Otolaryngology

Teaching nasal analysis to otolaryngology residents Publication date: Available online 15 May 2019 Source: American Journal of Otolaryngology Author(s): Katie Geelan-Hansen, Douglas Farquhar, Gita Fleischman, J. Madison Clark, William W. Shockley Abstract Purpose This prospective cohort study was completed to evaluate a systematic approach for teaching nasal analysis to otolaryngology-head and neck surgery residents. Methods Residents from each post graduate year (PGY) were randomized to the control group or study group. Residents in the study group were given a 10-slide PowerPoint (Microsoft Corp) instruction on nasal analysis using the standard sequence of photographs and anatomic elements to describe in each view. All residents were given the standard sequence of photographs of 3 patients for assessment on nasal analysis. Then 12–14 weeks later all residents were re-evaluated using photographs of 3 new patients. The results were blinded and graded using an 18 point scale modified from a previous publication [1]. Results Twenty otolaryngology-head and neck surgery residents completed the study. Analysis was performed with and without multivariate regression modeling to adjust for PGY, gender, and number of rhinoplasties performed. The study group had overall higher scores in both the initial and follow up assessment, specifically with subsite-specific dorsal deviation, tip projection, and nostril symmetry. Neither group obtained high scores in facial symmetry, skin thickness, tip shape and contour, and radix position at initial or re-assessment. Conclusion Nasal analysis is a complex task. A lecture on a systemic approach to facial analysis given to a group of residents, who performed significantly better on facial analysis cases than controls. Further research in providing feedback, periods of rehearsal or testing, or focused selected elements with serial exposure can be considered.

Barometric pressure and the incidence of benign paroxysmal positional vertigo Publication date: Available online 15 May 2019 Source: American Journal of Otolaryngology Author(s): Jonathan Korpon, Roy Sabo, Daniel H. Coelho Abstract Objectives To investigate the relationship between barometric pressure and the incidence of benign paroxysmal positional vertigo (BPPV). Methods 181 patients diagnosed with classic BPPV seen between 2011 and 2016 were identified. Demographic information, data of onset, and date of presentation were recorded. Historical barometric data for each of the 60 months were recorded. In addition, monthly counts of other atmospheric, infectious, and allergic variables for that time period were recorded. Correlation analysis compared monthly incidence of BPPV with absolute and relative changes in atmospheric conditions. Results The incidence of BPPV onset demonstrated a statistically significant positive correlation with barometric pressure, where every one-unit increase in barometric pressure leads to an expected increase of 6.1 diagnoses (p = 0.0008). The correlation coefficient (r) between barometric pressure and BPPV diagnoses was 0.66 (95% CI 0.14–0.90) with a p-value of 0.0131. Other seasonal variables demonstrated correlation, though none as strong as barometric pressure. Conclusions Barometric pressure has been long been associated with conditions of the inner ear, though its relationship to the pathogenesis of BPPV has not been investigated. Monthly changes in barometric pressure, rather than the absolute value, may be responsible for the observed changes in incidence. These findings demonstrate a clear association between barometric pressure and BPPV that may help to explain both the etiology of BPPV and its possible connection to migraine-related conditions.

Thermal injury to common operating room materials by fiber optic light sources and endoscopes Publication date: Available online 15 May 2019 Source: American Journal of Otolaryngology Author(s): Earl Harley, Raluca Tavaluc, Navin Prasad Abstract Purpose To determine the thermal energy damage potential by heat sources, such as endoscopes and fiber optic light cables, in contact with materials commonly placed around an operating room (OR) table. Materials and method Injury by xenon and halogen light sources were tested by direct and indirect contact using fiber optic light bundle cables and scopes at light intensities between ranging from Standby to 100%. The scopes had diameters ranging from 2.7 mm to 10 mm and were set at varying angles. The materials tested were surgical drapes, cotton towels, child shirts, child pants, lap sponges, X-ray detectable sponges, and Mayo covers. The damage potential was determined qualitatively by presence of smoking or smell of burning. Results Permutations involving direct contact were able to cause thermal injury, while permutations involving indirect contact, endoscopes, or halogen lamp were not. The xenon light source with the fiber optic light cable created thermal injury at light intensities of 50%, 75%, and 100%. Time to injury increased as light intensity was decreased. Only the surgical drape, child shorts, and cotton towel showed evidence of burn injury. Conclusions This report supports the potential for thermal injury to the patient secondary to fiber optic light sources, although this potential may be limited in extent. The injury risk can be reduced by avoiding direct contact to materials overlying the patient, confirming standby mode or 25% light intensity, and maintaining the endoscope connected to the fiber optic cable at all times.

3D-real IR MRI of Meniere's disease with partial endolymphatic hydrops Publication date: Available online 15 May 2019 Source: American Journal of Otolaryngology Author(s): Suming Shi, Feng Zhou, Wuqing Wang Abstract Objectives A three-dimensional inversion-recovery sequence with real reconstruction (3D-real IR) sequence 4 h after intravenous gadolinium injection (IV) has been used to visualize the endolymphatic hydrops (ELH) in Meniere's disease (MD). This study was designed to explore the pathology of MD with partial ELH. Methods We collected 338 patients with definite MD, all of whom underwent the IV method. Patients who were found to have partial ELH (vestibular or cochlear) were enrolled. The hearing thresholds of the enrolled patients were analyzed, the regions of interest of the cochlear perilymph and the cerebellum white matter were determined, and the signal intensity ratio in the former to the latter (CC ratio) for both sides in the patients was subsequently evaluated. Results Of the 338 collected patients with definite MD, 19 patients (5.6%) had unilateral vestibular ELH (N = 18) or cochlear ELH (N = 1), and 4 patients (1.2%) with bilateral ELH had contralateral cochlear ELH. The CC ratio of the affected side (1.44 ± 0.46) was higher than that of the unaffected side (1.15 ± 0.33, P < 0.05) in the 19 patients with unilateral ELH. Conversely, there was no difference between the ratio of the contralateral side (1.18 ± 0.16) and the unaffected side (P > 0.05) in the 4 patients with bilateral ELH. Conclusions Partial vestibular ELH was more common than partial cochlear ELH in MD. Moreover, vestibular ELH, rather than cochlear ELH, may correlate with the elevated contrast effect in the affected side, which may better reflect the pathologic mechanism of MD.

