Cerebrospinal Fluid Leaks From the Lateral Ventricle: A Case Series.

OBJECTIVES: Describe the diagnosis and management of lateral skull base (LSB) cerebrospinal fluid (CSF) leaks originating from the lateral ventricle. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral academic center. PATIENTS: Patients with CSF leaks with direct communication to the lateral ventricle on preoperative imaging. INTERVENTION: Surgical repair via the middle cranial fossa (MCF) approach. MAIN OUTCOME MEASURES: CSF leak patient characteristics (age, sex, body mass index [BMI]) and postoperative course (complications and CSF leak resolution) were collected. RESULTS: Three patients had CSF leaks from the lateral ventricle and all patients demonstrated encephalomalacia of the temporal lobe on preoperative imaging. Encephalomalacia resulted from trauma in one case (age 5) and neurodegeneration in two cases (age 77 and 84). BMI ranged from 16.3 to 26.6 mg/kg2 and follow-up ranged from 4 to 21 months. Two patients presented with preoperative meningitis and all patients had resolution of CSF leaks after MCF repair. With the exception of the higher rate of meningitis, patient presentations did not differ from other spontaneous CSF leaks through middle fossa defects. There were no minor or major postoperative complications. CONCLUSIONS: CSF leaks from the lateral ventricle represent a rare subset of LSB CSF leaks and can occur in non-obese patients secondary to temporal lobe encephalomalacia. The MCF approach allows for repair of the dura and skull base in this cohort of patients with high-flow CSF leaks and loss of brain parenchyma.

An Appraisal of Printed Online Education Materials on Spasmodic Dysphonia.

OBJECTIVE: The use of the Internet for seeking health-related information has increased exponentially. We aimed to comprehensively appraise the readability, understandability, actionability, and quality of printed online education materials (POEMs) pertaining to Spasmodic Dysphonia (SD). STUDY DESIGN: Descriptive, correlational study. METHODS: POEMs were identified using the Google search engine with the phrase "spasmodic dysphonia." The first 50 websites meeting criteria were included. Accreditation of POEMs was evaluated using Health on the Net Foundation Code of Conduct (HONcode) toolbar. Readability of the content was analyzed using the Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) tests. Understandability and actionability was evaluated using the Patient Education Material Assessment Tool for Printed Materials. Overall quality of POEMs was appraised using the DISCERN instrument. RESULTS: The overall mean [SD] FKGL and mean [SD] FRE score was 11.5 [2.5] and 42.1 [12.8], respectively. The mean understandability score was 65% [14], while the mean [SD] actionability score was only 17% [12]. The overall mean [SD] quality score for all websites was 43.5 [13]. Only four websites (8%) were HONcode certified. A moderately positive correlation was discovered between understandability and overall quality of POEMs (r = 0.38, P 0.01) CONCLUSIONS: POEMs pertaining to SD are written above recommended reading levels with subsequent poor understandability and actionability. We recommend that authors assess POEMs prior to publication to ensure alignment with the needs of the target audience.

Use of Adenosine to Facilitate Localization and Repair of Internal Carotid Artery Injury during Skull Base Surgery: A Case Report and Literature Review.

BACKGROUND: Internal carotid artery (ICA) injuries represent a rare, potentially fatal complication of endoscopic endonasal skull base surgery (EESBS). The use of adenosine to induce transient hypotension and facilitate management of high-flow, high-pressure arterial lesions has been well-documented in neuro-endovascular literature. A similar setting in which adenosine-induced hypotension may prove beneficial is during the management of major vascular injury encountered during EESBS. METHODS: A case of ICA injury and subsequent repair during EESBS is presented. RESULTS: A 74-year-old female underwent endoscopic transsphenoidal resection for a recurrent pituitary adenoma. During suprasellar resection, the right cavernous ICA was inadvertently injured resulting in brisk bleeding. Immediate vascular tamponade was applied, and a crushed muscle graft was obtained. Two intravenous doses of adenosine were administered in quick succession to produce transient hypotension and facilitate repair of the injury with the graft. Neurovascular imaging revealed a small pseudoaneurysm which remained stable throughout the postoperative course. The patient underwent definitive stent embolization of the pseudoaneurysm 1 month following discharge. CONCLUSION: Prompt repair of ICA injury during EESBS is crucial, but often limited by poor visualization. Adenosine-induced hypotension has demonstrated great efficacy as an adjuvant in neurovascular clipping of intracranial aneurysms and remains a valuable tool for the endoscopic skull-base surgeon as well. In cases with high risk for ICA injury, adenosine should be readily available.

