Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management

BACKGROUND

Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas.

METHODS

We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension.

AIMS

Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery.

RESULTS

Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes.

CONCLUSIONS

The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.

Management of Intracranial Sinusitis Complications in Children and Adolescents: Similarities and Differences Among Otolaryngology Subspecialists

The purpose of this study was to compare the management of intracranial sinusitis complications in pediatric patients between members of the American Rhinologic Society (ARS) and the American Society of Pediatric Otolaryngology (ASPO). A cross-sectional web-based survey was distributed twice to the ASPO and ARS membership over an 8-month period. The overall survey response rate was 12.1% (7.5% of ARS members and 17.3% of ASPO members). Recommended management was similar with respect to the use of intravenous antibiotics, nasal saline irrigations, topical decongestants, and nasal steroid sprays. Recommendations diverged with regards to systemic steroid use and urgent/emergent endoscopic sinus surgery (ESS). ARS members were more likely to recommend systemic corticosteroids. ASPO members were more likely to recommend immediate ESS. Based on survey responses, we found differences in practice patterns among subspecialists, which indicates additional collaborative research between societies is necessary to develop and disseminate evidence-based guidelines for these patients.

Level of Evidence: 4

Postoperative Disposition Following Pediatric Sistrunk Procedures: A National Database Query

OBJECTIVE/HYPOTHESIS

Variability exists in the postoperative disposition of children following Sistrunk procedures. Management options include discharge home versus overnight observation, with the latter allowing monitoring for immediate postoperative complications, presumably reducing the need for subsequent readmission. This study investigates the association between overnight observation and ambulatory management of children undergoing Sistrunk procedures and relevant postoperative complication and revisit rates to clarify best practice for these patients.

METHODS

This was a retrospective database review using the Pediatric Health Information System database from 2007 to 2016.

RESULTS

The cited dataset identified 6,434 qualifying patients, categorized into ambulatory versus overnight observation cohorts. The overall 30-day revisit rate was 4.9%; the revisit rate with overnight observation (6.1%) was higher than for ambulatory patients (3.8%, adjusted odds ratio (OR) 1.60; 95% confidence interval (CI): 1.21, 2.12). Revisit rates were significantly higher in patients 2 years of age or younger compared to older patients (6.7% vs. 4.3%). The rates of return to the operating room for the observation versus ambulatory groups were 1.8% and 0.5%, respectively. Cervical fluid collection and neck swelling were among the most common revisit indications in both groups, with a mean time to presentation of 9 days.

CONCLUSIONS

This study demonstrates that ambulatory management following a Sistrunk procedure is not associated with increased rates of common postoperative complications, readmission, or need for secondary surgical intervention. A Sistrunk procedure may be safely performed on an ambulatory basis in select cases.

LEVEL OF EVIDENCE

IV Laryngoscope, 131:E2352-E2355, 2021.

Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy?

OBJECTIVE

To evaluate risk factors for pediatric posttonsillectomy hemorrhage (PTH) and the need for transfusion using a national database.

STUDY DESIGN

Retrospective cohort study.

SETTING

The study was conducted using the Pediatric Health Information System (PHIS) database.

METHODS

Children ≤18 years who underwent tonsillectomy with or without adenoidectomy (T±A) between 2004 and 2015 were included. We evaluated the risk of PTH requiring cauterization according to patient demographics, comorbidities, indication for surgery, medications, year of surgery, and geographic region.

RESULTS

Of the 551,137 PHIS patients who underwent T±A, 8735 patients (1.58%) experienced a PTH. The risk of PTH increased from 1.33% (95% confidence interval [CI]: 1.15%, 1.53%) in 2010 to 1.91% (95% CI: 1.64%, 2.24%) in 2015 (P < .001). Older age (≥12 vs <5 years old: adjusted odds ratio [aOR] 3.17; 95% CI: 2.86, 3.52), male sex (aOR 1.11; 95% CI: 1.05, 1.17), medical comorbidities (aOR 1.18; 95% CI: 1.08, 1.29), recurrent tonsillitis (aOR 1.15; 95% CI: 1.07, 1.24), and intensive care unit admission (aOR 1.74; 95% CI: 1.55, 1.95) were significantly associated with an increased risk of PTH. Use of ibuprofen (aOR 1.36; 95% CI: 1.22, 1.52), ketorolac (aOR 1.39; 95% CI: 1.14, 1.69), anticonvulsant (aOR 1.23; 95% CI: 1.03, 1.76), and antidepressants (aOR 1.35; 95% CI: 1.03, 1.76) were also associated with an increased risk of PTH. The need for blood transfusion was 2.1% (181/8735).

