The economic impact of revision otologic surgery.

Revision otologic surgery places a significant economic burden on patients and the healthcare system. We conducted a retrospective chart analysis to estimate the economic impact of revision canal-wall-down (CWD) mastoidectomy. We reviewed the medical records of all 189 adults who had undergone CWD mastoidectomy performed by the senior author between June 2006 and August 2011 at Loyola University Medical Center in Maywood, Ill. Institutional charges and collections for all patients were extrapolated to estimate the overall healthcare cost of revision surgery in Illinois and at the national level. Of the 189 CWD mastoidectomies, 89 were primary and 100 were revision procedures. The total charge for the revision cases was $2,783,700, and the net reimbursement (collections) was $846,289 (30.4%). Using Illinois Hospital Association data, we estimated that reimbursement for 387 revision CWD mastoidectomies that had been performed in fiscal year 2011 was nearly $3.3 million. By extrapolating our data to the national level, we estimated that 9,214 patients underwent revision CWD mastoidectomy in the United States during 2011, which cost the national healthcare system roughly $76 million, not including lost wages and productivity. Known causes of failed CWD mastoidectomies that often result in revision surgery include an inadequate meatoplasty, a facial ridge that is too high, residual diseased air cells, and recurrent cholesteatoma. A better understanding of these factors can reduce the need for revision surgery, which could have a positive impact on the economic strain related to this procedure at the local, state, and national levels.

Body mass index predicts risk for complications from transtemporal cerebellopontine angle surgery.

OBJECTIVES: To determine the relationship between body mass index (BMI) and risk for specific complications from transtemporal cerebellopontine angle (CPA) surgery for nonmalignant disease. STUDY DESIGN: Case series with chart review. SETTING: Tertiary-care academic hospital. SUBJECTS AND METHODS: Retrospective review of 134 consecutive patients undergoing transtemporal cerebellopontine angle surgery for nonmalignant disease from 2009 to 2011. Data were collected regarding demographics, body mass index, intraoperative details, hospital stay, and complications including cerebrospinal fluid leak, wound complications, and brachial plexopathy. RESULTS: One hundred thirty-four patients were analyzed with a mean preoperative body mass index of 28.58. Statistical analysis demonstrated a significant difference in body mass index between patients with a postoperative cerebrospinal fluid leak and those without (P = .04), as well as a similar significant difference between those experiencing postoperative brachial plexopathy and those with no such complication (P = .03). Logistical regression analysis confirmed that body mass index is significant in predicting both postoperative cerebrospinal fluid leak (P = .004; odds ratio, 1.10) and brachial plexopathy (P = .04; odds ratio, 1.07). Elevated body mass index was not significant in predicting wound complications or increased hospital stay beyond postoperative day 3. CONCLUSION: Risk of cerebrospinal fluid leak and brachial plexopathy is increased in patients with elevated body mass index undergoing surgery of the cerebellopontine angle. Consideration should be given to preoperative optimization via dietary and lifestyle modifications as well as intraoperative somatosensory evoked potential monitoring of the brachial plexus to decrease these risks.

Preauricular infratemporal fossa approach for advanced malignant parotid tumors.

OBJECTIVES/HYPOTHESIS: The aims of this study were to demonstrate the surgical technique involved in the preauricular infratemporal fossa (ITF) approach, outline the clinical indications for use of this technique, and present the results in using this approach in 159 patients with malignant parotid tumors. At the conclusion of this article, the reader should be able to understand the utility of the preauricular infratemporal fossa approach in the management of patients with advanced malignant parotid tumors. STUDY DESIGN: This was a retrospective chart review of 159 patients treated at a tertiary care academic medical center following institutional review board approval. METHODS: A comprehensive medical records review was performed for all patients with malignant parotid tumors who underwent a preauricular ITF approach between July 1988 and July 2010. RESULTS: The most common presenting symptoms were pain and trismus, whereas the presence of a parotid mass and facial paralysis were the most common clinical signs. Mucoepidermoid and adenoid cystic carcinoma accounted for 63% of the tumors, and perineural invasion was found in nearly 71% of the patients. Despite negative surgical margins in 92% of the patients, local or regional tumor recurrence was found in 17% of the cases. The mean follow-up time was 12.8 years. CONCLUSIONS: The preauricular ITF approach should be used in the surgical extirpation of advanced malignant parotid neoplasms. This technique provides proximal facial nerve identification, internal carotid artery protection, and negative tumor margins at the skull base.

Linear energy relationships for the octahedral preference of Mg, Ca and transition metal ions.

The geometry, atomic charges, force constants, and relative energies of the symmetric and distorted M(2+)(H(2)O)(4)(F(-))(2), M(3+)(H(2)O)(4)(F(-))(2), M(2+)(H(2)O)(3)(F(-))(2), and M(3+)(H(2)O)(3)(F(-))(2) metal complexes, M = Mg, Ca, Co, Cu, Fe, Mn, Ni, Zn, Cr, V, were calculated by using the B3LYP/TZVP density functional method in both gas phase and aqueous solution, modeled using the polarized continuum model. The deformation energy associated with moving one water ligand 12 degrees from the initial "octahedral" arrangement, in which all O-M-O, O-M-F, and F-M-F angles are either 90 degrees or 180 degrees, was calculated to examine the angular ligand flexibility. For all M(2+)(H(2)O)(4)(F(-))(2) complexes, this distortion increased the energy of the complex in proportion to the electrostatic potential-derived (ESP) charge of the metal, and in proportion to D(-10), where D is the distance from the distorted ligand to its closest neighbor. The octahedral stability was further examined by calculating the energies for the removal of a water ligand from the octahedral complex to form a square-pyramidal or trigonal-bipyramidal complex. The octahedral preference, defined as the negative of the corresponding binding energy of the ligand, was found to linearly correlate with the ESP charge of the metal in both the gas phase and aqueous solution. The obtained results indicate that quantum-mechanical covalent effects are of secondary importance for both the flexibility and the octahedral preference of M(2+)(H(2)O)(4)(F(-))(2) and M(3+)(H(2)O)(4)(F(-))(2) complexes. This conclusion and supporting data are important for the development of consistent molecular mechanical force fields of the studied metal ions.