Management of Cholesteatoma: Extension Beyond Middle Ear/Mastoid.

Petrous bone cholesteatoma, or cholesteatoma that extends beyond the middle ear and mastoid, represents a rare but destructive pathology. Diagnosis can be difficult before substantial morbidity is incurred, and patients can present with life-threatening complications. Determination of disease extent and the functional status of the facial nerve and cochleovestibular system are critical in surgical planning. Typically, surgery involves ablative procedures with the goal of complete disease resection given the low likelihood of preserved inner ear function. In experienced hands, disease control and facial nerve outcomes are favorable; however, disease recidivism is not uncommon and, thus, these patients require lifelong surveillance.

Endobronchial Phenylephrine in Airway Bleeding During Bronchoscopy Does not Cause Hypertension: A Retrospective Observational Study.

BACKGROUND: Bleeding is a known complication during bronchoscopy, with increased incidence in patients undergoing a more invasive procedure. Phenylephrine is a potent vasoconstrictor that can control airway bleeding when applied topically and has been used as an alternative to epinephrine. The clinical effects of endobronchial phenylephrine on systemic vasoconstriction have not been clearly evaluated. Here, we compared the effects of endobronchial phenylephrine versus cold saline on systemic blood pressure. METHODS: In all, 160 patients who underwent bronchoscopy and received either endobronchial phenylephrine or cold saline from July 1, 2017 to June 30, 2022 were included in this retrospective observational study. Intra-procedural blood pressure absolute and percent changes were measured and compared between the 2 groups. RESULTS: There were no observed statistical differences in blood pressure changes between groups. The median absolute change between the median and the maximum intra-procedural systolic blood pressure in the cold saline group was 29 mm Hg (IQR 19 to 41) compared with 31.8 mm Hg (IQR 18 to 45.5) in the phenylephrine group. The corresponding median percent changes in SBP were 33.6 % (IQR 18.8 to 39.4) and 28% (IQR 16.8 to 43.5) for the cold saline and phenylephrine groups, respectively. Similarly, there were no statistically significant differences in diastolic and mean arterial blood pressure changes between both groups. CONCLUSIONS: We found no significant differences in median intra-procedural systemic blood pressure changes comparing patients who received endobronchial cold saline to those receiving phenylephrine. Overall, this argues for the vascular and systemic safety of phenylephrine for airway bleeding as a reasonable alternative to epinephrine.

Modern Trends in Otologic Surgery and Implications for Residency Training.

OBJECTIVE: Placing a middle ear prosthesis is considered a key competency for the general otolaryngologist, but surgeons struggle to obtain and maintain this skill. The current study aims to characterize pre-coronavirus disease 2019 trends in stapedectomy and ossiculoplasty. STUDY DESIGN: Database review. SETTING: Tricare beneficiaries are treated at civilian and military facilities. METHODS: The Department of Defense beneficiary population of more than nine million persons per year was reviewed for patients undergoing either stapedectomy or ossiculoplasty between 2010 and 2019, identified by the current procedural terminology code. RESULTS: A total of 3052 stapedectomies and 7197 ossiculoplasties were performed. Over the 10-year study period, stapedectomy decreased by 23%, with an average annual rate of -2.7% per year (Pearson r = -.91, P = .0003). Ossiculoplasties declined by 18%, an average annual rate of -1.9% (r = -.8, P = .006). In combination, cases declined by 20%, an average annual rate of -2.2% (r = -.87, P = .001). CONCLUSION: While declines in stapedectomy surgery have been well reported, here we show steady declines in ossiculoplasty as well. If these trends continue, more cochlear implantations may be performed annually than stapedectomy and ossiculoplasty combined, with cochlear implantation likely to overtake ossicular chain surgery in the near future. These changes in surgical volume have a direct implication on resident education and general otolaryngology expectations after graduation. Strong consideration should be made to replace "Stapedectomy/Ossiculoplasty" as resident key indicator with "Cochlear Implantation," a more professionally meaningful skill.

Precision Automated Critical Care Management: Closed-loop critical care for the treatment of distributive shock in a swine model of ischemia-reperfusion.

