel Alexandra G. , Sadeghi Nader , Goodman Joseph F.
Published: February 2015

Objective

1) To identify and define the cervical esophageal branches (CEB) of the recurrent laryngeal nerve (RLN), in vivo. 2) To study the feasibility of positively identifying the nonlaryngeal, distinct cervical esophageal branches of the RLN during thyroid surgery.

Method

Prospective and in vivo study of the CEB of the RLN, in a tertiary academic center. Inraoperative RLN monitoring was used. RLN and its cervical esophageal branches were identified visually. Nerve stimulation coupled with monitoring of the action potentials from the RLN, and direct observation of the cervical esophageal contractions were used for nerve confirmation.

Results

Fifty‐one RLNs (25 right and 26 left) were dissected in 31 patients undergoing thyroidectomy. In 17/25 (68%) right RLNs and 20/26 (77%) left RLNs, 1 or more distinct branches of the RLN to the cervical esophagus was identified and confirmed by nerve stimulation. These branches were distinct from the laryngeal branches of the RLN confirmed by direct visualization of esophageal contractions and laryngeal action potentials produced by nerve stimulation at different positions of the RLN and CEB. Overall, in 73% of all RLNs examined, functional esophageal branches could be identified.

Conclusion

Although the cervical esophageal branches of the RLN are well described in the basic anatomic literature, it is not referenced in thyroid surgery literature. It is important for the thyroid surgeon to be aware of these branches and preserve them, as they likely play an important role in swallowing.