Functional Hearing Preservation in Cochlear Implantation: The Miami Cocktail Effect.

OBJECTIVE: To investigate if pharmacological treatment with prednisone and L-N-acetylcysteine (STE + NAC) influence functional hearing preservation in cochlear implant (CI) surgery. STUDY DESIGNS: Preimplantation and postimplantation longitudinal case-control study. SETTING: Tertiary referral center. PATIENTS: Pediatric and adult recipients of CI with preimplantation functional hearing defined as an average of air-conducted thresholds at 125, 250, and 500 Hz (low-frequency pure-tone average [LFPTA]) <80 dB. INTERVENTIONS: Preimplantation and postimplantation audiometry. Weight-adjusted oral prednisone and L-N-acetylcysteine starting 2 days before surgery (Miami cocktail). Prednisone was continued for 3 days and L-N-acetylcysteine for 12 days after surgery, respectively. Cochlear implantation with conventional length electrodes. MAIN OUTCOME MEASURES: Proportion of patients with LFPTA <80 dB, and LFPTA change at 1-year postimplantation. RESULTS: All 61 patients received intratympanic and intravenous dexamethasone intraoperatively, with 41 patients receiving STE + NAC and 20 patients not receiving STE + NAC. At 1-year postimplantation, the proportion of functional hearing preservation was 83% in the STE + NAC group compared with 55% of subjects who did not receive STE + NAC ( p = 0.0302). The median LFPTA change for STE + NAC-treated and not treated subjects was 8.33 dB (mean, 13.82 ± 17.4 dB) and 18.34 dB (mean, 26.5 ± 23.4 dB), respectively ( p = 0.0401, Wilcoxon rank test). Perioperative STE + NAC treatment resulted in 10 dB of LFPTA better hearing than when not receiving this treatment. Better low-frequency preimplantation hearing thresholds were predictive of postimplantation functional hearing. No serious side effects were reported. CONCLUSION: Perioperative STE + NAC, "The Miami Cocktail," was safe and superior to intraoperative steroids alone in functional hearing preservation 1-year after cochlear implantation.

Development of a Surgical Video Atlas for Resident Education: 3-Year Experience.

OBJECTIVE: To create a high-quality annotated online surgical video atlas of key indicator otolaryngology cases and assess its use and overall journal trends over time. METHODS: Videos are recorded from multiple viewpoints within the operating room and compiled into a single stream. Postediting includes chaptering videos and overlaying relevant text annotations. Videos are published online and viewership trends analyzed. RESULTS: Over 3 years, 29 otolaryngology videos were published out of 161 journal publications (18%). Eight of the 14 key indicator procedures are included (57%). From the beginning of 2017 to the end of 2019, viewership of otolaryngology pages increased from 548 to 11,139 views per month, totaling >150,000 views. These now represent 10% of the total journal monthly views and 10% of the overall views. Users originate from the United States and from >10 other countries. DISCUSSION: Residents and faculty face challenges of providing the highest standard of clinical care, teaching, and learning in and out of the operating room. Inherent difficulties of surgical training, high-fidelity surgical simulation, and imposed work hour restrictions necessitate additional, more efficient and effective means of teaching and learning. Surgical videos demonstrating key anatomy, procedural steps, and surgical dexterity with hand positioning are increasing in their popularity among learners. IMPLICATIONS FOR PRACTICE: Surgical video atlases provide a unique adjunct for resident education. They are enduring and easily accessible. In a climate of work hour restrictions or elective case reduction, they may supplement how residents learn to operate outside the operating theater.

Associations of Video Head Impulse Test and Caloric Testing among Patients with Vestibular Schwannoma.

