Impact of superior semicircular canal dehiscence on cochlear implant audiologic outcomes

PURPOSE

Determine whether adult cochlear implant users with radiographic superior semicircular canal dehiscence experience clinically significant differences in audiological outcomes when compared to cochlear implant users with normal temporal bone anatomy.

MATERIALS AND METHODS

Retrospective, single institution review. Adult, post-lingual deaf patients implanted between 2010 and 2020. Inclusion criteria included age 18 years or older, available preoperative computed tomography imaging, and preoperative and postoperative AzBio audiological data for at least 6 months of cochlear implant use. Preoperative and postoperative AzBio Sentence Test scores were compared between patients with normal temporal bone anatomy and those with radiographic superior semicircular canal dehiscence or near dehiscence.

RESULTS

110 patients met inclusion criteria. Mean AzBio score for normal temporal bone anatomy group improved from 35.2 % (SD 28.2) preoperatively to 70.3 % (SD 25.7) postoperatively, an improvement of 35.1 % (SD 28.6). Mean AzBio score for near dehiscent temporal bone anatomy group improved from 26.6 % (SD 28.9) preoperatively to 64.5 % (SD 30.6) postoperatively, an improvement of 37.9 % (SD 27.9). Mean AzBio score for dehiscent temporal bone anatomy group improved from 26.3 % (SD 20.4) preoperatively to 65.1 % (SD 27.6) postoperatively, an improvement of 38.7 % (SD 26.9). Utilizing the one-way analysis of variance test, there was no significant difference in audiologic outcomes between the three groups.

CONCLUSIONS

Patients with complete or near complete radiographic superior canal dehiscence at the time of cochlear implantation achieve similar improvements in speech perception scores compared to normal anatomy adult cochlear implant users.

Educational Benefit of the Three-Dimensional Exoscope Versus Operating Microscope in Otologic Surgery

OBJECTIVE

To compare observation of otologic surgery using a traditional operating microscope (OM) and a three-dimensional exoscope.

STUDY DESIGN

Prospective, nonrandomized, noncontrolled study.

SETTING

Tertiary care center.

METHODS

Senior medical students and otolaryngology trainees observing otologic surgery performed with OM and exoscope were asked to complete a questionnaire comparing the two experiences. The key variables were image clarity, depth perception, observer's level of motion sickness during the surgery, the participant's understanding of middle ear anatomy, and their overall preference between OM and exoscope.

RESULTS

Twenty-two observers participated in the study. Subjective clarity of the image was significantly better with the exoscope compared with the OM (9.7 ± 0.6 versus 6.9 ± 1.7, p = 0.0004) as well as the depth perception (9.25 ± 0.87 versus 5 ± 2.69, p = 0.0007). Observers subjectively had an improved understanding of middle ear anatomy after observing an exoscopic surgery, but not a microscopic surgery. All but one observer preferred the exoscope.

CONCLUSION

The three-dimensional exoscope may be a valuable educational tool for teaching trainees otologic surgery. More objective studies are needed in the future to assess the degree of improvement.

Infectious causes and mimickers of meniere's disease

PURPOSE OF REVIEW

To review the evidence of a possible viral etiology of Meniere's disease, the role of antiviral therapy, as well as other infectious disease processes that may mimic Meniere's disease. Better understanding of the etiology of Meniere's disease and the role of various infectious disease processes may allow for more effective diagnosis and management.

RECENT FINDINGS

There is evidence that viral infections - to Herpes simplex virus, cytomegalovirus, Epstein Barr virus, influenza, adenovirus, Coxsackie virus B, and Varicella Zoster Virus - may be involved in the development of Meniere's disease, however the evidence is inconsistent and the underlying mechanism remains theoretical. Nevertheless, antiviral therapy may be effective for a subset of patients with Meniere's disease. Lastly, other infectious diseases including Lyme disease and syphilis can present with symptoms similar to Meniere's disease. It is important to discern these from Meniere's disease to determine the appropriate treatment.

