Airway Management of COVID-19 Positive Patients Aboard USNS COMFORT Mission to New York City.

During the USNS Comfort mobilization to New York City in response to the pandemic, the ship's medical team cared for over 35 mechanically ventilated corona virus disease 2019 (COVID-19) infected patients. Due to the better than expected mortality rates of these patients, tracheotomy for prolonged intubation or other indicated interventional bronchoscopies were performed on 7 COVID positive patients, as well as 2 with negative screening tests. No member of the health care team subsequently became symptomatic or tested positive for COVID-19. This was in part due to the formation of a dedicated surgical airway team, use of standardized procedural techniques and personal protective equipment (PPE), and construction of a negative pressure operating room within the COVID-19 isolation ward on the ship. This experience shows that tracheotomies and other aerosolizing procedures can be performed with due concern for patient and provider safety, regardless of patient's COVID status.

Radiographic findings in young adults with asymmetric sensorineural hearing loss.

PURPOSE: To evaluate radiographic findings in US Navy recruits found to have asymmetric sensorineural hearing loss (ASNHL) during routine medical screening. MATERIALS AND METHODS: Retrospective analysis of US Navy recruits receiving screening audiometry and medical suitability evaluation from January 2011 to October 2016. Single-institution, institutional review board-approved study of US Navy recruits screened for hearing loss over a six-year period. All recruits with ASNHL were evaluated by an otolaryngologist and received diagnostic radiographic evaluation. Audiometric and imaging results were retrospectively reviewed for this population and compared to common screening criteria. RESULTS: ASNHL was identified in 674 of 228,504 total recruits screened. This population was 91% male and between 17 and 29 years old (mean age 21.1). Six-hundred fifty-three (97%) met criteria for further ASNHL evaluation. Subjective hearing loss was reported in only 6% of patients. Six-hundred sixty-one (99%) received magnetic resonance imaging of the internal auditory canals. Intracranial pathology was identified in 43 (6.3%) patients and 2 (0.3%) had a causative intracranial lesion corresponding to ASNHL. No patients were found to have a vestibular schwannoma. CONCLUSIONS: In a population of healthy young adults with audiometric proven ASNHL, 0.3% had radiographic proven intracranial pathology explaining the hearing loss. Intracranial masses may be less likely to cause ASNHL in this population; further research is needed to determine appropriate MRI screening methods for young adults with ASNHL.

Respiratory Epithelial Adenomatoid Hamartoma.

BACKGROUND: Respiratory Epithelial Adenomatoid Hamartoma (REAH) is an uncommon, benign tumor of the sinonasal tract. It can, however, be confused with a sinonasal malignancy causing undo morbidity to patients. Therefore, the clinical as well as histological diagnosis is crucial in order to correctly care for patients. METHODS: This review of a patient, to include their clinical pictures, radiologic pictures, and histologic pictures, allow for the clinician to accurately evaluate and diagnose REAH. RESULTS: Our patient presented with a classic bilateral olfactory cleft mass on endoscopic exam. CT was obtained showing a non-enhancing homogenous mass, widening the olfactory cleft, with no evidence of skull base defects or bony erosion. MRI was additionally obtained, given the location, showing a homogenous cribriform mass with clearly defined borders with post-contrast enhancement on T1-weighted images and hyperintense T2-weighted images. A biopsy in clinic was done, showing small to medium, round to oval shaped glands lined with ciliated respiratory epithelium and separated by stroma. The surface epithelium extends into the submucosa, communicating with the proliferating glands. CONCLUSION: Our patient, presented in this case report, shows a classic presentation of REAH. Using these findings, patients can be better counseled on this benign entity, ranging from observation to surgical intervention.

Perioperative dexamethasone administration and risk of bleeding following tonsillectomy in children: a randomized controlled trial.

CONTEXT: Corticosteroids are commonly given to children undergoing tonsillectomy to reduce postoperative nausea and vomiting; however, they might increase the risk of perioperative and postoperative hemorrhage. OBJECTIVE: To determine the effect of dexamethasone on bleeding following tonsillectomy in children. DESIGN, SETTING, AND PATIENTS: A multicenter, prospective, randomized, double-blind, placebo-controlled study at 2 tertiary medical centers of 314 children aged 3 to 18 years undergoing tonsillectomy without a history of bleeding disorder or recent corticosteroid medication use and conducted between July 15, 2010, and December 20, 2011, with 14-day follow-up. We tested the hypothesis that dexamethasone would not result in 5% more bleeding events than placebo using a noninferiority statistical design. INTERVENTION: A single perioperative dose of dexamethasone (0.5 mg/kg; maximum dose, 20 mg), with an equivalent volume of 0.9% saline administered to the placebo group. MAIN OUTCOME MEASURES: Rate and severity of posttonsillectomy hemorrhage in the 14-day postoperative period using a bleeding severity scale (level I, self-reported or parent-reported postoperative bleeding; level II, required inpatient admission for postoperative bleeding; or level III, required reoperation to control postoperative bleeding). RESULTS: One hundred fifty-seven children (median [interquartile range] age, 6 [4-8] years) were randomized into each study group, with 17 patients (10.8%) in the dexamethasone group and 13 patients (8.2%) in the placebo group reporting bleeding events. In an intention-to-treat analysis, the rates of level I bleeding were 7.0% (n = 11) in the dexamethasone group and 4.5% (n = 7) in the placebo group (difference, 2.6%; upper limit 97.5% CI, 7.7%; P for noninferiority = .17); rates of level II bleeding were 1.9% (n = 3) and 3.2% (n = 5), respectively (difference, -1.3%; upper limit 97.5% CI, 2.2%; P for noninferiority < .001); and rates of level III bleeding were 1.9% (n = 3) and 0.6% (n = 1), respectively (difference, 1.3%; upper limit 97.5% CI, 3.8%; P for noninferiority = .002). CONCLUSIONS: Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with excessive, clinically significant level II or III bleeding events based on not having crossed the noninferior threshold of 5%. Increased subjective (level I) bleeding events caused by dexamethasone could not be excluded because the noninferiority threshold was crossed. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01415583.

