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To assess patient-related risk factors associated with poor outcomes following stapedotomy for otosclerosis.Retrospective study.Academic tertiary care center.Retrospective chart review of 107 patients with otosclerosis who underwent stapedotomy between 2013 and 2020. Demographics, comorbidities, and smoking history were obtained. Preoperative and postoperative audiogram data, including air-bone gap (ABG), and complications were collected. Data were analyzed using t test and Fischer's exact test for continuous and categorical variables, respectively.Among 107 patients, 29.5% were smokers and 70.1% non-smokers. Overall, the average ABG-gain 3-months postoperatively was 20.2 dB, and intraoperative and postoperative complications were 3.74 and 13.1%, respectively. Those with a history of otologic procedures had a lower mean ABG gain at 3 months compared with those without previous otologic surgery (14.4 dB versus 20.4 dB, p = 0.018). The average ABG gain at 3-months was not significantly different between those with current, former, or no smoking history, respectively (13.5 versus 18.1 versus 20.6, p = 0.08). Current smokers had 4.5 times greater odds of complications compared with non-smokers, although not statistically significant (95% CI 0.9-22.8, p = 0.1912).Age and history of otologic procedures as independent risk factors did impact hearing outcomes among our patient cohort; however, smoking history did not. Future prospective studies are required to further investigate complication rates by various modifiable risk factors, such as smoking status, body mass index (BMI), and obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) use, for stapedotomy surgeries. more...

Objective: To evaluate the safety profile, including adverse drug reactions and operative complications, of liposomal bupivacaine (LB) use for local anesthesia during functional septorhinoplasty. S... more...

Study Design: Systematic review of the literature. Objective: The goal of this study is to review the current literature on severe rhinophyma requiring operative management for significant cosmetic deformity or nasal obstruction. We aim to provide a treatment algorithm for the various surgical techniques employed in the treatment of severe rhinophyma. Methods: Independent searches of the PubMed and MEDLINE databases were performed. Articles from the period of 2010 to 2020 were collected. All studies which described surgical treatment of severe rhinophyma using the Boolean method and relevant search term combinations, including “rhinophyma,” “severe,” “operative” and “surgery” were collected. Results: A total of 111 relevant unique articles met criteria for eligibility analysis. Of these, 85 articles were deemed inappropriate for the literature review due to exclusion criteria. The remaining 26 articles were included in the literature review. Due to variability in study design and outcome measures, formal synthesis of data in the form of a meta-analysis was not possible. Conclusions: Severe rhinophyma may present a reconstructive challenge to reestablish normal contour and patent nasal airway. Significant deformity necessitates surgical correction. The present article reviews the current literature and provides a summary and stepwise explanation of established surgical techniques for addressing the cosmetic and functional deficits these patients encounter. more...

Introduction: The precise etiology of Ménière’s disease (MD) remains unknown; however, given the association of MD with serum antibodies and human leukocyte antigen (HLA) complex, several studies have proposed a relationship between MD and thyroid disorders. Similarly, multiple hypotheses exist regarding the metabolic disturbances of fluctuating thyroid hormone as a potential contributing agent in the development of MD. Methods: A total of 171 abstracts were identified and screened by 2 independent reviewers. Based on inclusion and exclusion criteria, 8 studies were selected for final analysis. Due to heterogeneity of clinical data, meta-analysis was not feasible. Results: The prevalence of autoimmune thyroid disease and hypothyroidism in MD varied significantly from 1 to 38%. Notable bias was introduced given the lack of standardization of diagnostic criteria across studies. Articles that described autoimmune thyroid-specific antibodies and HLA types also presented inconclusive results. Multiple studies noted a potential etiologic role of hypothyroidism in MD, which was often confounded by thyroxine supplementation. Conclusions: Despite a potential correlation in the medical literature between thyroid disorders and MD, there is currently no definitive causal relationship. Although most of the present medical literature focuses on autoimmunity, dysregulated thyroid hormone levels may also be implicated in the association of MD with thyroid disorders. more...

