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The economic impact of revision otologic surgery

March 16, 2016  |  Sahar Nadimi, MD; John P. Leonetti, MD; George Pontikis, MD


Revision otologic surgery places a significant economic burden on patients and the healthcare system. We conducted a retrospective chart analysis to estimate the economic impact of revision canal-wall-down (CWD) mastoidectomy. We reviewed the medical records of all 189 adults who had undergone CWD mastoidectomy performed by the senior author between June 2006 and August 2011 at Loyola University Medical Center in Maywood, Ill. Institutional charges and collections for all patients were extrapolated to estimate the overall healthcare cost of revision surgery in Illinois and at the national level. Of the 189 CWD mastoidectomies, 89 were primary and 100 were revision procedures. The total charge for the revision cases was $2,783,700, and the net reimbursement (collections) was $846,289 (30.4%). Using Illinois Hospital Association data, we estimated that reimbursement for 387 revision CWD mastoidectomies that had been performed in fiscal year 2011 was nearly $3.3 million. By extrapolating our data to the national level, we estimated that 9,214 patients underwent revision CWD mastoidectomy in the United States during 2011, which cost the national healthcare system roughly $76 million, not including lost wages and productivity. Known causes of failed CWD mastoidectomies that often result in revision surgery include an inadequate meatoplasty, a facial ridge that is too high, residual diseased air cells, and recurrent cholesteatoma. A better understanding of these factors can reduce the need for revision surgery, which could have a positive impact on the economic strain related to this procedure at the local, state, and national levels.

A limited thoracocervical approach for accessing the anterior mediastinum in retrosternal goiters: Surgical technique and implications for the management of head and neck emergencies

March 16, 2016  |  Petros V. Vlastarakos, MD, MSc, PhD, IDO-HNS(Eng); Aaron Trinidade, MD, PGDip, MRCS, DO-HNS; Marie-Claire Jaberoo, MD, FRCS(ORL-HNS), DO-HNS; George Mochloulis, MD, CCST(ORL-HNS)


In this article we describe the surgical management of retrosternal goiters via a limited thoracocervical approach, and we explore how the respective surgical know-how can be used in the management of the carotid blowout syndrome. Four cases involving patients who had undergone thyroidectomy via a limited thoracocervical approach are retrospectively reviewed. An acute blowout of the innominate artery managed with the same principal surgical technique is also reviewed. Three patients had a total thyroidectomy and one had a hemithyroidectomy. No malignancy was found. There was no mortality or unexpected morbidity from the limited thoracocervical approach. The median length of the inpatient stay was 3 days. The blowout survivor lived for 9 months, with no rebleeding and with an acceptable quality of life. We conclude that a limited thoracocervical approach can be safely performed by head and neck surgeons for accessing the anterior mediastinum in retrosternal goiters, and the respective surgical know-how can be used in the immediate management of an acute carotid blowout syndrome with satisfying long-term results and provision of quality end-of-life care.

Otogenic lateral sinus thrombosis in children: A review of 7 cases

March 16, 2016  |  Jesse T. Ryan, MD; Maria Pena, MD; George H. Zalzal, MD; Diego A. Preciado, MD, PhD


Otogenic lateral sinus thrombosis (LST) is a rare but serious intracranial complication of acute or chronic otitis media. Reported mortality rates have ranged from 8 to 25%; the pediatric mortality rate might be as low as 5%. Controversy still exists over the medical and surgical management of this condition. We conducted a retrospective chart review of 7 cases of pediatric otogenic LST that were treated at our institution over a period of 8 years. We hypothesized that good outcomes in very sick patients can be achieved by aggressively managing the mastoid cavity and without the need for a thrombectomy. Our study group was made up of 4 boys and 3 girls, aged 6 to 15 years (mean: 11.1). All patients received intravenous antibiotics and underwent mastoidectomy with unroofing of the sigmoid sinus and placement of a tympanostomy tube. Sinus exploration with thrombectomy was not performed in any patient. Anticoagulation was used perioperatively in 5 patients (71%) without complication. All patients recovered well without major sequelae, which supports our hypothesis. We also describe the case of a patient with multiple concomitant intracranial comorbidities associated with this rare condition.