CONCLUSION

The incidence of PTH increased significantly between 2011 and 2015, and ibuprofen appears to be one contributing factor. Given the benefits of ibuprofen, it is unclear whether this increased risk warrants a change in practice.

Perioperative pain control and tympanostomy tube outcomes

OBJECTIVE

To evaluate perioperative pain management regimens as they relate to tympanostomy tube outcomes.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral children's hospital.

SUBJECTS

and Methods: The medical records of patients ≤18 years old who underwent tympanostomy tube placement were reviewed for indications, perioperative pain medications, post anesthesia recovery unit (PACU) measures, and tympanostomy tube occlusion rates.

RESULTS

Four hundred and fifty-five patients met inclusion criteria. Median age was 1.7 years (interquartile range: 1.2-3.3 years). Recurrent acute otitis media (n = 239, 52.5%) was the most common indication. All patients were American Society of Anesthesiologists (ASA) class 1 (n = 244, 58.1%) or 2 (n = 176, 41.9%). Fentanyl alone (n = 321, 70.6%) was the most common intraoperative analgesic administered followed by ketorolac alone (n = 40, 8.8%), and fentanyl and ketorolac together (n = 58, 12.8%). There was no significant difference in FLACC pain score at discharge and recovery time (minutes) also did not differ by intraoperative analgesia group (34.3 ± 15.2 for fentanyl; 36.2 ± 13.0 for ketorolac; 31.0 ± 12.5 for fentanyl and ketorolac together). Forty nine patients (11.6%) had an occluded tympanostomy tube at follow-up. Patients ≤1 year of age had a significantly higher risk of tube occlusion than patients >1 year of age (23.7% vs. 8.9%; p < 0.001). There was no significant difference in tube occlusion rates based on indication for tube placement, history of tube placement, intraoperative findings, or intraoperative pain regimen.

CONCLUSIONS

Ketorolac is a reasonable non-narcotic alternative to fentanyl which provides equal pain control and does not increase tube occlusion rates.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Diagnosis, pre-operative, operative and post-operative pediatric choanal atresia care

OBJECTIVE

To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of young infants who present with signs or symptoms of choanal atresia.

METHODS

A two-iterative delphi method questionnaire was used to establish expert recommendations by the members of the International Otolaryngology Group (IPOG), on the diagnostic, intra-operative, post-operative and revision surgery considerations.

RESULTS

Twenty-eight members completed the survey, in 22 tertiary-care center departments representing 8 countries. The main consensual recommendations were: nasal endoscopy or fiberscopy and CT imaging are recommended for diagnosis; unilateral choanal atresia repair should be delayed after at least age 6 months whenever possible; transnasal endoscopic repair is the preferred technique; long term follow-up is recommended (minimum one year) using nasal nasofiberscopy or rigid endoscopy, without systematic imaging.

CONCLUSION

Choanal atresia care consensus recommendations are aimed at improving patient-centered care in neonates, infants and children with choanal atresia.

Readmissions following ambulatory pediatric endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Endoscopic sinus surgery (ESS) is indicated in select pediatric patients with medically refractory sinus disease. Our objectives were to examine indications and rates of readmission following ambulatory pediatric ESS and identify specific subgroups that may benefit from inpatient admission.

STUDY DESIGN

Retrospective database review.

METHODS

The Pediatric Health Information Systems (PHIS) 2004-2016 database was retrospectively reviewed for patients age <18 years who underwent ambulatory ESS between January 2011 and December 2016 and were readmitted within 30 days postoperatively. Data regarding demographics, extent of surgery, comorbidities, adjunctive procedures, and cost were collected. A multivariable mixed-effects logistic regression model was employed for analysis.

RESULTS

We identified 3,669 unique pediatric ESS cases with 128 readmissions within 30 days (3.5%; 95% confidence interval [CI]: 2.9%-4.1%). Median cost of readmission was $980 (mean, $5,890; standard deviation, $13,421). The most common indication for readmission was epistaxis (17.2%), followed by nausea/abdominal pain (14.1%). Respiratory infection (13.3%) and sinusitis (10.2%) presented a combined readmission rate exceeding that of epistaxis alone. Multivariable analysis indicated age <3 years (odds ratio [OR]: 3.41, 95% CI: 1.96-5.93) and a prior diagnosis of asthma (OR: 2.88, 95% CI: 1.99-4.18) or cystic fibrosis (OR: 1.57, 95% CI: 1.00-2.44) significantly increased the risk of readmission. Extent of ESS and simultaneous adenoidectomy, septoplasty, or turbinate reduction had no significant impact on readmission rates.