Objective: Congenital anomalies of the external ear may present a reconstructive challenge, particularly when normal chondrocutaneous components of the auricle fail to develop. Our goal was to develop a novel technique for lobule reconstruction of a congenitally absent earlobe with photographic documentation of the technique. Methods: Informed consent for perioperative photography and publication of case details was obtained. A postauricular, turnover flap with ipsilateral conchal cartilage grafting was performed to reconstruct the lobule, and a superiorly based, postauricular, rotation advancement flap was used to close the donor site defect. Results: Perioperative photographs are included demonstrating technique and cosmetic results. Conclusions: Malformations rarely involve the lobule or lower third of the ear primarily. Literature regarding lobule reconstruction for congenital malformations is scarce. We present a novel technique for lobule reconstruction of a congenitally absent earlobe performed in a single stage that avoids a visible neck scar and allows for simultaneous conchal cartilage harvest. The technique demonstrated satisfactory cosmesis regarding contour and overall appearance and these results remained stable at 1-year follow up. more...

Within the past two decades, vascularized facial composite allotransplantation has evolved into a viable option in the reconstructive surgeons' armamentarium for patients with extensive facial disfigurements. As it has expanded the frontiers of microsurgical reconstructive techniques, facial transplantation has come to garner widespread interest within both the medical community and the general public. The procedure has established itself as an amalgamation of the forefronts of reconstructive microsurgery, immunology, and transplantation science. Therein too lies its complexity as multifaceted scientific developments are met with ethical and social issues. Both patients and physicians are faced with the everlasting challenges of immunosuppression regimens and their inherent complications, long-term aesthetic and functional considerations, the role of revision procedures, and the inevitable psychosocial implications. This article reflects on the medical and surgical advancements in facial transplantation surgery and highlights anticipated future challenges. It aims to encourage discussion regarding anticipated barriers to current practice and suggest future directions as we transition into the next phase of facial allograft transplantation. more...

Study Design: The present study is a systematic review of the literature. Objective: The goal of this study is to review our experience and the current literature on airway management techniques in maxillofacial trauma. Methods: Independent searches of the PubMed and MEDLINE databases were performed from January 1, 2019 to February 1, 2019. Articles from the period of 2008 to 2018 were collected. All studies which described both airway management and maxillofacial trauma using the Boolean method and relevant search term combinations, including “maxillofacial,” “trauma,” and “airway,” were considered. Results: A total of 452 relevant articles in total were identified. Articles meeting inclusion criteria by abstract review included 68 total articles, of which 16 articles were focused on airway management techniques for maxillofacial trauma in the general population and were deemed appropriate for inclusion in the literature review. Conclusions: Establishing an effective and stable airway in patients with maxillofacial trauma is of paramount concern. In both the acute setting and during delayed reconstruction, special considerations must be taken when securing a reliable airway in this patient population. The present article provides techniques for securing the airway and algorithms for utilization of these techniques, including both during the initial evaluation and the definitive operative management. more...

The aim of the study is to: (1) evaluate national trends in care of facial paralysis, namely Bell's palsy, patients to identify the types of treatments patients are receiving and treatment gaps and (2) identify if newer, more complex surgical therapies published in the literature are being employed. Data were collected from the MarketScan Commercial Claims and Encounters Database by Truven Health. From the database, all inpatient and outpatient claims with International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes for facial paralysis/dysfunction between 2005 and 2013 were extracted. Trends in medical and surgical management were evaluated specifically cataloging the use of steroids, antivirals, botulinum toxin, surgical and rehabilitation service current procedural terminology codes. A total of 42,866 of patients with a formal diagnosis of Bell's palsy were identified with 39,292 (92%) adults and 3,754 (8%) children (< 18 years old), respectively. Steroids were provided to 50.1% of children and 59.8% of adults and antivirals were prescribed to 26.2 and 39.4% of the children and adults, respectively. Within the first 2 years after diagnosis, 0.5% of children and 0.9% of adults received surgery, 0.1% of children and 0.8% of adults received botulinum toxin treatments, and 10.9% of children and 21.5% of adults received rehabilitation services. Despite the limitations of a claims database study, results showing trends in care of facial paralysis are still nonsurgical with many patients receiving no treatment at all. Although limited literature has shown an increase in the use of pharmacotherapy as well as techniques including physiotherapy, chemodenervation, and various surgical therapies, these interventions may be underutilized. more...

