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Objectives Endoscopic endonasal anterior skull base surgery has expanding use in the pediatric population, but the anatomy of pediatric patients can lead to limitations. This study aims to characterize the important anatomical implications of the pediatric skull base using computed tomography (CT) scans. Design This study is designed as retrospective analysis. Setting The study setting comprises of tertiary academic medical center. Participants In total, 506 patients aged 0 to 18 who had undergone maxillofacial and or head CTs between 2009 to 2016 were involved. Methods Measurements included piriform aperture width, nare to sella distance (NSD), sphenoid pneumatization, olfactory fossa depth, lateral lamella cribriform plate angles, and intercarotid distances (ICD) at the superior clivus and cavernous sinus. These patients were then subdivided into three age groups adjusting for sex. Analysis of covariance (ANCOVA) models were fit comparing between all age groups and by sex. Results Piriform aperture width, NSD, sphenoid sinus pneumatization as measured using lateral aeration and anterior sellar wall thickness, olfactory fossa depth, and ICD at the cavernous sinus were significantly different among all age groups (p Conclusion The process of skull base development is age and sex dependent. During preoperative evaluation of pediatric patients for skull base surgery piriform aperture width, sphenoid pneumatization in both the anterior posterior and lateral directions, and ICD at the cavernous sinus should be carefully reviewed.

Juvenile nasopharyngeal angiofibromas (JNAs) are a rare, highly vascular benign tumor affecting adolescent males. Recent advances in endoscopic visualization and technique have allowed for complete extirpation of these tumors endoscopically. Proponents of this approach find benefit in the lack of facial incisions, decreased intraoperative blood loss, and excellent tumor control. This chapter describes the endoscopic approach to JNAs.

Juvenile nasopharyngeal angiofibromas are rare, benign vascular tumors of the nasopharynx that account for less than 0.5% of all head and neck tumors. These lesions occur almost exclusively in young males. There are various approaches that allow for successful resection of nasopharyngeal angiofibromas, including open, endoscopic, and combined procedures. With the advancement of endoscopic technologies, the endoscopic approach has become the favored technique for smaller, less extensive lesions.

Introduction The risk of skull base injury during choanal atresia repair can be mitigated via thorough understanding of skull base anatomy. There is a paucity of data describing differences in skull base anatomy between patients with coloboma, heart defects, atresia choanae, growth retardation, genital abnormalities, and ear abnormalities (CHARGE) syndrome and those without. Objectives The aim of this study was to measure nasal and skull base anatomy in patients with isolated bilateral choanal atresia (BCA), CHARGE syndrome, and other syndromic congenital anomalies. Methods Retrospective chart review of patients with bilateral choanal atresia and computed tomography of the face between 2001 and 2019 were evaluated. Choanal width, height, mid-nasal height, and skull base slope were measured radiographically. Differences in anatomy between healthy patients, those with CHARGE syndrome, and those with other congenital anomalies were compared. Results Twenty-one patients with BCA and relevant imaging were identified: 7 with isolated BCA, 6 with CHARGE syndrome, and 8 with other congenital anomalies. A t-test indicated insignificant difference in skull base slope, choanal height, choanal width, or mid-nasal skull base height between isolate BCA cases and patients with any congenital anomaly. When comparing CHARGE to isolated BCA cases, mid-nasal height was shorter in CHARGE patients (p = 0.03). There were no differences in measurements between patients with congenital anomalies excluding CHARGE (p > 0.05). Two patients in the congenital anomaly group were found to have bony skull base defects preoperatively. Conclusion This study represents the largest description of skull base and nasal anatomy in patients with CHARGE syndrome and BCA. Surgeons should be aware of the lower skull base in CHARGE patients to avoid inadvertent skull base injury.

