Bone Pate Obliteration in Canal Wall Down Mastoidectomy: Modifications of an Established Technique.

OBJECTIVE: To describe outcomes with obliteration of the mastoid and medial attic following canal wall down mastoidectomy for cholesteatoma. Our technique uses bone pate in the mastoid and cartilage in the epitympanum and supratubal recess. STUDY DESIGN: Retrospective observational study. SETTING: Tertiary medical center. PATIENTS: Ten years of sequential canal wall down mastoidectomies with obliteration from one neurotologist were reviewed. This included primary and revision cases in adults and children. MAIN OUTCOME MEASURES: Complications, location and extent of cholesteatoma, the presence of a dry ear after surgery, cholesteatoma recidivism, revision procedures, and postoperative hearing. RESULTS: Seventy-eight patients (79 ears) met inclusion criteria. There were few major complications. There was active follow-up of a year or more in 61. For these, the mean follow-up was 3.1 years, and approximately 90% had a dry cavity for the remainder of their follow-up. About half required minimal (if any) maintenance. There were five cases with residual disease, and no cases with recurrent disease. There were five cases that were considered failures, with three taking several years to manifest. There were no cases where cholesteatoma was buried in bone pate. A sizeable minority continued to have active tubotympanic disease despite successful treatment of the attic and mastoid. CONCLUSIONS: This seems to be a safe and reliable means to eradicate cholesteatoma and create a dry, low-maintenance cavity. It is not a cure for tubotympanic disease, and a small minority of initially stable cavities may fail several years following surgery. LEVEL OF EVIDENCE: 4.

Outcomes and Complications with Topical Epinephrine in Endoscopic Sinus Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the safety and efficacy of topical epinephrine in adults undergoing endoscopic sinus surgery (ESS). DATA SOURCES: PubMed, Embase, and Ovid MEDLINE online databases. REVIEW METHODS: Non-case report English articles studying the effects of topical epinephrine as the topical vasoconstrictor used in adult ESS were found from the online databases through January 2019. The PRISMA literature selection process was used (Preferred Reporting Items for Systematic Reviews and Meta-analyses). RESULTS: An overall 2216 articles were identified, with 9 meeting inclusion criteria involving a total of 5043 patients. All 9 studies assessed the safety of topical epinephrine, while 5 examined efficacy. Intraoperative average blood loss (ABL) ranged from 60 to 426 mL. Topical epinephrine concentrations varied from 1:1000 to 1:100,000, and 3 major complications were found for a rate of 0.06%. There were no reports of ophthalmic, orbital, or skull base injury, nor were there reports of cerebrospinal fluid leaks. A meta-analysis was performed on the 4 studies examining ABL. Estimated mean (95% CI) ABL was 119.4 mL (39.1-199.6) in the higher-concentration cohort (>1:10,000) and 372.2 mL (296.8-447.5) in the lower-concentration cohort (≤1:10,000) (P = .001). CONCLUSION: Topical epinephrine is generally safe and provides acceptable hemostasis during ESS, with higher concentrations (>1:10,000) providing improved hemostasis. Caution is advised for its use in patients with preexisting cardiovascular disease or in combination with other topical or injected vasoconstrictive agents. More prospective comparative studies are necessary to determine the ideal hemostatic concentration of epinephrine in ESS.

Invasive species cause large-scale loss of native California oyster habitat by disrupting trophic cascades.