Middle Cranial Fossa Repair of Temporal Bone Spontaneous CSF Leaks With Hydroxyapatite Bone Cement.

OBJECTIVES: To determine the safety and effectiveness of the middle cranial fossa (MCF) approach in repairing spontaneous cerebrospinal fluid (sCSF) leaks. STUDY DESIGN: Retrospective cohort study. METHODS: Patient with sCSF leaks repaired by MCF approach between January 1, 2014 and August 31, 2019 were included. Demographic information, clinical and surgical findings, and postoperative outcomes were recorded. RESULTS: The cohort (n = 45) included 24 tegmen repairs by multilayer reconstruction using hydroxyapatite cement and 21 cases of multilayer repair without hydroxyapatite cement. Ten MCF repairs were performed on patients ≥65 years old. Twenty (53%) ears had multiple tegmen defects (range, 1-9 tegmen defects) and 78% of patients had ≥1 encephaloceles. All sCSF leaks were resolved with one surgical intervention. There were no major intracranial complications. Transient expressive aphasia occurred in 2 patients. Medical complications occurred in four patients. There were no short-term postoperative CSF leaks with bone cement reconstruction and two postoperative leaks without bone cement. One resolved with lumbar drain (LD) and the other resolved without treatment. The average (SD) length of stay (LOS) with bone cement was shorter than in patients without bone cement (2.54 [0.83] days vs. 3.52 [1.99] days, P < .05). There have been no long-term CSF leak recurrences with an average (SD) follow-up of 13.5 (12.9) months (range 0.25-46 months). CONCLUSIONS: MCF approach for sCSF repairs demonstrate efficacious outcomes, particularly with tegmen reconstruction using hydroxyapatite cement. The approach exhibited no serious adverse events and few complications requiring intervention. Therefore, MCF is a safe and effective approach to resolve sCSF leaks. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:624-632, 2021.

Telehealth Opportunities for the Otolaryngologist: A Silver Lining During the COVID-19 Pandemic.

The utilization of telemedicine has seen a relatively slow progression over the past 50 years in the US health care system. Technological challenges limiting the ease of use of robust video platforms have been a major factor. Additionally, the perception by many health care providers that telehealth is reserved for only the rural population or that it provides limited value due to the inability to perform in-depth physical examinations contributes to the slow adoption. The COVID-19 pandemic, with its massive disruption in social interaction by way of "stay at home" orders, is serving as a catalyst for improving telehealth. Large health systems are investing millions of dollars and increasing telehealth visit numbers 100-fold to access patients. The "telehealth movement" is here to stay and will undoubtedly be incorporated into providers' daily lives years after the COVID-19 pandemic. By embracing virtual access to health care, otolaryngologists will be able to influence improvements to these systems and broaden access options for patient care well into the future.

Readability of Printed Online Education Materials on Pituitary Tumors: Untangling a Web of Complexity.

BACKGROUND: Patients are increasingly turning to the internet for health education. Due to the complex pathophysiology, clinic-diagnostic profile, and management spectrum of pituitary tumors, an evaluation of the readability of printed online education materials (POEMs) regarding this entity is warranted. OBJECTIVE: (1) To apply established readability assessment tools to internet search results on the topic of pituitary tumors. (2) To identify sources of complexity in order to guide the creation POEMs that are in line with the reading level of the target audience.Methodology: After independent, neutral internet search for the phrase "pituitary tumor," the first 100 results were subjected to inclusion criteria matching. Analysis was performed using 5 readability assessment tools including Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), Gunning-Fog Score (GFS), Coleman-Liau Index (CLI), and Simple Measure of Gobbledygook (SMOG). RESULTS: A total of 82 websites met inclusion criteria. All websites were found to be at a higher reading level (P < .01) than the United States Department of Health and Human Services (USDHHS) recommended sixth-grade level. Mean readability scores were as follows: FRE, 38.79; FKGL, 11.27; GFS, 12.83; CLI, 17.31; SMOG, 12.12. Intergroup comparison between FKGL, GFS, CLI, and SMOG yielded that CLI was significantly higher (P < .03). No significant differences in readability were noted between academic and other websites. CONCLUSION: There is a significant misalignment between the reading level of patients and the readability of pituitary tumor POEMs. This may lead patients to misconceive their diagnoses, management options, and prognosis.