Transoral robotic surgery in adults confers excellent results and decreased morbidity. Application of these techniques has not yet been rigorously investigated in children. The goal of this study is to evaluate the feasibility of a flexible robotic surgical system in a pediatric population.This was a non-randomized, non-blinded, prospective clinical trial. An Investigational Device Exemption was obtained from the FDA. Patients 8-12 years old scheduled for tonsillectomy and adenoidectomy between February and December 2019 at an academic tertiary care children's hospital were included. Exclusion criteria included pulmonary or vascular conditions posing risks for extended anesthesia, or a smaller mouth opening than the instrumentation (28 mm × 15 mm). Tonsillectomy was completed with standard monopolar cautery. After the surgery was complete, the robot was utilized for evaluation and assessment of exposure. A pediatric anesthesiologist screened patients for tolerance of additional anesthesia (up to 15 min). A flexible robotic surgical system, the MedRobotics Flex® Robotic System, was used to visualize and access the tonsillar fossa, posterior pharynx, base of tongue, epiglottis and false vocal folds. Visualization and access were graded on a five-point Likert scale.A total of ten patients, eight males and two females, with obstructive sleep apnea (OSA) or sleep disordered breathing (SDB) were recruited in 2019. One patient did not complete the study due to equipment malfunction. The average patient demographics were: age 10.1 years (8.6-11.8 years), height 142.4 cm (127-164.9 cm), weight 47.5 kg (24.4-84.5 kg), and BMI 22.6 (13.9-31.0). Study time averaged 10.3 min (5-13 min). The tonsillar fossa, base of tongue, and posterior pharynx were visualized completely and easily accessed with the robotic instruments. The epiglottis and false vocal folds were visualized and accessed in 66% and 55% of patients, respectively. There were no adverse effects.This study demonstrated that a flexible robotic surgical system is feasible for use in children 8-12 years of age when performing otolaryngology - head and neck surgery procedures of the oropharynx and larynx.

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.

Complex cervicofacial infections encompass a unique subset of upper and lower airway disorders with both potential to progress into a life-threating clinical condition. In the modern era, treatment of aggressive extracranial infections continues to revolve around the hallmark principles of airway stabilization, broad-spectrum antimicrobials, radiography, and surgical drainage. Approaches to complicated head and neck infections remain a multidisciplinary endeavor involving an experienced team of anesthesiologists, critical care intensivists, and otolaryngologists. This article aims to both review and highlight key therapeutic strategies in the management of this challenging pathologic entity with special consideration given to emergent airway maneuvers and operative techniques.

Simple Summary Pediatric thyroidectomies are performed by pediatric and adult general surgeons as well as pediatric and adult otolaryngologists. Surgeons may be high or low-volume thyroid surgeons. In this review, we discuss the roles of surgical subspecialty, surgeon volume, and institution volume as they relate to pediatric thyroidectomy outcomes. We also present institutional approaches to multidisciplinary treatment of pediatric thyroid cancer. Abstract Pediatric thyroid cancer is rare, but increasing in annual incidence. Differentiated thyroid cancer in pediatric patients is treated surgically. Pediatric thyroidectomies are performed by general surgeons, otolaryngologists, general pediatric surgeons, and pediatric otolaryngologists. In a comprehensive literature review, we discuss the evidence supporting the importance of surgeon subspecialty and surgeon volume on outcomes for pediatric thyroid cancer patients. Pediatric general surgeons and pediatric otolaryngologists perform most pediatric thyroidectomies. Certain subpopulations specifically benefit from a combined approach of a pediatric surgeon and a high-volume thyroid surgeon. The correlation between high-volume surgeons and lower complication rates in adult thyroid surgery applies to the pediatric population; however, the definition of high-volume for pediatric thyroidectomies requires further investigation. The development of dedicated pediatric thyroid malignancy centers and multidisciplinary or dual-surgeon approaches are advantageous.

Objective: Identify risk factors and perioperative morbidity for pediatric patients undergoing septoplasty. Methods: The American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was retrospectively queried to identify patients who underwent septoplasty (CPT 30520) for a diagnosis of deviated nasal septum (ICD J34.2) from 2018 to 2019. Outcomes analyzed include patient demographics, medical comorbidities, surgical setting, operative characteristics, length of stay, and postoperative outcomes. Results: A total of 729 children were identified. Median age at time of surgery was 15.8 years, with most patients (82.8%) >12 years of age; no significant association was identified between age at time of surgery and adverse surgical outcomes. Overall, postoperative complications were uncommon (0.6%), including readmission (0.4%), septic shock (0.1%), and surgical site infection (0.1%). A history of asthma was found to be a significant risk factor for postoperative complications ( P = .035) as well as BMI ( P = .028). Conclusion: The 30-day postoperative complications following pediatric septoplasty in children reported in the NSQIP-P database are infrequent. Special considerations regarding young age, complex sinonasal anatomy, and surgical technique remain important features in considering corrective surgery for the pediatric nose and certainly warrant further investigation in subsequent studies.