SUMMARY

There is a paucity of high-quality evidence to support a viral etiology of Meniere's disease, and the current evidence appears circumstantial and inconsistent. Additional research is necessary to establish the mechanism and causative pathogens. Antiviral therapy may provide therapeutic benefit for a subset of patients with Meniere's disease. Furthermore, clinicians should be aware of other infectious mimics of Meniere's disease and include them in the differential diagnosis of patients presenting with Meniere's-like symptoms. Research on this subject continues to evolve, and data from these studies represent a growing repository of evidence that can be used to guide clinical decision-making.

Audiologic comparison of classification systems of advanced otosclerosis

OBJECTIVE

To identify which patients with advanced otosclerosis may have the greatest audiologic improvement with stapedotomy based on different classifications of advanced otosclerosis.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary neurotology center.

METHODS

Patients were divided into different classifications of advanced otosclerosis based on either a bone conduction threshold of greater than 60 dB HL (Bone Conduction (BC) Group), a word recognition score of less than 70% (Word Recognition (WRS) Group), or pure tone average of greater than 85 dB HL (Pure Tone Average (PTA) Group). Audiologic outcomes and complication profiles were compared between these groups.

RESULTS

Nineteen patients met criteria for one or more group. There were 18 patients in the PTA group, 11 in the BC group, and 12 in the WRS group. There was no significant difference in the pre- or postoperative audiologic status between the different groups.

CONCLUSIONS

Patients with advanced otosclerosis have significant improvements in pure tone averages and air-bone gaps following stapedotomy regardless of the classification criteria used. Stapedotomy remains a reasonable primary intervention for the majority of patients with advanced otosclerosis.

Audiologic Outcomes of Footplate Drillout for Obliterative Otosclerosis

OBJECTIVE

To evaluate the audiologic outcomes of microdrill fenestration for obliterative otosclerosis compared to traditional stapedotomy technique.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adult patients undergoing stapedotomy for otosclerosis.

MAIN OUTCOME MEASURES

Patients were separated into groups that underwent either microdrill or laser fenestration based on intraoperative severity of disease. Audiologic outcomes and complications were compared between the two groups.

RESULTS

There were 588 ears in 519 patients that were evaluated. There was a significant postoperative improvement in pure tone average, air-bone gap, and mean bone conduction thresholds for both the obliterative and nonobliterative group (p < 0.001). There was no significant difference in the pre- or postoperative hearing status between the two groups. There was no significant difference in complications between the two groups, including no cases of postoperative profound hearing loss in the drill fenestration group.

CONCLUSIONS

Audiologic outcomes are similar between microdrill fenestration and laser fenestration for otosclerosis. Pure tone average, air-bone gap, and mean bone conduction thresholds all improved postoperatively and were similar between groups.

Comparison of Cranioplasty Techniques Following Translabyrinthine Surgery: Implications for Postoperative Pain and Opioid Usage

OBJECTIVE

To assess differences in postoperative pain, opioid usage, and surgical outcomes between cranioplasty using abdominal fat graft (AFG) versus hydroxyapatite cement (HAC) following translabyrinthine surgery.

STUDY DESIGN

Retrospective case control.

SETTING

Tertiary referral center.

PATIENTS

Sixty translabyrinthine procedures were evaluated, including 30 consecutive HAC patients and 30 matched AFG patients. Patients were matched by age, gender, body mass index, and tumor size.

INTERVENTION

Cranioplasty using HAC or AFG following translabyrinthine resection of vestibular schwannoma.

MAIN OUTCOME MEASURES

Postoperative patient pain ratings, narcotic usage, inpatient length of stay, and complication rates.

RESULTS

Patients who underwent HAC cranioplasty had lower postoperative pain scores on several measures (p < 0.05) and less postoperative narcotic usage (mean difference of 36.7 morphine equivalents, p = 0.0025) when compared to those that underwent AFG closure. HAC cranioplasty patients had shorter average length of hospital stay (2.2 vs 3.4 days, p = 0.0441). Postoperative cerebrospinal fluid leaks (one in HAC group, two in AFG group) and skin reactions in AFG closure patients (n = 1) were infrequent.

CONCLUSION

HAC cranioplasty is a safe technique comparable to AFG closure following translabyrinthine surgery which can decrease postoperative pain, narcotic usage, and hospital length of stay.