CONCLUSIONS

ESS is a relatively safe outpatient surgical procedure in pediatric patients, with an overall readmission rate of 3.5%. Clinicians should consider careful preoperative evaluation of very young patients and those with cystic fibrosis or asthma to optimize perioperative management and determine if postoperative admission is warranted, given their significantly higher readmission rates.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2681-2686, 2019.

Metastatic squamous cell carcinoma of the tonsil presenting as otorrhea: a case report

We describe the case of a 52-year-old man with a history of squamous cell carcinoma (SCC) of the tonsil who presented with right subacute otalgia and otorrhea. Dedicated computed tomography of the temporal bones showed opacification within the mastoid process with destruction of bony mastoid septations consistent with coalescent mastoiditis. Preoperative imaging showed no destruction or expansion of the bony eustachian tube that would indicate that a direct spread had occurred. An urgent cortical mastoidectomy was performed. Intraoperatively, a friable white mass surrounded with purulence and granulation tissue was biopsied and returned as SCC. The discrete metastasis was removed without complication. Postoperatively, the patient was prescribed palliative chemotherapy. This case shows that a metastatic SCC can be masked by an overlying mastoiditis, and thus it should be considered in the differential diagnosis of a patient with a history of oropharyngeal cancer.

Sinus Computed Tomography Imaging in Pediatric Cystic Fibrosis

Study Objective

To evaluate the prevalence of computed tomography (CT) sinus imaging in a pediatric cystic fibrosis (CF) population, determine changes in Lund Mackay (LM) scores over time, and estimate radiation exposure.

Study Design

Case series with chart review.

Setting

Tertiary care children’s hospital.

Subjects and Methods

In total, 202 pediatric patients with CF who underwent endoscopic sinus surgery (ESS) were included. The total number of CT scans was calculated for each patient, with specific focus on the indications for and subsequent outcomes of the sinus CT scan subgroup.

Results

Patients underwent a total of 1718 CT scans, 832 of which were sinus CT scans (mean of 4.2 sinus scans per patient). Disease evaluation (54%) and preoperative planning (35%) were the most common indications. Otolaryngologists were more likely to order imaging for preoperative evaluation, and those scans were more likely to result in surgery compared with those requested by other physicians ( P < .001). Ninety CT scans (10.8%) led to no change in management. There was no significant difference in LM scores between patients admitted to the hospital or prescribed antibiotics and those who were not. There was also no significant change in LM score following ESS after adjusting for age and sex ( P = .23).

Conclusion

Based on LM scores, all sinus CT scans in patients with CF reveal moderate to severe sinus disease. Effort should be made to minimize radiation exposure in patients with CF by limiting sinus CT scans to the preoperative context or for evaluation of potential sinusitis complications.

Evaluation and Management of Chronic Aspiration in Children With Normal Upper Airway Anatomy

IMPORTANCE

Chronic airway aspiration is a challenging problem for physicians and caregivers and can cause significant pulmonary morbidity in pediatric patients. Our knowledge regarding the causes and optimal management of these patients is in its infancy.

OBJECTIVE

To review our experience with the evaluation and management of pediatric patients with documented aspiration and normal upper airway anatomy.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective medical record review, we studied pediatric patients for airway disorders at a pediatric tertiary referral center who were diagnosed as having aspiration on modified barium swallow study during a 10-year period (June 1, 2002, through September 31, 2012).

INTERVENTIONS

Direct laryngoscopy and bronchoscopy performed with the patient under general anesthesia.

MAIN OUTCOMES AND MEASURES

Demographics, comorbidities, management, and swallowing outcomes were analyzed.

RESULTS

Forty-six patients met the inclusion criteria. The mean age at presentation was 1.56 years, and there was a male to female ratio of approximately 2:1. Eight patients (17%) were syndromic, 16 (35%) had developmental delay, and 12 (26%) had congenital heart disease. Fifteen patients (33%) underwent brain magnetic resonance imaging, and none had a brainstem or posterior fossa lesion that accounted for their aspiration. Patients were subdivided according to the consistency of the fluids that they aspirated: 25 (54%) aspirated thin liquids, 15 (33%) aspirated thickened liquids, and 6 (13%) aspirated purees. Of these patients, 21 (84%), 12 (80%), and 3 (50%) had resolution of their swallowing dysfunction with feeding and swallowing therapy, respectively. A total of 3 patients (7%) required a tracheostomy for their refractory aspiration.

