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Unusual case of sleep apnea in a child

March 24, 2017     Lisa Duffy, RN; Anita Jeyakumar, MD, FACS, FAAP

How successful is the fitting of digital hearing aids? Implications for the allocation of resources within national health systems

March 24, 2017     Petros V. Vlastarakos, MD, MSc, PhD; Alastair I. Cameron, BA (Hons), PGDip, MSc; Thomas P. Nikolopoulos, MD, DM, PhD


We conducted a retrospective study to determine the success rate of initial fittings in digital hearing aid (DHA) users. We also addressed the implications of national health systems' continuing to provide access to these devices. We identified 1,597 consecutively presenting adults who had undergone a first fitting or a new fitting (i.e., an upgrade from an analogue hearing aid in the first or second ear) of a behind-the-ear DHA during the previous year. We further sought to identify all nominal reprogram appointments that had taken place within 6 months after the first or new fitting; we found 460 such appointments (28.8%). Of these, 419 appointments had been for typical reasons other than patient dissatisfaction with the fitting itself-for example, poor hearing, a further hearing loss, an uncomfortably loud hearing aid level, difficulty with speech in noise, an imbalance between bilateral hearing aids, and a faulty or lost hearing aid. Only 41 of the 1,597 first or new fittings (2.6%) were considered unsatisfactory by patients and necessitated a follow-up reprogramming appointment. Overall, DHA fittings were generally successful, as most patients (1,137/1,597 [71.2%]) did not require any follow-up appointment during the study period. Principles of cost-effectiveness demand the maximum practicable efficiency in the utilization of resources to ensure the continuous delivery of high-quality audiologic services through national health systems. This can be achieved by scheduling group appointments to reduce costs and to increase the time allocated to fitting and training patients.

Fiddler's neck: A review

February 20, 2017     Calvin W. Myint, MD; Amy L. Rutt, DO; Robert T. Sataloff, MD, DMA, FACS


Fiddler's neck is a common dermatologic condition associated with instrument use in violin and viola players. It typically manifests as a submandibular and/or supraclavicular lesion. It is a benign condition, but it may be mistaken for lymphedema or a salivary gland malignancy. Otolaryngologists who treat patients with fiddler's neck should be aware of appropriate management protocols and the need to avoid surgical excision. We obtained informed consent from 3 violinists to present their cases as specific examples of fiddler's neck. In addition, we present a literature review based on our PubMed search for articles about this instrument-induced dermatitis. The literature suggests that submandibular fiddler's neck is caused by mechanical pressure and shear stress on the skin and that it can present as erythema, scarring, edema, and lichenification. Supraclavicular fiddler's neck, on the other hand, is caused by allergic contact dermatitis, and it can present as an eczematous, scaly, and/or vesicular lesion. In most cases, a good history (especially of string instrument use), physical examination, and a patch test are sufficient to diagnose this condition. Management of fiddler's neck includes a topical steroid, proper instrument handling, neck padding, changing the instrument's materials, and/or reducing the amount of playing time. Surgical excision is usually not advisable.

Mechanical venous anastomosis in head and neck microvascular reconstruction as an equivalent to the gold standard

February 20, 2017     Eric Thorpe, MD; Yash Patil, MD


To define the most successful and efficient manner to perform venous microvascular anastomoses, the effectiveness of mechanical venous anastomosis in head and neck microvascular reconstruction is reviewed. Head and neck reconstruction with free flap techniques has become the norm and gold standard for large defects. This retrospective, multicenter case series of a single microvascular surgeon's experience with mechanical venous anastomoses specifically assessed the effectiveness of head and neck reconstruction and the complications associated with it. Data were collected from two separate academic centers and are reported from a consecutive series of patients over the course of 10 years. All patients underwent microvascular reconstruction of the head and neck region using venous couplers and flap survival. Flap survival was greater than 98% using mechanical venous couplers as the primary means for venous outflow in this series of 402 consecutive patients and 431 total microvascular flaps. Venous couplers were performed in every instance. The study shows that mechanical venous anastomosis provides a highly effective and efficient means for venous outflow in head and neck microvascular reconstruction, and should be considered equivalent to the gold standard suture technique, even in the most difficult cases.