Burn Pit Exposure Is Associated With Increased Sinonasal Disease.

OBJECTIVE: The aim of this study was to determine whether self-reported burn pit exposure is associated with increased subjective and objective sinus disease. DESIGN: A cross-sectional study was performed evaluating consecutive adult patients presenting to a US Military rhinology clinic. Demographics, medical histories, sinonasal quality-of-life scores, and nasal endoscopy examinations were obtained. Participants were divided into three cohorts based on self-reported exposure histories and outcomes compared. RESULTS: One hundred eighty-six patients met the inclusion criteria, the majority of whom were male. Patients with burn pit exposure had worse Sinonasal Outcome Test-22 scores (49.9) compared with those deployed without burn pit exposure (31.8) or never deployed (31.5). Endoscopic findings demonstrated worse disease within those exposed (Lund-Kennedy score, 3.3) compared with the other cohorts (1.8 and 1.7, respectively). CONCLUSIONS: These novel findings suggest that deployment-related burn pit exposure is associated with increased subjective and objective sinus disease.

COVID-19 Preprocedural Testing: What About the False Positives?

In the COVID-19 era, preprocedural patients are almost uniformly screened for symptoms, asked to quarantine preoperatively, and then undergo a test of uncertain validity with very low pretest probability. A small percentage of these tests return positive. As a result, surgical procedures are delayed and patients are required to quarantine. Are these asymptomatic patients truly positive for COVID-19? What are the impacts of these test results on the patient and the health care system? In the following commentary, we review how the uncertain validity of reverse transcription polymerase chain reaction testing combined with a low-prevalence population predisposes for false-positive results. As a mitigation strategy, we ask that readers refocus on the fundamental principal of diagnostic testing: pretest probability.

Misconceptions About Negative Pressure Rooms and Their Impact Aboard USNS Comfort in New York City.

The outbreak of novel coronavirus disease 2019 (COVID-19) has had a momentous impact on the field of otolaryngology due to the high number of aerosol-generating procedures involving the upper aerodigestive tract. These procedures bear significant risk to the provider and clinical environment due to the possibility of viral aerosolization. While significant attention has been appropriately paid to personal protective equipment during this pandemic, an understanding of industrial hygiene is also necessary for the safe delivery of health care to mitigate the risk of exposure to other patients and health care workers. We provide a review of air ventilation practices and their role in reducing pathogen spread. In addition, we share our experiences with effectively treating COVID-19-positive patients aboard the USNS Comfort through proper environment control measures.

Parathyroid Computed Tomography Angiography: Early Experience with a Novel Imaging Technique in Primary Hyperparathyroidism.

OBJECTIVES: To describe parathyroid computed tomography angiography (PCTA), determine its accuracy, and, as a secondary objective, calculate its mean radiation dosimetry. STUDY DESIGN: Retrospective chart review of patients who underwent parathyroidectomy for primary hyperparathyroidism from 2007 to 2015. SETTING: Single-center tertiary care academic military hospital. SUBJECTS AND METHODS: PCTA is a 2-phase computed tomography imaging technique that uses individualized timing of contrast infusion and novel patient positioning to accurately identify parathyroid adenomas. Consecutive patients who underwent parathyroidectomy for primary hyperparathyroidism from 2007 to 2015 were reviewed; 55% of patients were women. The mean age was 50.9 years (range, 26-68 years). Sensitivity and specificity were calculated as well as mean radiation dosimetry and timing of contrast. RESULTS: A total of 108 procedures were performed during the study period. Twenty-one patients undergoing 22 PCTAs after prior sestamibi scans were nonlocalizing or equivocal. In this group, there were 15 true-positive, 3 false-positive, 4 true-negative, and 0 false-negative PCTAs. This represents a sensitivity of 100% (95% CI, 74.7%-100%) and a specificity of 57% (95% CI, 20%-88%). The mean calculated radiation dose was 5.15 mSv. In the most recent studies, a mean dose of 4.1 mSv was calculated. The ideal time of image acquisition contrast administration varied from 20 to 30 seconds after contrast infusion. CONCLUSIONS: PCTA is a new technique in anatomic imaging for hyperparathyroidism. In a single-center, single-radiologist retrospective study, it demonstrates excellent accuracy for patients with parathyroid adenomas that are otherwise difficult to localize preoperatively. Preliminary experience suggests that its use may be indicated as a primary imaging modality in the future.

