Arch Otolaryngol Head Neck Surg Research Articles

Tonsillectomy in adults—to do or not to do

Recurrent acute tonsillitis describes the repeated occurrence of acute bacterial infections of palatine tonsils with symptom-free intervals. Acute tonsillitis accounts for around a third of respiratory tract infections in primary care among people of all ages, 1 Petersen I Johnson AM Islam A Duckworth G Livermore DM Hayward AC Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007; 335: 982 Crossref PubMed Scopus (210) Google Scholar with an estimated 600 million symptomatic cases of group A streptococcus tonsillitis worldwide annually. 2 Carapetis JR Steer AC Mulholland EK Weber M The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005; 5: 685-694 Summary Full Text Full Text PDF PubMed Scopus (1995) Google Scholar Recurrent episodes occur in 12% of patients with tonsillitis—ie, around 12 000 per 100 000 people. 3 Kvestad E Kværner KJ Røysamb E Tambs K Harris JR Magnus P Heritability of recurrent tonsillitis. Arch Otolaryngol Head Neck Surg. 2005; 131: 383-387 Crossref PubMed Scopus (26) Google Scholar Beyond the relation to group A streptococcus infections, little is known about risk factors for the development of recurrent acute tonsillitis. 4 Roberts AL Connolly KL Kirse DJ et al. Detection of group A Streptococcus in tonsils from pediatric patients reveals high rate of asymptomatic streptococcal carriage. BMC Pediatr. 2012; 12: 3 Crossref PubMed Scopus (97) Google Scholar Recurrent acute tonsillitis could be a genetic immunosusceptibility disease because patients younger than 12 years show some subclinical antibody deficiency and aberrant T-cell function 5 Dan JM Havenar-Daughton C Kendric K et al. Recurrent group A Streptococcus tonsillitis is an immunosusceptibility disease involving antibody deficiency and aberrant TFH cells. Sci Transl Med. 2019; 11eaau3776 Crossref PubMed Scopus (1) Google Scholar and many undergo tonsillectomy. More than 30 000 tonsillectomies are performed annually in the UK. 6 Keltie K Donne A Daniel M et al. Paediatric tonsillectomy in England: a cohort study of clinical practice and outcomes using Hospital Episode Statistics data (2008–2019). Clin Otolaryngol. 2021; 46: 552-561 Crossref PubMed Scopus (16) Google Scholar Tonsillectomy can produce severe postoperative pain, complicated by postoperative bleeding which can result in death in rare cases. Clearly, we need evidence-based policies to guide health-care professionals for the indication of tonsillectomy. 7 Mandavia R Schilder AGM Dimitriadis PA Mossialos E Addressing the challenges in tonsillectomy research to inform health care policy: a review. JAMA Otolaryngol Head Neck Surg. 2017; 143: 943-947 Crossref PubMed Scopus (10) Google Scholar Unfortunately, not much has changed in the past 40 years. National guidelines are still based on the Paradise criteria from 1984, 8 Paradise JL Bluestone CD Bachman RZ et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children—results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984; 310: 674-683 Crossref PubMed Google Scholar stating that a tonsillectomy is indicated when around seven or more treated tonsillitis episodes occur in 1 year. The Paradise criteria were based on paediatrics clinical trials and later extrapolated for adult guidelines without any justifying research in the adult population. Thus, the 2014 Cochrane Review concluded that the effectiveness of tonsillectomy is low. 9 Burton MJ Glasziou PP Chong LY Venekamp RP Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev. 2014; 2014CD001802 PubMed Google Scholar Until now, there was no basis to make confident decisions using national guidelines. 7 Mandavia R Schilder AGM Dimitriadis PA Mossialos E Addressing the challenges in tonsillectomy research to inform health care policy: a review. JAMA Otolaryngol Head Neck Surg. 2017; 143: 943-947 Crossref PubMed Scopus (10) Google Scholar Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trialCompared with conservative management, immediate tonsillectomy is clinically effective and cost-effective in adults with recurrent acute tonsillitis. Full-Text PDF Open Access

Neonatal stridor presents at home – vocal fold paralysis as rare presenting feature of CHARGE syndrome