BACKGROUND: Goal-directed blood pressure management in the intensive care unit can improve trauma outcomes but is labor-intensive. Automated critical care systems can deliver scaled interventions to avoid excessive fluid or vasopressor administration. We compared a first-generation automated drug and fluid delivery platform, Precision Automated Critical Care Management (PACC-MAN), to a more refined algorithm, incorporating additional physiologic inputs and therapeutics. We hypothesized that the enhanced algorithm would achieve equivalent resuscitation endpoints with less crystalloid utilization in the setting of distributive shock. METHODS: Twelve swine underwent 30% hemorrhage and 30 minutes of aortic occlusion to induce an ischemia-reperfusion injury and distributive shock state. Next, animals were transfused to euvolemia and randomized into a standardized critical care (SCC) of PACC-MAN or an enhanced version (SCC+) for 4.25 hours. SCC+ incorporated lactate and urine output to assess global response to resuscitation and added vasopressin as an adjunct to norepinephrine at certain thresholds. Primary and secondary outcomes were decreased crystalloid administration and time at goal blood pressure, respectively. RESULTS: Weight-based fluid bolus volume was lower in SCC+ compared with SCC (26.9 mL/kg vs. 67.5 mL/kg, p = 0.02). Cumulative norepinephrine dose required was not significantly different (SCC+: 26.9 µg/kg vs. SCC: 13.76 µg/kg, p = 0.24). Three of 6 animals (50%) in SCC+ triggered vasopressin as an adjunct. Percent time spent between 60 mm Hg and 70 mm Hg, terminal creatinine and lactate, and weight-adjusted cumulative urine output were equivalent. CONCLUSION: Refinement of the PACC-MAN algorithm decreased crystalloid administration without sacrificing time in normotension, reducing urine output, increasing vasopressor support, or elevating biomarkers of organ damage. Iterative improvements in automated critical care systems to achieve target hemodynamics in a distributive-shock model are feasible.

Outcomes of Dexmedetomidine with Local Regional Anesthesia in Carotid Endarterectomy.

BACKGROUND: Adequate sedation to complement regional techniques in carotid endarterectomy (CEA) can be challenging. Dexmedetomidine has both analgesic and amnesic properties and is reported to be a safe and acceptable alternative to conventional general endotracheal anesthesia (GETA). Outcomes observing dexmedetomidine in conjunction with regional anesthesia in CEA are not well described or known. OBJECTIVE: Compare the immediate (during hospitalization) and short-term (within 30 days of hospitalization) postoperative outcomes in patients who underwent CEA using GETA versus local regional anesthesia (LRA) alone versus dexmedetomidine with LRA at a single institution to determine whether dexmedetomidine is a safe adjunct and if there are anesthesia advantages over LRA alone. METHODS: A retrospective cohort study from January 2015 to December 2019 at Saint Joseph Mercy Ann Arbor. Patients were stratified into three groups based on anesthesia type: GETA, LRA, and dexmedetomidine (D) + LRA. Primary outcomes included stroke, myocardial infarction (MI), and death. Patient demographics were characterized and adjusted using propensity score weighting. RESULTS: Three hundred seventy nine patients met inclusion criteria; 182 patients in the GETA group, 66 in the D + LRA, and 131 in LRA. There were no significant differences across anesthesia groups in primary outcomes of stroke, MI, and death during the admission. The GETA group had significantly longer length of stay (LOS) compared to the D + LRA group (LOS = 1.51 days versus 0.85 days; P = 0.011) and the LRA group (LOS = 1.08 days; P = 0.003). However, there was no significant difference in hospital LOS between the D + LRA group and LRA only groups (P = 0.952). There was no significant difference between stroke (LRA 0.87%, GETA 0.85%, and LRA + Dex 3.52%), MI (LRA 0%, GETA 0.49%, LRA + Dex 0%), or death (LRA 5.24%, GETA 1.16%, LRA + Dex 0%), within 30 days between all three of the anesthesia groups. There was no significant difference in postoperative pain scores when comparing the GETA group (mean 1.3, standard deviation [SD] 2.5) to LRA (mean 1.2, SD 2.1) and between LRA and D + LRA (mean 0.9, SD 2.1). Procedure time (time of skin incision to closure) and total room time were comparable among all three anesthesia groups (LRA 2.2 hr, SD 2.2; GETA 2.1 hr, SD 0.5; LRA + Dex 2.1 hr, SD 0.5). CONCLUSIONS: The use of dexmedetomidine in addition to LRA is a safe and acceptable alternative to conventional GETA or LRA alone in CEA with shorter length of hospital stay when compared with GETA, improved patient tolerance based on physician observation, and similar rates of immediate and short-term complications and postoperative pain scores.