Evaluation of the Quality of Printed Online Education Materials in Cosmetic Facial Plastic Surgery.

Importance: In the modern-day health care environment, it is expected that a large proportion of patients will utilize the Internet to gather health care-related information. However, online sources are often not subjected to adequate quality control measures. Objective: To evaluate the quality of printed online education materials (POEMs) pertaining to elective facial cosmetic surgery. Design, Setting, and Participants: This is a descriptive correlational study. Independent Internet searches for the terms "rhinoplasty," "rhytidectomy," "blepharoplasty," and "browlift" were carried out using the Google search engine. The top 20 web resources for each term were analyzed. Main Outcomes and Measures: All web resources were analyzed for HONcode certification. The DISCERN instrument was then used to determine reliability and specificity of information, whereas readability was assessed using the Flesch Reading Ease (FRE) score and the Flesch-Kincaid Grade Level (FKGL). Results: Of the resulting 80 web resources, 30% (n = 24) were HONcode certified. None of the surgical society web resources (n = 12) were HONcode certified, and only 42% (n = 8) of web resources associated with academic institutions were HONcode certified. Out of a maximum DISCERN score of 80, the mean (standard deviation [SD]) scores were 48 (11) for rhinoplasty, 50 (11) for rhytidectomy, 47 (11) for blepharoplasty, and 45 (10) for browlift. The mean DISCERN scores of the HONcode-certified web resources did not differ significantly from scores of uncertified web resources (p = 0.069). There was no significant difference in overall mean DISCERN scores for the different web resource categories. The mean (SD) FRE score was 45.7 (11.9), whereas the mean FKGL score was 10.7 (1.9). HONcode-certified web resources had significantly higher FRE scores (p = 0.028) and significantly lower FKGL scores (p = 0.0003). Conclusions and Relevance: A significant proportion of POEMs regarding elective cosmetic facial plastic surgery remains uncertified and of inadequate quality. This can negatively impact the informed decision-making process and increase the risk of poor outcomes and lower satisfaction rates.

Impact of Sarcopenia on Outcomes of Autologous Head and Neck Free Tissue Reconstruction.

BACKGROUND: Sarcopenia has been implicated as a positive predictor of postsurgical complications. Its role in head and neck (H&N) free flap reconstruction has yet to be examined. Our study aimed to determine the clinical impact of sarcopenia on postoperative outcomes in patients receiving autologous free tissue reconstruction for H&N cancer (HNC). METHODS: A retrospective case-control study was conducted at our tertiary referral center. Patients with HNC who received oncologic resection followed by autologous free tissue reconstruction were included. Preoperative abdominal computed tomography (CT) imaging was analyzed at the third lumbar vertebra (L3) to calculate skeletal muscle cross-sectional area (CSA, cm2). Skeletal muscle index (SMI, cm2/m2) was calculated by normalizing CSA to patient height. Sarcopenia at L3 was defined as SMI ≤ 41.6 cm2/m2 for males and ≤ 32.0 cm2/m2 for females. Data analyses were performed to compare postoperative outcomes. RESULTS: Of the 168 patients who met inclusion criteria, 47 patients (28.0%) were determined to have preoperative sarcopenia. The sarcopenic group was older (63 vs. 58 years, p = 0.017), had lower body mass index (BMI; 21.2 vs. 27.2, p < 0.001), had greater incidence of alcohol abuse (55.3 vs. 23.1%, OR = 4.11, p < 0.001). Intraoperatively, sarcopenic patients were found to have greater rates of blood transfusions (63.8 vs. 29.8%, p < 0.001). Postoperatively, sarcopenic patients had higher rates of pneumonia (p < 0.01), venous thromboembolism (p < 0.01), prolonged ventilation (p < 0.01), delirium (p < 0.01), fistula (p < 0.05), wound disruption (p < 0.05), and longer intensive care unit stays (p < 0.05). Sarcopenic patients were ultimately found to have higher overall rates of general postoperative complications (p < 0.001) and flap-specific complications (p < 0.01). CONCLUSION: Sarcopenia was found to be a predictor of postoperative complications in H&N free flap reconstruction, signifying its value as a negative prognostic factor in surgical outcomes. This study reflects level of evidence IV.