CONCLUSIONS AND RELEVANCE

We recommend feeding and swallowing therapy for children with normal upper airway anatomy. Brain magnetic resonance imaging should be considered for patients with suspected brainstem or posterior fossa lesion based on neurologic examination findings. Most patients who aspirate thin and thickened liquids will have resolution of their swallowing dysfunction within 1 year of beginning therapy.

Update on current evaluation and management of pediatric nasal dermoid

OBJECTIVES/HYPOTHESIS

To review the presentation of congenital pediatric nasal dermoid and present guidelines for its evaluation and management.

STUDY DESIGN

Retrospective chart review from 1970 to 2014 at a tertiary referral children's hospital.

METHODS

The medical records of all patients diagnosed with a nasal dermoid during the study period were reviewed for demographics, lesion characteristics, imaging, operative details, and outcomes.

RESULTS

Ninety-six patients underwent excision of a congenital nasal dermoid during the study period. The mean age at presentation was 3.1 years (range, 0.1-19.3 years). Thirty-four (35%) females and 62 (65%) males were included. The most common presentation was a nasal dorsal mass in 66 (69%) patients. Ninety-two (96%) of the patients underwent preoperative imaging. Seventy-eight (82%) of the patients did not show any clinical or radiographic evidence of intracranial extension preoperatively. Eighty-five (89%) of the patients underwent extracranial excision, and 11 (11%) underwent combined intracranial and extracranial excision. Eight patients (8%) presented with recurrence, on average 3.3 years (range, 1-6 years) after initial excision. Mean follow-up time was 8 years (range, 1-18 years).

CONCLUSION

Preoperative imaging of nasal dermoid is crucial to evaluate for intracranial extension, thus facilitating complete removal. Thin section, high-resolution magnetic resonance with contrast provides excellent detail of the extent of the nasal dermoid including intracranial extension. Thin-section high-resolution computed tomography with multiplanar reformatted images provides complimentary information regarding the bone anatomy of the frontonasal region. Surgical strategy is dictated by preoperative imaging and is dependent on the extent of the lesion, but limited facial incisions are preferred.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2151-2160, 2016.

Congenital nasal neuroglial heterotopia and encephaloceles: An update on current evaluation and management

OBJECTIVES/HYPOTHESIS

To describe our experience and current management approach for congenital nasal neuroglial heterotopia (NGH) and encephaloceles.

STUDY DESIGN

Retrospective chart review at a tertiary pediatric hospital from 1970 to 2013.

METHODS

Thirty patients met inclusion criteria: 21 NGH and nine encephaloceles. Data including demographics, pathology, imaging modality, surgical approach, resection extent, outcomes, and complications were analyzed.

RESULTS

Fourteen NGH patients (67%) presented with an internal nasal mass and nasal obstruction. Three patients (14%) presented with an external nasal mass and four (19%) had a mixed lesion. Median age at surgery was 0.51 years (interquartile range 1.32 years). Thirteen (62%) had an intranasal endoscopic approach. Median operative time was 1.6 hours (interquartile range 1.2 hours), and there were no major complications. Nine patients with encephalocele were identified: six (67%) presented with transethmoidal encephaloceles, two (22%) presented with nasoethmoidal encephaloceles, and one (11%) presented with a nasofrontal lesion. The median age at surgery was 1.25 years (interquartile range 1.4 years). All patients required a craniotomy for intracranial extension. Median operative time was 5 hours (interquartile range 1.9 hours), and eight patients (88%) had a total resection. Length of stay ranged from 3 to 14 days.

CONCLUSION

Nasal neuroglial heterotopia and encephaloceles are very rare lesions that require multidisciplinary evaluation and management. At our institution, there has been a shift to magnetic resonance imaging alone for the evaluation of NGH to avoid radiation exposure. Endoscopic extracranial resection is feasible for most intranasal and mixed NGH without an increase in operative time, residual disease, or complications.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2161-2167, 2016.

The Public Health Impact of Pediatric Deep Neck Space Infections

Objective

There is little consensus about the best management of pediatric deep neck space infections (DNSIs) and limited information about the national disease burden. The purpose of this study is to examine the health care burden, management, and complications of DNSIs from a national perspective.

Study Design

Retrospective administrative data set review.

Setting

National pediatric admission database.

Subjects and Methods

Pediatric patients diagnosed with a parapharyngeal space and/or retropharyngeal abscess were identified from the 2009 KIDS’ Inpatient Database. Patient demographic, hospital, and clinical characteristics were compared between patients who received surgical and nonsurgical management. All results for the analyses were weighted, clustered, and stratified appropriately according to the sampling design of the KIDS’ Inpatient Database.

