Incidence of synchronous malignancies found during triple endoscopy in head and neck cancer.

OBJECTIVES: To investigate the incidence of synchronous malignancies identified during triple endoscopy in patients with head and neck squamous cell carcinoma. METHODS: A retrospective chart review of patients from a tertiary academic medical center was performed. Patients with a primary head and neck squamous cell carcinoma who underwent triple endoscopy were included. Operative, radiographic, and pathology reports were reviewed to evaluate for the presence of synchronous malignancies in the aerodigestive tract diagnosed through endoscopy. Demographics, relevant medical history, including tobacco and alcohol use, and tumor characteristics were recorded. Univariate and multivariate regression analyses were conducted to assess for associations with synchronous malignancy on triple endoscopy. RESULTS: 215 patients were reviewed, 164 of which had a biopsy-positive head and neck squamous cell carcinoma and underwent triple endoscopy. Synchronous lesions were found in 8 patients (4.9%). Of the synchronous lesions, only two were identified on esophagoscopy and bronchoscopy; the remaining six were found on direct laryngoscopy. Clinical comorbidities including smoking and alcohol history, tumor p16 status, and tumor stage were not associated with presence of synchronous lesions. A positive synchronous lesion on positron emission tomography was significantly correlated with finding a synchronous lesion on triple endoscopy (p = 0.006). CONCLUSION: This study shows the incidence of synchronous lesions on triple endoscopy to be closer to 5%. While endoscopic examination can be useful in the anatomic characterization of head and neck malignancies, the low incidence of synchronous malignancies suggests that the need for triple endoscopy may be considered on a case-by-case basis.

Nuances of Septal Deviation Repair.

Septoplasty is one of the most common procedures performed by facial plastic surgeons. Surgical decision-making surrounding septal deviation repair centers around the location of deviation and need for dorsal and/or caudal septal correction. Endonasal approaches are often adequate and external approaches are utilized for significant L-strut involvement. For severe deformities, extracorporeal septoplasty and anterior septal reconstruction can be utilized. We present an overview of septal deviation repair with technical nuances and advanced reconstruction techniques.

Contemporary Management of Microtia.

Microtia techniques have evolved to improve esthetic outcomes, reduce donor site morbidities, and reduce complications. Patients with microtia commonly have aural atresia associated with conductive hearing loss. We present the evolution of our technique for microtia reconstruction and considerations for hearing management in these patients.

The power of a checklist: Decrease in emergency department epistaxis transfers after clinical care pathway implementation.

BACKGROUND: Annually, epistaxis costs US hospitals over $100 million dollars. Many patients visit emergency departments (ED) with variable treatment, thus providing opportunity for improvement. OBJECTIVE: To implement an epistaxis clinical care pathway (CCP) in the ED, and analyze its effects on treatment and ED transfers. METHODS: An interdisciplinary team developed the CCP to be implemented at a tertiary hospital system with 11 satellite EDs. The analysis included matched eight-month periods prior to pathway implementation and after pathway implementation. Subjects included patients with ICD-10 code diagnosis of epistaxis. Patients under 18 years old, recent surgery or trauma, or bleeding disorders were excluded. There were 309 patients from the pre-implementation cohort, 53 of which were transferred and 37 met inclusion criteria; 322 from the post-implementation cohort, 37 of which were transferred, and 15 met inclusion criteria. Outcome measures included epistaxis intervention by ED providers and otolaryngologists before and after pathway implementation. RESULTS: CCP implementation resulted in a 61% reduction in patient transfers (p < 0.001). ED providers showed a 51% increase in documentation of anterior rhinoscopy with proper equipment, 34% increased use of topical vasoconstrictors, 40% increased use of absorbable packing, 7% decrease in use of unilateral non-absorbable packing, and 17% decrease in use of bilateral non-absorbable packing. CONCLUSIONS: Prior to CCP implementation, ED treatment of epistaxis varied significantly. CCP resulted in standardized treatment and significant reduction in transfers. A CCP checklist is an effective way to standardize care and prevent unnecessary hospital transfers.

Improving efficiency in epistaxis transfers in a large health system: Analyzing emergency department treatment variability as pretext for a clinical care pathway.