Abstract Objectives To present an unusual presentation and diagnosis of CHARGE syndrome with vocal fold paralysis, a rarely associated congenital laryngeal anomaly, as the presenting feature. Case presentation A four-day old, full-term, male infant born via uncomplicated vaginal delivery with a nursery course significant for failed hearing screen presented to an emergency department (ED) with respiratory distress and worsening stridor. He was transferred to a level III neonatal intensive care unit (NICU) for further evaluation and required intubation due to progressive hypercarbia. Laryngoscopy revealed left-sided unilateral vocal fold paralysis (VFP). He underwent further evaluation that included a normal MRI brain, neck and chest. Genetics was consulted with concern for dysmorphic features on physical exam. Following gene panel testing, VFP was attributed to known association with CHARGE syndrome. Airway edema was noted on laryngoscopy that prevented extubation until two months of age. Further features of CHARGE syndrome identified included colobomas, glaucoma, sensorineural hearing loss, and genital abnormalities. He was discharged in room air and following gastrostomy tube placement with otolaryngology follow up. Conclusions Although choanal abnormalities are classically associated with CHARGE syndrome, other upper airway anomalies such as VFP may be present. VFP is a rarely reported anomaly in association with CHARGE syndrome (Naito Y, Higuchi M, Koinuma G, Aramaki M, Takahashi T, Kosaki K. Upper airway obstruction in neonates and infants with CHARGE syndrome. Am J Med Genet 2007;143A:1815–20; Morgan D, Bailey M, Phelps P, Bellman S, Grace A, Wyse R. Ear-nose-throat abnormalities in the CHARGE association. Arch Otolaryngol Head Neck Surg 1993;119:49–54).

Symptoms: Sudden Hearing Loss and Facial Paralysis

Symptoms: Sudden Hearing Loss and Facial Paralysis

Correlation between the transverse dimension of the maxilla, upper airway obstructive site, and OSA severity.

Acquiring a better comprehension of obstructive sleep apnea physiopathology can contribute to improving patient selection for surgical treatments. We hypothesize that maxillary transverse deficiency restricts the space available for the tongue, leading to upper airway obstruction during sleep. Our primary hypothesis was that maxillary transverse deficiency increases the prevalence of tongue collapse during drug-induced sleep endoscopy (DISE). The secondary hypothesis was that maxillary transverse deficiency will also increase the prevalence of circumferential collapse at the velopharynx. The exploratory hypothesis was that maxillary transverse deficiency is associated with increased obstructive sleep apnea severity. The objectives of this study were to correlate maxillary morphometric measurements with (1) the anatomic level of obstruction during DISE and (2) the apnea-hypopnea index on polysomnography. We made a cross-sectional analysis of patients with obstructive sleep apnea undergoing DISE in search of positive airway pressure alternative treatment. Maxillary measurements were collected from a computed tomography scan (interpremolar distance, intermolar distance [IMD] and sella-nasion A point angle), findings from DISE, and sleep study variables from polysomnography. Correlation between computed tomography, DISE, and polysomnography data was assessed using Pearson's correlation, and receiver operating characteristic curves were determined for each facial measurement. Sixty-nine patients were included in the study. The group with velopharyngeal circumferential collapse had mean IMD = 26.30 mm (25.5-31.45), and the group with anteroposterior collapse had mean IMD = 29.20 mm (26.8-33.10; P = .040). The group with complete tongue-base obstruction had mean interpremolar distance = 26.40 mm (25.1-28) and IMD = 26.30 mm (25.6-28.4), and the group without obstruction had mean interpremolar distance = 28.7 mm (27.2-30; P = .003) and IMD = 34.06 mm (32.1-37; P < .001). The receiver operating characteristic curve determined an IMD cutoff of 29.8 mm for predicting tongue-base obstruction. The maxillary transverse deficiency, identified by reduction in interpremolar distance and IMD, predicted the occurrence of complete tongue-base obstruction, complete concentric collapse at the velopharynx, and multilevel obstruction during DISE. We did not find an association between the maxillary measurements and obstructive sleep apnea severity. These associations hold some promise in ultimately supplanting insights previously available only through DISE.

Incidental Diagnosis of an Arachnoid Granulation on Ga-68 DOTATATE PET/MRI.