Consideration of the airway is paramount in management of facial fractures in both the acute setting and delayed repair. As experts in laryngotracheal surgery, otolaryngologists often play a key role in airway management in both settings. On presentation, soft tissue edema and prolapse or presence of blood in the airway may complicate placement of an endotracheal tube and may necessitate emergent intervention. During planned fracture repair, surgeons and anesthesiologists must collaborate to determine a precise airway plan due to the inherent conflict of a need for a secure airway and a need for surgical access. It is our goal to review current techniques for securing the difficult airway in these patients. more...

Identify risk factors and perioperative morbidity for patients undergoing branchial cleft cyst (BCC) excision.Cross-sectional analysis.American College of Surgeons National Surgical Quality Improvement Program adult and pediatric databases (NSQIP and NSQIP-P).Patients who underwent BCC excision (A total of 1775 children and 677 adults were identified. Mean age at time of surgery was 4.6 years for children and 38.6 years for adults. Outpatient procedures were performed in 87.1% of adults and 94.0% of children (Postoperative complications following BCC excision are relatively uncommon, demonstrating procedural safety when performed at any age. more...

Objective Due to the microscopic nature of otologic surgery, photographic image quality suffers from an inherent inability to maintain all the planes of surgery in focus under binocular microscopy. Our goal was to perform simple editing techniques to create improved imaging for educational and research purposes in the field of Otology and Neurotology. Patients/design The study was a proof of concept performed with series of cases including patients undergoing transmastoid and transcanal otologic surgery over time period of December 1, 2018 to March 1, 2019 at an academic medical center. The Zeiss OPMI Pentero 800 operating microscope was used with a camera capturing 2.1 megapixel, 1098 × 1080 resolution images. Intervention We created a systematic protocol for capturing images of multiple focal lengths during each surgery. With the image-editing technique of focus-stacking, multiple images of varying focal length, were spliced together to produce high-quality and high-fidelity composite images rendered using the Adobe Photoshop (San Jose, CA). Outcomes Subjective comparisons of pre and post photo-edited photographs. Results Composite, focus-stacked images with comparison to unedited microscopic pictures are reviewed in the manuscript. Conclusion We describe a simple and objectively practical method for improving the quality of medical imaging in the field of Otology/Neurotology. To achieve this enhanced image quality, a relatively expeditious and reliable photographic protocol can be used for image capturing and editing, requiring little to no additional training for a physician in the field. more...

Objective To characterize the association between scholarly activity, academic rank, practice setting, and malpractice claims among otolaryngologists over the past decade. Methods Data was extracted from the two legal databases, WestLaw and LexisNexis. The records were obtained from January 2010 to January 2020. Scopus and PubMed databases were used to identify bibliometric data. Results Of the 102 malpractice cases identified, 77.5% (N = 79) were ruled in favor of the defendant, 13.7% (N = 14) in favor of the plaintiff, and 8.8% (N = 9) were settled outside of the court. A total amount of $46,533,346.82 was rewarded to plaintiffs in 14 cases. Endoscopic sinus surgery was the procedure associated with the most malpractice claims (N = 16). Alleged improper performance (N = 51) was the most common underlying reason for litigation. Of the 102 defendant surgeons, 82 (80.4%) were in community/private settings. Among the 14 cases in that a surgeon was found at fault, 13 (92.8%) were in the community/private setting. Among the surgeons with at least one publication, the mean Hirsch Index ( h-index) was 8.2. There was a statistically significant correlation between the mean h-index and litigation outcome (95% CI: −8.9 to −0.9, P = .017). Conclusion Our analysis showed that most malpractice litigations were among otolaryngologists practicing in community/private settings. We also found that higher scholarly activity measured by the h-index was associated with verdicts in favor of the defendant/surgeon. This study was limited by not all-inclusive aspects of the legal databases that were used, the small sample size, and the lack of multivariable analysis. more...

There are insufficient data regarding the safety of otologic procedures in the setting of the coronavirus disease 2019 (COVID-19) pandemic. Given the proclivity for respiratory pathogens to involve the middle ear and the significant aerosolization associated with many otologic procedures, safety precautions should follow current recommendations for procedures involving the upper airway. Until preoperative diagnostic testing becomes standardized and readily available, elective cases should be deferred and emergent/urgent cases should be treated as high risk for COVID-19 exposure. Necessary otologic procedures on positive, suspected, or unknown COVID-19 status patients should be performed using enhanced personal protective equipment, including an N95 respirator and eye protection or powered air-purifying respirator (PAPR, preferred), disposable cap, disposable gown, and gloves. Powered instrumentation should be avoided unless absolutely necessary, and if performed, PAPR or sealed eye protection is recommended. more...