INTRODUCTION: Epistaxis is a common condition with an estimated $100 million in health care costs annually. A significant portion of this stems from Emergency Department (ED) management and hospital transfers. Currently there is no data in the literature clearly depicting the differences in treatment of epistaxis between Emergency Medicine (EM) physicians and Otolaryngologists. Clinical care pathways (CCP) are a way to standardize care and increase efficiency. Our goal was to evaluate the variability in epistaxis management between EM and Otolaryngology physicians in order to determine the potential impact of a system wide clinical care pathway. MATERIALS AND METHODS: A retrospective case study was conducted of all patients transferred between emergency departments for epistaxis over an 18-month period. Exclusion criteria comprised patients under 18 years old, recent sinonasal surgery, bleeding disorders, and recent facial trauma. RESULTS: 73 patients met inclusion criteria. EM physicians used nasal cautery in 8%, absorbable packing in 1% and non-absorbable packing in 92% (with 33% being bilateral). In comparison, Otolaryngologists used nasal cautery in 37%, absorbable packing in 34%, and non-absorbable packing in 23%. Eighty percent of patients treated by an Otolaryngology physician required less invasive intervention than previously performed by EM physicians prior to transfer. CONCLUSIONS: Epistaxis management varied significantly between Emergency Medicine and Otolaryngology physicians. Numerous patients were treated immediately with non-absorbable packing. On post-transfer Otolaryngology evaluation, many of these patients required less invasive interventions. This study highlights the variability of epistaxis treatment within our hospital system and warrants the need for a standardized care pathway.

A Pediatric Lateral Submental Mass: A Rare Presentation of Dermoid Cyst.

Dermoid cysts are benign cutaneous neoplasms that contain germ cells from the ectoderm and mesoderm. Approximately 70% are diagnosed during childhood before the age of 5. Although they can present throughout the body, the prevalence is 7% for those arising from the head and neck. These lesions present primarily as midline masses and are classified as sublingual, submental, or overlapping depending on their relationship with the muscles of the floor of mouth. A 10-year-old female presented with a 2-week history of right submental swelling. She denied pain, dysphagia, odynophagia, or respiratory distress. Physical examination showed nontender fullness of the submental region without erythema or induration and no palpable cervical lymphadenopathy. Ultrasound showed an oval-shaped cystic mass measuring 4.8 × 4.0 × 2.6 cm. After a course of clindamycin, a computed tomography was obtained which showed a right 4.5 × 4.0 × 2.6 cm fluid filled lesion, within the right lateral floor of mouth. Intraoral resection was performed and the mass was freed from the geniohyoid and mylohyoid. Histopathology was consistent with a dermoid cyst. Submental masses have a broad differential, but rarely are they dermoid cysts if they arise lateral to the midline. With appropriate diagnosis and total surgical excision, patients and their families can be reassured in similar cases.

Recurrent Hemoptysis: A Bronchial Dieulafoy's Lesion in a Pediatric Patient.

OBJECTIVE: This paper presents a case of a bronchial Dieulafoy's lesion in a pediatric patient with recurrent hemoptysis. CASE REPORT: A 11-year old female presented multiple times with dry cough and hemoptysis to an outside hospital, each time leading to a diagnosis of epistaxis and subsequent discharge. When she arrived to our tertiary center with heavy hemoptysis and no evidence of epistaxis, the patient was urgently taken to the operating room by both the otolaryngology and pediatric pulmonology services. Active bleeding from a Dieulafoy's lesion on the right lower bronchus was found and selective embolization of two tortuous arteries was subsequently performed. The patient was discharged in stable condition without recurrence of hemoptysis over the last two months. CONCLUSION: While rare, especially in pediatric patients, bronchial Dieulafoy's lesions may cause severe hemoptysis and should be considered in the differential diagnosis when the etiology for hemoptysis is unclear.

Heparin-mediated antibiotic delivery from an electrochemically-aligned collagen sheet.