Leach JL, Jones BV, Tomsick TA, Stewart CA, Balko MG. Normal appearance of arachnoid granulations on contrast-enhanced CT and MR of the brain: differentiation from dural sinus disease. AJNR Am J Neuroradiol. 1996;17:1523–32. CAS PubMed Google Scholar Roche J, Warner D. Arachnoid granulations in the transverse and sigmoid sinuses: CT, MR, and MR angiographic appearance of a normal anatomic variation. AJNR Am J Neuroradiol. 1996;17:677–83. CAS PubMed Google Scholar Katz SE, Klisovic DD, O'Dorisio MS, Lynch R, Lubow M. Expression of somatostatin receptors 1 and 2 in human choroid plexus and arachnoid granulations: implications for idiopathic intracranial hypertension. Arch Ophthalmol. 2002;120:1540–3. CAS Article Google Scholar Treglia G, Castaldi P, Rindi G, Giordano A, Rufini V. Diagnostic performance of Gallium-68 somatostatin receptor PET and PET/CT in patients with thoracic and gastroenteropancreatic neuroendocrine tumours: a meta-analysis. Endocrine. 2012;42:80–7. CAS Article Google Scholar Barresi V, Alafaci C, Salpietro F, Tuccari G. Sstr2A immunohistochemical expression in human meningiomas: is there a correlation with the histological grade, proliferation or microvessel density? Oncol Rep. 2008;20:485–92. CAS PubMed Google Scholar Dutour A, Kumar U, Panetta R, Ouafik L, Fina F, Sasi R, et al. Expression of somatostatin receptor subtypes in human brain tumors. Int J Cancer. 1998;76:620–7. CAS Article Google Scholar Henze M, Dimitrakopoulou-Strauss A, Milker-Zabel S, Schuhmacher J, Strauss LG, Doll J, et al. Characterization of 68Ga-DOTA-D-Phe1-Tyr3-octreotide kinetics in patients with meningiomas. J Nucl Med. 2005;46:763–9. CAS PubMed Google Scholar Ivanidze J, Roytman M, Lin E, Magge RS, Pisapia DJ, Liechty B, et al. Gallium-68 DOTATATE PET in the evaluation of intracranial Meningiomas. J Neuroimaging. 2019;29:650–6. Article Google Scholar Kunz WG, Jungblut LM, Kazmierczak PM, Vettermann FJ, Bollenbacher A, Tonn JC, et al. Improved detection of Transosseous Meningiomas using (68)Ga-DOTATATE PET/CT compared with contrast-enhanced MRI. J Nucl Med. 2017;58:1580–7. CAS Article Google Scholar Buetow MP, Buetow PC, Smirniotopoulos JG. Typical, atypical, and misleading features in meningioma. Radiographics. 1991;11:1087–106. CAS Article Google Scholar Lang FF, Macdonald OK, Fuller GN, DeMonte F. Primary extradural meningiomas: a report on nine cases and review of the literature from the era of computerized tomography scanning. J Neurosurg. 2000;93:940–50. CAS Article Google Scholar Chen TC. Primary Intraosseous meningioma. Neurosurg Clin N Am. 2016;27:189–93. Article Google Scholar Gacek RR. Evaluation and management of temporal bone arachnoid granulations. Arch Otolaryngol Head Neck Surg. 1992;118:327–32. CAS Article Google Scholar Download references No funding support was received. Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA Nghi C. Nguyen, Chan-Hong Moon & Joseph M. Mettenburg Department of Radiology, UPMC Presbyterian, 200 Lothrop Street East Wing, Suite 200, Pittsburgh, PA, 15213, USA Nghi C. Nguyen You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar Correspondence to Nghi C. Nguyen. Nghi C. Nguyen, Chan-Hong Moon, and Joseph M. Mettenburg declare that they have no conflict of interest. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The institutional review board of our institution approved this retrospective study, and the requirement to obtain informed consent was waived. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and Permissions Nguyen, N.C., Moon, C. & Mettenburg, J.M. Incidental Diagnosis of an Arachnoid Granulation on Ga-68 DOTATATE PET/MRI. Nucl Med Mol Imaging (2020). https://doi.org/10.1007/s13139-020-00664-5 Download citation Received: 14 July 2020 Revised: 12 August 2020 Accepted: 17 August 2020 Published: 21 August 2020 DOI: https://doi.org/10.1007/s13139-020-00664-5

Recurrent respiratory papillomatosis: update 2018.