Manifestations of Pediatric Extranodal Rosai Dorfman Disease in the head and neck.

OBJECTIVES: To systematically evaluate the clinico-diagnostic profile and management outcomes of otorhinolaryngologic manifestations of Extranodal Rosai-Dorfman Disease (ENRDD) in the pediatric population. METHODS: The search terms Rosai Dorfman Disease and Sinus Histiocytosis were used to query PubMed, Ovid/Medline, and Scopus databases from inception through September 30, 2018. Studies were systematically reviewed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. All reports of ENRDD involving at least one otorhinolaryngologic subsite in children less than 18 years were eligible for inclusion. RESULTS: A total of 31 studies met inclusion criteria resulting in identification of 31 ENRDD cases with a mean age of 11.5 years. Of the 31 patients, 23 were male (74.2%) and 7 were female (22.6%). Extranodal lesions were limited to otorhinolaryngologic subsites in 24 patients (77.4%), while 7 patients (22.5%) were found to have extranodal lesions simultaneously involving otorhinolaryngologic and nonotorhinolaryngologic sites. The nasal vault was the most common otorhinolaryngologic site involved (n = 13, 41.9%), followed by the paranasal sinuses (n = 10, 32.3%). The most common non-otorhinolaryngologic site that was concurrently involved was the orbit (n = 4, 57.1%). Concurrent cervical lymphadenopathy was present in 19 patients (61.2%). While not documented for 2 cases, emperipolesis on histopathology was confirmed in 29 patients (93.5%). Single therapy with surgical excision was the most common modality of treatment (n = 15, 53.6%) and yielded highest remission rates (80%). In 11 instances (34.36%), ENRDD was misdiagnosed. CONCLUSION: Pediatric ENRDD is a rare disease entity that maintains a high misdiagnosis potential. The most common otorhinolaryngologic location for extranodal manifestation is the sinonasal compartment. Surgical excision remains the most common treatment modality yielding lowest persistence and/or recurrence rates.

Understandability and actionability of audiovisual patient education materials on sinusitis.

BACKGROUND: Acute and chronic rhinosinusitis are debilitating diseases that affect from 5% to 16% of the population. YouTube is the second most commonly used search engine and is often utilized by patients to garner health information regarding various disease processes and their respective management options. An evaluation of these information resources for quality and reliability is warranted, especially in an era in which patients are increasingly turning to audiovisual (A/V) media to educate themselves regarding their ailments. METHODS: The YouTube video database was searched using the term "sinusitis" from its inception through to November 2018. The first 50 videos populated under the relevance-based ranking option were collected and parsed by time and language. Of the 50 videos, 10 were eliminated either for length (≤1 minute or ≥20 minutes), language (any language other than English), and/or for later being removed by YouTube for copyright violations. The videos were then assessed using the Patient Education Materials Assessment Tool-Audio/Visual (PEMAT-A/V) by 2 independent reviewers for understandability and actionability. RESULTS: A total of 40 videos were examined using the PEMAT-A/V tool. The average understandability score was 57.7%, whereas the average actionability score was 46.3%. Eleven videos (28%) had actionability scores of 0%. Videos most commonly addressed disease management options (38%). The second largest category was case presentations regarding surgical techniques (30%). There were only 6 videos focused primarily on education about the definition and common traits of sinusitis (15%). CONCLUSION: Our results show a paucity of high-quality online A/V educational material pertaining to sinusitis, with a majority of videos being neither understandable nor actionable. As patients increasingly turn to internet video databases like YouTube for medical information, it is critical that physicians and institutions create A/V material that is accurate, understandable, and actionable.

