Chondrosarcoma of the Epiglottis: A Case Report and Literature Review.

BACKGROUND: Laryngeal chondrosarcoma (LCS) is an exceedingly rare malignancy and least frequently reported in the epiglottis. METHODS AND RESULTS: We report a case of a 71-year-old male smoker who presented with sore throat, dysphagia, and odynophagia for 3 months. Computed tomography scan revealed an inhomogeneously enhancing necrotic mass emanating from the right epiglottis and traveling along the aryepiglottic fold. The mass was removed via endoscopic en bloc laser resection. Histopathological examination of the biopsied specimen confirmed low-grade LCS of the epiglottis. CONCLUSION: Differentiating low-grade LCS from laryngeal chondroma is a challenging task with an increased risk of potential misdiagnosis. This case study reinforces the need for a histopathological examination in forming the basis for ongoing management and follow-up observations. Timely surgery remains the optimal, primary means of treatment notwithstanding the rarity of LCS.

Olfactory loss in chronic rhinosinusitis is associated with neuronal activation of c-Jun N-terminal kinase.

BACKGROUND: Olfactory inflammation in chronic rhinosinusitis (CRS) is associated with cytokines that may result in the death of olfactory sensory neurons. The principal signaling molecules involved in the apoptotic pathway are c-Jun N-terminal kinases (JNK). Although the JNK pathway has emerged as a key player in programmed cell death in neuroinflammation, its specific role in CRS-associated olfactory loss has not been thoroughly investigated. METHODS: JNK activation was studied in human tissue samples from 9 control and 11 CRS patients by immunohistochemical staining for phosphorylated c-Jun. A mouse model of inducible olfactory cytokine expression was used to experimentally control inflammation and assess JNK activation over time. RESULTS: In patients with CRS, activation of c-Jun is significantly increased relative to non-CRS control subjects, and there is an associated loss of sensory neurons. In the olfactory inflammation mouse model, prolonged induction of inflammation results in elevation of c-Jun expression and neuronal apoptosis. CONCLUSION: Activation of neuronal JNK is a feature of chronic olfactory inflammation that is associated with neuronal apoptosis. Given that inhibition of JNK activity is neuroprotective in other settings, antagonism of this pathway may have therapeutic potential in the management of inflammatory olfactory loss or other disorders linked to olfactory neuronal apoptosis.

Interventional Drug-Induced Sleep Endoscopy: A Novel Technique to Guide Surgical Planning for Obstructive Sleep Apnea.

STUDY OBJECTIVE: One of the challenges of surgery for obstructive sleep apnea (OSA) is identifying the correct surgical site for each patient. The objective of this study was to use drug-induced sleep endoscopy (DISE) and nasopharyngeal tube (NPT) placement to determine the effect of eliminating palatal collapse on the obstruction seen on other segments of the upper airway. METHODS: Forty-one OSA patients were enrolled in this prospective study. All patients had a polysomnogram followed by DISE. DISE findings were recorded and compared with and without placement of a NPT. Obstruction was graded with a scale that incorporates location, severity, and interval of obstruction. RESULTS: Most patients (83%) demonstrated multilevel obstruction on initial DISE. With the nasopharyngeal airway in place, many patients with multilevel obstruction had at least a partial improvement (74%) and some a complete resolution (35%) of collapse (p < 0.05). Reduction in collapse was observed at the lateral walls (86%), epiglottis (55%), and tongue base (50%). NPT placement did not significantly alter upper airway morphology of patients with incomplete palatal obstruction or mild OSA. CONCLUSIONS: To our knowledge, this is the first study to evaluate the effect of soft palatal stenting on downstream pharyngeal obstruction during DISE. Our study provides evidence that reducing soft palatal collapse can reduce negative pharyngeal pressure and thereby alleviate other sites of upper airway obstruction. Taken together, these findings provide a means to identify appropriate candidates for isolated palatal surgery and better direct a minimally invasive approach to the surgical management of OSA.

Electronic health records and resident workflow: a time-motion study of otolaryngology residents.

OBJECTIVES/HYPOTHESIS: To evaluate the impact of electronic health records (EHRs) on the workflow of otolaryngology residents. STUDY DESIGN: Prospective, time-motion study. METHODS: A time-motion study was conducted both in the 2009 to 2010 and 2012 to 2013 postgraduate years. Eight otolaryngology residents were directly observed on both operative and clinic days, with resident activities categorized by way of a database program. Comparisons were made to the same data collected in the same setting prior to and following integration of an EHR system. RESULTS: Residents spent their day on direct patient care (41.1%), indirect patient care (35.3%), didactic education (14.0%), personal activities (6.9%), and transit (3.1%). The primary activity during operative days was direct patient care, and during clinic days it was indirect patient care. Activities of marginal educational value comprised a considerable component of their time (16.5%). Compared to data collected prior to use of an EHR, time was spent similarly. However, residents using an EHR devoted significantly more time to indirect patient care on clinic days (P < .05). CONCLUSIONS: This is the first study to evaluate EHR integration on otolaryngology resident workflow. Overall resident efficiency was not significantly altered by the implementation of an EHR. However, more time was shifted from directly caring for patients to documenting on the EHR in the clinic setting. These findings provide an important objective insight into EHRs, especially given the looming mandate for their use and the need to streamline resident curriculum in the duty hours era.