Recurrent respiratory papillomatosis (RRP) is the most common as well as the costliest benign airway neoplasm in the United States [Ivancic et al. (2018). Laryngoscope Investig Otolaryngol 3:22; Derkay (1995). Arch Otolaryngol Head Neck Surg 121:1386]. In addition, it is potentially deadly, with risk of airway obstruction as well as a 3-7% risk of malignant conversion [Schraff et al. (2004). Arch Otolaryngol Head Neck Surg 130:1039]. This review highlights exciting advancements over the past 1-2 years in scientific understanding of the pathophysiology, epidemiology, natural history, prevention, and treatment of this difficult disease. Recent studies have yielded the following findings: The primary quality of life reduction that patients perceive is voice-related; the membranous vocal folds are the most frequently involved anatomic subsite in adult-onset RRP; there may be a correlation between laryngopharyngeal reflux, herpes simplex virus type 2, and adult-onset RRP; there has been a decline in RRP incidence in Australia following the implementation of a national vaccination program; addition of educational audiovisual aids assists in vaccine acceptance rates; preventive vaccination can be used as treatment for pediatric as well as adult RRP patients with demonstrable effects on antibody titers and reoperation rates; calreticulin-linked DNA vaccines show promise in reducing the growth rate of human papilloma virus (HPV)11 E6/E7-expressing tumors in mice; injection of bevacizumab is associated with no adverse tissue affects; systemic bevacizumab is effective as a treatment for severe uncontrolled disease; pegylated interferon treatment is effective in select severe pediatric RRP disease; and finally, increased rates of programed death 1 T-lymphocyte infiltration and programed death-ligand 1 expression are seen on both papilloma and infiltrating immune cells. RRP is declining in incidence but remains a challenging disease to treat with great costs to patients, families, and the healthcare system. As the disease continues to be better understood, new frontiers are opening in treatment, particularly for severe or poorly controlled disease. Until the disease can be eradicated, it remains a vital area of research to help prevent new cases and treat afflicted patients.

Ins, Outs of Frequency-lowering Processing

Ins, Outs of Frequency-lowering Processing

Predictors of Obtaining Polysomnography Among Otolaryngologists Prior to Adenotonsillectomy for Childhood Sleep-Disordered Breathing.

(1) To assess the predictors for obtaining polysomnography (PSG) in children undergoing adenotonsillectomy (AT) for sleep-disordered breathing, and (2) to estimate the adherence to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline recommendations for pre-AT PSG. This was a retrospective cohort study of children who were seen in the Pediatric Otolaryngology Clinic and underwent AT for sleep-disordered breathing over a 13-month period at a single tertiary care children's hospital. Patients with and without pre-AT PSG were compared using bivariate and logistic regression analysis to identify predictors for PSG. Electronic medical records were reviewed for demographic variables, medical comorbidities, and PSG data. Adherence to AAO-HNS guideline recommendations was estimated by calculating the proportion of patients who had a PSG among those who met the recommended criteria for pre-AT PSG. Mean age was 6.6 ± 3.6 years with 53% male. A total of 65 of 324 children (20%) underwent PSG prior to AT. The only factor significantly associated with pre-AT PSG was age 1 to 3 years (odds ratio 4.5, 95% confidence interval [2.2, 9.0], P < .001). Among patients who met AAO-HNS criteria for pre-AT PSG, 28 of 128 (20%) underwent PSG compared to 35 of 186 (19%) who did not meet criteria (odds ratio 1.0, 95% confidence interval [0.6, 1.9], P = .87). Among children who underwent AT, the only significant predictor of obtaining pre-AT PSG was age 1 to 3 years. The rate of adherence to the AAO-HNS guideline recommendations was low (20%), which represents an educational opportunity.