Rate of Development of Venous Thromboembolism in Lateral Skull Base Surgery

OBJECTIVES

Venous thromboembolism (VTE) is a major cause of morbidity and mortality for surgical patients. This article aims to determine factors that may have contributed to the development of VTE in patients undergoing lateral skull base surgery, to assess the validity of the Caprini Risk Assessment Model (RAM) score in this subset of patients, and to determine the efficacy of mechanical DVT prophylaxis alone in preventing VTE.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review was conducted of patients who underwent skull base surgery for vestibular schwannoma, and the rate of VTE was assessed. Patient demographics, comorbidities, and treatment factors were examined to determine risk factors associated with the development of a postoperative thrombotic event. Caprini RAM scores were compared for patients who developed a VTE.

RESULTS

Among 197 patients, the rate of VTE formation was 3.5%. No individual risk factor independently contributed to the development of a thrombotic event. The mean Caprini RAM score was 4.06 in patients who did not develop a VTE and 5.14 in the patients that did develop a VTE (P = .005). The Caprini score was significant for the risk of VTE formation, with an odds ratio of 2.8 (P = .009, 95% CI = 1.3-6.2).

CONCLUSION

Venous thromboembolism rates are relatively low following lateral skull base surgery. While there is no individual risk factor associated with increased VTE risk, the Caprini RAM score appears to be a useful predictor of risk. The Caprini score may be useful in identifying high-risk patients who may benefit from chemoprophylaxis for VTE prevention.

LEVEL OF EVIDENCE

Level III-This is a retrospective chart review study Laryngoscope, 2021.

Risk Factors for Complications Following Lateral Skull Base Surgery and the Utility of ICU Monitoring

OBJECTIVE

To examine the role of intensive care unit (ICU) management following lateral skull base surgery for vestibular schwannoma and identify risk factors for complications warranting admission to the ICU.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral center.

PATIENTS

Two hundred consecutive patients undergoing lateral skull base surgery for vestibular schwannomas.

INTERVENTION

Lateral skull base approach for resection of vestibular schwannoma and postoperative monitoring.

MAIN OUTCOME MEASURES

Patients were grouped if they sustained an ICU complication, a non-ICU complication, or no complication. Analysis was performed to determine patient or treatment factors that may be associated with ICU complications. Multivariate and three-way analysis of variance compared groups, and multivariate logistic regression determined adjusted odds ratios (aOR) for analyzed factors.

RESULTS

Seventeen of 200 patients sustained ICU complications (8.5%), most commonly hypertensive urgency (n = 15). Forty-six (23%) sustained non-ICU complications, and 137 (68.5%) had no complications. When controlling for age, sex, obesity, and other comorbidities, only hypertension (aOR 5.43, 95% confidence interval (CI) 1.35-21.73, p = 0.017) and tumor volume (aOR 3.29, 95% CI 1.09-9.96, p = 0.035) were independently associated with increased risk of ICU complications.

CONCLUSIONS

The necessity of intensive care following lateral skull base surgery is rare, with the primary ICU complication being hypertensive urgency. Preoperative hypertension and large tumor volume (>4500 mm3) were independently associated with increased risk for ICU complications. These findings may allow for risk stratification of patients appropriate for admission to stepdown units following resection of vestibular schwannomas. Further prospective, multi-center, randomized studies are necessary to validate these findings before systematic changes to current postoperative care practices.

Hydroxyapatite cement cranioplasty in the setting of simultaneous translabyrinthine resection of cerebellopontine angle tumors and cochlear implantation

Cochlear implantation (CI) has become an option for the treatment of hearing loss after translabyrinthine resection of vestibular schwannomas. The surgical video presents the case of a 67-year-old male who had translabyrinthine resection of vestibular schwannoma with simultaneous CI and closure with a hydroxyapatite (HA) cement cranioplasty. HA cement cranioplasty can be utilized in place of abdominal fat graft for the closure of translabyrinthine approaches with similar efficacy and complication profile. To the authors’ knowledge, this is the first reported case of a simultaneous CI and translabyrinthine resection of vestibular schwannoma with HA cement cranioplasty.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID211

Effect of Surgical Start Time on Stapedotomy Outcomes

OBJECTIVE

To examine if performing stapedotomy as the first case of the day provides improved outcomes compared with those performed later in the day.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adult patients undergoing stapedotomy for otosclerosis.