Plunging ranula with lingual nerve tether: Case report and literature review Publication date: Available online 15 May 2019 Source: American Journal of Otolaryngology Author(s): Krish Suresh, Allen L. Feng, Mark A. Varvares Abstract Plunging ranulas are most often treated surgically; various surgical approaches may be necessary depending on the unique characteristics of each case. Here, we present the case of a plunging ranula noted on imaging to have a cordlike tether, which was revealed intraoperatively to be the lingual nerve. This case illustrates the importance of preoperative imaging for surgical planning, and when a transcervical approach may be the best choice for plunging ranulas.

The prognostic effect of anatomic subsite in HPV-positive oropharyngeal squamous cell carcinoma Publication date: Available online 15 May 2019 Source: American Journal of Otolaryngology Author(s): Tristan Tham, Michael Wotman, Ansley Roche, Dennis Kraus, Peter Costantino Abstract Background Since most HPV-associated disease occurs in the tonsillar-related areas (TRA) – palatine and lingual tonsils, the effect of HPV on survival in non-tonsillar oropharyngeal subsites (nTRA) is not well established. The objective of this study was to use a large population-based cohort to investigate the survival impact of HPV in nTRA subsites versus TRA subsites. Methods This SEER database study was conducted by stratifying the HPV-positive oropharyngeal cancer cohort into two primary groups, TRA and nTRA. Results HPV-positive squamous cell cancer was significantly more common in TRAs (73%) compared to nTRAs (31.2%, p < 0.001). After controlling for age, treatment, stage, race, and income, patients with HPV-positive disease in nTRAs had a worse cause-specific survival (CSS) than individuals with HPV-positive disease in TRAs (HR = 2.16, 95% CI 1.20–3.86, p = 0.01). Conclusion Patients with HPV-positive OPSCC in nTRAs had poorer survival outcomes compared to patients with HPV-positive OPSCC in TRAs.

Prognostic factors and survival for malignant conjunctival melanoma and squamous cell carcinoma over four decades Publication date: Available online 15 May 2019 Source: American Journal of Otolaryngology Author(s): Nicholas B. Abt, Jiawei Zhao, Yuru Huang, Allen O. Eghrari Abstract Purpose To determine the epidemiology and survival of primary conjunctival malignant neoplasms. Methods Retrospective analysis of primary malignant conjunctival neoplasms using Surveillance, Epidemiology, and End Results database from 1973 to 2012. Results Of 1661 cases, the most common neoplasms are squamous cell carcinoma (SCC) at 54.8% and melanoma at 38.8%. Mean diagnostic age for melanoma was 62.1 compared to 65.5 years for SCC (p = 0.002). 52.2% of melanoma are male versus 77.4% of SCC (p < 0.001). For SCC only age (HR: 1.09, 95% CI:1.04–1.14) is a predictor of survival. For melanoma, age (HR: 1.07, 95% CI: 1.05–1.10), male sex (HR: 2.04, 95% CI: 1.16–3.60), T4 tumors (HR: 3.38, 95% CI: 1.17–9.80) and N1 status (HR: 8.69, 95% CI: 2.75–27.42) are all survival predictors. The 5 and 10-year overall survival (OS) estimates are not significantly different between SCC and melanoma, with 70% and 50% respectively for SCC, and 71% and 50% respectively for melanoma. Median survival time is worse for blacks (52 months) compared to whites (118 months) and Asians/Native Americans/Pacific Islanders (145 months), however race was not found to be a significant prognostic factor in multivariate analysis. Five-year survival are similar between decades 1973–1982 (66.2%), 1983–1992 (69.2%), 1993–2002 (71.3%) and 2003–2012 (70.2%). Conclusion Age at diagnosis is a determinant of survival for both conjunctival SCC and melanoma. Male sex, T4 and N1 staging are also important prognostic factors for melanoma. With respect to overall survival, SCC and melanoma did not differ significantly.

Post-operative epiphora following the transcutaneous medial canthal incision Publication date: Available online 14 May 2019 Source: American Journal of Otolaryngology Author(s): Mark A. Prendes, John Mittel, Peter J. Timoney, Christopher J. Compton, Jeremy D. Clark, William R. Nunery, Jonathan Y. Ting, Taha Z. Shipchandler, H.B. Harold Lee Abstract Purpose The safety profile of the transcutaneous medial canthal incision for access to the medial orbit is assessed with a focus on the risk of post-operative iatrogenic epiphora. Methods A retrospective chart review of patients undergoing medial orbitotomy via the transcutaneous medial canthal incision was performed. Patients with a minimum of 3 months of follow-up were included and post-operative complications were assessed and characterized. Results One-hundred-fifty patients were included in the study. A total of 4 complications were identified, including one each of the following: nasolacrimal duct obstruction, hypertrophic scar, suture granuloma and soft tissue infection. Only the nasolacrimal duct obstruction required surgical intervention. Discussion Access to the medial orbit has been achieved through a variety of approaches, each with their own benefits and risk profile. The transcaruncular approach has increased in usage as a means to avoid a visible cutaneous scar and decrease the risk of iatrogenic epiphora, however, there are specific patients who may have relative contraindications to this approach. The current study demonstrates the low risk profile of the transcutaneous medial canthal incision, specifically the minimal risk of iatrogenic damage to the nasolacrimal outflow system. This approach is another useful tool which orbit surgeons should be familiar with to offer as an option to patients requiring medial orbitotomy.