OBJECTIVE: To determine relationships between caloric testing (CT) and video head impulse testing (vHIT) among patients with unilateral vestibular schwannoma (VS). To describe the distribution of CT and vHIT measurements and assess associations with tumor size and self-perceived handicapping effects. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral hospital. SUBJECTS AND METHODS: Subjects were adults with presumed unilateral VS between 2014 and 2017. Interventions were CT and vHIT. Primary outcomes were vHIT value (abnormal <0.8) and CT value (abnormal >25%). Secondary outcomes were tumor size and Dizziness Handicap Inventory scores. RESULTS: Fifty-one individuals had complete data for CT and vHIT. The odds of abnormal gain increases by 2.18 for every 10% increase in unilateral weakness on CT (range, 1.44-3.34; P < .001). A significant negative correlation between CT and gain exists (rs = -0.64, P < .001). Odds of observing saccades increased by 2.68 for every 10% increase in unilateral weakness (range, 1.48-4.85; P = .001). This association was larger in magnitude for overt than covert saccades (odds ratios, 2.48 and 1.59, respectively). Tumor size was significantly associated with an increase in caloric weakness (ß = 0.135, P < .001). With every 10-mm increase of tumor size, odds of abnormal gain on vHIT increased 4.13 (range, 1.46-11.66; P = .007). Mean Dizziness Handicap Inventory score was 19.7 (σ = 22), without association to caloric weakness, gain, or tumor size. CONCLUSION: CT and vHIT both effectively assess vestibular function for patients with VS and correlate to tumor size. These findings are important as vHIT has a lower overall cost, improved patient tolerance, and demonstrated reliability.

Low-Grade Papillary Schneiderian Carcinoma of the Sinonasal Cavity and Temporal Bone.

OBJECTIVES:: The aim of this study was to further characterize a newly described neoplasm, low-grade papillary Schneiderian carcinoma, occurring simultaneously in the sinonasal cavity and mastoid. Additionally, the authors review the only 2 similar cases within the literature and describe the common clinical features, radiographic findings, and pathologic characteristics of this exceptionally rare disease process. METHODS:: Chart review for single patient, review of literature. RESULTS:: The patient presented with bilateral nasal obstruction. Computed tomography revealed a left sinonasal mass with skull base hyperostosis, and follow-up magnetic resonance imaging showed a concomitant olfactory groove meningioma. Examination showed a bilateral, completely obstructing sinonasal mass with skip areas, and biopsy confirmed inverted papilloma (human papilloma virus strains 16 and 18 indeterminate). The patient underwent bilateral endoscopic sinus surgery, left medial maxillectomy, and left partial nasopharyngectomy. Given her multifocal disease, she was advised that she would require additional excision, but was lost to follow up. One year later she developed acute left facial paralysis. Magnetic resonance imaging demonstrated an enhancing mass in the left mastoid with enhancement along the Eustachian tube in addition to her known recurrent sinonasal disease. Simultaneous endoscopic sinus surgery and mastoidectomy were performed. Polypoid tissue was removed from the nasopharynx, mesotympanum, epitympanum, and retrofacial air cells. Immunohistochemistry showed that cells stained positive for p63 and dermCK and negative for synaptophysin. Morphologically, cells were bland, without classic stromal invasion, retaining their smooth, cystic, and papillary features, despite their increased depth within the tissue. Upon further review and consultation with an outside pathologist, a diagnosis of low-grade papillary Schneiderian carcinoma was made. The patient was referred for radiation therapy and is disease free at 3-month follow-up, with return of her facial function. CONCLUSIONS:: This case represents the first report of concurrent low-grade papillary Schneiderian carcinoma of both the nasal cavity and mastoid. It emphasizes the importance of recognizing this new entity through pathologic analysis and suspecting it when the clinical course does not follow an expected pattern.

The Role of Postoperative Imaging after Orbital Floor Fracture Repair.

