Recurrent Peritonsillar Abscess Caused by Vaginal Flora: A Common Problem From a Unique Source.

Peritonsillar abscesses (PTAs) are typically caused by group A Streptococcus or mixed oral flora. Gardnerella vaginalis is a part of the normal vaginal microbiome, and overgrowth can cause bacterial vaginosis. We present a case of recurrent PTA with G. vaginalis superinfection, which occurred after the patient performed oral sex on a female after incision and drainage of her initial PTA. The patient continued to have recurrent PTAs until G. vaginalis was identified, and antibiotic coverage was broadened to cover both group A Streptococcus and G. vaginalis. This case highlights the importance of culturing PTA aspirate for directed antibiosis in persistent or recurrent infections. The rare superinfection also raises the question of advising abstinence from oral-genital contact after oral procedures to minimize risk of superinfection.

Primary tracheal adenoid cystic carcinoma: A case report and analysis of the tumor immune microenvironment using single cell RNA sequencing.

BACKGROUND: Tracheal adenoid cystic carcinoma (ACC) is a slow growing yet aggressive malignancy with high rates of local recurrence as well as distant metastasis. Tracheal ACC exhibit a low mutation burden along with high mutational diversity, and generally do not respond well to chemotherapeutics. METHODS: We present a rare case of primary tracheal ACC initially presenting with nonspecific cervicalgia and globus sensation that was ultimately treated with tracheal resection followed by chemoradiation. Immune profiling of intratumoral T-cell receptor (TCR) repertoire was subsequently performed using single cell RNA sequencing (scRNAseq). RESULTS: We describe a rare case of primary tracheal adenoid cystic carcinoma highlighting several management principles as well as providing new insights into intratumor T cell populations. CONCLUSIONS: Primary tracheal ACC is most commonly treated with surgical resection followed by adjuvant therapy. Further characterization of the tumor immune microenvironment is necessary to better understand ACC disease biology and to identify potential therapeutic targets.

Patterns of virtual reality and Fitbit wearable activity device use after skull base surgery.

KEY POINTS: Virtual reality (VR) and Fitbit devices are well tolerated by patients after skull base surgery. Postoperative recovery protocols may benefit from incorporation of these devices. However, challenges including patient compliance may impact optimal device utilization.

Emerging Imaging Technologies for Parathyroid Gland Identification and Vascular Assessment in Thyroid Surgery: A Review From the American Head and Neck Society Endocrine Surgery Section.

Importance: Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery. Observation: This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)-both label free and in combination with indocyanine green-based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery. Conclusions and Relevance: Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.

Cosmetic Approaches to Parotidectomy.

The parotid gland is located in a cosmetically sensitive area. Given cultural emphasis on cosmesis, using minimally invasive or hidden incisions, when appropriate, can significantly improve patient satisfaction and quality of life following surgery. Facelift-style incisions have been used since the late 1960s to approach parotid pathology. Several alternative incisions, including technology-assisted approaches, also have been described in the literature. To that end, this article explore the existing data regarding several historical and emerging cosmetic approaches to the parotid gland comparing relative advantages and disadvantages of each.

Partial parotidectomy via periauricular incision: Retrospective cohort study and comparative analysis to alternative incisional approaches.

BACKGROUND: We investigated a periauricular approach to the parotid and compared outcomes to alternative parotidectomy incisions. METHODS: Retrospective chart review of patients (n = 97) undergoing partial parotidectomy for benign or malignant pathology by a single surgeon. After October 2017, most patients were approached via a periauricular incision (n = 59). RESULTS: There was no significant difference in patient age, tumor location, length of hospital stay, postoperative complication, or pathology. Mean tumor diameter was significantly smaller in the periauricular group (2.1 cm) than in the traditional incision group (2.6 cm). No permanent injuries to facial nerve branches occurred in either group. Patients were followed for a median of 44 days after surgery. CONCLUSIONS: This is the largest study to date that demonstrates the periauricular incision is a safe and feasible approach for most parotid neoplasms. The cosmetic advantage of this approach is that the resulting scar is smaller and does not extend into the neck.

Reevaluating a Standardized Sedation Weaning Protocol for Pediatric Laryngotracheal Reconstruction for Continuous Quality Improvement.