Efficacy analysis of medical and surgical treatments in chronic kidney disease patients with secondary hyperparathyroidism Publication date: Available online 14 May 2019 Source: American Journal of Otolaryngology Author(s): Yajing Huang, Hao Wu, Yaqun Wu, Zhiyong Luo Abstract Purpose To investigate the effects of surgical and medical treatments on chronic kidney disease (CKD) patients with secondary hyperparathyroidism (SHPT). Materials and methods A total of 198 CKD patients with SHPT were identified at Tongji Hospital from January 2013 to June 2017. Results Surgical group (53 patients) received maintenance dialysis for 78.0 ± 4.9 months, while medical group (84 patients) for 62.0 ± 6.4 months. The serum intact parathyroid hormone (iPTH) in surgical group reduced apparently compared with medical group (P = 0.015) and maintained satisfied result during three years of follow-up (67.4 ± 7.4 pg/ml). The recurrence rate in surgical group was 7.5% and in medical group was 15.5% (P = 0.024). Beyond that, 5 (5.9%) patients suffered persistent hyperparathyroidism in medical group. Conclusion Although the progress of medical treatment is changing rapidly, surgical treatment is still an effective way to control serum iPTH and calcium chronically for SHPT patients. Complex SHPT patients can also receive satisfied effect by surgical treatment, without apparently increasing the risk of complications.

The case of the eyelid silicone granulomas Publication date: Available online 14 May 2019 Source: American Journal of Otolaryngology Author(s): Jacqueline A. Wulu, Laura Garcia-Rodriguez, Andrey Prilutskiy, Jeffrey Spiegel Abstract Foreign body granulomas can develop even several years after autologous fat or filler injection. In some instances the foreign body granulomas have been found at sites other than the original injection site. We present a case of a 48-year-old male with reported "hyaluronic acid fillers" injected into his upper and lower eyelids several years prior. He subsequently developed periorbital swelling with negative allergic and rheumatologic workup. The patient ultimately underwent a blepharoplasty for improvement of the swelling. Histopathology suggested silicone granulomas of the upper and lower eyelid. This case illustrates the importance of keeping foreign body granulomas on the differential for all patients with a history of facial dermal filler injections. Although hyaluronic acid is the most common dermal filler, providers should suspect the use of other dermal fillers including those not FDA approved particularly when common conservative treatment methods are not sufficient.

Otolaryngology–Head and Neck Surgery

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Otolaryngology–Head and Neck Surgery  

Last updated May 14, 2019

Original Research

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Upper Airway Stimulation Response in Older Adults with Moderate to Severe Obstructive Sleep Apnea

Kirk Withrow, MD, Sean Evans, MD, John Harwick, MD, Eric Kezirian, MD, Patrick Strollo, MDon Behalf of the ADHERE Registry Investigators

https://doi.org/10.1177/0194599819848709 | First Published May 14, 2019

Abstract

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Objective

To evaluate the impact of age on safety, efficacy, and usage of upper airway stimulation (UAS).

Study Design

Multicenter observational study.

Setting

Thirteen US hospitals and 3 German hospitals.

Subjects and Methods

The ADHERE registry is a multicenter database enrolling patients undergoing UAS implantation from October 2016 to April 2018. Outcome measures included the Epworth Sleepiness Scale, apnea-hypopnea index (AHI), therapy usage, and complications. Data were segmented by age (<65 vs ≥65 years).

Results

Younger adults (n = 365) were a mean ± SD 52.7 ± 7.9 years old and 82% male, with a body mass index of 29.6 ± 3.8. Older adults (n = 235) were 71.1 ± 4.8 years old and 71% male, with a body mass index of 28.8 ± 3.8. Baseline AHI was similar (younger, 36.2 ± 15.9; older, 36.1 ± 14.8). Both groups had lower AHI at 12 months versus baseline (P < .001), but the older group showed a greater reduction (7.6 ± 6.9 vs 11.9 ± 13.4, P = .01). The Epworth Sleepiness Scale score decreased from 12.3 ± 5.4 to 7.1 ± 4.8 (P < .001) among younger adults and from 10.7 ± 5.7 to 6.3 ± 4.4 (P < .001) among older adults. Usage was slightly higher among older adults (6.0 ± 2.0 vs 5.4 ± 2.1 hours/night, P = .02). Surgical time was similar between younger patients (2.4 ± 0.7 hours) and older patients (2.3 ± 0.7 hours, P = .40), with comparably low complications.

Conclusion

AHI reduction and therapy usage were found to be somewhat higher among patients aged ≥65 years who were treated with UAS. Surgical complications were low, in contrast to traditional sleep surgery.

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Clinical Techniques and Technology

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Longus Capitis Reconstruction of the Soft Palate

Jennifer H. Gross, MD, Joseph Zenga, MD, Jeffrey D. Sharon, MD, Ryan S. Jackson, MD, Patrik Pipkorn, MD, MSCI

https://doi.org/10.1177/0194599819849031 | First Published May 14, 2019

Abstract

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Soft palate (SP) reconstruction remains a challenge for the head and neck reconstructive surgeon. One favorable local flap option is the longus capitis muscle (LCM), a deep neck flexor with redundant muscle function, appropriate bulk, and a relatively straightforward surgical harvest. A retrospective review of 3 patients with T2 to T4 tonsil squamous cell carcinoma requiring SP resection and LCM reconstruction at a single institution was performed. Three patients underwent primary transoral resection, all resulting in at least 50% full-thickness SP defects. Reconstruction comprised a superiorly based LCM local flap. Patients underwent adjuvant (chemo)radiation therapy as indicated. Within 3 to 8 months, each patient was tolerating a full oral diet with no dysphagia, nasal regurgitation, or velopharyngeal insufficiency. For select patients with SP defects, a superiorly based LCM flap may provide a functionally acceptable reconstruction with minimal donor site morbidity.