MAIN OUTCOME MEASURES

Patients were separated into either a first case group or a later case group based on surgical start time. Audiologic outcomes and complications were compared between the two groups.

RESULTS

The first case group had a smaller postoperative air-bone gap (ABG) compared with the later case group of 9.81 dB HL compared with 11.73dB HL and 3.79 dB HL compared with 6.29 dB HL at 1000 and 2000 Hz, respectively (p = 0.03, p < 0.01). The mean postoperative ABG was 10.63 dB HL for the first start group compared with 12.12 dB HL for the later start group, which was statistically significant (p = 0.05).

CONCLUSIONS

First start stapedotomy is associated with slightly improved audiologic outcomes compared with those starting later in the day, although both groups had significantly improved postoperative outcomes overall. There was no significant difference in complications when comparing stapedotomy by case start time.

Post-stapedotomy reparative granuloma following use of acellular porcine small intestinal submucosa

PURPOSE

There have been multiple proposed etiologies of reparative granuloma following stapes surgery. In this report, we present the first case of post-stapedectomy reparative granuloma following the use of Biodesign (Cook Medical, Bloomington, IN) otologic graft material, an acellular matrix derived from porcine small intestinal submucosa, and review the literature of post-stapes surgery reparative granuloma.

PATIENT

50-year-old woman who developed a reparative granuloma following stapedotomy with acellular porcine intestinal submucosa presenting with profound hearing loss and vertigo.

INTERVENTION

Middle ear exploration with excision of granuloma and revision stapedotomy.

MAIN OUTCOME MEASURES

Audiologic outcomes as measured by pure-tone air and bone conduction thresholds and word recognition scores. Improvement in vertigo.

MAIN FINDINGS

Surgical excision of the reparative granuloma with revision stapedotomy resolved vertigo. Hearing has improved progressively postoperatively.

CONCLUSIONS

We report the first case of post-stapedotomy reparative granuloma following the use of acellular porcine intestinal submucosa. Although exact etiology cannot be determined from a single case report, this illustrates the need for careful use of novel foreign graft material. This case additionally confirms that removal of granuloma and inciting materials can salvage serviceable hearing.

Early Outcomes of Simultaneous Translabyrinthine Resection and Cochlear Implantation

OBJECTIVES/HYPOTHESIS

Hearing rehabilitation after translabyrinthine resection of a vestibular schwannoma (VS) has largely been based on the transfer of acoustic stimulus to the contralateral ear, typically through a contralateral routing of signal hearing aid or bone-anchored hearing aid (BAHA). Cochlear implant, either as a subsequent surgery or simultaneously, has become a more common treatment option; however, there is still relatively limited data available on its success. The purpose of this study is to evaluate the early outcomes of simultaneous cochlear implantation in patients with sporadic VS undergoing translabyrinthine resection.

STUDY DESIGN

Prospective, nonrandomized study.

METHODS

A prospective study of nonrandomized patients was completed at a tertiary care neurotology center. Audiologic outcomes, primarily based on AzBIO in quiet and background noise, as well as consonant-nucleus-consonant (CNC) testing of the affected ears were utilized. Tinnitus, dizziness, and spatial hearing questionnaries were also completed. Audiologic outcomes and questionnaires were compared between the pre- and postoperative groups.

RESULTS

Ten patients were included in the study with 3 month follow-up data. There was statistically significant improvement in AzBO with +10 and +5 signal to noise ratio and in quiet, as well as in CNC testing (P < .05). There was a significant improvement in Tinnitus Handicap Inventory between the two groups.

CONCLUSIONS

Simultaneous cochlear implantation is a viable treatment for hearing loss after translabyrinthine approach to VS. These patients have improved hearing in background noise and tinnitus compared to their preoperative state. Further prognostic data are required to determine which patients are the best candidates.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2312-E2317, 2021.