Objective: Temporal bone computed tomography (CT) requires a relatively high radiation dose to produce high-resolution images required to define surgical anatomy. In the acute setting, the need for this detailed evaluation of temporal bone pathology may not be required for nonsurgical management and clinical decision-making. We performed a retrospective review of the clinical characteristics and subsequent management of children who underwent CT of the temporal bone with the goal of optimizing clinical decision-making and mitigating the risks of radiation exposure in children. Methods: We included pediatric patients ( more...

To evaluate the current trends and usage patterns of radiographic imaging for otologic disease by specialty, length of practice, practice setting, geographic region, and pediatric volume.Cross-sectional study.Survey of physicians.General Otolaryngologists and Otologists/Neurotologists (O/N) of the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS).An electronic questionnaire was distributed to AAO-HNS members. Respondents were separated into groups by specialty, length of practice, practice setting, region, and pediatric exposure. Chi-square tests were performed for the determination of significance.The survey was sent to 5,168 members of AAO-HNS. The response rate was 10.6% (n = 546) and 18.1% for only O/N (n = 143). Most respondents were generalists (74%), in practice20 years (51%), with a primarily adult practice (95%). O/N were more often academics (44 versus 17% combined, 40% private; p 0.001) and saw fewer children (80 fewer than 25%; p 0.001). Compared with generalists, O/N were more likely to respond with more frequent and earlier magnetic resonance imaging (MRI) utilization in the workup of the majority of otologic diseases. Significant differences in usage patterns for various conditions were demonstrated across all categories, but specialty training was the most common. Generalists (34 versus 12% of O/N; p 0.001), physicians practicing20 years (32 versus 18% of 5 yrs; p = 0.006), and private practice physicians (34 versus 14-20% of others; p 0.001) relied more heavily on the radiology report to interpret MRI scans.Subspecialty training seems to be the main variable correlating with significant differences in the use of MRI and computed tomography imaging in patients with otologic disease. more...

To compare the effect of patient factors, including age, on 30-day postoperative outcomes and complications for patients undergoing transcervical Zenker's diverticulectomy.Retrospective cross-sectional analysis.American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database.Patients who underwent open Zenker's diverticulectomy (A total of 614 patients were identified. Mean age at time of surgery was 71.1 years, with 13.4% older than 85 years. Outpatient procedures were performed in 29.8%. Postoperative complications occurred in 6.7%, with reoperation and readmission rates of 6.4% and 7.2%, respectively. A mortality rate of 0.3% was observed. Only smoking status (odds ratio, 2.94;Smoking status confers a high risk for postoperative complication. Age was not an independent risk factor associated with adverse outcomes following open diverticulectomy, suggesting this procedure can be safely performed in patients with advanced age. more...

Objective To compare the effect of surgical specialty and patient factors on 30-day postoperative outcomes and complications for children undergoing autologous costochondral grafting for microtia reconstruction. Methods The American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was searched from 2012 through 2017 for patients who underwent autologous rib grafting (CPT 21230). The group was further filtered for coexisting ICD 9 or 10 code for microtia (744.23, Q17.2) as an indication for surgery. Outcomes analyzed included patient demographics, medical comorbidities, admission type (inpatient vs. outpatient), operative time, surgeon specialty, length of hospital stay (LOS), complications, and readmission. Results A total of 375 pediatric patients were identified of which 157 were female and 218 were male. Mean age at time of surgery was 9.6 years. Postoperative complications and readmission occurred in 5.6% and 3.5% of patients, respectively. Surgical site infection was the most common complication. Average operative time was 246.9 min. When comparing Otolaryngology to Plastic Surgery with multivariate analysis, there was no difference in admission type (OR 1.00, p = 0.993), complication rate (OR 0.91, p = 0.744), readmission (OR 0.68, p = 0.576), operative time (p = 0.471) or total LOS (p = 0.266). Conclusion The present study demonstrated postoperative complications and readmission rates following microtia repair as reported by the NSQIP-P database. Overall complication and readmission rates were low. No significant risk factors were identified on multivariate analysis. There were no differences between surgical specialty for complication rate, operative time, hospital stay or readmission when accounting for demographic data and comorbidities. more...