Retrospective review of 69 patients undergoing open reduction and internal fixation of mandibular fractures at a regional maxillofacial centre

We describe a cohort of patients presenting to Northwick Park Hospital, a regional maxillofacial centre, with mandibular fractures requiring open reduction and internal fixation (ORIF). In particular, we reviewed their airway management for evidence of unexpected difficulty. A search of the electronic system used to code operating theatre activity was cross-referenced with the maxillofacial team’s database to identify patients undergoing mandibular ORIF between November 2016 and April 2017. Data were extracted from electronic records and paper case notes. A total of 104 patients underwent surgery over 6 months. The case notes of 80 patients were obtained: 11 were incomplete and 69 were suitable for a detailed analysis. The mean age was 28 yr. The majority of patients, 64/69 (93%), were male. By mechanism of injury, 55 (80%) were assaulted, there were five sports injuries (7%), four road traffic accidents (6%), four trips/falls (6%), and one case where the mechanism was unclear. Fifty-seven patients (83%) suffered isolated injuries; 12 (17%) sustained concomitant injuries, although none required any other operative intervention. No patients suffered a C-spine injury. The most widely used ‘primary’ laryngoscopy strategy, in 43 cases (62%), was video laryngoscope (C-MAC®, Karl Storz GmbH & Co. KG (Tuttlingen, Germany) in our centre). Direct laryngoscopy with a Macintosh blade was performed in 20 cases (29%). Six cases (9%) were intubated electively with a fibreoptic scope (four awake and two asleep), although the reasons for this choice of technique were not clear. Mouth opening was quantitatively recorded in all 69 cases. There was no intubation difficulty in any of the 69 cases, and none required a ‘secondary’ intubation strategy. This cohort, most of whom presented with an isolated injury, represents a subset of patients with mandibular fractures. Polytrauma patients are managed at our regional trauma centre. No patients sustained C-spine injuries, similar to a previously published work,1 showing that isolated mandibular fractures are rarely associated with C-spine injury. Despite the typical presentation with significant trismus, and despite 26% of patients having a condylar fracture, which can be associated with mechanical obstruction to mouth opening,2 the vast majority of patients in this cohort (91%) were intubated uneventfully using either a videolaryngoscope or a standard Macintosh blade. 1.Bayles SW, Abramson PJ, McMahon SJ, et al. Arch Otolaryngol Head Neck Surg 1997; 123: 1304–72.Sood J. Indian J Anaesth 2008; 52: 688–98

Test-retest reliability of drug-induced sleep endoscopy using midazolam.

Drug-induced sleep endoscopy (DISE) has been suggested to be a valuable method for determining the obstruction patterns causing sleep-disordered breathing. However, since DISE is not performed throughout the duration of sleep but for less than 1 hour, the reproducibility and reliability of DISE are questionable. Therefore, we aimed to determine the test-retest reliability of DISE using midazolam. Thirty-four patients diagnosed with obstructive sleep apnea were prospectively included in this study. The patients underwent 2 separate DISE examinations that were performed at different days using the same drug and technique. For a more accurate comparison, the depth of sleep and examination time were identically controlled. VOTE classification was used to classify the obstruction findings, and the findings of upper airway obstruction were compared between the 2 tests. There were 30 men and four women; the mean age was 45.4 ± 13.1 years. The mean apnea-hypopnea index was 38.3 ± 22.6, and the lowest oxygen saturation was 77.5% ± 12.4%. The lateral wall of the oropharynx, tongue base, and epiglottis showed very good agreement, and the velum showed good agreement between the first and second DISE examinations. The reliability of DISE is debatable because it observes only a small portion of the total sleep, but this study suggests that DISE is a reliable test because the findings of 2 separate DISE examinations on different days showed a high concordance rate.

Abstract: Adipose Derived Stem Cells Improve Union Rates and Biomechanical Strength Following Fracture in the Irradiated Murine Mandible