Frequency-specific Electrocochleography and Traveling Wave Time as a Clinical Test for Menière's Disease

INTRODUCTION

Menière's disease is a clinical entity with no definitive objective testing. It has been hypothesized that underlying endolymphatic hydrops stiffens the basilar membrane leading to increased speed of the acoustic stimulus, therefore traveling wave velocity has been proposed as an objective test to aid in the diagnosis. The objective of this study is to compare electrocochleography frequency-specific action potential latency, basilar membrane traveling wave time, and summation to action potential (SP/AP) ratio in Menière's and non-Menière's patients.

METHODS

Tympanic electrocochleography was performed with frequency-specific action potential latency time and SP/AP ratio recorded. Patient demographics, symptoms, audiogram data, AAO-HNS classification of Menière's disease, management interventions, and follow-up were recorded. Statistical analysis was performed to compare outcome measures across patient groups, demographics, and clinical data.

RESULTS

Ninety-one patients (182 ears) were included. There was a significant difference between a "definite" Menière's diagnosis and an "unlikely" or "probable" diagnosis by an average of 13 dB HL for the pure-tone thresholds at 250 Hz on the affected side (p = 0.006). There was no significant difference in pure-tone thresholds at any other frequency, AP latency at any frequency, or AP/SP ratio between the different Menière's classification groups.

CONCLUSIONS

Our study fails to show significance of the traveling wave velocity as an objective test for Menière's disease. A significant correlation was found with low-frequency hearing loss between AAO-HNS Menière's classification groups.

Bone Cement Fixation of Stapedotomy Prostheses: Long-term Outcomes in Primary and Revision Stapes Surgery

OBJECTIVES

To describe audiologic outcomes following hydroxyapatite bone cement fixation of stapedotomy prostheses.

METHODS

A retrospective case review at a tertiary neurotology referral center was performed of patients undergoing primary or revision stapedotomy between 2010 and 2017. Patients with hydroxyapatite bone cement fixation of stapes prostheses were assessed. Pre- and postoperative hearing was compared, consisting of air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Short and long-term outcomes were assessed.

RESULTS

Forty-six patients with otosclerosis underwent stapedotomy with bone cement fixation: 21 primary cases and 25 revision cases, with an average follow-up time of 17 months. Mean AC PTA was 56 dB preoperatively, and 34 dB postoperatively (P < .0001), while the ABG improved on average from 27 dB to 9 dB (P < .0001). There was no significant difference in postoperative ABG between primary and revision stapes surgery (6 dB vs 10 dB, P = .07). These results persisted through long-term follow-up in a subgroup of patients with significantly longer follow-up time (mean 44 months). There was no significant change in BC PTA or word recognition scores. Three patients underwent subsequent revisions, one patient developed sensorineural hearing loss.

CONCLUSION

Stapedotomy with bone cement fixation of the prosthesis provides excellent hearing outcomes in both primary and revision treatment of otosclerosis. Results are consistent and stable through long-term follow-up. The use of bone cement should be incorporated into the surgical armamentarium of the otologist for the prevention and treatment of loose-wire syndrome and incus necrosis.

Perioperative cost evaluation of canal wall down mastoidectomy

INTRODUCTION

To evaluate perioperative costs of canal wall-down (CWD) mastoidectomy as an initial surgery compared to revision surgery following initial canal wall-up (CWU) mastoidectomy.

METHODS

This study is a retrospective chart review of adult patients who underwent CWD mastoidectomy for chronic otitis media with or without cholesteatoma at a tertiary referral center. Patients were divided into groups that had previous CWU surgery and were undergoing revision CWD and those that were having an initial CWD mastoidectomy. Cost variables including previous surgeries, imaging costs, audiometric testing, and post-operative visits were compared between the two groups using t-test analysis.

RESULTS

There was no significant difference with regards to the cost of post-operative visits, peri-operative imaging, or revision surgeries between the two groups. Hearing outcomes based on mean speech reception threshold (SRT) were not statistically different between the two groups (p = 0.087). There was a significant difference in total cost with the revision group having a higher mean cost by $6967.84, most of which was accounted for by the difference in the cost of the previous surgeries of $6488.53.