Indiscriminate Pathologic Examination of Pediatric Supraglottoplasty Specimens: An Evidence-Based Approach toward Exempt Status.

OBJECTIVE: The primary aim of this study was to demonstrate that indiscriminate pathologic evaluation of supraglottoplasty specimens is unnecessary and does not influence postoperative management. The secondary objective was to determine the costs associated with pathologic evaluation of supraglottoplasty specimens. METHODS: A planned chart review was conducted to evaluate data from consecutive patients undergoing supraglottoplasty. Demographic data were extracted and pathology reports were reviewed. Projected cost savings were estimated based on 2018 Centers for Medicare & Medicaid Services reimbursement rates for Current Procedural Terminology code 88304 (surgical pathology, gross and microscopic examination). RESULTS: A total of 1417 consecutive patients were identified. All specimens underwent gross and microscopic examination. Pathologic outcomes were categorized into 3 major categories: no diagnostic abnormality (n = 1069), chronic inflammation (n = 346), and other (n = 2). Pathologic evaluation did not alter postoperative management in any patient. Projected yearly and 5-year cost- savings totaled $11,818.08 and $59,173.92, respectively. DISCUSSION: These findings demonstrate that pathologic examination of supraglottoplasty specimens adds no value to patient management. A more selective approach to pathologic examination of certain surgical specimens is an improvement opportunity to enhance the value of patient care by eliminating direct financial costs and "hidden costs" associated with unnecessarily increased workload. IMPLICATIONS FOR PRACTICE: Addressing inappropriate, indiscriminate pathologic examination of certain surgical specimens is a potential quality improvement opportunity that has a meaningful impact on the value of patient care and reduces strains on the workload of surgical and pathology department personnel.

Validity testing of a three-dimensionally printed endoscopic sinonasal surgery simulator.

OBJECTIVES/HYPOTHESIS: To assess the face, content, construct, and concurrent validity of the PHACON Sinonasal Surgery Simulator (SNSS). STUDY DESIGN: Prospective cohort study. METHODS: A total of 12 otolaryngology residents were recruited to perform sinonasal surgery on the simulator followed by cadaveric heads. Resident performances were recorded and de-identified. Face and content validities were evaluated based on 5-point Likert scale questionnaires. The recordings were evaluated by extramural expert rhinologists based on a validated Global Rating Scale (GRS). These results were analyzed and compared to assess construct and concurrent validity. RESULTS: The appearance of anatomic structures was rated as realistic by 75% of all participants, while only 30% and 41.7% rated the mucosal and bony tissues as realistic, respectively. A total of 91.7% of participants found the model useful for teaching anatomy, while 66.7% said it was useful for teaching operative technique. Construct validity was confirmed by showing significant differences in performance between the novice and experienced groups. Concurrent validity was confirmed by showing significant correlation between performance on the model and gold standard (i.e. cadaver head). CONCLUSIONS: This study demonstrates the face, content, concurrent, and construct validity of a 3D-printed SNSS. Although this model has the potential to be a valuable tool in endoscopic sinus surgery training for otolaryngology residents, improvements are required with respect to the quality of simulated mucosal tissue as well as the simulated anatomy of the fronto-ethmoid compartment Level of Evidence: NA Laryngoscope, 2019.

Complications, Mortality, and Functional Decline in Patients 80 Years or Older Undergoing Major Head and Neck Ablation and Reconstruction.