Usefulness of sleep endoscopy in predicting positional obstructive sleep apnea.

OBJECTIVES: The aim of the study was to (1) evaluate whether position affects drug-induced sleep endoscopy (DISE) findings in positional and nonpositional patients and (2) determine which areas of the upper airway obstruct in different body positions. STUDY DESIGN: Prospective, case-controlled study. SETTING: Academic tertiary care center. SUBJECTS AND METHODS: Twenty-two patients with obstructive sleep apnea (OSA) were enrolled. Two groups were individually recruited to make 11 consecutive patients with positional OSA and 11 consecutive patients with nonpositional OSA. Positional OSA was defined by nonsupine 50% reduction in apnea-hypopnea index. DISE was performed with patients in both lateral and supine sleep positions. Upper airway collapse was compared between the sleep positions and between the 2 groups. RESULTS: Most patients (77%) demonstrated multilevel obstruction on DISE. Nearly all patients with positional OSA (91%) had at least a partial improvement in collapse while in the lateral sleep position. Most of the reduction in collapse involved the tongue base and epiglottis (P < .05). Sleep position did not significantly alter the upper airway morphology of patients with nonpositional OSA. Apnea-hypopnea index and body mass index were not significantly different between the 2 groups. CONCLUSIONS: Sleep position can change upper airway morphology on DISE, particularly positional OSA patients. Hypopharyngeal collapse was the primary site that improved with change in position. DISE in multiple sleep positions should be considered as part of a minimally invasive approach to surgical therapy of OSA.

Effects of nasal surgery on the upper airway: a drug-induced sleep endoscopy study.

OBJECTIVES/HYPOTHESIS: To evaluate the impact of nasal surgery on the oropharyngeal and hypopharyngeal anatomy of patients with obstructive sleep apnea (OSA) by comparing drug-induced sleep endoscopy (DISE) data prior to and following nasal surgery. STUDY DESIGN: Retrospective review of medical records and DISE video recordings. METHODS: Twenty-four patients with OSA were identified who underwent nasal surgery for symptomatic nasal obstruction. Clinic charts and DISE video recordings were reviewed. Preoperative and postoperative DISE recordings were compared to determine whether nasal surgery affected the level, degree, and sustainability of upper airway obstruction. RESULTS: Overall, the pattern of upper airway obstruction did not change significantly following nasal surgery (P > .05). Almost all patients demonstrated residual obstruction by postoperative DISE (96%), with no change in plans for surgical management of oropharyngeal and hypopharyngeal collapse (83%). Partial improvement in palatal collapse was present in a subset of patients without tongue base obstruction (P < .05). Postoperative apnea-hypopnea index decreased from a mean of 23.6 to 20.4 events/hr, but this change was not significant (P > .05). CONCLUSIONS: For most patients with OSA, surgical repair of nasal obstruction does not significantly improve oropharyngeal or hypopharyngeal collapse as seen on DISE. However, mild improvement in palatal collapse is seen in a subset of patients without tongue base obstruction. This study reveals that if DISE is being utilized to direct surgical management of OSA, it does not need to be repeated for most patients after nasal surgery.

Otolaryngology resident workflow: a time-motion and efficiency study.

OBJECTIVE: To investigate workflow in an otolaryngology-head and neck surgery residency program over 1 year and identify areas for improvement in the efficiency of resident education and training. STUDY DESIGN: Time-motion study. SETTING: An urban, county hospital and a Veterans Affairs medical center hospital. Subjects and Methods. Eight otolaryngology residents (4 residents at postgraduate year [PGY] 2 and 4 at PGY 4) were studied using direct observations early and late in the 2008-2009 academic year. Resident activities were categorized, and a database program was generated for a handheld computer to facilitate time entry. Resident activities were classified into a taxonomy of tasks and their educational value was assessed. For each PGY level studied, observations were made for clinic and operative days. RESULTS: Residents spent their day on direct patient care (43.5%), indirect patient care (33.7%), didactic education (9.6%), personal activities (7.5%), and transit (5.8%), with activities of marginal educational value consuming 16% of their time. Major inefficiencies included managing administrative tasks, scheduling, and technical difficulties. On average, residents devoted significantly more time to marginal tasks on clinic days (19%) than on operative days (12%; P < .001). These data were compared with previously published data obtained during the pre­Accreditation Council for Graduate Medical Education (ACGME) duty hour mandates era. CONCLUSION: This study evaluates resident workflow and efficiency over the course of a PGY in an ACGME-accredited otolaryngology residency program. By understanding the time motion of residents, interruptions and inefficiencies in workflow can be identified to direct future changes to enhance resident education and training in the era of the ACGME duty hours mandate.