Auricular solitary gouty tophus in a young adult

February 20, 2017     Chao-Yin Kuo, MD; Chih-Hung Wang, MD, PhD

The auricle, with its supersaturation of blood uric acid due to decreased temperature and reduced blood flow, is prone to develop gouty tophi.

Posterior epistaxis from inferior meatus: An endoscopic view

February 20, 2017     Jae Hoon Lee, MD

Most of the bleeding in posterior epistaxis originates from the posterior end of the lateral aspect of the middle and inferior turbinates and the lateral wall of the meatuses.

The use of high-resolution pharyngeal manometry as biofeedback in dysphagia therapy

February 20, 2017     Ashli O'Rourke, MD; Kate Humphries, MS

HRPM biofeedback therapy may be particularly beneficial for patients with sensory deficits by providing a visual mechanism for accurate exercise and strategy implementation.

Thyroglossal duct cyst

February 20, 2017     Lester D. Thompson, MD

Most patients present with a mobile, painless midline neck mass, usually inferior to the hyoid bone, showing movement with tongue protrusion.

Estimation of partitioning of airflow in septal surgery: A prospective study with reference to the NOSE scale

February 20, 2017     Indranil Sen, MS; Mainak Dutta, MS; Dibakar Haldar, MD; Ramanuj Sinha, DLO, MS, DNB


Improper patient selection for septal surgery often has been found to result in therapeutic failure, and there needs to be an objective assessment of nasal obstruction before the surgery and for postoperative follow-up that can be applied in the routine otolaryngology practice. The purpose of this study is to assess the usefulness of a cost-effective device for objective measurement of the nasal airway partitioning in selecting patients for septal surgery and for postoperative outcome evaluation. A hospital-based, prospective, observational study was carried out in a tertiary-care teaching institution involving 74 patients waiting for septal surgery. Each patient was exposed to subjective assessment of nasal obstruction by the Nasal Obstruction Symptom Evaluation (NOSE) scale and objective measurement by Nasal Partitioning Ratio (NPR) using a new device, Nasal Airway Partition Meter (NAPM), once before and twice after surgery. Overall, average NOSE score and NPR values were 66.42 ± 9.42 and 0.57 ± 0.18, respectively, at preoperative assessment (correlation coefficient 0.441). Sixty of the 74 patients had high values for both NPR and NOSE scores (Group 1), but in the remaining 14, NPR values were found to be lower despite high NOSE scores (Group 2). Postsurgery, the NOSE score and NPR values were significantly reduced in Group 1. In contrast, participants in Group 2 showed no alteration in the values of both the parameters after the same operative maneuver. However, 2 patients in Group 1 had NOSE score and NPR values unaltered, while 1 patient in Group 2 had a reduced NOSE score after surgery. Therefore, the validity of the new equipment was calculated to be 96.7% sensitive and 92.9% specific to identify patients who needed to undergo septal surgery for their nasal obstruction. It can be deduced from the present study that NAPM can be a cost-effective device for clinicians to objectively measure nasal airway obstruction and screen patients for septal surgery.

Efficacy of Intralipid infusion in reducing amphotericin-B-associated nephrotoxicity in head and neck invasive fungal infection: A randomized, controlled trial

February 20, 2017     Mehrdad Hasibi, MD; Sirous Jafari, MD; Seyyed Ali Dehghan Manshadi, MD; Marjan Asadollahi, MD; Mohammadreza Salehi, MD; Varasteh Vakili Zarch, MD; Ali Kouhi, MD


Amphotericin B deoxycholate (ABD) is the best therapeutic agent available for the treatment of most systemic fungal infections. However, some untoward adverse effects such as nephrotoxicity may limit its appropriate therapeutic use. We conducted a randomized, controlled trial ofthe infusion of fat emulsion (Intralipid) shortly after the infusion of ABD to evaluate its effects on reducing ABD-associated nephrotoxicity. Our patient population was made up of 31 patients who were randomized into two groups: an intervention group (n = 16) and a control group (15 patients). There were no statistically significant differences between the two groups in demographic or clinical variables. All patients received 1mg/kg/day of ABD in dextrose 5%. In addition, the patients in the intervention arm received Intralipid 10%, which was started as soon as possible within 1 hour after the infusion of ABD. ABD-associated nephrotoxicity was defined as a minimum 50% increase in baseline serum creatinine to a minimum of 2mg/dl. We also measured daily serum creatinine changes during the first 2 weeks of treatment, and we compared some other relevant indices of renal function, as well as ABD-related hypokalemia. We found no statistically significant differences between the two treatments in terms of ABD-associated nephrotoxicity or any of the other indices. We conclude that the administration of Intralipid 10% early after infusion of ABD in dextrose 5% does not have any effect in decreasing ABD-associated nephrotoxicity or hypokalemia.