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Antacid Tablets Oral Treatment Causing Respiratory Distress: An Uncommon Cause of Dyspnea

François Thibouw, MD, Mireille Folia, MD, PhD

https://doi.org/10.1177/0194599819849034 | First Published May 14, 2019

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High-Frequency Ultrasound: A Novel Diagnostic Tool to Measure Pediatric Tonsils in 3 Dimensions

Emily Kay-Rivest, MD, Christine Saint-Martin, MD, MSc, Sam J. Daniel, MD, MSc, FRCSC

https://doi.org/10.1177/0194599819850139 | First Published May 14, 2019

Abstract

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Objective

A wide variety of pathologies can affect the palatine tonsils. Ultrasound is a commonly used modality for assessing head and neck masses in children; however, its use in tonsillar evaluation has not been widely explored. The objective of this study was to measure 3-dimensional tonsillar size with ultrasound, in centimeters, and correlate these measurements with actual ex vivo dimensions on pathology specimens.

Study Design

We performed a prospective cohort study.

Setting

The study was set in a tertiary care children's hospital.

Subjects and Methods

Children undergoing tonsillectomy were included in the study. Transcervical high-frequency ultrasonography (HFU) was performed prior to surgery to obtain 3-dimensional measurements of the right and left palatine tonsils. Mean sizes were compared to ex vivo tonsil measurements and correlations were obtained.

Results

Seventy-five consecutive children underwent a transcervical HFU, with a total of 150 tonsils analyzed. The mean differences between HFU and pathology measurements were −0.08 cm and −0.24 cm for the right and left craniocaudal axes, −0.19 cm and −0.18 cm for the right and left mediolateral axes, and 0.05 cm and 0.03 cm for the right and left anteroposterior axes. Correlation coefficients between ultrasound and pathology measurements were all above 0.5.

Conclusion

HFU can accurately measure the size of pediatric tonsils in 3 dimensions.

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Salivary Gland Cancers of the Nasopharynx: A Population-Based Analysis of 383 Cases

J. Renee Booth, MD, Aykut A. Unsal, DO, Sandra Tadros, J. Kenneth Byrd, MD, Stilianos E. Kountakis, MD, PhD

https://doi.org/10.1177/0194599819849923 | First Published May 14, 2019

Abstract

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Objectives/Hypothesis

Salivary gland nasopharynx cancers (SGNPCs) are rare malignancies with few cases discussed in the literature. This study represents the largest cohort of SGNPC to date.

Study Design

Retrospective population-based analysis.

Methods

The Surveillance, Epidemiology, and End Results registry from 1973 to 2015 was utilized to extract 383 cases of SGNPC. Data were analyzed for demographic characteristics, incidence, clinicopathologic traits, and outcome prognosticators.

Results

White female patients aged >40 years were most commonly affected. The incidence was measured as 0.019 per 100,000 people. The majority of tumors presented at advanced stages (stage III/IV, 60.8%). Adenoid cystic carcinoma, adenocarcinoma, and mucoepidermoid carcinoma were the most commonly encountered histologies (43.1%, 31.6%, 13.3%, respectively). Cervical node involvement and distant metastasis were measured at 23% and 11.9%, respectively. Mucoepidermoid carcinomas presented with the best disease-specific survival at 5 and 10 years. Asian ethnicity, age <80 years, and earlier American Joint Committee on Cancer stages were positive prognostic factors. The inclusion of surgical therapy improved 5-year outcomes among the most common histologies, except for mucoepidermoid carcinoma.

Conclusions

Salivary gland nasopharyngeal cancer represents a group of rare histologies with similar outcomes as squamous cell carcinomas. However, prognosis is primarily dependent on histologic subtype, race, age, and American Joint Committee on Cancer stage.

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Original Research

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Impact of Distraction Osteogenesis Maxillary Expansion on the Internal Nasal Valve in Obstructive Sleep Apnea

Mohamed Abdelwahab, MD, Audrey Yoon, DDS, MS, Tyler Okland, MD, Sasikarn Poomkonsarn, MD, Chris Gouveia, MD, Stanley Yung-Chuan Liu, MD, DDS

https://doi.org/10.1177/0194599819842808 | First Published May 14, 2019

Abstract

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Objective

To assess the effect of distraction osteogenesis maxillary expansion (DOME) on objective parameters of the internal nasal valve and correlate findings with subjective outcomes.

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Subjects and Methods

After Institutional Review Board approval, included subjects were those with obstructive sleep apnea, had undergone DOME from September 2014 to April 2018, and had cone beam computed tomography scans available before and after expansion. Measurement of the internal nasal valve parameters was performed with Invivo6 Software (version 6.0.3). Interrater reliability of all pre- and postexpansion parameters was measured. Patient-reported outcome measures included the Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE) and Epworth Sleepiness Scale scores, and correlation between objective and subjective outcomes were evaluated by Spearman correlation analysis.

Results

Thirty-two subjects met inclusion criteria. All showed significant improvement in their subjective outcomes as well as an increase in their internal valve parameters. Significant correlation was observed between increased angles and improvement in postexpansion NOSE score (right angle, P = .024; left angle, P = .029).

Conclusion

DOME widens the internal nasal valve objectively (dimensions), which correlates significantly with subjective improvement (NOSE scores).

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Analysis of Process-Related Quality Metrics and Survival of Patients with Oral Cavity Squamous Cell Carcinoma

Swathi Appachi, MD, Janki Shah, MD, Chandana Reddy, MS, Andrew Bowen, MD, Shlomo Koyfman, MD, Eric Lamarre, MD

https://doi.org/10.1177/0194599819845864 | First Published May 7, 2019

Abstract

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Objective

To analyze the association of prior reported key quality metrics—neck dissection ≥18 nodes, radiation oncology referral for stage III/IV disease, unplanned surgery ≤14 days, and unplanned readmission ≤30 days—with disease-free survival (DFS) and overall survival (OS) in oral cavity cancer (OCC).

Study Design

A retrospective chart review.

Setting

A tertiary care center from 1995 to 2016.

Subjects and Methods

Data from patients with OCC who underwent primary surgery were studied. The association of quality metrics and pathology with DFS/OS was determined by Cox proportional hazards regression analysis.