Obtaining postoperative images of maxillofacial fractures does not affect the clinical management of asymptomatic patients; however, few studies have evaluated the role of postoperative imaging in the context of orbital floor fractures. In this study, we evaluate current practice techniques and the role of postoperative imaging in the management of orbital floor fractures in isolation and with concomitant facial fractures. Retrospective review of patients who underwent open reduction and internal fixation of orbital floor fractures between 2005 and 2015 at a single medical institution. Operative and perioperative records were reviewed to characterize postoperative imaging as routine or as indicated by concerning clinical symptoms, and to correlate clinical outcomes to postoperative imaging patterns across all identified orbital floor fractures. A total of 139 patients underwent open reduction and internal fixation of orbital floor fractures. Of these, 75 (54%) had zygomaticomaxillary (ZMC) involvement. The remaining 64 (46%) were isolated orbital floor fractures. Overall, 54 (39%) patients underwent postoperative imaging. Of these, 38 (70%) had postoperative imaging in the absence of concerning clinical symptoms. There was no observed difference in complication rates in those who underwent postoperative imaging, and those who did not. Patients with orbital + ZMC fractures underwent a significantly higher number of postoperative imaging studies ( p < 0.001); however, there was no observed difference in complications between isolated orbital and orbital + ZMC fractures. Routine postoperative imaging is not warranted in the absence of persistent clinical symptoms following open reduction and internal fixation of orbital floor fractures.

Preoperative Imaging Findings and Cost in Adults With Postlingual Deafness Prior to Cochlear Implant.

OBJECTIVE: To assess the imaging findings of computed topography (CT) and magnetic resonance imaging (MRI) in adults with postlingual deafness and otherwise normal clinical history and physical exam. Additionally, determine the influence and implications of these findings with respect to surgical outcomes and cost. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral hospital. PATIENTS: Adults with postlingual deafness with no history of prior ear surgery, chronic ear disease, meningitis, otosclerosis, or head trauma. INTERVENTIONS: Cochlear implantation of 1 or both ears, with preoperative CT, MRI, or both. MAIN OUTCOME MEASURES: Imaging results were classified as normal, abnormal affecting surgery, incidental requiring follow-up, or incidental not requiring follow-up. Average cost of each imaging modality was determined. RESULTS: A total of 128 patients met the inclusion criteria. Of these, 82 (64.1%) had both CT and MRI performed, 33 (25.8%) had CT, and 13 (10.2%) had MRI prior to cochlear implant (CI). Scans were normal in 125 (97.7%) of cases. Of the remaining 3 (2.3%) patients, there were incidental findings requiring follow-up. All implants were placed successfully, and in no instance did the results of the scan influence the surgery. The average cost of imaging per patient was $4707. CONCLUSION: In adults with postlingual deafness with an otherwise benign clinical history, CT and MRI are unlikely to affect or preclude surgery. With new MRI safe cochlear implants, imaging can be performed safely postoperatively if needed.

Osseointegrated implants for auricular prostheses: An alternative to autologous repair.

OBJECTIVES/HYPOTHESIS: This study compares the hospital cost of osseointegrated implants for retention of an auricular prosthesis to autologous ear reconstruction. STUDY DESIGN: Retrospective review. METHODS: This study includes patients who underwent reconstruction for either congenital or acquired ear defects at Duke University Medical Center during 2009 to 2015. RESULTS: A total of nine patients had autologous repair representing nine operative ears, and 16 patients had an osseointegrated implant representing 18 operative ears (two bilateral). The average age for the autologous repair was 11.6 years with 56% male versus 40.7 years with 56% male for the osseointegrated implant patients. For autologous patients, indications for surgery were anotia/microtia in 8/9 (89%) and trauma in 1/9 (11%) versus 6/16 (387.5%) anotia/microtia, 8/16 (50%) cancer, and 2/16 (132.5%) trauma in the osseointegrated implant group. The mean number of surgeries was 3.1 for autologous repairs and 1.0 for osseointegrated repairs (mean difference confidence interval [CI]: -2.4 to -1.8, P < .001). The average cost to the hospital for an osseointegrated repair was $6,491.39 versus $10,047.93 for autologous repairs (CI: $6,496.38 to $-616.68, P = .02) CONCLUSIONS: Osseointegrated implants for retaining an auricular prosthesis has a similar cost to autologous repair of ear defects, but patients underwent an average of two more surgeries with autologous repair. Patients should be able to choose the reconstruction option that best suits their condition and preferences. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2153-2156, 2018.