Ultrasonography-guided minimally invasive removal of parotid calculi: A prudent approach

February 24, 2016  |  Uma Patnaik, MS, DNB; Sreejith Nair, MS; Atul Mishra, MD


The trend in modern salivary calculi surgery is toward minimally invasive procedures because these benign conditions do not warrant open salivary gland surgery. Since ultrasonography is readily available, highly specific, noninvasive, and cost-effective, we have used an ultrasonography-guided technique for patients with parotid gland calculi, as both a diagnostic and a therapeutic tool for calculi removal, thus avoiding the morbidity of open surgery. We describe a case in which we used this novel technique for the peroral removal of multiple parotid calculi in a 29-year-old man. The use of ultrasonography in parotid calculi removal has been reported in the literature, but only infrequently. Our extensive search of the peer-reviewed English-language literature found no article reporting the technique that we describe here.

The immediate use of a silicone sheet wound closure device in scar reduction and prevention

February 24, 2016  |  James R. Parry, DO; Howard D. Stupak, MD; Calvin M. Johnson, MD


Silicone has been used successfully postoperatively in the prevention of hypertrophic and other types of adverse scars. The Silicone Suture Plate (SSP) is a new, minimally invasive, sterile wound closure device that is applied intraoperatively to prevent adverse scarring. The SSP device permits immediate application of silicone while concurrently allowing for wound-edge tension redistribution. In this prospective, controlled, single-blinded clinical study, 8 consecutive patients undergoing deep-plane rhytidectomy were selected. SSP devices were placed on the patients' posterior rhytidectomy hairline incision; the mirror-image control site underwent standard suturing techniques. Three blinded, independent raters assessed the treatment and control sides at 6-week and 4-month follow-up visits, using the Objective Scar Assessment Scale (OSAS), a validated scar assessment tool. The 6-week OSAS scores revealed an 18.4% improvement on the side with the SSP device (13.3) when compared to the control side (16.3). The 4-month OSAS scores showed a 27.3% improvement on the treatment side from 12.7 (control) to 9.2 (SSP). These OSAS results were found to be statistically significant when taken as an aggregate of the observers' scores, but not when observers' scores were measured individually (p < 0.05). In our series of patients, we showed promising results with the use of the SSP device. Early silicone application and tissue tension distribution contributed to an overall more aesthetically pleasing scar compared to those seen with standard suturing techniques, although more testing is required.

Endoscopic view of a unilateral nasal soft-tissue obstruction

February 24, 2016  |  Joseph P. Mirante, MD, MBA, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS

It is often impossible to classify the disease process on the basis of endoscopic findings alone, but tissue biopsy and culture will lead to the appropriate diagnosis.

Changes in the nasalance of vowels within the first week following uvulopalatopharyngoplasty

February 24, 2016  |  Cheng-Chien Yang, MD; Ying-Piao Wang, MD, PhD; Chin-Wen Chang, MSc SLP


We conducted a retrospective study to evaluate the short-term effect of uvulopalatopharyngoplasty (UPPP) on changes in the nasalance of five vowels: /a/, /ε/, /i/, /ɔ/, and /u/. Our study group was made up of 20 patients-15 males and 5 females, aged 16 to 57 years (mean: 37.3 ± 11.5)-who had undergone UPPP as a treatment for mild to moderate obstructive sleep apnea. Nasometry was used to obtain nasalance scores in all patients on the morning of the operation (day 1) and subsequently on day 4 or 5 (mean: 4.5 ± 0.5). Preoperatively, nasalance scores were highest for /i/ (mean: 29.8 ± 12.6) and /a/ (mean: 24.1 ± 10.3). After the operation, nasalance scores for all five studied vowels increased; they were highest for /i/ (mean: 40.7 ± +17.8) and /ε/ (mean: 30.0 ± 10.8). The increases in the nasalance of /i/, /ε/, and /u/ were statistically significant (p < 0.05). Our findings indicate that UPPP has a significant impact on nasalance immediately after surgery.

Novel injection technique into the interarytenoid area to treat dysphagia

February 24, 2016  |  Meghan Brooking, DO; Amanda Hu, MD, FRCSC; Robert T. Sataloff, MD, DMA, FACS

Augmentation of the interarytenoid space is a simple and innovative alternative to the traditional paraglottic space injection.

Blood flow to a hemorrhagic vocal fold mass

February 24, 2016  |  Jaime Eaglin Moore, MD; Natalie Krane, MD; Robert T. Sataloff, MD, DMA, FACS

While the value of treatment of the vessels that feed an area of mass formation seems self-evident, the wisdom of treating draining vessels has not been established.

Laser myringoplasty for tympanic membrane retraction

February 24, 2016  |  Brian S. Chen, MD; John W. House, MD; James V. Crawford, MD

Only selected patients are good candidates for this procedure. Patients who are able to lift their TM with the Valsalva maneuver are ideal.