Juvenile nasopharyngeal angiofibromas are benign yet aggressive anterior skull base tumors that occur almost exclusively in male adolescents. Diagnosis is typically made through radiographic findings and clinical characteristics; biopsy is not recommended due to the vascular nature of the disease. As with most tumors, there is a spectrum of tumor extent and invasion. In juvenile nasopharyngeal angiofibromas, one of the most important components of extent is the vascular supply. Once the vascular supply is identified, a systematic approach to resection can be planned. The majority of these tumors can be excised endoscopically, and those approaches are the focus of this article.

Objective To describe and analyze the demographics and academic backgrounds of United States otolaryngology program directors (PD) and assess gender disparity in the field. Methods This was a cross-sectional study in which an online search using publicly available sources was performed to gather information on PDs for 125 United States otolaryngology programs from May 14, 2021, to May 30, 2021. Data collected included PD appointment year, age, gender, resident gender breakdown, degree, as well as training location and graduation year. Results There were 69.6% programs with a male PD and 30.4% with a female PD. Ninety percent of PDs have an MD degree and 9.6% have a DO degree. The current average age of PDs was 49.9 years old (range 35–79). Males were older than females PD (51.0 vs 47.1 years, P = 0.045) and have served a longer time as PD (7.1 vs 4.8 years, P = 0.019). There was no significant difference in other variables collected. There were 27.3% of program directors that held the position of professor, 44.5% associate professor, and 28.2% assistant professor. The most common subspecialty practiced by otolaryngology PDs was head and neck oncology. Conclusion Disparity in women’s representation in otolaryngology still exists, but the program director leadership position demonstrates better parity. There is an equal percent representation when examining female PDs and female otolaryngologists in academic medicine. Continued efforts to encourage women to enter and become leaders in otolaryngology are necessary moving forward.

The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a Sistrunk procedure via either same day surgery or overnight observation.A retrospective review of patients undergoing Sistrunk procedures between January 1, 2008 to January 1, 2019 was performed. 76 cases were identified for review. Bivariate and multivariable analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement.No patients had life-threatening adverse events. There was no difference in complication rates between same day discharge (17%) and overnight observation (23%, p = 0.47). Otolaryngologists were more likely to admit patients overnight (88% vs. 14%, p = 0.042) as well as place a drain (97% vs. 24%, p 0.001) when compared to pediatric surgeons. Drain placement was associated with overnight observation (73% vs. 3%, p 0.001). Multivariable logistic regression demonstrated drain placement (OR 21.9, 95%CI (2.5-189.7), p = 0.005) and otolaryngologist as operative surgeon (OR 11.7, 95%CI (2.8-48.2), p 0.001) as strong predictive variables for overnight observation. There was no association between other investigated variables and adverse events or overnight stay.Same day Sistrunk operations are safe in select healthy patients. Overnight observation appears to be driven by drain placement and surgeon practice patterns.

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.

Fibro-osseous lesions of the skull base include a variety of lesions with different biologic behavior. The most common lesions include fibrous dysplasia, osteoma, aneurysmal bone cyst, and juvenile ossifying fibroma. The diagnosis can usually be established with radiographic imaging. In the absence of symptoms, slow-growing lesions can often be observed. When surgery is indicated for relief of symptoms, endoscopic endonasal techniques are well suited for all age groups.

OBJECTIVE Review current literature and guidelines for malignant hyperthermia in the context of neurotologic surgery. PATIENT A case of malignant hyperthermia during vestibular schwannoma surgery, in a patient previously exposed to anesthesia. INTERVENTIONS Excision of vestibular schwannoma, acute management of malignant hyperthermia. MAIN OUTCOME MEASURES Knowledge of the basic pathophysiology, clinical manifestations, and treatment protocols for malignant hyperthermia. RESULTS Rapid termination of the procedure and appropriate modifications in surgical technique permitted expeditious treatment of malignant hyperthermia and prevented its lethality. CONCLUSIONS Malignant hyperthermia is a rare and lethal condition that may arise in neurotologic surgery, even in patients who have previously received general anesthesia. The neurotologic surgeon has a role in early recognition and expeditious termination of surgery to help reduce its mortality.