Results

The prevalence of DNSIs was 3444 in 2009, and the estimated incidence was 4.6 per 100,000 children. The total hospital charges were >$75 million. The patients who were drained surgically had a 22% longer length of stay (mean = 4.19 days) than that of those who were managed without surgery (mean = 3.44 days). Mean hospital charges for patients who were drained surgically were almost twice those of patients who were managed medically ($28,969 vs $17,022); 165 patients (4.8%) had a complication.

Results

There are >3400 admissions for pediatric DNSIs annually, and they account for a significant number of inpatient days and hospital charges. A randomized controlled trial of management may be indicated from a public health perspective.

Vocal fold avulsion in the pediatric population: Presentation and management

OBJECTIVE

Laryngeal injury among pediatric patients is uncommon; traumatic vocal fold (VF) avulsion is even more rare. The objective of this paper is to present the endoscopic management of a pediatric patient with VF avulsion and review the relevant literature.

METHODS

A relevant case of a pediatric patient with a VF avulsion secondary to blunt laryngeal trauma who underwent successful endoscopic repair is presented. A comprehensive search in PubMed was conducted for cases of pediatric VF avulsion in the English-language literature.

RESULTS

Sixteen cases of pediatric VF avulsion were reviewed (8 cases of external trauma and 8 cases of internal trauma). All cases of external laryngeal trauma presented in male patients and ranged in age from 5 to 15 years. Three patients had bilateral VF avulsions and four had unilateral avulsions. Three patients were successfully managed endoscopically. Four patients underwent tracheotomy; all patients were successfully decannulated in the postoperative period. Voice quality returned to normal for most patients. Clinical pearls and controversies in the evaluation and management of pediatric VF avulsion are presented.

CONCLUSIONS

Accurate and timely diagnosis of pediatric VF avulsion is important. CT imaging without sedation should be considered in stable patients. The endoscopic approach is the preferred method of repair when it is amenable to the extent of injury and availability of expertise from both surgeon and anesthesiologist.

Corrective nasal surgery in the younger patient

IMPORTANCE To describe clinical parameters for the management of the pediatric patient with nasal anatomical deformity or functional impairment. OBJECTIVES To review the authors' experience with corrective nasal surgery in pediatric patients and make recommendations regarding indications for surgery and surgical techniques. DESIGN, SETTING, AND PARTICIPANTS A retrospective medical chart review was performed for all male patients younger than 16 years and female patients younger than 14 years seen by the senior author (F.G.F.) at a tertiary referral center between August 1996 and August 2012. The database was searched for patients who underwent septoplasty or corrective nasal surgery by the senior author. EXPOSURES Patients included in the study underwent either septoplasty or corrective nasal surgery by the senior author. MAIN OUTCOMES AND MEASURES Age, indication for surgery, surgery performed, and last follow-up appointment was recorded for each patient. In addition, any complications or need for revision surgical or adjunct procedures were noted. RESULTS Demographics and outcomes for 54 pediatric patients were included in the study. The most common indications for surgery were posttraumatic deformities (n = 36) and severe airway obstruction (n = 48). Fifteen patients with severe nasal airway obstruction did not have a documented history of trauma. The mean follow-up period was 646 days (approximately 21 months), with a range of 8 to 4062 days. Five patients underwent a staged procedure, and no patients underwent a revision procedure for unsatisfactory results. CONCLUSIONS AND RELEVANCE Children with nasal obstruction and deformity can safely undergo nasal corrective surgery prior to adolescence. Special considerations include preserving normal structures and the judicious use of grafts. The recommended approaches to managing the pediatric septoplasty and nasal surgery patient are described herein through a series of representative cases.

A chief of service rotation as an alternative approach to pediatric otolaryngology inpatient care

IMPORTANCE

Maintaining an outpatient practice and providing high-quality inpatient care pose significant challenges to the traditional call team approach.

OBJECTIVE

To introduce a unique rotating hospitalist inpatient program and assess its clinical, educational, and financial impact. The chief of service (COS) program requires 1 attending physician to rotate weekly as chief of the inpatient service with no conflicting elective duties.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective internal billing data review performed at a tertiary pediatric hospital. A total of 1241 patients were evaluated by the COS from October 2012 through October 2013.

INTERVENTIONS

All patients were treated by the inpatient service under the supervision of the COS.

MAIN OUTCOMES AND MEASURES

A retrospective analysis of patient encounters and procedures, including International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes, locations of service, clinicians, service dates, and average weekly relative value units (RVUs).

