Preoperative Lumbar Drain Use During Acoustic Neuroma Surgery and Effect on CSF Leak Incidence.

OBJECTIVE: To determine if preoperative lumbar drain (LD) use reduces the incidence of postoperative cerebrospinal fluid (CSF) leak in patients undergoing acoustic neuroma resection. METHODS: Retrospective review of 282 patients presenting for acoustic neuroma resection between 2005 and 2014. RESULTS: Two hundred and eighty-two patients had a mean tumor size of 19.1 mm ± 10.2 mm. Twenty-nine (10.3%) patients developed a postoperative CSF leak. Two hundred and twenty patients (78.0%) received a preoperative LD, and 20 (9.1%) developed a CSF leak. Sixty-two (22.0%) patients did not receive a preoperative LD, and 9 (14.5%) developed a CSF leak. No significant difference in CSF leak frequency was observed with use versus no use of a LD (P = .23). Fifteen (5.3%) patients with an LD placed had a complication related to the LD. No significant difference in CSF leak frequency was observed with patient age, neurofibromatosis type-2 diagnosis, tumor size, or sidedness. CONCLUSIONS: Postoperative CSF leaks are among the most common complications of acoustic neuroma microsurgery. No formal guidelines exist for elective placement of a preoperative LD to lower the incidence of CSF leaks. Our reported CSF leak incidence with preoperative LD placement is not significantly lower than without LD use, and there is a complication rate associated with LD use.

Update on reconstructive options for nasal Mohs defects 1.5 cm or less.

PURPOSE OF REVIEW: The article reviews the current literature to provide an overview on contemporary reconstructive options for closure of Mohs defects of the nose that are 1.5 cm or less. RECENT FINDINGS: Although some of the techniques described in the literature are of historical importance only, others have undergone modification and metamorphosis to be broadly used in their contemporary form. Others are implemented in their original design, irrespective of relative age or multiple attempted adaptations. The increase in variable closure options available provides the surgeon with the ability to tailor reconstruction in such a way as to maximize form and function for the patient. SUMMARY: Here we will provide an update on the core techniques in terms of subtle modifications, expanded applications, and examination of outcomes as well as newly described closure techniques that may fill a certain niche in nasal reconstruction.

Opportunity Cost of Surgical Management of Craniomaxillofacial Trauma.

The provision of trauma care is a financial burden, continually associated with low reimbursement, and shifts the economic burden to major trauma centers and providers. Meanwhile, the volume of craniomaxillofacial (CMF) trauma and the number of surgically managed facial fractures are unchanged. Past financial analyses of cost and reimbursement for facial trauma are limited to mandibular and midface injuries, consistently revealing low reimbursement. The incurred financial burden also coincides with the changing landscape of health insurance. The goal of this study is to determine the opportunity cost of operative management of facial trauma at our institution. From our CMF database of greater than 3,000 facial fractures, the physician charges, collections, and relative value units (RVUs) for CMF trauma per year from 2007 to 2013 were compared with a general plastic surgery and otolaryngology population undergoing operative management during this same period. Collection rates were analyzed to assess if a significant difference exists between reimbursement for CMF and non-CMF cases. Results revealed a significant difference between the professional collection rate for operative CMF trauma and that for other operative procedures (17.25 vs. 29.61%, respectively; p < 0.0001). The average number of RVUs billed per provider for CMF trauma declines significantly, from greater than 700 RVUs to 300 over the study period, despite a stable volume. Surgical management of CMF trauma generates an unfavorable financial environment. The large opportunity cost associated with offering this service is a potential threat to the sustainability of providing care for this population.

Vitamin D3 deficiency increases sinus mucosa dendritic cells in pediatric chronic rhinosinusitis with nasal polyps.

OBJECTIVE: Dendritic cells are professional antigen presenting cells, capable of initiating Th1 or Th2 responses, and have been implicated in the pathogenesis of a number of diseases, including sinusitis. Vitamin D(3) is a steroid hormone that acts on dendritic cells in a manner similar to corticosteroids. Investigators examined whether children with allergic fungal rhinosinusitis (AFRS) or chronic rhinosinusitis with nasal polyposis (CRSwNP) were vitamin D(3) deficient and the relationship of vitamin D(3) deficiency to dendritic cell infiltrate in the sinus mucosa. SETTING: Tertiary care university hospital. STUDY DESIGN: Retrospective, controlled study using samples collected from pediatric patients seen from August 2009 to July 2011. SUBJECTS AND METHODS: Plasma levels of 25-hydroxy vitamin D(3) were measured by enzyme-linked immunosorbent assay in children (≤18 years old) with AFRS, CRSwNP, or CRS without nasal polyposis (CRSsNP) and in controls undergoing surgery for adenotonsillar hypertrophy. Vitamin D(3) levels were confirmed using clinical diagnostic methods for those with CRSwNP or AFRS. Tissue samples were immunohistochemically stained for the dendritic cell marker CD209 and the costimulatory molecules CD80 and CD86. RESULTS: There was no difference in mean vitamin D(3) levels between control and CRSsNP, whereas mean CRSwNP and AFRS levels were both well below the minimum recommended level of 30 ng/mL and significantly lower than control and CRSsNP levels. CD209(+) dendritic cells inversely correlated with vitamin D(3) but not costimulatory molecule expression. CONCLUSIONS: These studies identify that children with CRSwNP or AFRS are vitamin D(3) deficient, which may be linked to increased dendritic cell infiltrate. These results suggest a role for vitamin D(3) as a key player in the immunopathology of pediatric CRSwNP.