Papillary thyroid carcinoma in a thyroglossal duct cyst is very rare. We present the case of a teenage boy with a large thyroglossal duct cyst containing papillary thyroid carcinoma. There was no evidence of carcinoma within the thyroid gland, making this an important case of primary thyroglossal duct cyst carcinoma.

There is increasing discussion worldwide on explicitly including cost as part of the clinical practice guideline development process. While this could enhance our understanding of value-based care and improve resource utilization, there are many practical challenges for cost inclusion. This commentary explores this issue, examining it from multiple angles and giving pros and cons to inclusion in future guidelines.

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.

The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a removal of second branchial cleft anomalies (BCA) via either same day surgery or overnight observation.A retrospective review of patients undergoing second BCA removal between January 1, 2008 to January 1, 2019 was performed. 40 cases were identified for review. Bivariate analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement.There were no life-threatening adverse events. Same day discharge was not associated with adverse events (p = 0.24). Overnight observation was associated with a history of preoperative infection (p = 0.003), cyst 3.0 cm (p = 0.046), operative time 90 min (p 0.001), and drain placement (p = 0.001). There was no association between other investigated variables and adverse events or overnight stay.Same day discharge following second branchial cleft anomalies appears safe and feasible. Further study is needed to determine the safety profile of same day discharge and etiologies of practice patterns of overnight observation.

To examine otolaryngology resident interest in subspecialty fellowship training and factors affecting interest over time and over the course of residency trainingCross-sectional study of anonymous online survey data.Residents and fellows registered as members-in-training through the American Academy of Otolaryngology-Head and Neck Surgery.Data regarding fellowship interest and influencing factors, including demographics, were extracted from the Section for Residents and Fellows Annual Survey response database from 2008 to 2014.Over 6 years, there were 2422 resident and fellow responses to the survey. Senior residents showed a statistically significant decrease in fellowship interest compared with junior residents, with 79% of those in postgraduate year (PGY) 1, 73% in PGY-2 and PGY-3, and 64% in PGY-4 and PGY-5 planning to pursue subspecialty training (P.0001). Educational debt, age, and intended practice setting significantly predicted interest in fellowship training. Sex was not predictive. The most important factors cited by residents in choosing a subspecialty were consistently type of surgical cases and nature of clinical problems.In this study, interest in pursuing fellowship training decreased with increased residency training. This decision is multifactorial in nature and also influenced by age, educational debt, and intended practice setting.

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.

Developmental anomalies of the skull base may present in childhood or as an adult. The most common pathologies include dermoid, encephalocele, and glioma. Encephaloceles may present as part of a syndrome. Other entities include infantile hemangiomas and teratoma. Endoscopic techniques provide a less invasive and morbid option for treatment. Proper evaluation and treatment is necessary to prevent complications such as meningitis.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Allergic Rhinitis. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed address the evaluation of patients with allergic rhinitis, including performing and interpretation of diagnostic testing and assessment and documentation of chronic conditions and comorbidities. It will then focus on the recommendations to guide the evaluation and treatment of patients with allergic rhinitis, to determine the most appropriate interventions to improve symptoms and quality of life for patients with allergic rhinitis.

The purpose of this study was to examine the experiences of prior governing council (GC) members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Section for Residents and Fellows-in-Training (SRF) and assess the impact of early Academy involvement. A survey was conducted via email on all prior AAO-HNS SRF GC members. The AAO-HNS SRF has elected 52 GC members since its 2003 inception. Each member served an average of 1.5 year-long terms. The mean time since completion of training is 4.1 years. A subspecialty fellowship was pursued in 86%. Fifty-seven percent practice in academic settings, with 3 members advancing to subspecialty division director within their department. More than half (58%) have served on an AAO-HNS committee, and most are frequent attendees of the annual meeting. All prior members felt involvement in the SRF GC was beneficial, enabling them to gain leadership skills and deeper understanding of the specialty.

Robotic surgery has revolutionized surgical capabilities and continues to change surgical approaches and management. Robotic surgery is in its infancy with respect to head and neck surgery. However, there are several validated indications for robotics in ENT. The authors discuss the role of robotic surgery specifically related to salivary gland disease and discuss the indications, complications and anatomic nuances that justify the current role and continued effort to expand indications for robotic surgery in the field of head and neck surgery.