RESULTS

Over the study period, the COS was involved in the care of 1241 patients, generating 2786 billable patient encounters. The COS averaged 11.2 patient encounters per day. The most common reasons for consultation were respiratory distress, dysphagia, and stridor. Of patient encounters, 63.0% resulted in a procedure; 82.8% of those procedures were performed in the operating room with the most common being lower airway endoscopy (340 [19.4%]). The average weekly RVUs for the COS (232) were comparable with those of the average weekly outpatient clinic and procedural RVUs of the other otolaryngology faculty in the group (240).

CONCLUSIONS AND RELEVANCE

The COS program was created to meet the clinical, educational, and organizational demands of a high-volume and high-acuity inpatient service. It is a financially sustainable model with unique advantages, particularly for the staff who maintain their outpatient practices without disruption and for the trainees who have the opportunity to work closely with the entire faculty. Patients are provided supervised evaluations and continuity of care. This rotating hospitalist program is a viable alternative to the full-time hospitalist staff model.

Pathologic fracture of the mandible secondary to traumatic bone cyst

The traumatic bone cyst (TBC) is an uncommon and poorly understood lesion. First described in 1929, TBCs lack an epithelial lining, typically occur during the second decade of life, and are most frequently located in the jaw. Although the majority of TBCs are asymptomatic, rarely a TBC can cause a pathologic fracture of the mandible. We present a case of an adolescent suffering a sports-related pathologic mandible fracture secondary to a traumatic bone cyst.

Dedifferentiated epithelial-myoepithelial carcinoma: analysis of a rare entity based on a case report and literature review

Dedifferentiated epithelial-myoepithelial carcinoma (DEMC) is very rare salivary gland neoplasm with only anecdotal reports. We present an analysis of DEMC, based on a case and review of literature. Our patient, an 85-year-old woman, presented with a submandibular mass of 5 years duration that was increasing in size over a 5-week period. Histologically, there were areas of typical epithelial-myoepithelial carcinoma, with dedifferentiation of both components, manifesting morphologically as salivary duct carcinoma and areas of myoepithelial carcinoma. A review of literature revealed 21 previously reported cases of DEMC. DEMC occurs at an average age of 72 years, most often in the parotid gland (72%) followed by submandibular gland (17%). Dedifferentiation more often involves the epithelial component (13/15 cases) than the myoepithelial component (5/15 cases). Although typical epithelial-myoepithelial carcinomas are fairly indolent (average disease-free survival of 11.34 years), dedifferentiation confers a poor prognosis (survival reported from 1 to 72 months).

Impact of Tonsillectomy Clinical Practice Guidelines

Objective: To evaluate the effect of the recently published pediatric tonsillectomy and polysomnography clinical guidelines on current practice patterns.

Method: An anonymous 15-question survey was sent to members of the American Academy of Otolaryngology–Head and Neck Surgery regarding their awareness of the Clinical Practice Guideline: Tonsillectomy in Children and Clinical Practice Guideline: Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children and whether or not they have changed their practice as a result.

Results: A total of 93% of respondents read the guidelines. Most respondents had completed a pediatric otolaryngology fellowship (84%). A small majority of physicians (54%) continue to prescribe antibiotics within 24 hours after surgery. One-third of respondents stopped prescribing antibiotics because of the new guidelines. Discord between severity of symptoms and tonsil size was the most common reason cited for ordering a polysomnogram prior to tonsillectomy (76%) in concordance with the guideline’s recommendations. A total of 45% of physicians prescribe NSAIDs for pain control despite its safety profile, and 23% reported that the guidelines influenced their use of NSAIDs postoperatively. Most respondents use intraoperative steroids (90%).

Conclusion: The guidelines are intended to provide evidence- based direction in tonsillectomy practices and improve referral patterns for polysomnography prior to tonsillectomy. A majority of the surveyed otolaryngologists reviewed these guidelines. There is some evidence practice has changed secondary to the guidelines.

Location of airway obstruction in term and preterm infants with laryngomalacia

OBJECTIVE

The aim of this study was to describe and compare the airway findings in term and preterm infants with laryngomalacia.

METHODS

A retrospective review of 130 patients diagnosed as having laryngomalacia at a tertiary referral center between July 2004 and August 2009 was conducted. Medical records were reviewed for demographic data, supraglottic and glottic airway findings, concomitant airway lesions, and the need for intervention.