Results

A total of 514 patients were included, and 398 (77.4%) underwent elective neck dissection. Key metrics were not associated with DFS on analysis, but higher pathologic stage and extracapsular extension (ECE) were. When stratified by stage, unplanned readmission within 30 days was associated with decreased survival on multivariate analysis (HR = 0.40; 95% CI, 0.20-0.85; P = .02) for patients with clinical stage III or IV disease. ECE was associated with decreased survival among these patients as well. Neck dissection with ≤18 nodes (HR = 0.62; 95% CI, 0.44-0.86; P = .004) and unplanned surgery within 14 days (HR = 0.56; 95% CI, 0.32-0.96; P = .03) were associated with decreased survival on univariate analysis but not on multivariate analysis. ECE and higher-stage disease were associated with decreased OS on multivariate analysis.

Conclusion

In this study, aggressive pathology, rather than adherence to key quality metrics, was associated with lower DFS and OS among patients with OCC. More studies are needed to elucidate the association of quality metrics with survival.

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Feasibility of High-Resolution Computed Tomography Imaging for Obtaining Ear Impressions for Hearing Aid Fitting

Chin-Kuo Chen, MD, PhD, Li-Chun Hsieh, MD, PhD, Yuan-Chuan Chiang, PhD, Wei-De Cheng, MS

https://doi.org/10.1177/0194599819847938 | First Published May 7, 2019

Abstract

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Objective

This study investigated the feasibility of obtaining ear impressions for hearing aids by using 3-dimensional high-resolution computed tomography (HRCT) images.

Study Design

Case series.

Setting

One referral tertiary center.

Subjects and Methods

Hearing-impaired adults who were fitted with 1 or 2 behind-the-ear hearing aid(s) and had undergone temporal bone HRCT for various ear pathologies were enrolled in this study. Earmolds were fabricated from the impressions obtained using the conventional ear canal silicone injection technique and the HRCT reconstructed technique. Outer ear canal resonance frequencies and amplitude in open ears and those measured with silicon and HRCT reconstructed earmolds were determined through real-ear gain measurements, including real-ear unaided gain (REUG) and real-ear occluded gain (REOG), for comparison.

Results

A total of 50 HRCT reconstructed earmolds were compared with 50 conventional silicon injection earmolds. The average value of open ear canal resonance amplitude (REUG) for each ear was 0.41 to 16.76 dB. No statistically significant difference in resonance amplitude (REOG) was observed between silicon and reconstructed earmolds (paired t test, P > .05). The mean insertion loss (REOG-REUG) at all frequencies also did not differ significantly between the two earmolds (paired t test, P > .05).

Conclusion

According to our real-ear measurements, acoustic characteristics of the HRCT reconstructed earmolds were compatible with those of the silicone injection earmolds. Despite concerns about increased cost and radiation exposure, the HRCT reconstructed technique is a clinically useful and applicable method and can reduce potential safety complications for difficult cases.

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Systematic Review/Meta-analysis

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The Influence of Cochlear Implantation on Tinnitus in Patients with Single-Sided Deafness: A Systematic Review

Nicole Peter, MD, Nuwan Liyanage, MSc, Flurin Pfiffner, PhD, Alexander Huber, MD, Tobias Kleinjung, MD

https://doi.org/10.1177/0194599819846084 | First Published May 7, 2019

Abstract

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Objectives

This systematic review provides an overview of the available studies (published by January 29, 2018) with descriptive data analysis about the influence of cochlear implantation on tinnitus in patients with single-sided deafness (SSD).

Data Sources

PubMed, EMBASE, Web of Science, Cochrane Library, and Google Scholar.

Review Methods

Original studies about the influence of cochlear implantation on tinnitus, measured with different tinnitus questionnaires or visual analog scale, in patients with SSD were included. The pre- and postimplantation tinnitus scores of the included studies were extracted for the further systematic review.

Results

The systematic search yielded 1028 studies. After evaluating titles, abstracts, and full texts, 1011 of these were dismissed. From the remaining 17 studies, 4 showed a low directness of evidence or high risk of bias and were therefore excluded. Due to the nature of cochlear implantation in SSD, only cohort studies and no randomized trials exist, which limits the evaluation in a systematic review. Generally, the mean tinnitus questionnaire scores decreased after cochlear implantation in these 13 studies with a total of 153 patients. The most widely used tinnitus questionnaire was the Tinnitus Handicap Inventory. In these studies, 34.2% of patients demonstrated complete suppression, 53.7% an improvement, 7.3% a stable value, and 4.9% an increase of tinnitus, and none of the patients reported an induction of tinnitus.

Conclusion

This review shows a clear improvement of tinnitus complaints after cochlear implantation in patients with SSD. Therefore, tinnitus might be considered as an additional indication for cochlear implantation in SSD.

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Human Otopathology of Cochlear Implant Drill-out Procedures

Danielle R. Trakimas, MSE, Reuven Ishai, MD, Elliott D. Kozin, MD, Joseph B. Nadol, Jr., MD, Aaron K. Remenschneider, MD, MPH

https://doi.org/10.1177/0194599819847636 | First Published May 7, 2019

Abstract

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Objective

Human otopathology following drill-out procedures for cochlear implantation (CI) in cases with labyrinthitis ossificans (LO) has not been previously described. This study uses the high sensitivity of histopathology to (1) evaluate surgical drill-out technique with associated intracochlear findings and (2) quantify spiral ganglion neuron populations in a series of patients with LO who underwent CI.

Study Design

Retrospective otopathology study.

Setting

Otopathology laboratory.

Subjects and Methods

Temporal bone (TB) specimens from cases with evidence of preoperative intracochlear fibroossification that required a drill-out procedure for CI electrode array insertion were included. All cases were histopathologically evaluated and 3-dimensional reconstructions of the cochleae were performed to interpret drilling paths and electrode trajectories.