Objective The types of otogenic cerebrospinal fluid (CSF) fistulae were previously classified into defects through, adjacent to, or distal to the otic capsule. This article presents cases of the three different types of spontaneous CSF fistulae and reviews pertinent literature. We examine the management of the different types of otogenic CSF leaks with modern audiovestibular testing, imaging, and surgical techniques. Design Case series and review of the literature. Setting Academic tertiary neurotologic referral practice. Participants Four patients identified through a retrospective search. Main outcome measures Resolution of CSF leak and absence of meningitis. Results Surgical intervention was performed on the four cases described in this series; none had a return of CSF otorrhea in the postoperative period or meningitis. Conclusions Otogenic CSF fistulae may lead to life-threatening infection and in congenital forms are typically not diagnosed unless meningitis has occurred. Rapid and proper recognition, work-up, and treatment of such leaks decrease the risk of permanent neurologic sequelae as well as recurrent meningitis.

Surgical correction of palatal obstruction is frequently needed as part of the multilevel treatment of moderate and severe obstructive sleep apnea/hypopnea syndrome. The classic uvulopalatopharyngoplasty technique described by Fujita has limited success rates. Uvulopalatopharyngoplasty has been modified in the form of Z-palatoplasty. Although this technique was first described for patients without tonsils, it has been further modified to include tonsillectomy along with pharyngoplasty. We describe the author's technique and experience with this new modification.

Background: Intranasal steroids are 1 of the most frequently prescribed medications for the treatment of chronic rhinosinusitis (CRS), and saline irrigations are commonly used as an adjunct to medical therapy. We aimed to compare the efficacy of Dead Sea salt (DSS) irrigations and DSS nasal spray vs saline irrigations and topical nasal steroid spray in the treatment of symptoms of CRS. Methods: A total of 145 symptomatic adult patients without acute infection were initially enrolled and 114 completed the study. Patients completed a Sino-Nasal Outcomes Test 20 (SNOT-20) survey (primary outcome metric) and underwent endonasal examination, acoustic rhinometry, and smell testing (secondary outcome metrics). Patients were randomized to 2 groups. The experimental group (n = 59) self-administered hypertonic DSS spray and DSS irrigation; the control group (n = 55) self-administered fluticasone spray and hypertonic saline irrigation and spray. Patients and staff were blinded to group assignment. Outcomes were reassessed at 4 weeks. Results: The 2 groups were homogeneous with respect to pretreatment primary and secondary outcome metrics. Dropout rates were 30% in the DSS group and 36.6% in the control group. Both groups showed significant improvement in mean SNOT-20 scores following treatment; however, the degree of improvement was not significantly different between groups (p = 0.082). There were no significant changes in secondary outcome metrics between the 2 groups. Conclusion: For patients with CRS, treatment with DSS irrigations and sprays appears as effective for symptom reduction as a combination of hypertonic saline irrigations and sprays and a topical steroid spray. © 2011 ARS-AAOA, LLC.

The objective of this study is to describe the modification of port placement for the four-arm technique of robotic thyroidectomy to avoid a chest incision and eliminate crowding of the working space provided by the trans-axillary incision. The study methodology involved description of port placement modification to avoid chest incision and report of two cases with appropriate literature review is presented. Trans-axillary robotic thyroidectomy (TART) is often performed with a second chest incision, but the move toward single incision operation and placement of four arms via a single incision require expertise. We describe two patients who underwent TART using a trans-axillary incision and a separate 1 cm incision in the anterior axilla 2.5-cm below the trans-axillary incision for placement of the fourth arm. This design allowed for a more ergonomic placement of the fourth arm while not compromising the working space provided by the trans-axillary incision. Additionally this port was used for surgical drain placement Robot-assisted trans-axillary thyroidectomy poses several challenges in the early surgical learning curve. One roadblock to exposure and efficiency is appropriate port and arm placement. Our modification offers an alternative where a four-arm technique is made possible without a chest port and not occupying the working space provided by the trans-axillary incision. Use of this inferior axillary port is cosmetically acceptable, surgically efficient, and allows avoidance of a visible chest incision for placement of the fourth arm.