INTRODUCTION: Pathologic fractures and associated non-unions arising in irradiated bone are complex management dilemmas for the reconstructive surgeon. These complications are commonly managed with debridement of necrotic bone and vascularized free tissue transfers. Unfortunately, free tissue transfers remain complex and invasive procedures which are fraught with additional risk and morbidity1-4. This study examines a novel treatment paradigm for the management of non-unions and pathologic fractures utilizing implanted adipose derived stem cells (ASCs). Herein, we hypothesize that ASCs will mitigate the detrimental effects of radiation induced injury to the murine mandible and improve clinical union rates and metrics of biomechanical strength. METHODS: Isogenic Lewis rats (n=36) were divided into 3 groups. Control fracture (n=5), radiated fracture (n=15), radiated fracture + ASCs (n=16). The radiated groups received fractionated, 35Gy (human dose equivalent of 70Gy) radiation over 5 days, two weeks prior to mandibular osteotomy. The radiated fracture + ASCs group received implantation of the ASCs at the time of surgery on a Surgifoam scaffold. Following a 40-day healing period, mandibles were assessed for bony-union and mechanically tested to failure. ANOVA was used for comparison of continuous variables (p<0.05) and Chi Square for categorical variables χ2< 0.05. RESULTS:Bony Union: A statistically significant increase in bony union rates was seen in the radiated fracture + ASCs group (94%) vs radiated fracture alone (20%) χ2=0.00003. Clinical union rates in the radiated fracture + ASCs group (94%) approximated that of the control fracture group (100%) χ2=0.57. Biomechanical Testing: Significant improvements were found between radiated fracture + ASCs group and radiated fracture group in the metrics of Yield (61.46 N vs 23.5 N, p=0.003), Energy (56.12 Nmm vs 9.97 Nmm p=0.001), and Ultimate Load (73.47 N vs 33.72 N, p=0.002). Additionally, metrics of Yield and Ultimate Load were not statistically different between the radiated fracture + ASCs group and control fracture whereas Energy was significantly improved with ASC treatment (56.12 Nmm vs 9.91 Nmm p=0.001) CONCLUSION: Our data demonstrate the in-vivo efficacy of adipose derived stems cells (ASCs) and their ability to improve clinical union rates and biomechanical properties in the irradiated murine mandible. We support the continued investigation of this novel treatment paradigm and its further translational development for the management of pathologic fractures and associated non-unions after radiotherapy. 1. Urken ML, Buchbinder D, Costantino PD, et al. Oromandibular reconstruction using microvascular composite flaps: report of 210 cases. Arch Otolaryngol Head Neck Surg 1998; 124:46–55. 2. Peled M, El-Naaj IA, Lipin Y, Ardekian L. The use of free fibular flap for functional mandibular reconstruction. J Oral Maxillofac Surg 2005; 63:220–224. 3. Ross DA, Hundal JS, Son YH, et al. Microsurgical free flap reconstruction outcomes in head and neck cancer patients after surgical extirpation and intraoperative brachytherapy. Laryngoscope 2004; 114:1170–1176. 4. Shaari CM, Buchbinder D, Constantio PD, Lawson W, Biller HF, Urken ML. Complications of microvascular head and neck surgery in the elderly. Arch Otolaryngol Head Neck Surg 1998; 124:407–411.

Effect of Sleep State and Position on Obstructive Respiratory Events Distribution in Adolescent Children.

This study aimed to examine the effect of sleep state (rapid eye movement [REM] versus non-rapid eye movement [NREM]) and position (supine versus non-supine position) on obstructive respiratory events distribution in adolescent population (ages 12 to 18 y). This was a retrospective study that included 150 subjects between the ages of 12 to 18 y with an apnea-hypopnea index (AHI) > 1/h. Subjects using REM sleep-suppressant medications and subjects with history of genetic anomalies or craniofacial syndromes were excluded. The median age was 14 y with interquartile range (IQR) of 13 to 16 y, 56% of patients were males and the median body mass index (BMI) z-score was 2.35 (IQR: 1.71-2.59) with 77.3% of patients fulfilling obesity criteria. Respiratory obstructive events were more common in REM sleep. The median REM obstructive AHI (OAHI) was 8.9 events per hour (IQR: 2.74-22.8), whereas the median NREM OAHI was 3.2 events per hour (IQR: 1.44-8.29; p < 0.001). African American adolescents had more REM obstructive events with median REM OAHI of 13.2 events per hour (IQR: 4.88-30.6), which was significantly higher than median REM OAHI of 4.94 (IQR: 2.05-11.36; p = 0.004) in white adolescents. Obstructive events were more common in supine position with higher median supine OAHI of 6.55 (IQR: 4-17.73) when compared to median non-supine OAHI of 2.94 (IQR: 1-6.54; p < 0.001). This study shows that sleep related obstructive respiratory events in the adolescents (12 to 18 y of age) occur predominantly in REM sleep and in supine position.