To review the impact of coronavirus disease 2019 (COVID-19) on pediatric otolaryngology and provide recommendations for the management of children during the COVID-19 pandemic.Clinical data were derived from peer-reviewed primary literature and published guidelines from national or international medical organizations. Preprint manuscripts and popular media articles provided background information and illustrative examples.Included manuscripts were identified via searches using PubMed, MEDLINE, and Google Scholar, while organizational guidelines and popular media articles were identified using Google search queries. Practice guidelines were developed via consensus among all authors based on peer-reviewed manuscripts and national or international health care association guidelines. Strict objective criteria for inclusion were not used due to the rapidly changing environment surrounding the COVID-19 pandemic and a paucity of rigorous empirical evidence.In the face of the COVID-19 pandemic, medical care must be judiciously allocated to treat the most severe conditions while minimizing the risk of long-term sequelae and ensuring patient, physician, and health care worker safety.The COVID-19 pandemic will have a profound short- and long-term impact on health care worldwide. Although the full repercussions of this disease have yet to be realized, the outlined recommendations will guide otolaryngologists in the treatment of pediatric patients in the face of an unprecedented global health crisis. more...

Papillary thyroid cancer often presents with cervical lymph node involvement and has a high incidence of recurrence, which requires routine follow-up with ultrasound imaging. Elastography is a novel ultrasound technique that has been demonstrated to be effective clinically in detecting tissue pathology in areas such as the liver and breast. Preliminary data suggest that it may be effective in screening tissues in the neck for malignancy, specifically cervical lymph nodes. However, diagnostic criteria and elastographic techniques vary significantly among the studies we have reviewed, which all tend to focus on populations of patients with many different types of primary malignancies. Further research is required on the feasibility of creating standardized and reproducible clinical criteria in a specific patient population. To study the clinical utility of elastography in cervical lymph nodes, patients with diagnosed papillary thyroid carcinoma may serve as an ideal population because of their need for ultrasound surveillance and the propensity of papillary thyroid cancer to metastasize to and recur in cervical lymph nodes. We will review the limitations, techniques, and reported clinical utility of elastography on cervical lymph nodes and its potential as a screening modality for papillary thyroid cancer. more...

Hypothesis Treatment modalities administered by Otolaryngologists vary based on patient volume and years of experience. Objective It was our goal to evaluate the current trends in treatment modalities administered by Otolaryngologists based on patient volume and years of experience. Methods An electronic questionnaire was distributed to all General Otolaryngologists and fellowship-trained Neurotologist members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). Respondents were separated into groups by patients per year ( 100 patients) and years in practice (0-5, 6-10, 11-15, 16-20, or >20 yrs). Results Eight hundred and sixty members replied for a response rate of 14.5% for generalists and 35% for neurotologists. Patient volume was found to have a positive association with perceived benefit of lifestyle and diet modification, and use of intratympanic steroids, intratympanic gentamycin, oral steroids, benzodiazepines, acetazolamide, endolymphatic sac procedures, vestibular nerve section, and surgical labyrinthectomy. Only endolymphatic sac procedures were found to have a significant positive association with a physician's length in practice. The only negative association was between intratympanic steroids and a physician's length in practice. Conclusion Physicians who see more MD patients annually are more likely to use these treatment modalities: diet and lifestyle modification, intratympanic steroids, intratympanic gentamycin, surgical labyrinthectomy, vestibular nerve section, acetazolamide, alprazolam, lorazepam, dexamethasone, and prednisone. Physicians with a longer length of time in practice are more likely to use only endolymphatic sac procedures, and they are less likely to use intratympanic steroids. more...

Our goal was to elucidate the efficacy and outcome profile of cadaveric allografts (homograft costal cartilage) in functional septorhinoplasty as compared with autografts (quadrangular cartilage, conchal cartilage, and autologous costal cartilage).Retrospective chart review.Otolaryngology division of the Penn State Health Milton S. Hershey Medical Center.A chart review of a single surgeon's practice was conducted withA total of 171 cases were included in our data analysis. On multivariate analysis, there were no significant differences between patients who had autografts and those who had allografts in 3-, 6-, or 12-month postoperative NOSE score. Preoperative NOSE score was the only covariate to demonstrate a significant positive relationship to postoperative NOSE score. Regarding outcomes between autograft and allograft, no significant differences were found in rate of graft resorption (3.4% vs 5.6%,Autologous grafting is often the first choice in septorhinoplasty because of its presumed resistance to infection and resorption. Similar to autologous grafts, allografts are resistant to infection and resorption and demonstrate prolonged efficacy following functional septorhinoplasty. more...