Objectives To determine the sensitivity and specificity of the Berlin Questionnaire and the Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS) score for individually predicting a diagnosis of OSAHS, and to propose a method for OSAHS screening incorporating objective and subjective factors. Study Design Cross-sectional survey. Setting Tertiary care center. Methods Charts were reviewed from 223 consecutive patients for whom complete data regarding the Berlin questionnaire, OSAHS score (Friedman tongue position + tonsil size + body mass index grade), Epworth Sleepiness Scale, and visual analog scale for snoring were obtained prior to polysomnography (PSG). Sensitivity and specificity were determined for the Berlin questionnaire and OSAHS score for predicting an apnea hypopnea index (AHI) ≥ 5. Patient data were subjected to multivariate stepwise discriminant analysis and used to construct a screening system based on the Fisher's linear classification equation. Results were cross-validated by PSG findings. Results In predicting an AHI ≥ 5, the sensitivity and specificity, respectively, were 0.615 and 0.226 for the Berlin questionnaire, 0.863 and 0.468 for OSAHS score, and 0.82 and 0.834 for our predictive equation. When applied case-wise to the study population, this equation correctly predicted 82.5 percent of diagnoses. Accuracy was highest for severe OSAHS (87.4%) and lowest for mild disease (77.0%). Sensitivity was lowest for mild OSAHS (0.50). Conclusions Neither the Berlin questionnaire nor the OSAHS score alone was both highly sensitive and specific for diagnosing OSAHS. By incorporating subjective and objective metrics into a single predictive equation, sensitivity and specificity were maximized, and 82.5 percent of diagnoses were accurately predicted.

Z-palatopharyngoplasty (ZPPP) combined with radiofrequency to the base of tongue (RFBOT) resulted in short-term morbidity only. This study shows the clinical benefits of ZPPP plus RFBOT in patients with moderate/severe obstructive sleep apnea/hypopnea syndrome (OSAHS).To study the safety and efficacy of ZPPP combined with RFBOT for the treatment of moderate/severe OSAHS.Charts of all patients with moderate/severe OSAHS who failed or refused CPAP therapy and underwent surgical treatment of ZPPP plus RFBOT were reviewed. The subjective symptoms and objective polysomnographic parameters were collected preoperatively and postoperatively. Postoperative morbidity was recorded.Forty-three OSAHS patients (2 females, 41 males, mean age 39 years) had full data and a minimum 6 month follow-up to assess efficacy. Intraoperative, short-term, and long-term morbidities are reported. No long-term velopharyngeal insufficiency was encountered. The classical success rate was 60.5% (26/43). Six months after the treatment, the mean Epworth sleepiness scale changed from 12.8 +/- 5.1 to 10.0 +/- 4.3 (p = 0.002). The apnea/hypopnea index (/h), lowest oxygen saturation (%), and bed partner assessed snoring visual analog scale (0-10) changed from 51.5 +/- 25.4 to 23.4 +/- 24.7, 75.5 +/- 10.4 to 82.1 +/- 10.9, and 8.4 +/- 1.6 to 2.9 +/- 1.6, respectively (all p0.0001, paired t test).

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Objectives:(1) Examine resident interest in otolaryngology subspecialty fellowship and factors affecting that interest over time and throughout residency. (2) Examine changes in fellowship availability and match rate over time.Methods:Data regarding fellowship interest, influencing factors, and demographics were extracted from the 2008-2013 Section for Residents and Fellows-in-Training annual survey and examined in uni- and multivariate analyses. Historic fellowship match data available through match resources for pediatric otolaryngology, laryngology/broncho-esophagology surgery, rhinology, and neurotology were collected.Results:Over 6 years, a total of 1958 residents and fellows responded to the survey. A statistically significant decrease in fellowship interest was seen between junior (PGY-1 or PGY-2/3) and senior residents (PGY-4/5), with 79.9%, 73.3%, and 61.6% of PGY-1, PGY-2/3, and PGY-4/5 residents, respectively, planning to pursue subspecialty training (P < .001). Of the portion planning fellowsh...

Objectives:1) Review our first 13 robotic assisted trans-axillary thyroidectomy and parathyroidectomy (TART/TARP) cases, looking at the clinical and pathological data as well as technical challenges associated with this approach. 2) Examine and discuss complications associated with this approach.Methods:Retrospective series of 13 patients who underwent TART/TARP at our institution. Patient demographics, pathology and size of thyroid glands removed, intraoperative details, length of stay, and postoperative complications were recorded.Results:Over a 14-month period from October 2011 to December 2012, 11 patients (12 female, 1 male) underwent TART, and 2 patients underwent TARP. Mean age was 54 years (range, 29-76 years). All thyroidectomies were partial. Both left-sided parathyroid adenomas had been localized with preoperative imaging to fit criteria for single gland exploration. The largest thyroid lobe removed was 6.5 x 3.5 x 2.8 cm. Pathology was benign thyroid disease in 9 and well differentiated papill...