Traitement de la stérilité et mélanome : question non résolue en 2016

The most common congenital midline nasal masses are nasal dermoid sinus cysts (NDSC) [Hughes GB, Sharpino G, Hunt W, Tucker HM. Management of the congenital midline nasal mass—a review. Head Neck Surg 1980;2:222–33.1]. Their clinical importance hinges on their potential to communicate with the central nervous system. Preoperative diagnosis of an intracranial extension allows for referral to a craniofacial team with the appropriate skills and experience for a transcranial approach. All patients with a NDSC require imaging with high resolution multiplanar MRI scans and complimentary fine cut CT scan to reveal the anatomical extent of the tract and its relationship to the anterior cranial fossa.A single-stage craniofacial approach to resection of midline NDSC extending to the anterior cranial base is effective with minimal morbidity [Yavuzer R, Bier U, Jackson IT. Be careful: it might be a nasal dermoid cyst. Plast Reconstr Surg 1999;103:2082–3; Denoyelle F, Ducroz V, Roger G, Garabedian EN. Nasal dermoid sinus cysts in children. Laryngoscope 1997;107:795–800; Rohrich RJ, Lowe JB, Schwartz MR. The role of open rhinoplasty in the management of nasal dermoid cysts. Plast Reconstr Surg 1999;104:2163–70; Rahbar R, Shah P, Mulliken JB, et al. The presentation and management of nasal dermoid—a 30-year experience. Arch Otolaryngol Head Neck Surg 2003;129:464–71; Posnick JC, Bortoluzzi P, Armstrong DC, Drake JM. Intracranial nasal dermoid sinus cysts: computed tomographic scan findings and surgical results. Plast Reconstr Surg 1994;93:745–54 [discussion 755–56]; Bartlett SP, Lin KY, Grossman R, Kratowitz J. The surgical management of orbitofacial dermoids in the pediatric patient. Plast Reconstr Surg 1993;91:1208–15.2, 3, 7, 9, 11, 18]. The cyst and tract are accessed through a combination of a nasal and transcranial approach. This allows visualisation and dissection of the tract with only a small incision on the nasal dorsum to include the cutaneous punctum when present. Transnasal endoscopic techniques have been advocated where the dermoid is located within the nasal cavity and there is little or no cutaneous involvement [Weiss DD, Robson CD, Mulliken JB. Transnasal endoscopic excision of midline nasal dermoid from the anterior cranial base. Plast Reconstr Surg 1998;101:2119–23.26].We present a review of five cases referred to our unit between 1999 and 2004 with a diagnosis of a midline nasal dermoid sinus cyst and radiological evidence of intracranial communication. All cases had a communication with the anterior cranial fossa diagnosed preoperatively and were treated surgically with a craniofacial approach. An intracranial extension was identified at operation in each case and this was confirmed on histopathology. The only significant complication resulted from an early postoperative infection, requiring re-operation. There were no recurrences and acceptable aesthetic outcomes have been observed in all cases.

Bone-Conduction Hearing Aids

Bone-Conduction Hearing Aids

Characteristics and surgical and clinical outcomes of severely obese children with obstructive sleep apnea.

To describe characteristics and surgical and clinical outcomes of obese children with obstructive sleep apnea (OSA). At our institution from 2000 to 2010, 143 obese children with an overnight polysomnography (OPSG) diagnosis of OSA, excluding children with comorbidities, were identified. Relationships between demographics, clinical findings, and the severity of OSA were assessed. Presurgery and postsurgery OPSG indices were compared. We defined cure as an apneahypopnea index (AHI) < 1.5/h on the postsurgery OPSG, and we compared the cure rates of different surgeries. A total of 143 children, median age 12.4 y (interquartile range [IQR] 9.6-14.9) and BMI z-scores 2.8 (IQR 2.6-2.9), were included. Seventy-eight (55%) (Median age 12 y [IQR 9-15]) underwent surgery: 1 had tonsillectomy; 1 tonsillectomy + uvulopharyngopalatoplasty (UPPP); 23 adenotonsillectomy (AT); 27 AT + UPPP; 11 adenoidectomy + UPPP; 8 UPPP; and 7 AT + turbinate trim ± tongue base suspension. Overall, surgery cured 19 children (26%), but AHI improved in the majority of children (p = 0.001). Similarly, the arousal index, PETCO2, and SpO2 nadir improved significantly (p < 0.002, p = 0.019, p < 0.001, respectively). AHI improved significantly in children with mild-to-moderate OSA in comparison to severe OSA (p < 0.001). Children with enlarged tonsils and no history of prior surgery benefitted more often from surgery (p < 0.004 and p = 0.002, respectively). AT was the only surgery reducing the AHI significantly (p = 0.008). Children did not lose weight despite intervention. Adherence with PAP was poor. Surgery improved OPSG indices in the majority of obese children with OSA.