BACKGROUND Our goal was to elucidate the differences in degree of technical difficulty of thyroidectomy in patients with autoimmune thyroid diseases. METHODS Charts of adult patients who had undergone thyroidectomy were reviewed. Patients with Hashimoto's Thyroiditis (HT) or Graves' Disease (GD) were individually compared to a control group of patients with early stage malignancy or goiter. RESULTS The HT (n = 65) group was significantly more likely to have friable (P = .001) and fibrotic (P more...

Objective To compare tracheoscopy and chest radiograph measurements of tracheostomy tube position in infants. Study design Retrospective chart review. Setting Otolaryngology Department at Penn State Milton S. Hershey Medical Center. Subjects and methods All cases of pediatric patients who underwent tracheotomy at less than 1 year of age from 2014 to 2019 were reviewed. Patients were included if they had both intraoperative measurement of tracheostomy tube position relative to the carina by tracheoscopy and postoperative chest radiograph. Documented intraoperative findings were compared to measurements made on chest radiograph by an attending radiologist blinded to the intraoperative measurements. Results The study included 66 patients; 30 patients (14:16, M:F) had available data. The mean distance from the distal tracheostomy tube to the carina measured by tracheoscopy was 8.88 mm (range, 3.5–20 mm) and measured radiographically was 11.71 mm (range, 2.4–23.3 mm). The mean difference between the measurements was 2.82 mm (p-value = 0.016). Ninety percent (n = 27) of patients had measurements that differed by greater than 2 mm; 53% (n = 16) had measurements that differed by 5 mm and 1% (n = 3) had measurements differing by greater than 10 mm. Conclusion In the infant population, significant discrepancy was found between direct tracheoscopy and chest radiograph measurements of the tracheostomy tube position. Measurements obtained by chest radiographs tend to overestimate the relative distance of the distal tracheostomy tube to the carina as compared to that of tracheoscopy. Clinical decisions regarding changes to tracheostomy tube sizes should mostly rely on tracheoscopy performed with the patient supine. more...

Among the options for the reconstructive surgeon in repairing an auricular defect, prosthetics are often not strongly considered due to unfamiliarity with benefits and outcomes. In many patients who are poor surgical candidates or who do not wish a multistaged reconstruction, auricular prostheses can be an excellent option and should be discussed when counseling patients. Osseointegrated implant-retained prostheses are becoming more popular given the relative simplicity of the surgical procedure, reliable retention and orientation, and low complication rates. Adhesive-retained prostheses provide a nonsurgical option with good esthetic results. Studies have found successful long-term stability and improvements in quality of life. more...

A common indication for tonsillectomy in children is clinically diagnosed sleep disordered breathing (SDB) without confirmation of obstructive sleep apnea (OSA) by polysomnography (PSG). Our goal was to review rates of post-tonsillectomy respiratory complications in children with SDB without prior PSG in order to develop recommendations for postoperative monitoring and safe hospital discharge in this population.Following Institutional Review Board (IRB) approval at Penn State Milton S. Hershey Medical Center, a database query using Current Procedural Terminology (CPT) codes for tonsillectomy with or without adenoidectomy (42820, 42821, 42825, 42826) between January 1, 2012 and December 31, 2017 was performed. International Classification of Diseases (ICD) codes for sleep disordered breathing (G47.30), snoring (R06.83), and obstructive sleep apnea (G47.33) were applied for further selection. Charts were individually reviewed to confirm the inclusion criteria of pediatric patients (≤18 years) who underwent tonsillectomy without prior PSG and were monitored overnight. Demographic, operative, and relevant postoperative hospital course data (including desaturations, supplemental oxygen requirements, and upgraded level of care) were collected.A total of 1874 unique patient encounters were identified by our database search and 364 children met inclusion criteria. The average age of the patient population was 6.5 ± 3.1 years and 52.2% of children were female. Mean z-score for the population was 0.6. The rate of overnight oxygen desaturation events (95%) was 2.2%, with no severe complications found in this population. Children with desaturation events were supplemented with oxygen and resolved prior to hospital discharge. Only race was found to be significantly related to risk of mild overnight desaturations (P = 0.023).A lack of significant postoperative respiratory complications or alterations in the clinical management of children with SDB without prior PSG supports the idea that such patients may safely be discharged from the hospital following tonsillectomy without overnight oxygen monitoring. more...