Importance: Health care organizations are complex and evolving systems. To date, longitudinal evaluation to ensure the sustainability of quality improvement (QI) initiatives has been missing from the otolaryngology literature. We sought to reassess perioperative management of laryngotracheal reconstruction, which requires adequate sedation. Objective: Using principles of continuous QI, the objectives of this study were to (1) describe step-by-step methods to sustain QI efforts and (2) revisit a series of process, outcome, and balance measures for sedation weaning management following implementation of a new electronic health record (EHR). Design, Setting, and Participants: A standardized sedation weaning protocol was previously developed and instituted in February 2013. To address healthcare system-wide changes, a 7-step, Institute for Healthcare Improvement methodology was used to reevaluate a series of measures comparing a previous postweaning group (2013-2014; 13 patients) and current post-EHR group (2016; 11 patients). We conducted a focus group review of these 24 patients. Main Outcomes and Measures: The primary outcome measure was length of sedation weaning. Secondary outcome, process, and balance measures included total length of sedation, absence of standardized wean document, absence of specific recommendations on weaning regimen, length of stay, continued weaning at discharge, discharge location, absence of discharge instructions on weaning regimen or iatrogenic withdrawal syndrome (IWS), discharge within 72 hours of stopping weaning, and readmission. Results: The postweaning and post-EHR groups were similar in age (20.5 months [95% CI, 11.92-29.15] vs 26.5 months [95% CI, 17.68-35.40]), as well as male sex (11 of 13 [85%] vs 10 of 11 [91%]), respectively. In the post-EHR group, the standardized sedation wean document was missing from 9 of 11 (82%) medical records. However, the primary outcome measure, length of sedation weaning, remained stable at 9.45 (95% CI, 7.62-11.29) days in the post-EHR group compared with 9.08 (95% CI, 7.00-11.18) days in the postweaning group. In addition, only 5 of 11 (46%) of discharges in the post-EHR group had specific guidance on weaning since the standardized template was no longer in use. As a result, in the post-EHR group, patients were 15.2 (95% CI, 0.46-242.34) times as likely to lack discharge instructions on weaning or IWS. Conclusions and Relevance: Quality improvement is meant to be a continuous process in which reevaluation of care practices are regularly performed. System-wide redesign can be achieved using a formal methodological approach. Moving forward, notable QI opportunities for our institution included the development of a flexible sedation weaning template, as well as enhancements to discharge instructions to include IWS diagnosis and treatment.

Integrating Data Collection Into Office Work Flow and Electronic Health Records for Clinical Outcomes Research.

Meticulous collection of clinical outcomes metrics in patients undergoing elective surgery is important to ensure quality care; it is also increasing in importance as the Centers for Medicare & Medicaid Services moves to tie reimbursement to outcomes and insurance approval. This study assesses a systematic method for gathering preoperative and postoperative data on patients with nasal obstruction who undergo functional septorhinoplasty that was developed at the Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts. The electronic database was initiated in July 2013, patients continue to be actively enrolled, and follow-up data continue to be collected. This procedure represents a systematic method for the initial visit evaluation, collection of patient-reported outcome measures, documentation of surgical management, and follow-up of patients. For consistency and ease of data collection, as well as data interpretation, this method is integrated into a RedCap survey database and the institution's electronic health record system. During the 4 years that this process has been in place, outcomes data have been collected on more than 1000 patients at 7 time points to create an institutional database. This system allows the tracking of patients' outcomes data and the mining of the institutional database for future research. As Centers for Medicare & Medicaid Services moves from a volume-driven health care model to a value-driven health care model, demonstration of measurable outcomes in patients undergoing elective surgery will be of paramount importance.

Robotic epiglottopexy for severe epiglottic prolapse limiting decannulation.

Surgical management of supraglottic collapse at the level of the epiglottis limiting decannulation has historically consisted of placement of epiglottopexy sutures which are technically challenging and often unsuccessful. Herein we describe the use of robotic technology to assist with epiglottopexy for a case of a 9 year old child with severe epiglottic petiole prolapse limiting capping and decannulation. Postoperatively the patient is tolerating capping during waking hours.

Novel Mobile App Allows for Fast and Validated Intraoperative Assessment of Otolaryngology Residents.

Evaluation of resident operative skills is challenging in the fast-paced operating room environment and limited by lack of validated assessment metrics. We describe a smartphone-based app that enables rapid assessment of operative skills. Accreditation Council for Graduate Medical Education (ACGME) otolaryngology taxonomy surgical procedures (n = 593) were uploaded to the software platform. The app was piloted over 1 month. Outcomes included (1) completion of evaluation, (2) time spent completing the evaluation, and (3) quantification of case complexity, operative autonomy, and performance. During the study, 12 of 12 procedures, corresponding to 3 paired evaluated by the resident/attending dyad. Mean ± SD time of evaluation completion was 98.0 ± 24.2 and 123.0 ± 14.0 seconds for the resident and attending, respectively. Mean time between resident and attending evaluation completion was 27.9 ± 26.8 seconds. Resident and attending scores for case complexity, operative autonomy, and performance were strongly correlated (P < .0001). Rapid evaluation of resident intraoperative performance is feasible using smartphone-based technology.