RESULTS

The mean gestational age and age at diagnosis was 36 and 15 weeks, respectively. Combined posterior and anterior supraglottic collapse was the most common finding (31%). Posterior collapse alone occurred in 25%, anterior collapse in 14%, and lateral collapse in 10%. Twelve percent of patients had all 3 sites of collapse. Forty-one percent of patients had a secondary airway lesion, with tracheomalacia being the most common. Preterm infants had significantly higher rates of reflux and more sites of collapse than did term infants (P < .0001). Eight patients required an intervention for their symptoms.

CONCLUSIONS

Children with laryngomalacia tend to have more than 1 area of supraglottic collapse, and more than one third have a secondary lesion. All patients who required an intervention had more than 1 area of collapse, and 63% of these patients had a secondary airway lesion. Our high incidence of secondary lesions is similar to recent reports.

Congenital nasal obstruction: clinical and radiologic review

Congenital nasal obstruction can result in neonatal respiratory distress because neonates are obligate nasal breathers. Therefore, all physicians who deal with infants should be familiar with the structural abnormalities, masses, and syndromes that cause nasal obstruction, so that appropriate work-up and treatment can be promptly initiated. This paper reviews the embryology of the nasal passage and then continues with the different causes of nasal obstruction. Special attention is paid to the presentation, physical exam findings, and imaging modality of choice.

Minimally invasive radioguided parathyroidectomy performed for primary hyperparathyroidism

OBJECTIVE

Parathyroid surgery is often challenging due to considerable variability in anatomy. Minimally invasive radioguided parathyroidectomy (MIRP) is a directed surgical approach that has been made possible by the advent of new imaging techniques, specifically sestamibi scanning. In this study, we review our experience and outcomes with MIRP in one of the largest case series reported in the literature.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

Subjects were 305 patients who underwent MIRP in our institution between 1997 and 2007. Data including symptoms, preoperative and postoperative calcium levels, and PTH levels were collected. Analyses were performed using Excel AnalysisPak.

RESULTS

MIRP in this series had a 100 percent rate of success in removing a hyperfunctional parathyroid gland. The mean preoperative calcium was 10.9 whereas the mean postoperative level was 9.8. There was a significant difference between preoperative and postoperative calcium levels (both ionized and total) (P<0.01). Mean preoperative and postoperative serum PTH levels were 138 and 50, respectively. PTH levels were therefore significantly lower postoperatively (P<0.01). Rapid PTH testing showed a similar pattern. There were no cases of recurrent laryngeal nerve palsy.

CONCLUSION

MIRP is an effective method for removal of image-localized hyperfunctional parathyroid glands.

Minimally Invasive Radioguided Parathyroidectomy

Objective

Parathyroid surgery is often challenging due to considerable variability in anatomy. Minimally invasive radioguided parathyroidectomy (MIRP) is a surgical option that has been made possible by the advent of new imaging techniques, specifically Sestamibi scanning. In this study, we review our experience, methods, and outcomes with MIRP in one of the largest case series reported in the literature.

Methods

A retrospective chart review was performed on 365 patients who underwent MIRP between 1997 and 2007. Data including symptoms, pre- and postoperative calcium levels, and PTH levels were collected. Analyses were performed using Excel AnaylsisPak.

Results

Intraoperatively, an average of 20mCi Tc-99m was injected for Sestamibi scanning. The mean pre-op calcium was 10.9, whereas the mean post-op level was 9.8. There was a significant difference between pre-op and post-op calcium levels (both ionized and total) (p<.01). Mean pre- and post-op PTH levels were 277 and 46 respectively. Rapid PTH levels were therefore significantly lower post-operatively (p<.01).

Conclusions

MIRP is an effective method for removal of parathyroid adenomas. The benefits of MIRP include more accurate localization, shorter operative and recovery time, a shorter hospital stay, and better cosmetic results.

Dexamethasone and methylprednisolone do not inhibit neuritic outgrowth while inhibiting outgrowth of fibroblasts from spiral ganglion explants

CONCLUSION

Dexamethasone and methylprednisolone do not inhibit neuritic outgrowth while inhibiting fibroblastic outgrowth from spiral ganglion micro-explants.

OBJECTIVES

To demonstrate reduced fibroblastic outgrowth while maintaining neurite outgrowth for several corticosteroids using an in vitro test system of neonatal rat spiral ganglion micro-explants.

MATERIALS AND METHODS

The in vitro test system comprised 3-day-old rat spiral ganglion micro-explants. Dexamethasone, methylprednisolone, triamcinolone acetonide, and human recombinant brain-derived neurotrophic factor (hrBDNF) were tested in vitro. The control was ganglion micro-explants in supplemented Dulbecco's modified Eagle's medium. Areas of the ganglion explant, neurite and fibroblast outgrowth of ganglion explants after 10 days in vitro were imaged, digitized, and analyzed using Image Tool 3.00 on a PC workstation. Areas of neurite and fibroblast outgrowth from the experimental explants were compared against values obtained from control explants.