Technology is integral to the diverse diagnostics and interventions of Otolaryngology. Historically, major advances in this field derive from advances of associated technologies. Challenges of visualization and surgical access are increasingly overcome by integrating endoscopic, electronic, and robotic instruments. Otolaryngology is often limited to urban areas and large academic centers, making it difficult to allocate care and resources to many underserved populations. The widespread use of technology has important implications in regards to global access to this field as telemedicine is most effectively applied to specialties that are heavily reliant on data and visuals that may be electronically disseminated. more...

The introduction of robotic-assisted surgery in tonsillar cancer has allowed more advanced and extensive tumors to be treated with surgery. The transoral approach avoids the morbidity of an open procedure while still achieving complete oncologic resection, including margins. The magnified three-dimensional view along with the use of angled endoscopic cameras with 360° radius provides visualization beyond the tonsillar fossa to the great vessels laterally, the palate and nasopharynx superiorly, and the tongue base inferiorly, which could not be achieved using traditional transoral headlight or operative microscope alone. more...

Dog bites in the pediatric population commonly cause injuries to the head and can be associated with fractures, often leading to prolonged hospital stays, multiple surgical interventions, and long-term complications. Our goal was to evaluate our experience with dog-bite–related craniofacial fractures, understand frequency and demographics of these fractures, identify common fracture patterns, and provide recommendations based on management and complications encountered. The institution's electronic medical record was reviewed. A review of the English literature for the past 20 years was also conducted. A retrospective chart review was conducted using ICD-9 codes to include all patients with head and neck dog bites and craniofacial fractures. Fractures resulting from canine bites to the face and scalp were rare, occurring in our study in less than 1% of total facial dog bites (1,069 cases) and 1.5% of pediatric facial dog bites (462 cases). Ages ranged from 5 months to 9 years at the time of presentation. A total of seven patients, all pediatric, were documented. All seven patients required operative intervention for their wounds, and five patients required at least two operative interventions. Midface and skull fractures were the most commonly encountered fracture sites. Dog bite injuries to the face in young children, especially when severe, should raise suspicion for fracture of underlying bone. Management of these injuries should include a multidisciplinary approach and focus on repair of soft tissue and skeletal deformities. Furthermore, it is prudent to follow up patients who require operative management after injury to monitor for long-term complications, given the significant proportion of complications and operative takebacks in this study. more...

We describe the case of a 46-year-old woman with a rare presentation of angioleiomyoma of the subcutaneous nasal tissue. The patient presented with pain and severe nasal obstruction. Her nasal deformity was sufficient to indicate an external rhinoplasty for both extirpation of the tumor and reconstruction of the defect with cartilage grafts. The procedure resulted in successful removal of the tumor and a satisfactory cosmetic outcome. more...