Oral Secondary Syphilis.

Secondary syphilis develops in approximately 25% of patients infected with the spirochete bacterium Treponema pallidum. It typically develops several weeks to several months after the primary infection, which is recognized by a painless chancre. Secondary syphilis is characterized by systemic symptoms, such as malaise and fever as well as a maculopapular rash involving the trunk and extremities including the palms and soles. Condyloma lata, which are raised, fleshy lesions, tend to develop at the site of the primary chancre. Diagnosis is achieved primarily through screening and confirmational serologic testing. Histologic findings seen in condyloma lata are largely non-specific. Therefore, a high index of suspicion should be maintained and immunohistochemical stains specific for T. pallidum should be utilized.

Management of the incus body in ossiculoplasty.

OBJECTIVE: (1) Evaluate the sound transfer impact of removal of the incus body in ossicular chain reconstruction (OCR) using an incus strut prosthesis. (2) Provide basic science data to assist clinical decision making in ossiculoplasty. STUDY DESIGN: Basic science. SETTING: Cadaveric temporal bone research laboratory. SUBJECTS AND METHODS: Ossicular chain reconstruction with an incus strut prosthesis was performed on 7 human temporal bones with and without the incus body. The difference in round window membrane (RWM) peak-to-peak displacements (90-dB sound pressure level, 250-8000 Hz) using single-point laser Doppler vibrometry (LDV) was compared with observed baseline, intact ossicular chain values. RESULTS: Comparing OCR using an incus strut prosthesis to an intact ossicular chain across all 7 temporal bones, the largest differences in RWM velocity occurred at 1011 and 2011 Hz. With increasing frequencies, RWM velocities of the OCR approached the intact ossicular chain. Using a Wilcoxon rank-sum test comparing the ossicular chain with and without the incus body showed no statistically significant difference across all frequencies (P = .925). Removing the incus body resulted in improved median RWM velocity (× 10(-2) mm/s) by 0.6 at 1011 Hz and a decrease of 0.6 at 2011 Hz. A rank-sum test to evaluate the difference at 1011 and 2011 Hz did not demonstrate statistical significance. CONCLUSION: Removal of the incus body in OCR using an incus strut prosthesis did not significantly change sound transfer function of the middle ear relative to its preservation. Our data suggest the impact of the retained mass in OCR to be minimal.

Antibiotic therapy for pediatric deep neck abscesses: a systematic review.

OBJECTIVE: To evaluate the current evidence regarding the safety and efficacy of medical management for deep neck abscesses in children. DATA SOURCES: Pubmed and Embase databases accessed 3/27/2012. REVIEW METHODS: An a priori protocol defining inclusion and exclusion criteria was developed to identify all articles addressing medical therapy of pediatric deep neck abscesses where details regarding diagnostic criteria, specifics of medical therapy and definitions of failure were presented. The search included electronic databases to identify candidate articles as well as a manual crosscheck of references. The level of evidence was assessed and data extracted by three authors independently. Data were pooled using a random effects model due to significant study heterogeneity. RESULTS: Eight articles met inclusion criteria. The overall level of evidence was grade C. There was significant heterogeneity among the studies (I(2)=98.8%; p<.001). However, each article uniformly presented cases suggesting that medical therapy may be a viable alternative to surgical drainage in some patients. The pooled success rate of medical therapy in avoiding surgical drainage in children with deep neck infections was 0.517 (95%CI: 0.335, 0.700). When patients taken immediately to surgery were excluded and patients were placed on author defined medical protocols, the success rate increased to 0.951 (95%CI: 0.851, 1.051). Subgroup analysis by duration of intravenous antibiotic trial greater than 48h demonstrated a pooled success rate of 0.740 (95%CI: 0.527, 0.953). CONCLUSION: The current literature suggests medical management may be a safe alternative to surgical drainage of deep neck abscesses in children. However, the level of evidence lacks strength and further investigation is warranted.

Paranasal sinus mucocele.

Paranasal sinus mucoceles are epithelium-lined cystic masses usually resulting from obstruction of sinus ostia. They most frequently occur in the frontal and ethmoid sinuses. While ophthalmologic symptoms are most common, patients also report rhinological or neurological complaints. The close proximity of paranasal sinus mucoceles to the orbit and skull base predisposes the patient to significant morbidity. Computed tomography displays a non-enhancing homogenous mass with expansion of bony walls. Magnetic resonance imaging reveals variable intensity of T1-weighted images and a hyperintense mass on T2-weighted images. Histopathologically mucoceles have features of respiratory mucosa with areas of reactive bone formation, hemorrhage, fibrosis, and granulation tissue. Surgical excision is the standard treatment with trends towards endoscopic techniques.