RESULTS

Dexamethasone gave the best result of the three corticosteroids tested for inhibiting fibroblast outgrowth while not inhibiting neurite outgrowth from the ganglion micro-explants. Media containing hrBDNF (10 ng/ml) stimulated significantly greater neurite outgrowth than outgrowth from control explants (p < 0.001). Ganglion micro-explants treated with dexamethasone (0.02 mg/ml) and methylprednisolone (0.5 mg/ml) provided the greatest inhibition of fibroblast outgrowth compared with control explants (p < 0.001).

Local Dexamethasone Therapy Conserves Hearing in an Animal Model of Electrode Insertion Trauma-Induced Hearing Loss

HYPOTHESIS

The progressive loss of hearing that develops after electrode insertion trauma (EIT) can be attenuated by local dexamethasone (DXM) therapy.

BACKGROUND

Hearing loss (HL) that develops after cochlear implant EIT occurs in two stages in laboratory animals, that is, an immediate loss followed by a progressive loss. Direct infusion of DXM into the guinea pig cochlea can attenuate both ototoxin- and noise-induced HL.

MATERIALS AND METHODS

Auditory-evoked brainstem responses (ABRs) of guinea pigs were measured for 4 frequencies (i.e., 0.5, 1, 4, and 16 kHz) before, immediately after, and more than 30 days post-EIT for experimental (EIT,EIT + artificial perilymph, and EIT + DXM) and for the contralateral unoperated cochleae of each group. An electrode analog of 0.14-mm diameter was inserted through a basal turn cochleostomy for a depth of 3 mm and withdrawn. DXM in artificial perilymph was delivered immediately post-EIT into the scala tympani via a miniosmotic pump for 8 days.

RESULTS

The ABR thresholds of EIT animals increased progressively post-EIT. Contralateral unoperated cochleae had no significant changes in ABR thresholds. Immediately post-EIT, that is, Day 0, the DXM-treated animals exhibited a significant HL at 1, 4, and 16 kHz, but this HL was no longer significant by Day 30 compared with contralateral control ears.

CONCLUSION

The results from immediate local treatment of the cochlea with DXM in an animal model of EIT-induced HL suggest a novel therapeutic strategy for hearing conservation by attenuating the progressive HL that can result from the process of electrode array insertion during cochlear implantation.

Blocking c-Jun-N-terminal kinase signaling can prevent hearing loss induced by both electrode insertion trauma and neomycin ototoxicity

Neomycin ototoxicity and electrode insertion trauma both involve activation of the mitogen activated protein kinase (MAPK)/c-Jun-N-terminal kinase (JNK) cell death signal cascade. This article discusses mechanisms of cell death on a cell biology level (e.g. necrosis and apoptosis) and proposes the blocking of JNK signaling as a therapeutic approach for preventing the development of a permanent hearing loss that can be initiated by either neomycin ototoxicity or electrode insertion trauma. Blocking of JNK molecules incorporates the use of a peptide inhibitor (i.e. D-JNKI-1), which is specific for all three isoforms of JNK and has been demonstrated to prevent loss of hearing following either electrode insertion trauma or loss of both hearing and hair cells following exposure to an ototoxic level of neomycin. We present previously unpublished results that control for the effect of perfusate washout of aminoglycoside antibiotic by perfusion of the scala tympani with an inactive form of D-JNKI-1 peptide, i.e. JNKI-1(mut) peptide, which was not presented in the original J. Neurosci. article that tested locally delivered D-JNKI-1 peptide against both noise- and neomycin-induced hearing loss (i.e. Wang, J., Van De Water, T.R., Bonny, C., de Ribaupierre, F., Puel, J.L., Zine, A. 2003a. A peptide inhibitor of c-Jun N-terminal kinase protects against both aminoglycoside and acoustic trauma-induced auditory hair cell death and hearing loss. J. Neurosci. 23, 8596-8607). D-JNKI-1 is a cell permeable peptide that blocks JNK signaling at the level of the three JNK molecular isoforms, which when blocked prevents the increases in hearing thresholds and the loss of auditory hair cells. This unique therapeutic approach may have clinical application for preventing: (1) hearing loss caused by neomycin ototoxicity; and (2) the progressive component of electrode insertion trauma-induced hearing loss.