Putting Research into Practice for Autism Spectrum Disorder

Putting Research into Practice for Autism Spectrum Disorder

Clinical pathways in transplantation: a review and examples from Beth Israel Deaconess Medical Center

Clinical pathways (CP) have been developed to aid in the management of many surgical and medical conditions. Studies show the benefits of CP on outcomes including reduction in length of stay (LOS), morbidity, costs, and improvement in patient satisfaction (Arch Surg 2008: 394: 31; J Eval Clin Pract 2007: 13: 920; Arch Otolaryngol Head Neck Surg 2000: 126: 322; Circulation 2000: 101: 461; BMC Pulm Med 2006: 6: 22; Int J Health Care Qual Assur 2006: 19: 237; Am J Med Qual 2005: 20: 83; Am J Surg 2006: 192: 399; Am Surg 2005: 71: 152). Reports of CP in solid organ transplantation are lacking, possibly given the complexity of the transplant procedures that entail a complex, multidisciplinary pre-operative evaluation, inpatient, and post-operative time frames. We have developed CP from presentation for transplant evaluation to post-transplant follow-up for liver, kidney, and pancreas transplantation and live kidney and live liver donation and are making them available online for viewing. Our CPs encompass the pre-operative, peri-operative, and post-operative period, including both outpatient and inpatient care. We propose that transplantation is an ideal forum for successful implementation of CP, given the rigorous process that centers are subject to for CMS approval and the ample opportunity for improving our patients' lives by improvement in and streamlining of the entire process of clinical care from end-stage organ failure to post-transplant long-term management. Our CPs can be found at http://bidmc.org/CentersandDepartments/Departments/TransplantInstitute/TransplantClinicalPathways.aspx.

Oxymetazoline Superior to Cocaine and Lidocaine for Nosebleeds

Oxymetazoline Superior to Cocaine and Lidocaine for Nosebleeds

Case 171: Facial Nerve Hemangioma

The patient’s imaging features, especially the honeycomb pattern of ossific changes in the geniculate fossa, were virtually pathognomonic for ossifying hemangioma of the facial nerve.

Incidental parathyroidectomy during thyroid resection: incidence, risk factors, and outcome

BACKGROUND AND OBJECTIVES:Thyroidectomy is a commonly performed procedure for thyroid problems. Inadvertent removal of the parathyroid glands is one of its recognized complications, which occurs more frequently in certain high-risk patients. The aim of this study was to identify the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery.DESIGN AND SETTING:A retrospective review of thyroid operations performed at a tertiary referral hospital between January 2004 and December 2008.METHODS:Pathology reports were reviewed to identify the specimens that included parathyroid tissue and underlying thyroid pathology. Postoperative calcium levels were reviewed in these patients.RESULTS:During the study period, 287 thyroidectomies were performed and 47 (16.4%) patients had incidentally removed parathyroid glands. Risk factors for inadvertent parathyroid resection included total thyroidectomy (P=.0001), Hashimoto thyroiditis (P=.004), and extrathyroidal spread (P=.0003). Postoperative hypocalcemia occurred in 18 (38.3%) of the patients in whom the parathyroid gland was removed inadvertently and in 48 (20%) of the rest of the patients (P=.0123).CONCLUSION:The incidence of incidental removal of parathyroid tissue during thyroidectomy is 16.4%. Total thyroidectomy, extrathyroidal extension of the tumor, and thyroiditis were found to be the risk factors. Hypocalcemia was significantly higher among patients who had inadvertent parathyroidectomy.