Results

Five TB specimens were identified, of which 4 underwent drill-out of the basal turn of the cochlea and 1 underwent a radical cochlear drill-out. In multiple TBs, drilling was imprecise with resultant damage to essential structures. Two TBs showed injury to the modiolus, which was associated with substantially decreased or even absent neuronal populations within these areas. In addition, 2 cases with inadequate drill-out or extensive LO of the basal turn resulted in extracochlear placement of electrode arrays into the vestibule due to persistent obstruction within the basal turn.

Conclusion

Otopathology highlights the challenges of drill-out procedures in cases of LO. Imprecise drilling paths, due to distortion of normal cochlear anatomy, risk injury to the modiolus and adjacent neurons as well as extracochlear placement of electrode arrays, both of which may contribute to poorer hearing outcomes.

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Organ Function Preservation Failure after (Chemo)Radiotherapy in Head and Neck Cancer: A Retrospective Cohort Analysis

Jolien Heukelom, MD, Arash Navran, MD, Zeno A. R. Gouw, MD, Margot E. Tesselaar, MD, PhD, Charlotte L. Zuur, MD, PhD, Erik van Werkhoven, PhD, Jan-Jakob Sonke, PhD, Coen R. N. Rasch, MD, PhD, Abrahim Al-Mamgani, MD, PhD

https://doi.org/10.1177/0194599819846073 | First Published May 7, 2019

Abstract

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Objective

The aim of the current study was to determine the incidence of organ function preservation failure (OFPF) in patients with head and neck squamous cell carcinoma (HNSCC) treated by (chemo)radiotherapy and to identify its risk factors.

Study Design

Retrospective cohort analysis.

Setting

Tertiary cancer care center.

Subjects and Methods

A single-center retrospective cohort analysis was done (n = 703) in which OFPF after (chemo)radiotherapy was assessed. OFPF was defined as local failure or pure functional failure in the absence of local failure because of major surgical intervention (total laryngectomy, commando resection, permanent tracheostomy) or feeding tube dependence >2 years.

Results

OFPF occurred in 153 patients (21.8%). Reasons for OFPF were local failure in 103 patients (14.6%) and functional failure in 50 patients (7.2%). Evidence of functional failure included need for total laryngectomy (n = 9, 1.3%), commando resection (n = 2, 0.3%), permanent tracheostomy (n = 16, 2.3%), and/or long-term feeding tube for functional reasons (n = 23, 3.3%). In a Cox proportional hazards model, OFPF was worse for patients with T4 tumors (hazard ratio [HR] <0.5 and P < .001 for all other stages), for laryngeal vs oropharyngeal cancer (HR, 1.83; 95% confidence interval [CI], 1.20-2.79, P = .005, hypopharyngeal not significant), and for smokers (HR, 1.68; 95% CI, 1.10-2.56, P = .015). Exploratory multivariate analysis by tumor site showed that T4 tumor and pretreatment tracheostomy were the strongest predictive factors for OFPF in laryngeal and hypopharyngeal carcinoma while T4 tumor and smoking were predictive for poor OFPF in oropharyngeal carcinoma.

Conclusion

This work shows a detrimental effect of smoking on functional outcomes after (chemo-)radiotherapy for HNSCC. Moreover, T4 tumor, laryngeal subsite, and pretreatment tracheostomy are strong predictors of OFPF.

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Plastic Surgery

Pediatric Craniomaxillofacial Oncologic Reconstruction Publication date: April 2019 Source: Clinics in Plastic Surgery, Volume 46, Issue 2 Author(s): Robert F. Dempsey, Daniel C. Chelius, William C. Pederson, Marco Maricevich, Amy L. Dimachkieh, Michael E. Kupferman, Howard L. Weiner, Larry H. Hollier, Edward P. Buchanan

Pierre Robin Sequence Publication date: April 2019 Source: Clinics in Plastic Surgery, Volume 46, Issue 2 Author(s): Sun T. Hsieh, Albert S. Woo

Pediatric Facial Trauma Publication date: April 2019 Source: Clinics in Plastic Surgery, Volume 46, Issue 2 Author(s): Tom W. Andrew, Roshan Morbia, H. Peter Lorenz

Parry Romberg Syndrome Publication date: April 2019 Source: Clinics in Plastic Surgery, Volume 46, Issue 2 Author(s): Kelly P. Schultz, Elaine Dong, Tuan A. Truong, Renata S. Maricevich

Porous Polyethylene Ear Reconstruction Publication date: April 2019 Source: Clinics in Plastic Surgery, Volume 46, Issue 2 Author(s): Youssef Tahiri, John Reinisch

Craniofacial Microsomia Publication date: April 2019 Source: Clinics in Plastic Surgery, Volume 46, Issue 2 Author(s): Craig Birgfeld, Carrie Heike

Treacher Collins Syndrome Publication date: April 2019 Source: Clinics in Plastic Surgery, Volume 46, Issue 2 Author(s): Albaraa Aljerian, Mirko S. Gilardino

State-of-the-Art Hypertelorism Management Publication date: April 2019 Source: Clinics in Plastic Surgery, Volume 46, Issue 2 Author(s): Sameer Shakir, Ian C. Hoppe, Jesse A. Taylor

Pediatric Cranioplasty Publication date: April 2019 Source: Clinics in Plastic Surgery, Volume 46, Issue 2 Author(s): Michael R. Bykowski, Jesse A. Goldstein, Joseph E. Losee

Orthognathic Surgery for Patients with Cleft Lip and Palate Publication date: April 2019 Source: Clinics in Plastic Surgery, Volume 46, Issue 2 Author(s): Andree-Anne Roy, Michael Alexander Rtshiladze, Kyle Stevens, John Phillips