Persistent Acute Onset Macroglossia Treated with Compression Therapy.

Acute macroglossia, while rare and often limited in duration, can present significant management challenges. The anatomic position of the tongue, which can result in airway compromise in cases of enlargement, contributes significantly to difficulty with management. We review several management options for persistent acute onset lingual macroglossia and present a novel noninvasive management technique in a case which was refractory to several strategies.

Coblation of suprastomal granulomas in tracheostomy-dependent children.

OBJECTIVE: Suprastomal granulomas pose a persistent challenge for tracheostomy-dependent children. They can limit phonation, cause difficulty with tracheostomy tube changes and prevent decannulation. We describe the use of the coblator for radiofrequency plasma ablation of suprastomal granulomas in five consecutive children from September 2012 to January 2016. METHOD: Retrospective case series at a tertiary medical center. RESULTS: The suprastomal granuloma could be removed with the coblator in all 5 cases. Three were removed entirely endoscopically and 2 required additional external approach through the tracheal stoma for complete removal. There were no intraoperative or postoperative complications. One patient was subsequently decannulated and 2 patients have improved tolerance of their speaking valves. Two patients remain ventilator dependent, but their bleeding and difficulty with tracheostomy tube changes resolved. Three of the patients have had subsequent re-evaluation with bronchoscopy, demonstrating resolution or markedly decreased size of the granuloma. This technique is time efficient, simple and minimizes risks associated with other techniques. The relatively low temperature and use of continuous saline irrigation with the coblator device minimizes the risk of airway fires. Additionally, the risk of hypoxia from keeping a low fractional inspiratory oxygen level (FIO2) to prevent fire is avoided. The concurrent suction in the device decreases blood and tissue displacement into the distal airway. CONCLUSION: Coblation can be used safely and effectively with an endoscopic or external approach to remove suprastomal granulomas in tracheostomy-dependent children. More studies that are larger and have longer follow-up are needed to evaluate the use of this technique.

Traumatic tracheal injury in children: a case series supporting conservative management.

OBJECTIVES: Injuries to the tracheobronchial region are rare, but have the potential for rapid progression and can become life-threatening. Etiologies of non-penetrating tracheobronchial injuries include blunt cervical trauma, endotracheal intubation, and other iatrogenic causes. Several options for treatment ranging from conservative to surgical exist, but no single treatment has been implemented with consensus. While early surgical repair was once considered the cornerstone of therapy, evidence supporting conservative treatment continues to gain strength. METHODS: All pediatric patients who suffered from non-penetrating injuries to the tracheobronchial tree who were treated by the Otolaryngology Service at a tertiary children's hospital from May 2012 through March 2014 were recorded. A total of 8 patients were identified. The cases were collected from the patients treated by the Otolaryngology Department based on retrospective review. The available electronic medical records were reviewed for each patient. Data including type of injury, endoscopic assessment of injury, treatment received, and follow-up were collected. RESULTS: The ages ranged from 2 to 15 years old, with a mean of 9.25 years old. Six of the eight patients had injuries related to endotracheal intubation. Each patient was taken to the operating suite for diagnostic direct laryngoscopy and bronchoscopy, and treated with initial conservative management. All but one of the patients was treated with endotracheal intubation, and the average length of intubation was 11.71 days. All of the injuries healed spontaneously without requiring initial open surgery. Five patients (62.5%) developed some degree of tracheal stenosis. Three patients (37.5%) required further surgery; one received a tracheostomy and two patients required balloon dilation. CONCLUSIONS: This case series is the largest to date documenting the outcomes of conservative treatment of non-penetrating traumatic tracheal injuries in children. By using initial conservative therapy, we were able to avoid open surgical procedures in many of our patients. We believe that this case series provides further support for conservative management for children with tracheobronchial injuries.