CONCLUSIONS

The revision CWD surgery group had increased total cost that could be attributed to the cost of previous surgery. Increased peri-operative cost was not noted with the initial CWD surgery group for any individual variables examined. Initial CWD mastoidectomy should be considered in the proper patient population to help decrease healthcare costs.

Stapes surgery with a persistent stapedial artery

PURPOSE

To review surgical outcomes of stapes surgery for otosclerosis with persistence of the stapedial artery.

MATERIALS AND METHODS

A retrospective case review of a tertiary neurotology referral center of patient with otosclerosis undergoing primary stapes surgery between 2010 and 2017 found to have a persistent stapedial artery. Stapedectomy was performed with or without cauterization of the stapedial artery. The primary outcome measures include pre- and postoperative hearing as well complications. Hearing was measured by air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Neurologic complications, including facial nerve function, were assessed.

RESULTS

Four patients out of 853 with otosclerosis undergoing stapedectomy were found to have a persistence of the stapedial artery. Mean AC PTA was 55 dB preoperatively, and 24 dB postoperatively (p = .0041), while the ABG improved on average from 31 dB to 6 dB (p = .0014). Mean follow-up time was 32 months, and there were no significant complications. Facial nerve function was preserved in all patients (House-Brackmann grade I/VI).

CONCLUSIONS

In the case of a persistent stapedial artery, excellent hearing outcomes are achievable for otosclerosis via stapedectomy without an apparent increased risk of neurologic complication.

Pediatric tracheostomy practice patterns

OBJECTIVE

Despite recent guidelines and the frequency of pediatric tracheostomy, surgical techniques and perioperative management are variable. We aim to describe the post-operative practice patterns following tracheostomy in children.

METHODS

An electronic cross-sectional survey was distributed to American Society of Pediatric Otolaryngologists (ASPO) members in academic and private practice settings. Responses were collected anonymously and analyzed by percentages of respondents who employ specific management strategies. Statistical analysis of response distributions performed using the Z test of proportions for binary questions and the Mantel-Haenszel chi-square test for questions with more than two options. For questions with ordered categorical responses, Cuzick's nonparametric test of trend was used.

RESULTS

One-hundred twenty-four responses were received (22.3%). Most respondents were fellowship trained and practiced in academic medical centers. A greater number of tracheostomies were performed by respondents practicing in the Midwest region (p = 0.042). There was no variability in the number of tracheostomies performed based on practitioner age, hospital setting, or fellowship training. The majority perform stoma maturation and/or stay suture techniques intraoperatively and send patients to the intensive care unit postoperatively. The routine use of postoperative paralysis was reported by a minority of respondents and 50% reported the use of sedation. There was a roughly-even distribution of respondents who reported postoperative immobilization, mobilization to a chair, and ambulation respectively. Routine; postoperative airway evaluations were reported by 35% of respondents. Clinic follow-up was; variable.

CONCLUSION

These results demonstrate ongoing variability in the postoperative management strategies following tracheostomy in children and highlight areas for further study.

Risk Assessment and Early Mobilization Pathway Following Pediatric Tracheostomy: A Pilot Study

OBJECTIVES/HYPOTHESIS

To confirm the standard of care pertaining to postoperative mobilization practices following initial tracheostomy, to establish face validity of novel early mobilization tools, and to conduct a safety and feasibility pilot study.

STUDY DESIGN

Multi-institutional survey and prospective cohort study.

METHODS

Experts at our tertiary-care children's hospital developed an Early Pediatric Mobility Pathway for tracheostomy patients utilizing a novel risk-assessment tool. Surveys were distributed to professional colleagues in similar children's hospitals to establish face validity and incorporate respondent feedback. Additional surveys were disseminated to tertiary-care children's hospitals across the country to establish the current standard of care, and a pilot study was conducted.