A Least Absolute Shrinkage and Selection Operator-Derived Predictive Model for Postoperative Respiratory Failure in a Heterogeneous Adult Elective Surgery Patient Population.

BACKGROUND: Postoperative respiratory failure (PRF) is associated with increased hospital charges and worse patient outcomes. Reliable prediction models can help to guide postoperative planning to optimize care, to guide resource allocation, and to foster shared decision-making with patients. RESEARCH QUESTION: Can a predictive model be developed to accurately identify patients at high risk of PRF? STUDY DESIGN AND METHODS: In this single-site proof-of-concept study, we used structured query language to extract, transform, and load electronic health record data from 23,999 consecutive adult patients admitted for elective surgery (2014-2021). Our primary outcome was PRF, defined as mechanical ventilation after surgery of > 48 h. Predictors of interest included demographics, comorbidities, and intraoperative factors. We used logistic regression to build a predictive model and the least absolute shrinkage and selection operator procedure to select variables and to estimate model coefficients. We evaluated model performance using optimism-corrected area under the receiver operating curve and area under the precision-recall curve and calculated sensitivity, specificity, positive and negative predictive values, and Brier scores. RESULTS: Two hundred twenty-five patients (0.94%) demonstrated PRF. The 18-variable predictive model included: operations on the cardiovascular, nervous, digestive, urinary, or musculoskeletal system; surgical specialty orthopedic (nonspine); Medicare or Medicaid (as the primary payer); race unknown; American Society of Anesthesiologists class ≥ III; BMI of 30 to 34.9 kg/m2; anesthesia duration (per hour); net fluid at end of the operation (per liter); median intraoperative FIO2, end title CO2, heart rate, and tidal volume; and intraoperative vasopressor medications. The optimism-corrected area under the receiver operating curve was 0.835 (95% CI,0.808-0.862) and the area under the precision-recall curve was 0.156 (95% CI, 0.105-0.203). INTERPRETATION: This single-center proof-of-concept study demonstrated that a structured query language extract, transform, and load process, based on readily available patient and intraoperative variables, can be used to develop a prediction model for PRF. This PRF prediction model is scalable for multicenter research. Clinical applications include decision support to guide postoperative level of care admission and treatment decisions.

The Case Against Stapedectomy as a Core Competency for General Practice: A Study of Care Patterns in the Department of Defense.

OBJECTIVE: Stapedectomy remains a key indicator case reportable to the Accreditation Council of Graduate Medical Education despite the decline in the incidence of otosclerosis over the last half century. This study compared the rates of stapedectomy performed by otolaryngologists at academic and nonacademic centers. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral academic centers, nonacademic centers, and civilian purchased-care across the Department of Defense between 2015 and 2020. PATIENTS: Department of Defense beneficiaries with otosclerosis near a military treatment facility with an otolaryngologist. INTERVENTIONS: Stapedectomy (Current Procedural Terminology codes 69,660, 69,661, and 69,662). MAIN OUTCOME MEASURES: Number of stapedectomies performed by setting. RESULTS: From 2015 to 2020, 426 stapedectomies were performed at or near a military treatment facility with an otolaryngologist (274 directly by military otolaryngologists, 152 by community providers). Military providers performed 94% of stapedectomies at or near military academic centers, versus only 30% at or near nonacademic centers ( p < 0.0001). Among the 60 stapedectomies performed at nonacademic centers, only 30 were performed by general otolaryngologists (7% of all stapedectomies performed; 11% of procedures by military providers) while the rest were performed by fellowship-trained otologist or neurotologist. CONCLUSIONS: Low stapes surgical volume by military general otolaryngologists reinforces recent epidemiologic trends and suggests that few general otolaryngologists graduate residency with sufficient competency to pursue independently performing stapedectomy or have difficulty maintaining competency after graduation.

Posterior Vault Distraction Outcomes in Patients With Severe Crouzon Syndrome Resulting from Ser347Cys and Ser354Cys Mutations.

