Outcomes of parathyroidectomy for primary hyperparathyroidism with nonlocalizing preoperative imaging.

BACKGROUND: The purpose of this study was to evaluate our surgical experience in patients with primary hyperparathyroidism (PHPT) with nonlocalizing sestimibi and ultrasound scans. METHODS: A retrospective review of 521 patients treated from April 2005 to July 2017 at Loma Linda University Medical Center who received parathyroidectomy for PHPT. One hundred forty-seven patients (28%) had double negative localization (nonlocalizing sestamibi and ultrasound). RESULTS: Surgical cure for PHPT was 97.3% and 99.2% with nonlocalized and localized disease, respectively, and complication rates were similar between groups. Preoperative parathyroid hormone and gland weight were significantly lower with nonlocalization. The incidence of multigland disease (MGD) was greater in patients with nonlocalization on sestamibi and ultrasound. CONCLUSION: Nonlocalization of parathyroid glands was not associated with decreased cure rate or increased morbidity. The presence of MGD and requirement for more extensive surgery were greater in patients with nonlocalizing disease.

Incidence and burden of comorbid pain and depression in patients with chronic rhinosinusitis awaiting endoscopic sinus surgery in Canada.

BACKGROUND: This study sheds important light on the association between sino-nasal symptoms and global quality of life in patients with chronic rhinosinusitis waiting for endoscopic sinus surgery. Using patient-reported information collected pre-operatively, the primary objective was to report on patients' pre-surgical sino-nasal symptoms and their association with self-reported pain and depression. The secondary objective was to report on levels of depression and pain among patients in the sample reporting severe sleep problems. METHODS: This is a cross-sectional study of patient-reported outcomes collected prospectively from a cohort of 261 patients assigned to the wait list for elective endoscopic sinus surgery in a large urban region of Canada. RESULTS: Younger patients and patients with other medical comorbidities were most likely to report significant symptoms of chronic rhinosinusitis and substantial associated pain and depression. In the primary analyses, patients reporting significant symptoms of chronic rhinosinusitis were more likely to report moderate depression or high pain (p < 0.01). Subsequently, chronic rhinosinusitis patients with severe sleep problems were 82% likely to report moderate or severe depression and pain. CONCLUSION: Preoperative management of depression and pain may be considered in order to improve the health-related quality of life of patients waiting for ESS. As depression and pain were highly prevalent, patients with severe sleep problems may be candidates for prioritized access.

Comparison of stapedotomy minus prosthesis, circumferential stapes mobilization, and small fenestra stapedotomy for stapes fixation.

OBJECTIVE: To compare the outcomes of 3 surgical techniques for primary stapes fixation: stapedotomy minus prosthesis (STAMP), circumferential stapes mobilization (CSM), and small fenestra stapedotomy (SFS). STUDY DESIGN: Retrospective review of 277 primary cases operated for stapes fixation from 1997 to 2007. SETTING: Tertiary academic center. PATIENTS: Consecutive adult and pediatric cases operated for conductive hearing loss because of stapes fixation. INTERVENTIONS: STAMP was performed for otosclerosis limited to the anterior footplate, CSM was conducted for congenital stapes fixation, SFS was performed for more extensive otosclerosis or anatomic contraindications to STAMP/CSM. MAIN OUTCOME MEASURES: Pure-tone audiometry was performed preoperatively and postoperatively (3-6 wk) and the most recent long-term results (≥ 12 mo). RESULTS: Ninety-nine ears in 90 patients had audiologic follow-up data over 12 months. Sixty-seven ears (68%) underwent SFS, 16 (16%) STAMP, and 16 (16%) CSM. There was significant improvement in average air conduction (AC) thresholds and air-bone gap (ABG) for all techniques. Mean ABG for SFS closed from 29 to 7.1 dB (SD, 6.0), for STAMP from 29 to 3.8 dB (SD, 5.8 dB), and for CSM from 34 to 20 dB (SD, 8.2 dB). AC results were better in the STAMP than in the SFS group, especially in high frequencies. Bone conduction improvements were seen in all groups, highest in STAMP (4.3 dB) and CSM (3.8 dB) groups, but the differences between groups were not statistically significant. CONCLUSION: Satisfactory hearing results were achieved with all the techniques, and STAMP showed better hearing outcomes, especially in high frequencies. CSM is a good option for children and patients in whom it is desirable to avoid a footplate fenestration or prosthesis. CSM and STAMP had significantly higher rates of revision for refixation than SFS.

Minimally invasive functional approach for cholesteatoma surgery.

OBJECTIVES/HYPOTHESIS: Report the efficacy of a functional minimally invasive approach for cholesteatoma surgery. STUDY DESIGN: Retrospective review of surgical cases performed between 1996 and 2008. METHODS: One hundred sixty-nine patient charts were reviewed in which ears with primary cholesteatomas that extended beyond the mesotympanum were operated on with a plan for canal wall up (CWU) mastoidectomy. The surgical approach consisted of progressive exposure from transcanal to postauricular tympanoplasty to CWU mastoidectomy, as needed, to identify and lyse the fibrous attachments that bind the capsule to the surrounding mucosa. Endoscopic guidance was employed as appropriate to minimize exposure needs. Any planned second-stage operations were attempted with a transcanal approach if appropriate and with endoscopic assistance. RESULTS: One hundred eighty-four ears of 169 patients were included. The median age was 32 years (range, 1-79 years). The mean follow-up was 3.2 years (range, 1-11 years). Eighty-three (45%) were planned for a second-look operation, and three (2%) required unplanned second operations. The overall recurrence rate was 24/184 (13%), and the unexpected residual rate was 5/184 (3%). The residual rate with endoscopy (5/119, 4%,) or without endoscopy (1/65, 2%), were not significantly different. Hearing results in 156 ears improved significantly, from a preoperative pure-tone average (PTA) of 41 dB to a postoperative PTA average of 29 dB (P < .0001). CONCLUSIONS: A functional minimally invasive approach to cholesteatoma surgery provided equivalent residual rates but higher recurrence rates compared to published canal wall down mastoidectomy. Endoscopic techniques were helpful in providing adequate views while minimizing exposure.

Middle turbinate suture technique: a cost-saving and effective method for middle meatal preservation after endoscopic sinus surgery.

BACKGROUND: Lateralization of the middle turbinate following endoscopic sinus surgery (ESS) can lead to increased patient morbidity. Numerous techniques have been proposed to avoid this complication, including middle turbinectomy, stents, controlled synechiae formation, and metal clips. OBJECTIVES: To determine if a suture technique is an effective middle turbinate stabilization procedure and to determine the cost savings of this technique compared to commercially available middle meatal stents. MATERIAL AND METHODS: Retrospective review of 60 cases, all performed by the senior author using a middle turbinate suture technique, and the 3-month postoperative results. The efficacy of the technique was determined, as well as its cost compared to other materials for middle meatal preservation. RESULTS: A total of 110 turbinates were treated with the suture technique in 60 patients. The success rate was 98.2% (108 of 110). Commercial stent use cost ranged from 8 to 83 times the price of the suture depending on the stent. CONCLUSION: The middle turbinate suture technique is effective in preventing turbinate lateralization and has a significantly lower cost than commercially available middle meatal spacer materials.