Auricular complications in parotid, temporal bone, infratemporal fossa, and lateral skull base surgery

February 20, 2017     Patrick S. Carpenter, MD; Ryan C. Burgette, MD; John P. Leonetti, MD; Sam J. Marzo, MD


Neoplasms located in the parotid region, temporal bone, infratemporal fossa, and lateral skull base represent a challenge due to their difficult anatomic location and surrounding neurovascular structures. A variety of surgical approaches are appropriate to access this area, although several of them can place the auricular blood supply in danger. If the auricular blood supply is compromised, ischemia and, eventually, avascular necrosis of the auricle can occur. Auricular necrosis often can cause patients a delay in adjuvant radiation therapy and result in the need for additional reconstructive procedures. Therefore, it is imperative to identify risk factors associated with the development of this disabling complication. We conducted a retrospective review of 32 individuals undergoing treatment of benign and malignant lesions in the parotid gland, infratemporal fossa, and lateral skull base. To identify potential risk factors for auricular necrosis, the patients were analyzed based on the type of neoplasm (malignant or benign), risk factors affecting blood flow (diabetes mellitus, smoking history, prior radiation, prior surgery), body mass index, and the length of surgery. In our population examined, 3 instances of auricular necrosis occurred. None of the potential risk factors proved to be statistically significant (although malignant pathology approached significance at p = 0.07). Two of the patients required an auriculectomy with reconstruction. The third had multiple postoperative clinic visits for surgical debridement. Although no potential risk factors were statistically significant, surgeons should remain cognizant of the auricular blood supply while performing surgery via preauricular and postauricular approaches to this area.

Atypical parathyroid adenoma with diffuse fibrosis

February 20, 2017     Christine M. Clark, BA; Sakeena J. Payne, MD; Joshua I. Warrick, MD; David Goldenberg, MD, FACS

Atypical parathyroid adenomas are infrequently encountered and can present a diagnostic challenge, as they share overlapping clinical and histologic features with parathyroid carcinoma.

Comparison of cidofovir and the measles, mumps, and rubella vaccine in the treatment of recurrent respiratory papillomatosis

February 20, 2017     Ryan Kent Meacham, MD; Jerome W. Thompson, MD, MBA


We conducted a retrospective study of the use of cidofovir and the measles, mumps, and rubella (MMR) vaccineas adjunctive treatments to lesion debridement in patients with recurrent respiratory papillomatosis (RRP). Our study population was made up of 15 children-7 boys and 8 girls, aged 1 to 16 years at diagnosis (mean: 6.2)-with pathologically confirmed RRP who had been followed for at least 1 year. In addition to demographic data, we compiled information on disease severity, the type of adjunctive treatment administered to each patient, the frequency of debridements, the length of observation, and remission rates. Of the 15 patients, 5 had been treated with cidofovir after debridement (cidofovir-only group), 6 were treated with MMR vaccine after debridement (MMR-only group), 3 were treated with one and later switched to the other based on parental preference, and 1 received neither treatment, only debridement. The initial mean Derkay disease severity scores were 12.6 for the cidofovir-only group and 11.0 for the MMR-only group (p = 0.61). The cidofovir-only patients underwent an average of 11.8 adjunctive treatments and the MMR-only patients an average of 17.7 (p = 0.33). The average duration of observation was 44.0 months in the cidofovir-only group and 64.7 months in the MMR-only group (p = 0.29). Remission rates were 20% in the cidofovir-only group and 50% in the MMR-only group (p = 0.54). Our study found insufficient evidence of any significant differences between cidofovir and the MMR vaccinein terms of the number and frequency of adjunctive treatments and the rates of remission.