BACKGROUND: In this study, the authors present the outcomes of 4 patients with a severe form of Crouzon syndrome characterized by mutation of fibroblast growth factor receptor 2 (FGFR2) c.1040 C > G p.Ser347Cys or the pathogenic c.1061C > G p.Ser354Cys variant of FGFR2, who underwent posterior vault distraction osteogenesis (PVDO) to alleviate elevated intracranial pressure. METHODS: Patients with diagnosed Crouzon syndrome who were found by genetic testing to have an FGFR2 c.1040 C > G p.Ser347Cys mutation or the c.1061C > G p.Ser354Cys variant were included. Outcome data and presence of hydrocephalus, Chiari Malformation type I (CMIs), and the presence/absence of a tracheostomy were recorded. RESULTS: Three patients with the FGFR2 c.1040 C > G p.Ser347Cys mutation and 1 with the pathogenic FGFR2 c.1061C > G p.Ser354Cys variant were identified as having characteristics of severe Crouzon syndrome. The mean age at PVDO was 15 months and the mean posterior advancement was 20 mm. All 4 patients experienced sufficient relief of the elevated intracranial pressure from the PVDO to prevent the need for shunt placement, stabilize the ventricular dimensions (n = 2), and resolve the CMIs (n = 2). Intracranial pressure screening ruled out malignant cerebrospinal fluid volume increase. CONCLUSIONS: PVDO effectively prevented hydrocephalus and resolved CMIs, successfully alleviating intracranial pressure and maximizing clinical outcomes for patients with severe Crouzon syndrome.

Junctional instability in neuroepithelium and network hyperexcitability in a focal cortical dysplasia human model.

Focal cortical dysplasia is a highly epileptogenic cortical malformation with few treatment options. Here, we generated human cortical organoids from patients with focal cortical dysplasia type II. Using this human model, we mimicked some focal cortical dysplasia hallmarks, such as impaired cell proliferation, the presence of dysmorphic neurons and balloon cells, and neuronal network hyperexcitability. Furthermore, we observed alterations in the adherens junctions zonula occludens-1 and partitioning defective 3, reduced polarization of the actin cytoskeleton, and fewer synaptic puncta. Focal cortical dysplasia cortical organoids showed downregulation of the small GTPase RHOA, a finding that was confirmed in brain tissue resected from these patients. Functionally, both spontaneous and optogenetically-evoked electrical activity revealed hyperexcitability and enhanced network connectivity in focal cortical dysplasia organoids. Taken together, our findings suggest a ventricular zone instability in tissue cohesion of neuroepithelial cells, leading to a maturational arrest of progenitors or newborn neurons, which may predispose to cellular and functional immaturity and compromise the formation of neural networks in focal cortical dysplasia.

Complications Following Orbital Floor Repair: Impact of Intraoperative Computed Tomography Scan and Implant Material.

Importance: Orbital floor fracture repair is complex and postoperative complications are common. A variety of applicable surgical techniques and technologies are available to surgeons, so data about which of these may decrease postoperative complication rates can help better guide clinical decision making. Objectives: To characterize the patient demographics and surgical techniques utilized in orbital floor fracture repairs at San Antonio Military Medical Center and their relationship with rates of postoperative complications. Design, Setting, and Participants: Retrospective chart review of patients who underwent orbital floor fracture repairs from March 2014 to March 2019 with a mean follow-up time of 1.86 months at a tertiary care academic military hospital and level 1 trauma center. Main Outcomes and Measures: Demographic data, indication for surgical repair, fracture severity, orbital floor approach, implant material, and use of intraoperative computed tomography (CT) scan were recorded. Chi-square analysis was performed to determine the relationship between these factors and postoperative diplopia, hypoglobus, enophthalmos, and infection. Results: A total of 124 procedures were performed during the study period: 71.8% of patients were male and 74% were civilian. Mean age was 39 years (range 19-81). Thirty-one patients were lost to follow-up. The most common approach was transconjunctival (83%), which was most frequently used exclusively (68.5%), but was also combined with cantholysis, transcaruncular, or transantral approach. Postoperative diplopia at follow-up was common (53.8%), resolved after an average of 36.3 days, and was significantly associated with surgical indication of entrapment or revision (p = 0.01) and nonutilization of intraoperative CT (p = 0.04). From 2014 to 2016, intraoperative CT was utilized in 21% of cases and revision rate was 10.5%. From 2017 to 2019, 50% of cases utilized intraoperative CT and revision rate was 2% (p = 0.15). Three cases were revisions performed for abnormal plate position noted on postoperative CT scan. Conclusions and Relevance: A statistically significant association was found between postoperative diplopia, surgical indication of entrapment or revision, and nonutilization of intraoperative CT. Revision rates decreased when use of intraoperative CT increased. Three revision cases may have been prevented by use of an intraoperative CT scan. Patients with entrapment should be counseled regarding the increased risk of postoperative diplopia.