Physical Medicine & Rehabilitation

Making patients fit for surgery: introducing a four pillar multimodal prehabilitation program in colorectal cancer Background Considering the relation between preoperative functional capacity and postoperative complications, enhancing a patients functional capacity prior to surgery with a prehabilitation program may facilitate faster recovery and improve quality of life. However, time before surgery is short, mandating a multimodal and high-intensity training approach. This study investigated feasibility and safety of a prehabilitation program for colorectal cancer. Methods Multimodal prehabilitation was offered to patients eligible for participation. They were assigned to an intervention or control group by block randomisation. The prehabilitation program consisted of four interventions: in-hospital high-intensity endurance and strength training, high-protein nutrition, smoking cessation and psychological support. Program attendance, patient satisfaction, adverse events and functional capacity were determined. Results Fifty patients participated in this study (prehabiilitaiton 20, control 30). Program evaluation revealed a high (90%) attendance rate and high level of patient satisfaction. No adverse events occurred. Endurance and/or strength were improved. 86% of patients with prehabilitation recovered to their baseline functional capacity 4 weeks post-operatively, 40% in the control group (p<0.01). Conclusions Multimodal prehabilitation including high-intensity training for colorectal cancer patients is feasible, safe and effective. A randomized controlled trial (NTR5947) was initiated to determine whether prehabilitation may lower morbidity and mortality rates in colorectal surgery. Corresponding author + request for reprints: S.J. van Rooijen MD PhD, Máxima Medical Center, Department of Surgery, P.O. Box 7777, Veldhoven, the Netherlands, stefanvanrooijen@msn.com / prehab.resurge@mmc.nl This pilot was financially supported (MMC2620) by the National Foundation against Cancer (Nationaal Fonds tegen Kanker). FrieslandCampina provided the Refit®TMP 90 Shakes. The funding sources had no role in the design of this study and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Evaluating Physician Knowledge of Commonly Prescribed Inpatient Rehabilitation Unit Discharge Medication's Costs: An Observational Study The objective of this study was to assess physiatrists' knowledge of the cost of medications commonly prescribed at discharge from inpatient rehabilitation units across the spectrum of practice experience from residents to attending physicians. Investigators contacted 92 pharmacies across 4 major regions of the United States (U.S.) and averaged the cash price of each medication. An electronic survey was created highlighting 17 medications in which physicians estimated the cost of a medication per pill and per month for a 30-day supply. Surveys were sent to all ACGME-accredited programs across the U.S.; 43 participants responded to the survey. Most respondents overestimated the cost of the medications chosen for the survey. There was no significant difference between medication cost knowledge and practice experience (p = 0.497) or post-graduate year of training (p = 0.593). This raises awareness that physiatrists may not know the cost of medications they commonly prescribe at discharge, which may have implications on patient medication compliance, quality of care and patient satisfaction. Correspondence: Allison Capizzi, MD, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132. Office Phone: 801-585-2589. Mobile: 805-403-1763. Fax: 801-587-5757 Author Disclosures: No authors involved in this study have any competing interests, financial benefits, funding, grants or equipment to disclose. This material has not been presented at an AAPM&R Annual Assembly. Funding: No funding was acquired in completion of this project Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Clinical Practice Guidelines for the Rehabilitation of Lower Limb Amputation: An Update from the Department of Veterans Affairs and Department of Defense Between 2015 and 2017, the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD) developed a Clinical Practice Guideline (CPG) for Rehabilitation of Lower Limb Amputation to address key clinical questions. A multidisciplinary workgroup of VA and DoD amputation care subject-matter-experts was formed and an extensive literature search was performed which identified 3,685 citations published from January 2007 through July 2016. Articles were excluded based upon established review criteria resulting in 74 studies being considered as evidence addressing one or more of the identified key issues. The identified literature was evaluated and graded utilizing the National Academies of Science GRADE criteria. Recommendations were formulated following extensive review. Eighteen recommendations were confirmed with four having strong evidence and workgroup confidence in the recommendation. Key recommendations address patient and caregiver education, consideration for the use of rigid and semi-rigid dressings, consideration for the use of microprocessor knees, and managed lifetime care that includes annual transdisciplinary assessments. In conclusion, this CPG utilized the best available evidence from the past 10 years to provide key management recommendations to enhance the quality and consistency of rehabilitation care for persons with lower limb amputation. Corresponding Author: Joseph B. Webster, M.D.; 1201 Broad Rock Boulevard, Richmond, VA 23112, 804-675-7036, joseph.webster@va.gov Disclosure: This work represents the opinions of the authors and not necessarily those of any government agency, academic institution or healthcare agency. This work was fully funded by the Departments of Defense and Veterans Affairs. No funding was received from any commercial entity. Material was presented at the 2018 AAPM&R Annual Assembly on October 26, 2018. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Authors' Response to the Letter to the Editor on "An Obvious and Potentially Neglected Cause of Buttock Pain: Gluteus Maximus Dysfunction" No abstract available

Impact of a Stroke Recovery Program Integrating Modified Cardiac Rehabilitation on All-cause Mortality, Cardiovascular Performance and Functional Performance Objective Using a feasibility analysis and matched subgroup analysis, this study investigated the implementation/safety/outcomes of a Stroke Recovery Program(SRP) integrating modified cardiac rehabilitation(CR) for stroke survivors. Design This prospective cohort study of 783 stroke survivors were discharged from an inpatient rehabilitation facility to an outpatient setting; 136 SRP-participants completed a feasibility study and received the SRP including modified CR, 473 chose standard of care rehabilitation(non-participants) and a group(n=174) were excluded. The feasibility study assessed: safety/mortality/pre-post cardiovascular-performance/pre-post function/patient/staff-perspective. In addition to the feasibility study, a non-randomized subgroup analysis compared SRP-participants(n=76) to matched pairs of non-participants(n=66, with 10 non-participants used more than once) for mortality/pre-post function. Results The feasibility study showed the SRP to have:1)excellent safety, 2)markedly low 1-year post-stroke mortality from hospital admission(1.47%) compared to national rate of 31%,1 3)improved cardiovascular-performance over 36 sessions(103% increase in Metabolic Equivalent of Tasks times minutes), 4)improved function in Activity Measure of Post-Acute Care(AM-PAC)TM domains(P<0.001), 5)positive reviews from SRP-participants/staff. Subgroup analysis showed the SRP to:1)positively impact mortality; non-participants had a 9.09 times higher hazard of mortality(P=0.039), and 2)improve function in AM-PACTM domains(P<0.001). Conclusion Stroke survivors receiving a SRP integrating modified CR may potentially benefit from reductions in all-cause mortality, and improvements in cardiovascular-performance and function. Corresponding Author: Sara J. Cuccurullo, M.D., JFK Johnson Rehabilitation Institute, 65 James Street, Edison, NJ 08818, Phone 732-321-7000 X62780; Fax 732-744-5846; Email: Sara.Cuccurullo@hackensackmeridian.org Disclosures: This study was supported in part by a Project Grant from the NorthEast Cerebrovascular Consortium (NECC) awarded to Dr. Cuccurullo and Dr. Fleming. NuStep® cross-training bicycles were provided in-kind. The statistical analysis performed for this study has not been presented in another format. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Comments on "An Obvious and Potentially Neglected Cause of Buttock Pain: Gluteus Maximus Dysfunction" No abstract available