BACKGROUND: Implantable medical devices and hardware are prolific in medicine, but hardware associated infections remain a major issue. OBJECTIVE: To develop and evaluate a novel, biologic antimicrobial coating for medical implants. METHODS: Electrochemically compacted collagen sheets with and without crosslinked heparin were synthesized per a protocol developed by our group. Sheets were incubated in antibiotic solution (gentamicin or moxifloxacin) overnight, and in vitro activity was assessed with five-day diffusion assays against Pseudomonas aeruginosa. Antibiotic release over time from gentamicin-infused sheets was determined using in vitro elution and high performance liquid chromatography (HPLC). RESULTS: Collagen-heparin-antibiotic sheets demonstrated larger growth inhibition zones against P. aeruginosa compared to collagen-antibiotic alone sheets. This activity persisted for five days and was not impacted by rinsing sheets prior to evaluation. Rinsed collagen-antibiotic sheets did not produce any inhibition zones. Elution of gentamicin from collagen-heparin-gentamicin sheets was gradual and remained above the minimal inhibitory concentration for gentamicin-sensitive organisms for 29 days. Conversely, collagen-gentamicin sheets eluted their antibiotic load within 24 hours. Overall, heparin-associated sheets demonstrated larger inhibition zones against P. aeruginosa and prolonged elution profile via HPLC. CONCLUSION: We developed a novel, local antibiotic delivery system that could be used to coat medical implants/hardware in the future and reduce post-operative infections.

Assessing delays in laryngeal cancer treatment.

OBJECTIVES/HYPOTHESIS: To see if there has been a decrease in patient delay, professional delay, diagnostic delay, and treatment delay in laryngeal cancer. STUDY DESIGN: Institutional review board-approved retrospective chart review of patients diagnosed with laryngeal cancer. METHODS: Nine hundred sixty-six patients with International Classification of Diseases, Ninth Revision code for laryngeal cancer were identified from 1993 to 2013. Two hundred fifty patients met inclusion criteria. Patients were placed into two groups based on time at presentation to primary care physician, 1993 to 2004 and 2005 to 2013. Patient delay, professional delay, diagnostic delay, and treatment delay were calculated. Statistical analysis was applied using the Student t test and generalized linear model. RESULTS: From 1993 to 2004, patient delay was 88.7 days, professional delay was 40.9 days, diagnosis delay was 33.1 days, and treatment delay was 24.7 days. From 2005 to 2013, patient delay was 119.2 days, professional delay was 37.9 days, diagnosis delay was 23.8 days, and treatment delay was 23.2 days. Comparison using the Student t test demonstrated the difference in patient delay (shorter before 2005) was statistically significant (P = .045), whereas professional delay (P = .269), diagnosis delay (P = .289), and treatment delay (P = .328) did not reveal any significant differences. There was no association between stage at initial diagnosis and days prior to ear, nose, and throat visit (P = .402). CONCLUSIONS: Delays in the presentation of patients to primary care physicians and otolaryngologists have significantly increased in the past 9 years. Earlier referral to otolaryngologists from primary care physicians in high-risk patients with voice changes will lead to more prompt diagnosis and treatment of laryngeal cancer. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1612-1615, 2016.

Recreational motor vehicle use and facial trauma.

OBJECTIVES/HYPOTHESIS: The use of recreational motorized vehicles (RMVs), including all-terrain vehicles (ATVs), snowmobiles, and go-carts, has increased in recent decades. Because RMVs are lightly regulated, there are numerous safety concerns. This analysis examines a nationally representative resource to estimate the incidence of craniofacial trauma secondary to RMV accidents, evaluating injury and demographic patterns. METHODS: The Consumer Product Safety Commission's National Electronic Injury Surveillance System was examined for facial trauma resulting in emergency department (ED) visits stemming from the use of ATVs, motorbikes/scooters, snowmobiles, and utility vehicles. Characteristics including demographics, anatomic sites, mechanism, and location of injury were evaluated, as well as details regarding helmet and alcohol use. RESULTS: There were 1,464 entries extrapolating to an estimated 61,312 ED visits over a 5-year period for facial trauma from RMV use. From 2009 to 2013, there was a 28% reduction in ED visits. The majority of patients were male, and the median age was 17 years. Lacerations (45.1%), contusions/abrasions (26.7%), and fractures (24%) were the most frequent injuries. Among fractures, the most common types were nasal (29%), followed by mandible (20%) and orbital (8%) fractures. All-terrain vehicles (62%) were the most common vehicles. Alcohol consumption resulted in a higher rate of facial fractures (48.5% vs. 22.8%). CONCLUSION: As there is a significant potential for injury, familiarity with injury patterns associated with RMVs is useful in the management of facial trauma. Recreational motorized vehicles facial trauma results in tens of thousands of ED visits annually. This data reinforces the importance of pursuing further efforts to raise public awareness and improve safety measures.