Importance: Data regarding outcomes after major head and neck ablation and reconstruction in the growing geriatric population (specifically ≥80 years of age) are limited. Such information would be extremely valuable in preoperative discussions with elderly patients about their surgical risks and expected functional outcomes. Objectives: To identify patient and surgical factors associated with 30-day postoperative complications, 90-day mortality, and 90-day functional decline; to explore whether an association exists between the type of reconstructive procedure and outcome; and to create a preoperative risk stratification system for these outcomes. Design, Setting, and Participants: This retrospective, multi-institutional cohort study included patients 80 years or older undergoing pedicle or free-flap reconstruction after an ablative head and neck surgery from January 1, 2015, to December 31, 2017, at 17 academic centers. Data were analyzed from February 1 through April 20, 2019. Main Outcomes and Measures: Thirty-day serious complication rate, 90-day mortality, and 90-day decline in functional status. Preoperative comorbidity and frailty were assessed using the American Society of Anesthesiologists classification, Adult Comorbidity Evaluation-27 score, and Modified Frailty Index. Multivariable clustered logistic regressions were performed. Conjunctive consolidation was used to create a risk stratification system. Results: Among 376 patients included in the analysis (253 [67.3%] men), 281 (74.7%) underwent free-flap reconstruction. The median age was 83 years (range, 80-98 years). A total of 193 patients (51.3%) had 30-day serious complications, 30 (8.0%) died within 90 days, and 36 of those not dependent at baseline declined to dependent status (11.0%). Type of flap (free vs pedicle, bone vs no bone) was not associated with these outcomes. Variables associated with worse outcomes were age of at least 85 years (odds ratio [OR] for 90-day mortality, 1.19 [95% CI 1.14-1.26]), moderate or severe comorbidities (OR for 30-day complications, 1.80 [95% CI, 1.34-2.41]; OR for 90-day mortality, 3.33 [95% CI, 1.29-8.60]), body mass index (BMI) of less than 25 (OR for 30-day complications, 0.95 [95% CI, 0.91-0.99]), high frailty (OR for 30-day complications, 1.72 [95% CI, 1.10-2.67]), duration of surgery (OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), flap failure (OR for 90-day mortality, 3.56 [95% CI, 1.47-8.62]), additional operations (OR for 30-day complications, 5.40 [95% CI, 3.09-9.43]; OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), and surgery of the maxilla, oral cavity, or oropharynx (OR for 90-day functional decline, 2.51 [95% CI, 1.30-4.85]). Age, BMI, comorbidity, and frailty were consolidated into a novel 3-tier risk classification system. Conclusions and Relevance: Important demographic, clinical, and surgical characteristics were found to be associated with postoperative complications, mortality, and functional decline in patients 80 years or older undergoing major head and neck surgery. Free flap and bony reconstruction were not independently associated with worse outcomes. A novel risk stratification system is presented.

A Systematic Review of Sellar and Parasellar Brown Tumors: An Analysis of Clinical, Diagnostic, and Management Profiles.

OBJECTIVE: To systematically review and analyze clinical, diagnostic, and management trends in sellar and parasellar brown tumors reported in existing literature. METHODS: In this systematic review, PubMed, Ovid MEDLINE, Scopus, and Google Scholar databases were searched for reported cases of sellar/parasellar brown tumors. Relevant titles and abstracts were screened in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Articles meeting inclusion criteria were subjected to data extraction, summarization, and analysis. A rare case of parasellar brown tumor was also presented. RESULTS: Eight reports (including the current report) were eligible for inclusion. Mean patient age was 42.75 years. Reported symptoms included visual disturbances (n = 6), headache (n = 5), fatigue (n = 3), nausea/vomiting (n = 2), chest pain (n = 1), neck pain (n = 1), and dysphagia (n = 1). In cases where computed tomography findings were provided (n = 6), lesions were noted to be expansile and lytic. Lesions were hyperintense on T2-weighted magnetic resonance imaging (66.7%) and demonstrated contrast enhancement (83.3%). Histology unanimously showed multinucleated giant cells in a fibrovascular connective tissue stroma. Dramatic symptom resolution was noted in all patients who underwent resection of the sellar/parasellar brown tumor (n = 4; 50%). CONCLUSIONS: Sellar/parasellar brown tumors are a rare, tertiary manifestation of hyperparathyroidism and can be elusive to diagnose. Diagnosis requires a high index of clinical suspicion in addition to comprehensive biochemical testing, imaging, and histopathologic analysis. Surgical extirpation is favored in cases where the lesion is causing compressive symptoms, or if it is unresponsive to management of hyperparathyroidism.