The major outward chloride transporter in neurons is the potassium chloride co-transporter 2 (KCC2), critical for maintaining an inhibitory reversal potential for GABA(A) receptor channels. In a recent study, we showed that Zn(2+) regulates GABA(A) reversal potentials in the hippocampus by enhancing the activity of KCC2 through an increase in its surface expression. Zn(2+) initiates this process by activating the Gq-coupled metabotropic Zn(2+) receptor/G protein-linked receptor 39 (mZnR/GPR39). Here, we first demonstrated that mZnR/GPR39 is functional in cortical neurons in culture, and then tested the hypothesis that the increase in KCC2 activity is mediated through a soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE)-dependent process. We established the presence of functional mZnR in rat cultured cortical neurons by loading cells with a Ca(2+) indicator and exposing cells to Zn(2+), which triggered consistent Ca(2+) responses that were blocked by the Gq antagonist YM-254890, but not by the metabotropic glutamate receptor antagonist (RS)-α-methyl-4-carboxyphenylglycine (MCPG). Importantly, Zn(2+) treatment under these conditions did not increase the intracellular concentrations of Zn(2+) itself. We then measured KCC2 activity by monitoring both the rate and relative amount of furosemide-sensitive NH(4)(+) influx through the co-transporter using an intracellular pH-sensitive fluorescent indicator. We observed that Zn(2+) pretreatment induced a Ca(2+)-dependent increase in KCC2 activity. The effects of Zn(2+) on KCC2 activity were also observed in wild-type mouse cortical neurons in culture, but not in neurons obtained from mZnR/GPR39(-/-) mice, suggesting that Zn(2+) acts through mZnR/GPR39 activation to upregulate KCC2 activity. We next transfected rat cortical neurons with a plasmid encoding botulinum toxin C1 (Botox C1), which cleaves the SNARE proteins syntaxin 1 and synaptosomal-associated protein 25 (SNAP-25). Basal KCC2 activity was similar in both transfected and non-transfected neurons. Non-transfected cells, or cells transfected with marker vector alone, showed a Zn(2+)-dependent increase in KCC2 activity. In contrast, KCC2 activity in neurons expressing Botox C1 was unchanged by Zn(2+). These results suggest that SNARE proteins are necessary for the increased activity of KCC2 after Zn(2+) stimulation of mZnR/GPR39. more...

The delayed-rectifier K(+) channel Kv2.1 exists in highly phosphorylated somatodendritic clusters. Ischemia induces rapid Kv2.1 dephosphorylation and a dispersal of these clusters, accompanied by a hyperpolarizing shift in their voltage-dependent activation kinetics. Transient modulation of Kv2.1 activity and localization following ischemia is dependent on a rise in intracellular Ca(2+)and the protein phosphatase calcineurin. Here, we show that neuronal free Zn(2+)also plays a critical role in the ischemic modulation of Kv2.1. We found that sub-lethal ischemia in cultured rat cortical neurons led to characteristic hyperpolarizing shifts in K(+) current voltage dependency and pronounced dephosphorylation of Kv2.1. Zn(2+)chelation, similar to calcineurin inhibition, attenuated ischemic induced changes in K(+) channel activation kinetics. Zn(2+)chelation during ischemia also blocked Kv2.1 declustering. Surprisingly, we found that the Zn(2+)rise following ischemia occurred in spite of calcineurin inhibition. Therefore, a calcineurin-independent rise in neuronal free Zn(2+) is critical in altering Kv2.1 channel activity and localization following ischemia. The identification of Zn(2+) in mediating ischemic modulation of Kv2.1 may lead to a better understanding of cellular adaptive responses to injury. more...

Methamphetamine is a drug of abuse that can induce oxidative stress and neurotoxicity to dopaminergic neurons. We have previously reported that oxidative stress promotes the liberation of intracellular Zn 2+ from metal-binding proteins, which, in turn, can initiate neuronal injurious signaling processes. Here, we report that methamphetamine mobilizes Zn 2+ in catecholaminergic rat pheochromocytoma (PC12) cells, as measured by an increase in Zn 2+ -regulated gene expression driven by the metal response element transcription factor-1. Moreover, methamphetamine-liberated Zn 2+ was responsible for a pronounced enhancement in voltage-dependent K + currents in these cells, a process that normally accompanies Zn 2+ -dependent cell injury. Overnight exposure to methamphetamine induced PC12 cell death. This toxicity could be prevented by the cell-permeant zinc chelator N,N,N′, N′-tetrakis(2-pyridylmethyl)-ethylenediamine (TPEN), and by over-expression of the Zn 2+ -binding protein metallothionein 3 (MT3), but not by tricine, an extracellular Zn 2+ chelator. The toxicity of methamphetamine to PC12 cells was enhanced by the presence of co-cultured microglia. Remarkably, under these conditions, TPEN no longer protected but, in fact, dramatically exacerbated methamphetamine toxicity, tricine again being without effect. Over-expression of MT3 in PC12 cells did not mimic these toxicity-enhancing actions of TPEN, suggesting that the chelator affected microglial function. Interestingly, P2X receptor antagonists reversed the toxicity-enhancing effect of TPEN. As such, endogenous levels of intracellular Zn 2+ may normally interfere with the activation of P2X channels in microglia. We conclude that Zn 2+ plays a significant but complex role in modulating the cellular response of PC12 cells to methamphetamine exposure in both the absence and presence of microglia. more...