Guideline Adherence and Hearing Outcomes of Sudden Sensorineural Hearing Loss in the Military Health System.

INTRODUCTION: The American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline (CPG) proposes several treatment recommendations regarding sudden sensorineural hearing loss (SSNHL). The treatments for this disorder have been controversial and remain varied. We sought to determine CPG adherence and hearing outcomes of SSNHL within the Military Health System (MHS). MATERIALS AND METHODS: This was a retrospective case series with chart review of the MHS's electronic medical record. Patients with SSNHL (n = 112) were treated between March 1, 2012 and September 30, 2015. Clinical improvement was defined as a 20-dB improvement in pure tone averages or a 20% increase in word recognition scores. RESULTS: Oral steroids were used in 63 (56%) patients, intratympanic (IT) steroids were utilized in 11 (10%) patients, and combination therapy was used in 38 (34%) patients. Average pure tone averages improvements with oral steroids, IT steroids, and combination therapy were 31.2 dB (95% CI, 24.4-38.0), 13.4 dB (95% CI, 0.4-29.6), and 17.3 dB (95% CI, 9.32-25.3), respectively. Average word recognition scores improvements with oral steroids, IT steroids, and combination therapy were 29.64% (95% CI, 19.5-39.7), 14.43% (95% CI, -8.32 to 45.3), and 18.48% (95% CI, 5.48-31.5), respectively. Clinical improvements with oral steroids, IT steroids, and combination therapy were 65, 46, and 50%, respectively. CONCLUSION: The MHS is uniquely positioned to evaluate adherence to CPGs on a national and international level given the robust and standardized electronic medical record. Areas identified for improvement include more timely initiation of treatment, standardization of IT steroid dosing, more accurate coding for diagnosis and treatment, and standardization of audiology evaluation.

The use of cochlear implantation in the elderly.

PURPOSE OF REVIEW: To evaluate the impact of cochlear implantation on hearing outcomes, quality of life, complications, and cognitive function in elderly patients. RECENT FINDINGS: Nine articles published between 2014 and 2019 pertain to cochlear implantation in the elderly population. The findings conclude that cochlear implantation improves autonomy and overall quality of life in the elderly. SUMMARY: Design: a pubmed search was employed with title search terms 'cochlear implant,' AND 'elderly' or 'aged.' Twenty-one articles were generated. Of the 21, articles without evidence-based findings were excluded and those published more than 5 years ago were excluded, yielding a final number of nine articles for review. RESULTS: nine articles published on the use of cochlear implantation in the elderly were identified through the literature search between the years 2014-2019. Outcomes included quality of life, speech recognition improvement, improvement in cognitive function as defined by geriatric validated scales, outcomes of hearing rehabilitation, improvement in verbal comprehension, surgical complications, and the ability to manage the external components of the device. CONCLUSION: cochlear implantation improves autonomy and the quality of life in the elderly. Age should not be a factor limiting surgical decision-making, and cochlear implantation can be utilized as a well tolerated, efficient treatment option for severe-to-profound hearing loss in the elderly population.

A 51-Year-Old Man With Unresolved Pulmonary Infiltrates Following Streptococcus pneumoniae Pneumonia.

CASE PRESENTATION: A 51-year-old man presented to the clinic 8 weeks after a 6-day hospital admission for severe multilobar pneumonia caused by Streptococcus pneumoniae. His productive cough resolved after antibiotics, but he reported persistent dyspnea. He recounted a lifelong history of recurrent sinusitis but no previous episodes of pneumonia. The patient denied fever, weight loss, or tobacco, alcohol, or drug use. He worked as an upholstery craftsman with no work-related exposures. He had no bird or exotic animal exposures, and no history of travel outside Sacramento, California, where he lived. Aside from the recently completed 2-week course of levofloxacin, he was not taking any medications.