RESULTS

Seventy-seven percent of respondents from tertiary hospitals across the country confirmed the standard of care to defer mobilization until the first trach change. Greater than 83% of the respondents used to establish face validity of the tools agreed with the clinical components and scoring structure. The safety and feasibility of early mobilization prior to initial trach change was confirmed with a pilot of 10 pediatric patients without any adverse events.

CONCLUSIONS

Mobilization of pediatric patients prior to initial trach change is feasible and can be safe when risk factors are assessed by a multidisciplinary team.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E653-E658, 2021.

Outcomes of Overlapping Surgery in Otolaryngology

Objective

To compare outcomes in otolaryngology between overlapping and nonoverlapping surgeries.

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Subjects and Methods

All patients undergoing otolaryngologic procedures at Stanford University Hospital between January 2009 and June 2016 were included (n = 13,479). Cases were divided into 2 cohorts: overlapping (n = 1806, 13.4%) vs nonoverlapping (n = 11,673, 86.6%). Variables reviewed were type of operation performed, multidisciplinary team involvement, complications, reoperations, readmissions, and deaths.

Results

The total complication rate over 7.5 years studied was 3.3% (n = 450). Complication rates were lower for overlapping cases (0.77%) compared to nonoverlapping cases (3.73%) with an odds ratio of 0.2014, which was statistically significant ( P < .0001). When examined by subspecialty, the complication rate for rhinology and endoscopic skull base procedures was approximately 10 times lower when overlapping (0.30%) was compared to nonoverlapping (3.15%), with an odds ratio of 0.094 ( P = .0001). There was no difference in complication rates for other surgical subspecialties. There were no deaths associated with overlapping surgery. The rate of major complications requiring reoperation was similarly lower for overlapping procedures (0.276%) compared to nonoverlapping procedures (1.35%) with an odds ratio of 0.2023 ( P = .0004). Readmission rates were lower for overlapping cases (0.49%) when compared to nonoverlapping cases (1.09%), with an odds ratio of 0.4553 ( P = .0229).

Conclusions

Patients undergoing overlapping surgery had lower overall complication rates, lower reoperation rates, lower readmission rates, and no mortalities. The institutional experience presented provides evidence that with appropriate patient and case selection, otolaryngologists may safely perform overlapping surgery without increased risk of adverse patient outcomes.

Effects of decreased dopamine transporter levels on nigrostriatal neurons and paraquat/maneb toxicity in mice

How genetic variations in the dopamine transporter (DAT) combined with exposure to environmental toxins modulate the risk of Parkinson's disease remains unclear. Using unbiased stereology in DAT knock-down mice (DAT-KD) and wild-type (WT) littermates, we found that decreased DAT caused a loss of tyrosine hydroxylase-positive (dopaminergic) neurons in subregions of the substantia nigra pars compacta at 3-4 days, 5 weeks, and 18 months of age. Both genotypes lost dopaminergic neurons with age and remaining neurons at 11 months were resilient to paraquat/maneb. In 5-week-old mice, the toxins decreased substantia nigra pars compacta dopaminergic neurons in both genotypes but less in DAT-KD. Regional analysis revealed striking differences in the subsets of neurons affected by low DAT, paraquat/maneb, and aging. In particular, we show that a potentially protective effect of low DAT against toxin exposure is not sufficient to reduce death of all nigrostriatal dopaminergic neurons. Thus, different regional vulnerability of nigrostriatal dopaminergic neurons may contribute to an increased risk of developing Parkinson's disease when multiple factors are combined.

Considering the Ectopic Pituitary Gland in Evaluation of the Nasopharyngeal Mass

IMPORTANCE

Extracranial pituitary ectopia is an uncommon finding characterized by all or a portion of the pituitary gland situated in an aberrant location. Often these lesions come to clinical attention only once they begin to function abnormally or increase in size significantly.

OBSERVATIONS

We describe an incidentally noted, asymptomatic pedunculated nasopharyngeal lesion in a 13-month-old girl that may be an extracranial pituitary gland. Consideration of this rare anomaly cautioned against performing a biopsy and may have prevented inadvertent removal of functional pituitary tissue. We describe the embryologic origins of ectopic pituitary tissue, discuss the differential diagnosis for nasopharyngeal lesions in children, and emphasize physical and radiologic findings suggestive of ectopic pituitary tissue to prevent potential inadvertent removal of this rare anomaly.