Significance of imaging in the diagnosis of olfactory disorder

February 20, 2017     Teemu Harju, MD; Markus Rautiainen, MD, PhD; Ilkka Kivekas, MD, PhD


The aim of this retrospective analysis was to examine olfactory disorders among the patients in the Ear, Nose, and Throat Clinic of Tampere University Hospital, Finland, from 2001 to 2011, and to evaluate the necessity of imaging in the examination of patients with olfactory disorders. Charts of 143 consecutive patients with a primary olfactory disorder were examined, and 69 patients who had undergone the necessary testing were included in the study. The most common causes of olfactory disorder were upper respiratory infection (23%), chronic rhinosinusitis (19%), head trauma (17%), and allergic or nonallergic rhinitis (6%). In 25% of the patients, no obvious cause for the symptoms was found. Computed tomography (CT) scans were normal in 37 of 52 (71%) patients and magnetic resonance imaging was normal in 21 of 25 (84%) patients. No intracranial or intranasal tumors were found in the overall cohort. Of the patients with additional symptoms (facial pain, headache, nasal discharge, or stuffiness), 58% had chronic rhinosinusitis. Of the patients with no additional symptoms or signs associated with chronic rhinosinusitis on clinical evaluation, only 2% had chronic rhinosinusitis on imaging. Only the detection of chronic rhinosinusitis and head trauma had clinical value in the determination of the etiology. A sinonasal CT scan should be considered in patients who have at least one symptom associated with sinusitis in addition to an olfactory disorder to confirm the etiology and to find those patients who may benefit from medical therapy or surgical treatment.

Is malignant otitis externa on the increase? A retrospective review of cases

February 20, 2017     Diana Bhasker, MBBS, MRCS(ENT); Angela Hartley, MBchB; Frank Agada, FRCS, RCS(ORL-HNS)


We performed a retrospective review of all patients with malignant otitis externa (MOE) treated in our center between July 2004 and December 2012 to evaluate the current epidemiology in our region and to ascertain causative factors associated with the perceived increase in the number of cases diagnosed. Eleven patients were identified (5 men and 6 women), with a mean age of 77 years (range: 38 to 97 years). Diabetes was present in 36%. Pseudomonas aeruginosa was the causative organism in 64% of cases; all pathogens were sensitive to ciprofloxacin. We noted a significant increase in the diagnostic frequency of MOE during the study period (p = 0.0027) No obvious causative factors were identified. Due to the mortality associated with this condition, further studies are required to establish national trends.

Unable to say hello from the other side

February 20, 2017     Adam D. Rubin, MD

Radiofrequency turbinate volume reduction vs. radiofrequency-assisted turbinectomy for nasal obstruction caused by inferior turbinate hypertrophy

February 20, 2017     Saumitra Kumar, MS(ENT); Trivender Singh Anand, MS(ENT), PhD; Indranil Pal, MS(ENT)


Radiofrequency procedures are a well-accepted treatment for nasal obstruction. We conducted a randomized, noncontrolled study to compare the effectiveness of submucosal bipolar radiofrequency turbinate volume reduction (RFTVR) and bipolar radiofrequency-assisted turbinectomy (RFaT) in patients presenting with nasal obstruction caused by inferior turbinate hypertrophy. A total of 30 patients-15 males and 15 females, aged 15 to 60 years (mean: 32)-were randomly divided into one of the two homogeneous treatment groups. Outcomes were determined by comparisons of subjective symptom scores on a visual analog scale and by anterior active rhinomanometry at postoperative days 7, 14, and 28 and again at 6 months postoperatively. Both groups demonstrated significant and similar improvements in nasal airway function both subjectively and objectively. However, we noted that the incidence of adverse effects and postoperative morbidity was higher in the RFaT group. Therefore, we conclude that when surgery is indicated, RFTVR is the preferred treatment for nasal obstruction secondary to inferior turbinate hypertrophy. RFaT is equally effective, but it is associated with a slightly higher incidence of adverse effects.

