Resection of the innominate artery to prevent an impending tracheoinnominate fistula and to permit tracheotomy in a patient with subglottic stenosis and high-riding innominate.

OBJECTIVE: This study aimed to determine the long-term viability of innominate artery resection and tracheotomy for a patient at high risk of developing a tracheoinnominate fistula (TIF) in the setting of subglottic stenosis and a high-riding innominate artery. METHODS: Chart review with 2-year follow-up. RESULTS: A 45-year-old diabetic man with obstructive sleep apnea and multiple admissions for coma and delirium tremens associated with alcohol abuse developed subglottic stenosis. He was found to have a palpable supraclavicular pulse during preoperative examination for a tracheotomy. Computed tomography examination revealed a high-riding innominate artery at the level of stenosis along with granulation tissue and disruption of the cartilaginous trachea, suggesting a high risk of impending TIF. The patient underwent a sternotomy-approach resection of the innominate artery with closure of the distal stump with a sternohyoid muscle flap. Intraoperatively, a plane of adhesions between the posterior innominate artery and trachea was dissected. The anterior tracheal wall appeared calcified but without evidence of erosion of either the trachea or the artery. Six weeks later, a tracheotomy was performed. Follow-up at 27 months did not identify complications from the innominate artery resection. CONCLUSION: Resection of the innominate artery is an option for some patients either to address the warning signs of TIF or to permit a tracheotomy to be performed in the presence of a high innominate artery.

High throughput screening for compounds that alter muscle cell glycosylation identifies new role for N-glycans in regulating sarcolemmal protein abundance and laminin binding.

Duchenne muscular dystrophy is an X-linked disorder characterized by loss of dystrophin, a cytoskeletal protein that connects the actin cytoskeleton in skeletal muscle cells to extracellular matrix. Dystrophin binds to the cytoplasmic domain of the transmembrane glycoprotein ß-dystroglycan (ß-DG), which associates with cell surface α-dystroglycan (α-DG) that binds laminin in the extracellular matrix. ß-DG can also associate with utrophin, and this differential association correlates with specific glycosylation changes on α-DG. Genetic modification of α-DG glycosylation can promote utrophin binding and rescue dystrophic phenotypes in mouse dystrophy models. We used high throughput screening with the plant lectin Wisteria floribunda agglutinin (WFA) to identify compounds that altered muscle cell surface glycosylation, with the goal of finding compounds that increase abundance of α-DG and associated sarcolemmal glycoproteins, increase utrophin usage, and increase laminin binding. We identified one compound, lobeline, from the Prestwick library of Food and Drug Administration-approved compounds that fulfilled these criteria, increasing WFA binding to C2C12 cells and to primary muscle cells from wild type and mdx mice. WFA binding and enhancement by lobeline required complex N-glycans but not O-mannose glycans that bind laminin. However, inhibiting complex N-glycan processing reduced laminin binding to muscle cell glycoproteins, although O-mannosylation was intact. Glycan analysis demonstrated a general increase in N-glycans on lobeline-treated cells rather than specific alterations in cell surface glycosylation, consistent with increased abundance of multiple sarcolemmal glycoproteins. This demonstrates the feasibility of high throughput screening with plant lectins to identify compounds that alter muscle cell glycosylation and identifies a novel role for N-glycans in regulating muscle cell function.

Repair of Anterior Tracheal Defect by Trans-Tracheostomy Placement of Acellular Dermal Matrix.

Severe infections of the neck can lead to life-threatening consequences when not treated promptly and correctly. This case report is the first to illustrate the successful use of an acellular dermal matrix to repair a tracheal defect in the setting of a severe neck infection. Laryngoscope, 133:1961-1963, 2023.

Outcome of Haploidentical Peripheral Blood Allografts Using Post-Transplantation Cyclophosphamide Compared to Matched Sibling and Unrelated Donor Bone Marrow Allografts in Pediatric Patients with Hematologic Malignancies: A Single-Center Analysis.