Although invasive species often resemble their native counterparts, differences in their foraging and anti-predator strategies may disrupt native food webs. In a California estuary, we showed that regions dominated by native crabs and native whelks have low mortality of native oysters (the basal prey), while regions dominated by invasive crabs and invasive whelks have high oyster mortality and are consequently losing a biologically diverse habitat. Using field experiments, we demonstrated that the invasive whelk's distribution is causally related to a large-scale pattern of oyster mortality. To determine whether predator-prey interactions between crabs (top predators) and whelks (intermediate consumers) indirectly control the pattern of oyster mortality, we manipulated the presence and invasion status of the intermediate and top trophic levels in laboratory mesocosms. Our results show that native crabs indirectly maintain a portion of the estuary's oyster habitat by both consuming native whelks (density-mediated trophic cascade) and altering their foraging behavior (trait-mediated trophic cascade). In contrast, invasive whelks are naive to crab predators and fail to avoid them, thereby inhibiting trait-mediated cascades and their invasion into areas with native crabs. Similarly, when native crabs are replaced with invasive crabs, the naive foraging strategy and smaller size of invasive crabs prevents them from efficiently consuming adult whelks, thereby inhibiting strong density-mediated cascades. Thus, while trophic cascades allow native crabs, whelks, and oysters to locally co-exist, the replacement of native crabs and whelks by functionally similar invasive species results in severe depletion of native oysters. As coastal systems become increasingly invaded, the mismatch of evolutionarily based strategies among predators and prey may lead to further losses of critical habitat that support marine biodiversity and ecosystem function.

Supraglottoplasty surgery types 1-3: A practical classification system for laryngomalacia surgery.

OBJECTIVE: The objective of this study is to review the published literature on supraglottoplasty techniques for correcting laryngomalacia, and to subsequently provide a standardized classification system. METHODS: Three authors independently and systematically searched Pubmed/MEDLINE and six additional databases for all studies that included descriptions of supraglottoplasty techniques for correcting laryngomalacia. Sub-sites operated on and specific technique descriptions were reviewed, cataloged and subsequently categorized. This data was then used to develop a new classification system. RESULTS: 231 articles were identified, downloaded and reviewed in full text. 53 articles with 1669 patients from the included articles described in detail the supraglottoplasty procedure. 84 articles with 5731 patients had to be excluded secondary to not providing detail about the supraglottoplasty procedure. The resultant data identifies the need for a more standardized reporting of the supraglottoplasty procedure in order to more accurately evaluate technique specific outcomes. Currently 77% of the patients in the literature cannot be assessed for outcomes as they did not describe the details for the procedures. Eight variations of supraglottoplasty and four variations of epiglottis surgery were described. Based on the literature, we consolidated the surgery into the following types: Type 1: Debulking of arytenoids, Type 2: Division of aryepiglottic folds, Type 3: Epiglottis surgery. CONCLUSION: This descriptive review identified 53 articles with 1669 patients from the included articles detailing multiple variations of supraglottoplasty techniques. The new classification supplements a previously established system describing laryngomalacia, and simplifies the supraglottoplasty into three descriptive and logical types of categories. Our classification system would give surgeons a universal language to describe the supraglottoplasty performed, which could improve reporting of techniques, and facilitate future communication and research.

Sensorimotor Rhythm BCI with Simultaneous High Definition-Transcranial Direct Current Stimulation Alters Task Performance.

BACKGROUND: Transcranial direct current stimulation (tDCS) has been used to alter the excitability of neurons within the cerebral cortex. Improvements in motor learning have been found in multiple studies when tDCS was applied to the motor cortex before or during task learning. The motor cortex is also active during the performance of motor imagination, a cognitive task during which a person imagines, but does not execute, a movement. Motor imagery can be used with noninvasive brain computer interfaces (BCIs) to control virtual objects in up to three dimensions, but to master control of such devices requires long training times. OBJECTIVE: To evaluate the effect of high-definition tDCS on the performance and underlying electrophysiology of motor imagery based BCI. METHODS: We utilize high-definition tDCS to investigate the effect of stimulation on motor imagery-based BCI performance across and within sessions over multiple training days. RESULTS: We report a decreased time-to-hit with anodal stimulation both within and across sessions. We also found differing electrophysiological changes of the stimulated sensorimotor cortex during online BCI task performance for left vs. right trials. Cathodal stimulation led to a decrease in alpha and beta band power during task performance compared to sham stimulation for right hand imagination trials. CONCLUSION: These results suggest that unilateral tDCS over the sensorimotor motor cortex differentially affects cortical areas based on task specific neural activation.