Analysis of caloric test responses in sudden hearing loss

February 20, 2017     Cheng-Ping Shih, MD; Yu-Ching Chou, PhD; Hsin-Chien Chen, MD, PhD; Jih-Chin Lee, MD; Yueng-Hsiang Chu, MD, PhD; Chih-Hung Wang, MD, PhD


Sudden sensorineural hearing loss is characterized by a rapid-onset hearing loss that develops within 3 days. Vertigo may also be present. We conducted a retrospective study to investigate whether the severity of a loss of caloric function is associated with the initial hearing loss and with hearing recovery. Our study population was made up of 135 patients-67 men and 68 women, aged 25 to 71 years (mean: 50.9)-with sudden sensorineural hearing loss who had undergone bithermal caloric testing. We compared various patient factors according to patients' hearing level and their response to caloric testing. We also analyzed the canal paresis (CP) value in patients with an abnormal caloric response according to three factors: disease severity, vertigo, and hearing recovery, and we evaluated the correlation between the loss of caloric function and hearing outcomes. We found that an abnormal caloric response was significantly associated with a profound hearing loss at presentation, the presence of vertigo, and poor hearing recovery. Among patients with an abnormal caloric response, the CP value was significantly correlated with hearing recovery (r = 0.503, p = 0.001). Poor hearing recovery was seen in 80% of patients with a CP value of ≥40% but in only 25% of patients with a value of <40%; in addition, the degree of hearing recovery was worse in the patients with a CP value of ≥40% (p = 0.002). We conclude that a CP value of ≥40% is a significant prognostic factor for an unfavorable treatment outcome.

Predictors of adverse events after neck dissection: An analysis of the 2006-2011 National Surgical Quality Improvement Program (NSQIP) Database

February 20, 2017     Umang Jain, BS; Jessica Somerville, MD; Sujata Saha, BS; Jon P. Ver Halen, MD; Anuja K. Antony, MD, MPH; Sandeep Samant, MD; John Y. Kim, MD


While neck dissection is an important primary and adjunctive procedure in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database was performed to identify factors associated with adverse events (AEs) in patients undergoing neck dissection. A total of 619 patients were identified, using CPT codes specific to neck dissection. Of the 619 patients undergoing neck dissection, 142 (22.9%) experienced an AE within 30 days of the surgical procedure. Risk factors on multivariate regression analysis associated with increased AEs included dyspnea (odds ratio [OR] 2.57; 95% confidence interval [CI] 1.06 to 6.22; p = 0.037), previous cardiac surgery (OR 3.38; 95% CI 1.08 to 10.52; p = 0.036), increasing anesthesia time (OR 1.005; 95% CI 1 to 1.009; p = 0.036), and increasing total work relative value units (OR 1.09; CI 1.04 to 1.13; p < 0.001). The current study is the largest, most robust analysis to identify specific risk factors associated with AEs after neck dissection. This information will assist with preoperative optimization, patient counseling, and appropriate risk stratification, and it can serve as benchmarking for institutions comparing surgical outcomes.

Alteration of serum levels of inflammatory cytokines and polysomnographic indices after uvulopalatal flap surgery in obstructive sleep apnea

February 20, 2017     Murad Mutlu, MD; Erkan Vuralkan, MD; Istemihan Akin, MD; Hikmet Firat, MD; Sadik Ardic, MD; Sevgi Akaydin, PhD; Ece Miser, PhD


The aim of the current study was to compare the changes in polysomnographic indices and serum levels of C-reactive protein (CRP), cystatin C, tumor necrosis factor-α (TNF-α), and intercellular adhesion molecule-1 (ICAM-1) in patients with obstructive sleep apnea (OSA) who were treated surgically via a uvulopalatal flap (UPF) technique. Twenty-five patients (14 men, 11 women), average age 46.2 ± 9.3 years, who underwent UPF surgery were included in this study. Serum biochemical analyses and polysomnographic examinations were performed before and 6 months after the surgery. Pre- and postoperative values of apnea hypopnea index (AHI), oxygen desaturation index (ODI), and minimum oxygen concentrations, as well as serum levels of CRP, cystatin C, TNF-α, and ICAM-1 were compared. Comparison of variables before and after UPF surgery demonstrated that AHI (p = 0.001), ODI (p < 0.001) and oxygen saturation (p < 0.001) were significantly improved. In addition, serum levels of CRP (p = 0.036), cystatin C (p = 0.005), TNF-α (p < 0.001), and ICAM-1 (p < 0.001) were significantly reduced 6 months after surgery. Our results suggest that UPF is an effective surgical method that alleviates the severity of OSA. Moreover, it may have the potential to prevent the development of atherosclerosis by attenuating the inflammatory process induced by activation of inflammatory mediators such as CRP, TNF-α, ICAM-1, and cystatin C.