Objectives:1) Look at the experiences of prior governing council (GC) members of the American Academy of Otolaryngology (AAO) Section for Residents and Fellows (SRF), and 2) assess the impact of early Academy involvement.Methods:Survey of all prior members of the AAO SRF GC.Results:The AAO-SRF has elected 52 GC members since its 2003 inception. Ten members are currently in training, and no data were obtained for 3. The remaining 38 prior GC members were analyzed. Each member served an average of 1.5 years (terms ranged 1 - 3 years). The mean time since completion of training to present is 4.1 years (range 0 - 10 years). A subspecialty fellowship was pursued in 86%, with 92% matching into their fellowship field of choice. Fifty-seven percent practice in an academic setting, with 3 members advancing to a subspecialty division director within their department. All prior GC members are current AAO members. Over half (59%) have served on an AAO committee, and most are frequent attendees of the annual meeting. ...

Objectives:Describe modification of port placement for the four-arm technique for robotic thyroidectomy to avoid a chest incision and eliminate crowding of the working space provided by the trans-axillary incision.Methods:Description of port placement modification to avoid chest incision as well as report of two cases and appropriate literature review.Results:Placement of four arms via a trans-axillary incision requires expertise. Transitioning from a chest port for placement of the fourth arm to a single-incision surgery, avoiding a visible chest incision, can be challenging. We describe this technique and two cases of trans-axillary robotic hemithyroidectomy (TART) using a trans-axillary incision and a separate 1 cm incision in the anterior axilla, 2.5 centimeters below the trans-axillary incision, for placement of the fourth arm. This design allowed for a more ergonomic placement of the fourth arm while not compromising the working space provided by the trans-axillary incision. Additionally this port i...

(1) Review airway management in pediatric patients undergoing cardiothoracic surgery (CTS); (2) determine the incidence of airway-related complications of CTS in this population.Case series with chart review. Setting Tertiary care children's hospital. Patients Children undergoing CTS over a 4-year period.Patients who underwent CTS at a single, tertiary care, children's hospital between June 1, 2007, and May 31, 2011, were retrospectively reviewed; those18 years who had open CTS were included. Statistical analysis examined relationships of intubation duration, complications, and need for tracheotomy while comparing patient characteristics, comorbidities, and types of surgery.Eight hundred seventy-five primary surgeries in 745 patients met inclusion criteria. Mean postoperative intubation duration was 7.2 days and median 3 days. On univariate analysis, significantly longer postoperative intubation requirements were found in patients younger in age, with congenital comorbidities or prematurity, with preoperative ventilation requirements, and those with early postoperative complications. Multivariate analysis found younger age, presence of congenital comorbidities, preoperative intubation requirements, and early postoperative complications each lengthen ventilation requirements. Four patients developed vocal cord paralysis and 5 developed phrenic nerve palsy. Nineteen patients required tracheotomy.In this large cohort, CTS in the pediatric population is associated with few long-term or permanent airway-related complications. Patients who are younger in age and those with congenital comorbidities, preoperative ventilation requirements, or early postoperative complications required longer periods of postoperative intubation.