CONCLUSIONS AND RELEVANCE

We report this unusual case to review embryologic origins of ectopic pituitary tissue and to alert otolaryngologists of the need to consider ectopic pituitary tissue in the diagnosis of nasopharyngeal lesions in children.

A GCase chaperone improves motor function in a mouse model of synucleinopathy

Mutation of the lysosomal hydrolase acid-β-glucosidase (GCase), which leads to reduced GCase activity, is one of the most frequent genetic risk factors for Parkinson's disease (PD) and promotes α-synuclein accumulation in the brain, a hallmark of PD and other synucleinopathies. Whether targeting GCase pharmacologically is a valid therapeutic strategy for sporadic PD in the absence of GCase mutation is unknown. We have investigated whether increasing the stability, trafficking, and activity of wild-type GCase could be beneficial in synucleinopathies by administering the pharmacological chaperone AT2101 (afegostat-tartrate, isofagomine) to mice that overexpress human wild-type α-synuclein (Thy1-aSyn mice). AT2101 administered orally for 4 months to Thy1-aSyn mice improved motor and nonmotor function, abolished microglial inflammatory response in the substantia nigra, reduced α-synuclein immunoreactivity in nigral dopaminergic neurons, and reduced the number of small α-synuclein aggregates, while increasing the number of large α-synuclein aggregates. These data support the further investigation of pharmacological chaperones that target GCase as a therapeutic approach for sporadic PD and other synucleinopathies, even in the absence of glucocerebrosidase mutations.

Chronic administration of cholesterol oximes in mice increases transcription of cytoprotective genes and improves transcriptome alterations induced by alpha-synuclein overexpression in nigrostriatal dopaminergic neurons

Cholesterol-oximes TRO19622 and TRO40303 target outer mitochondrial membrane proteins and have beneficial effects in preclinical models of neurodegenerative diseases leading to their advancement to clinical trials. Dopaminergic neurons degenerate in Parkinson's disease (PD) and are prone to oxidative stress and mitochondrial dysfunction. In order to provide insights into the neuroprotective potential of TRO19622 and TRO40303 for dopaminergic neurons in vivo, we assessed their effects on gene expression in laser captured nigrostriatal dopaminergic neurons of wildtype mice and of mice that over-express alpha-synuclein, a protein involved in both familial and sporadic forms of PD (Thy1-aSyn mice). Young mice were fed the drugs in food pellets or a control diet from 1 to 4months of age, approximately 10months before the appearance of striatal dopamine loss in this model. Unbiased weighted gene co-expression network analysis (WGCNA) of transcriptional changes revealed effects of cholesterol oximes on transcripts related to mitochondria, cytoprotection and anti-oxidant response in wild-type and transgenic mice, including increased transcription of stress defense (e.g. Prdx1, Prdx2, Glrx2, Hspa9, Pink1, Drp1, Trak1) and dopamine-related (Th, Ddc, Gch1, Dat, Vmat2, Drd2, Chnr6a) genes. Even at this young age transgenic mice showed alterations in transcripts implicated in mitochondrial function and oxidative stress (e.g. Bcl-2, Bax, Casp3, Nos2), and both drugs normalized about 20% of these alterations. Young Thy1-aSyn mice exhibit motor deficits that differ from parkinsonism and are established before the onset of treatment; these deficits were not improved by cholesterol oximes. However, high doses of TRO40303 improved olfaction and produced the same effects as dopamine agonists on a challenging beam test, specifically an increase in footslips, an observation congruent with its effects on transcripts involved in dopamine synthesis. High doses of TRO19622 increased alpha-synuclein aggregates in the substantia nigra; this effect, not seen with TRO40303 was inconsistent and may represent a protective mechanism as in other neurodegenerative diseases. Overall, the results suggest that cholesterol oximes, while not improving early effects of alpha-synuclein overexpression on motor behavior or pathology, may ameliorate the function and resilience of dopaminergic neurons in vivo and support further studies of neuroprotection in models with dopaminergic cell loss.