Physical Medicine and Rehabilitation: Trends in Graduate Medical Education and Sub-Specialization Amidst Changing Demographics With an aging and growing U.S. population, American healthcare faces an impending physician shortage. This is important for the field of Physical Medicine and Rehabilitation (PM&R), as physiatrists' skills in managing chronic conditions and functional outcomes are especially relevant to an older population. The present study was designed to better understand the future PM&R workforce, by recording and analyzing the quantities of ACGME-accredited PM&R graduate medical education programs and positions between 2001-02 and 2017-18. Results indicated that PM&R graduate medical education has grown since 2001-02, especially in subspecialties such as Pediatric Rehabilitation and Sports Medicine. However, the growth in PM&R residency positions has been three-fold lower than that of total GME. In addition, sub-specialization has become increasingly prevalent, and residency positions have declined relative to the population of older adults. The future identity of PM&R will continue to develop as professional and demographic trends shape this important medical specialty. Correspondence to: Aldis H. Petriceks, Stanford University School of Medicine, 269 Campus Dr., CCSR 0135A, Stanford, CA 94305. Email: aldisp@stanford.edu. Phone: 650-796-0340. Fax: 650-498-5394. Author Disclosures: The authors declare no competing interests; no funding, grants, or equipment received for this project; no financial benefits incurred from this project; and no previous presentation of this research in any form. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

TIME EFFECTOF INTRA-ARTICULAR INJECTION WITH TRIAMCINOLONE HEXACETONIDE AND ITS CORRELATIONS: A CASE – CONTROL PROSPECTIVE 12 MONTH STUDY Objective To assess the time effect of intra-articular (IA) injection with triamcinolone hexacetonide (TH) in rheumatic patients. Design A prospective case-control study with patients submitted to one IA injection with TH. Patients were followed monthly (12 months) for pain and swelling. Results 262 joints were assessed in 158 patients with mean age of 60 (±13.7) years. Remission were observed at 3, 6 and 12 months in 142 (54.19%), 111 (42.36%) and 105 (40.07%) joints, respectively.The mean time effect were 8 (±4.0) months; 8.4 (±3.9) for rheumatoid arthritis (RA) patients and 6.9 (±4.0) for osteoarthritis patients (p=0.012); and 10.4 (±2.7) months for small; 7.7 (±4.1) for medium and 6.8(±4.0) for large joints. The joints were divided into two groups: long-term group (LTG- time effect of IA injection longer than six months) and short-term group (STG).Variables associated (p <0.05) with LTG: RA, small and medium-sized joints, female gender, lower pain and swelling VAS scores and use of leflunomide. Variables associated with STG: receiving only one IA injection, hypertension, diabetes mellitus, biological therapy. Conclusion The time effect of IA injection with TH was 8.0 (±4.0) months. The associated predictors were RA, small and medium-sized joints, lower pain/swelling VAS scores, and use of leflunomide. Financial information: none Corresponding Author: Rita Nely Vilar Furtado, Universidade Federal de São Paulo, Rua Botucatu, 740 – 04023-900, São Paulo/SP – Brazil, Telephone contact/ Fax: 55-11-55764239, Email: rvfurtado@hotmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Time course and recovery of the movements of hyoid bone and thyroid cartilage during swallowing in a patient with sarcopenic dysphagia: a case report Sarcopenia is known to adversely affect swallowing function. In this report, we describe the treatment progress of an older patient with dysphagia caused by sarcopenia and the analysis results from videofluorographic examination images. An 89-year-old man who had been hospitalized for lumbar fracture experienced lower back pain, and thus had his oral intake reduced. After transfer to a rehabilitation hospital, he developed aspiration pneumonia and then sarcopenia with low nutrition and low activity. At the beginning of intervention, he aspirated food paste, but he recovered sufficiently to be able to ingest a normal meal via a nutritional approach combined with rehabilitation at the time of discharge. During this process, the maximum amounts of displacements and maximum moving velocities of his hyoid bone and thyroid cartilage during swallowing of moderately thick water were improved. Adequate nutrition intake and training for hyoid muscles are considered effective for the patient with sarcopenic dysphagia. It was concluded that measuring the maximum displacements and moving velocities of the hyoid bone and thyroid cartilage during swallowing in patients with sarcopenic dysphagia was an effective way to monitor their improvement. Correspondence : Enri Nakayama, Department of Dysphagia Rehabilitation/ Nihon University School of Dentistry/ 1-8-13, Kanda Surugadai, Chiyoda/ Tokyo/ 101-8310/ Japan. Tel: +81-3-3219-8198, FAX: +81-3-3219-8203, E-mail address: nakayama.enri@nihon-u.ac.jp Author Disclosures: Competing Interests: none (All authors) Funding or grants or equipment provided for the project from any source: This report was supported by Sato Fund and Dental Research Center, Nihon University School of Dentistry. (Enri Nakayama) Financial benefits to the authors: none (All authors) Details of any previous presentation of the research, manuscript, or abstract in any form: none (All authors) Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Luxatio erecta in a Frisbee player: Magnetic resonance imaging findings of a rare injury No abstract available

Otolaryngology

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