Sialadenitis, or recurrent salivary gland infection associated with pain and swelling of the major salivary glands, is a common presentation to emergency rooms and outpatient clinics. One of the most frequent causes of sialadenitis is obstruction in the salivary ductal system. Salivary calculi affect 1.2% of the population and account for 60-70% of salivary duct obstruction (Nahlieli 2004; Kim 2007; Bomeli 2009; Nahlieli 2006). Additional causes of obstruction to salivary flow include strictures in 25-25%, inflammation (5-10%) and other rare pathologies such as foreign bodies (1%) Conservative treatment is the first line of therapy that includes treatment with antibiotics, salivary stimulants or sialogogues, and anti-inflammatory agents. However, conservative therapy fails in up to 40% of people with sialadenitis; in which case the recommended treatment is excision of the involved salivary gland. There as several important nerves that are in close proximity to the major salivary glands. The facial nerve, motor to facial muscles, runs through the parotid glandular system. Similarly, the submandibular gland is associated with the lingual nerve that is 1sensory to the anterior two thirds of the oral tongue; marginal mandibular nerve that allows movement of the angle of the mouth; and the hypoglossal nerve, motor to the tongue. Surgical excision of the gland carries numerous risks include but are not limited to paresis or palsy of the facial nerve, lingual nerve, and hypoglossal nerve. Other complications include Frey syndrome (gustatory sweating), sialoceles, salivary fistula, xerostomia, numbness in the distribution of the greater auricular nerve, infection, and hemorrhage. Consequently, although surgical resection in experienced hands is safe, it’s often not desired due to the associated surgical risk and external scar in the neck associated with it. In 1988, salivary duct endoscopes were introduced. Since their introduction, sialendoscopes have undergone technical refinements that have been instrumental in permitting clear and high definition visualization and manipulation of the salivary ductal system. Today, salivary duct endoscopy or “Sialendoscopy” allows the minimally invasive endoscopic visualization of major salivary gland ductal system and endoscopic interventions to treat chronic sialadenitis with or without sialolithiasis.

Purpose To determine the prevalence of normal tension glaucoma (NTG) in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) and further investigate whether the severity of OSAHS would increase the risk of glaucoma. Patients and methods Two hundred fifty-six participants were consecutively admitted for polysomnographic exam to diagnose OSAHS. All participants, then underwent a complete ophthalmologic evaluation, including best-corrected visual acuity, intraocular pressure, slit lamp biomicroscopy, gonioscopy, fundoscopy, automated visual field (VF), and retinal nerve fiber layer (RNFL) evaluation. Results A total of 247 participants were enrolled in the study. Two hundred nine patients were OSAHS and 38 participants were classified as the normal group. Among the OSAHS patients, NTG was found in 12 patients with a prevalence of 5.7%, which was higher than that in the normal group (P=0.003). In the NTG patients, 1 was in the mild, 3 were in the moderate, and 8 were in the severe OSAHS group. There was no glaucoma patient in the normal group. The prevalence of NTG in moderate/severe OSAHS patients was 7.1%, significantly higher (P=0.033) than that in normal/mild OSAHS patients. The mean saturation of oxygen and lowest saturation of oxygen correlated with the average thickness of RNFL in the OSAHS patients. Conclusions Patients with OSAHS had a high prevalence of NTG, especially in patients with moderate and severe OSAHS. The severity of OSAHS inversely correlated with retinal nerve fiber layer thickness. Clinicians need to consider the possibility of glaucoma in patients with moderate and severe OSAHS.

1) Share our experiences treating patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) with titratable and nontitratable thermoplastic mandibular advancement devices (MADs) fitted in our otolaryngology clinic. 2) Compare these devices in terms of objective response (OR), as defined by aor = 50 percent decrease in baseline apnea-hypopnea index (AHI) and an AHI20, and subjective parameters, including adherence. 3) Determine overall success, as defined by OR plus adherence at two months follow-up.Cohort study.Tertiary care center.Patients with OSAHS who tried and failed or refused both continuous positive airway pressure (CPAP) and surgical therapy were fitted with a nontitratable Snore Guard (n = 38), nontitratable SomnoGuard 2.0 (n = 8), or titratable SomnoGuard AP (n = 41). Pre- and post-treatment assessment included: 1) Epworth Sleepiness Scale, 2) snoring level, 3) polysomnogram. Patients were contacted at two months follow-up to assess adherence and subjective parameters.OR was achieved in 62.1 percent of patients. Overall mean reduction in AHI was from 39.96 +/- 23.70 to 14.86 +/- 13.46 (P = 0.000). Adherence at two months was 58.5 percent. No significant differences were observed in OR or adherence according to MAD type, though improvements in AHI and minimum oxygen saturation were significantly better for the SomnoGuard AP than for the nontitratable devices. Overall success was 38.6 percent.Thermoplastic MADs are a relatively inexpensive treatment alternative for patients with OSAHS who fail/refuse CPAP and upper airway surgery. They can be easily fitted in the otolaryngology clinic. Long-term compliance, efficacy, and safety are unknown at this time.