The introduction of post-transplantation cyclophosphamide (PTCy) as graft-versus-host disease (GVHD) prophylaxis has made haploidentical (haplo) hematopoietic stem cell transplantation (HSCT) a common approach in adults, but pediatric experience is limited. Based on the encouraging adult data and with the aim of decreasing the risk of graft failure, our center is increasingly using peripheral blood stem cells (PBSCs) from haplo donors with PTCy. Here we compare outcomes of bone marrow (BM) transplantation with traditional donor choices, including matched sibling donors (MSDs) and 10/10 HLA matched unrelated donors (MUDs), with those of haplo PBSC grafts in pediatric patients with hematologic malignancies. In this retrospective single-center study, the primary endpoint was the comparison of GVHD-free relapse-free survival (GRFS; defined as absence of acute GVHD [aGVHD] grade III-IV, relapse, death, or chronic GVHD [cGVHD] requiring systemic therapy) for the 3 cohorts. Secondary endpoints included overall survival (OS), relapse-free survival (RFS), nonrelapse mortality (NRM), and incidence of aGVHD and cGVHD). A total of 104 consecutive patients underwent first allogeneic (allo)-HSCT for a hematologic malignancy or myelodysplastic syndrome between January 2014 and December 2020 using a haplo family donor (PBSCs; n = 26), an MSD (BM; n = 31), or an MUD (BM; n = 47). Patient demographic and transplantation characteristics were not significantly different across the cohorts, apart from remission status, with the haplo cohort having more patients in third or later complete remission before HSCT (P < .01). The median duration of follow-up for the entire cohort was 573 days. The cumulative incidence of aGVHD (grade II-IV or grade III-IV) was not significantly different among the cohorts; however, the cumulative incidence of cGVHD at 18 months was highest in the MUD cohort (31.7%, versus 10.0% in the MSD cohort and 9.2% in the haplo cohort; P = .02). There were no differences in the 18-month cumulative incidence of relapse or NRM. OS and RFS at 18 months were 80.7% (95% confidence interval [CI], 61.7% to 100%) and 73.8% (95% CI, 55.5% to 98.1%) for the haplo cohort, 83.4% (95% CI, 72.8% to 95.5%) and 70.3% (95% CI, 57.9% to 85.3%) for the MUD cohort, and 80.9% (95% CI, 66.9% to 97.7%) and 66.5% (95% CI, 50.5% to 87.5%) for the MSD cohort, with no statistically significant differences among the cohorts. GRFS at 18 months was 61% (95% CI, 43.3% to 85.9%) for the haplo cohort, 44.6% (95% CI, 31.8% to 62.5%) for the MUD cohort, and 62.1% (95% CI, 45.7% to 84.3%) for the MSD cohort (P = .26). Haploidentical PBSC HSCT with PTCy had comparable outcomes to MSD and MUD BM HSCT and less cGVHD compared with MUD BM HSCT in children. The logistical advantages and lower resource burden of haplo HSCT with PBSCs make it a feasible alternative to MUD HSCT in children with hematologic malignancies. Given that this is a retrospective comparison of transplantation platforms rather than donor types, further prospective studies are warranted. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.

Cost-effectiveness Analysis of Submandibular Gland Preservation With Sialendoscopy for the Management of Sialolithiasis.

OBJECTIVE: To compare the cost-effectiveness of sialendoscopy with gland excision for the management of submandibular gland sialolithiasis. STUDY DESIGN: Cost-effectiveness analysis. SETTING: Outpatient surgery centers. METHODS: A Markov decision model compared the cost-effectiveness of sialendoscopy versus gland excision for managing submandibular gland sialolithiasis. Surgical outcome probabilities were found in the primary literature. The quality of life of patients was represented by health utilities, and costs were estimated from a third-party payer's perspective. The effectiveness of each intervention was measured in quality-adjusted life-years (QALYs). The incremental costs and effectiveness of each intervention were compared, and a willingness-to-pay ratio of $150,000 per QALY was considered cost-effective. One-way, multivariate, and probabilistic sensitivity analyses were performed to challenge model conclusions. RESULTS: Over 10 years, sialendoscopy yielded 9.00 QALYs at an average cost of $8306, while gland excision produced 8.94 QALYs at an average cost of $6103. The ICER for sialendoscopy was $36,717 per QALY gained, making sialendoscopy cost-effective by our best estimates. The model was sensitive to the probability of success and the cost of sialendoscopy. Sialendoscopy must meet a probability-of-success threshold of 0.61 (61%) and cost ≤$11,996 to remain cost-effective. A Monte Carlo simulation revealed sialendoscopy to be cost-effective 60% of the time. CONCLUSION: Sialendoscopy appears to be a cost-effective management strategy for sialolithiasis of the submandibular gland when certain thresholds are maintained. Further studies elucidating the clinical factors that determine successful sialendoscopy may be aided by these thresholds as well as future comparisons of novel technology.

Does a "Fundal Fluid Cap" Predict Successful Hearing Preservation in Vestibular Schwannoma Resections Via the Middle Cranial Fossa Approach?

OBJECTIVE: To determine the association between radiographic cerebrospinal fluid (CSF) cap in the lateral internal auditory canal (IAC) and likelihood of successful hearing preservation in middle cranial fossa (MCF) vestibular schwannoma (VS) surgery. STUDY DESIGN: Retrospective chart review. SETTING: Academic tertiary referral center. PATIENTS: One hundred thirty-eight consecutive patients (mean age/standard deviation, SD, 50/11 yr) who underwent MCF VS resection. INTERVENTIONS: MCF VS excision. MAIN OUTCOME MEASURES: Size of fundal fluid cap on preoperative magnetic resonance imaging (MRI), pre- and postoperative pure-tone average (PTA), and word recognition score (WRS). RESULTS: Mean tumor and fundal fluid sizes were 9.7 mm (SD, 3.9 mm) and 2.8 mm (SD, 1.7 mm), respectively. On bivariate analysis, fundal fluid size was associated with larger tumor size (p = 0.005) but not changes in postoperative PTA (p = 0.45) or WRS (p = 0.17). When fundal fluid size was stratified as none (<1 mm), small (≥1 mm and <4 mm), and large (≥4 mm), no significant differences were seen in rates of hearing preservation. Using multivariate linear regression models adjusting for patient age, sex, tumor nerve of origin, neurofibromatosis type II status, and preoperative PTA and WRS, superior vestibular nerve tumor origin but not increasing fundal fluid size was associated with preserved postoperative PTA or WRS. CONCLUSIONS: Presence or size of CSF fluid cap may not be a reliable prognostic indicator for hearing preservation in MCF VS resection, with important implications for patient counseling.

How Well Does Intraoperative Audiologic Monitoring Predict Hearing Outcome During Middle Fossa Vestibular Schwannoma Resection?

OBJECTIVE: To evaluate the association between signal changes during intraoperative audiologic monitoring and postoperative audiometric outcome in patients undergoing vestibular schwannoma (VS) resection via middle cranial fossa (MCF) approach. STUDY DESIGN: Retrospective chart review. SETTING: Academic tertiary referral center. PATIENTS: One hundred twenty-six consecutive patients (mean age 48.6 yrs, range 16-67; mean tumor size 9.9 mm, range 1.8-18.9 mm) who underwent MCF VS resection. INTERVENTIONS: Intraoperative audiologic monitoring using auditory brainstem response (ABR) and direct cochlear nerve action potential (CNAP). MAIN OUTCOME MEASURES: Intraoperative ABR wave V and CNAP N1 amplitudes and postoperative pure-tone average (PTA) and word recognition score (WRS). RESULTS: On ABR, absent wave V amplitude was associated with an 81.1% increase and 82.3% decrease in postoperative PTA and WRS, respectively. On CNAP, decreased or absent N1 amplitude was associated with 47.3 and 100% increase, respectively, in postoperative PTA, and 45.3% and 100% decrease, respectively, in postoperative WRS. Receiver-operating curve analysis showed that ABR combined with CNAP using a Cueva electrode achieved the highest diagnostic accuracy in predicting postoperative hearing decline when measured by WRS class (sensitivity 83.3%, specificity 100%), and performed better compared with each modality alone. CONCLUSION: Intraoperative ABR wave V and CNAP amplitude changes are associated with changes in postoperative hearing, and dual modality monitoring was more diagnostic of postoperative hearing decline compared with each modality alone during MCF VS resection. Overall, intraoperative ABR and CNAP were more specific than sensitive for postoperative hearing decline.

Intraductal Laser Fiber Tip Fracture and Retrieval During Sialendoscopic Laser-Assisted Lithotripsy.

Fragmentation of flexible laser fiber tips has been reported to occur during therapeutic bronchoscopy and urologic stone treatment. We report fragmentation of 200-µm single-use silica-based fibers during sialendoscopy-controlled Holmium:YAG laser treatment of a parotid and a submandibular stone. The technique employed to successfully retrieve the fiber tips is described in the context of identifying this potential complication from endoscopic management of sialolithiasis.