Topical intranasal fluorescein to localize a cerebrospinal fluid leak: a demonstration.

BACKGROUND: Intrathecal fluorescein is commonly used to localize cerebrospinal fluid leaks. This technique is invasive and associated with several potential adverse effects. The purpose of this video presentation is to demonstrate an alternative technique, the intranasal use of dilute topical fluorescein, to localize a cerebrospinal fluid leak intraoperatively. METHODS: A 45-year-old male with a history of benign intracranial hypertension and 2 months of right-sided rhinorrhea underwent surgical repair of a cerebrospinal fluid leak. Topical fluorescein was applied intraoperatively to localize the defect. RESULTS: At 1- and 3-month follow-ups the patient was without cerebrospinal fluid rhinorrhea and the middle turbinate flap was intact. CONCLUSION: Topical application of dilute intranasal fluorescein is a feasible and efficient tool for localizing cerebrospinal fluid leaks.

Descriptive Analysis of Otolaryngology Program Directors with a Focus on Gender Disparity.

OBJECTIVE: To describe and analyze the demographics and academic backgrounds of United States otolaryngology program directors (PD) and assess gender disparity in the field. METHODS: This was a cross-sectional study in which an online search using publicly available sources was performed to gather information on PDs for 125 United States otolaryngology programs from May 14, 2021, to May 30, 2021. Data collected included PD appointment year, age, gender, resident gender breakdown, degree, as well as training location and graduation year. RESULTS: There were 69.6% programs with a male PD and 30.4% with a female PD. Ninety percent of PDs have an MD degree and 9.6% have a DO degree. The current average age of PDs was 49.9 years old (range 35-79). Males were older than females PD (51.0 vs 47.1 years, P = 0.045) and have served a longer time as PD (7.1 vs 4.8 years, P = 0.019). There was no significant difference in other variables collected. There were 27.3% of program directors that held the position of professor, 44.5% associate professor, and 28.2% assistant professor. The most common subspecialty practiced by otolaryngology PDs was head and neck oncology. CONCLUSION: Disparity in women's representation in otolaryngology still exists, but the program director leadership position demonstrates better parity. There is an equal percent representation when examining female PDs and female otolaryngologists in academic medicine. Continued efforts to encourage women to enter and become leaders in otolaryngology are necessary moving forward.

A model for classification of invasive fungal rhinosinusitis by computed tomography.

Our purpose was to classify acute invasive fungal rhinosinusitis (AIFR) caused by Mucor versus Aspergillus species by evaluating computed tomography radiological findings. Two blinded readers retrospectively graded radiological abnormalities of the craniofacial region observed on craniofacial CT examinations obtained during initial evaluation of 38 patients with eventually pathology-proven AIFR (13:25, Mucor:Aspergillus). Binomial logistic regression was used to analyze correlation between variables and type of fungi. Score-based models were implemented for analyzing differences in laterality of findings, including the 'unilateral presence' and 'bilateral mean' models. Binary logistic regression was used, with Score as the only predictor and Group (Mucor vs Aspergillus) as the only outcome. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were determined for the evaluated models. Given the low predictive value of any single evaluated anatomical site, a 'bilateral mean' score-based model including the nasal cavity, maxillary sinuses, ethmoid air cells, sphenoid sinus and frontal sinuses yielded the highest prediction accuracy, with Mucor induced AIFR correlating with higher prevalence of bilateral findings. The odds ratio for the model while integrating the above anatomical sites was 12.3 (p < 0.001). PPV, NPV, sensitivity, specificity and accuracy were 0.85, 0.82, 0.92, 0.69 and 0.84 respectively. The abnormal radiological findings on craniofacial CT scans of Mucor and Aspergillus induced AIFR could be differentiated based on laterality, with Mucor induced AIFR associated with higher prevalence of bilateral findings.

Impact of coronavirus (COVID-19) on otolaryngologic surgery: Brief commentary.

BACKGROUND: The Coronavirus disease-2019 (COVID-19) pandemic is a global health crisis and otolaryngologists are at increased occupational risk of contracting COVID-19. There are currently no uniform best-practice recommendations for otolaryngologic surgery in the setting of COVID-19. METHODS: We reviewed relevant publications and position statements regarding the management of otolaryngology patients in the setting of COVID-19. Recommendations regarding clinical practice during the severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks were also reviewed. RESULTS: Enhanced personal protective equipment (N95 respirator and face shield or powered air-purifying respirator, disposable cap and gown, gloves) is required for any otolaryngology patient with unknown, suspected, or positive COVID-19 status. Elective procedures should be postponed indefinitely, and clinical practice should be limited to patients with urgent or emergent needs. CONCLUSION: We summarize current best-practice recommendations for otolaryngologists to ensure safety for themselves, their clinical staff, and their patients.

Best Practice Recommendations for Pediatric Otolaryngology during the COVID-19 Pandemic.

OBJECTIVE: To review the impact of coronavirus disease 2019 (COVID-19) on pediatric otolaryngology and provide recommendations for the management of children during the COVID-19 pandemic. DATA SOURCES: Clinical data were derived from peer-reviewed primary literature and published guidelines from national or international medical organizations. Preprint manuscripts and popular media articles provided background information and illustrative examples. METHODS: Included manuscripts were identified via searches using PubMed, MEDLINE, and Google Scholar, while organizational guidelines and popular media articles were identified using Google search queries. Practice guidelines were developed via consensus among all authors based on peer-reviewed manuscripts and national or international health care association guidelines. Strict objective criteria for inclusion were not used due to the rapidly changing environment surrounding the COVID-19 pandemic and a paucity of rigorous empirical evidence. CONCLUSIONS: In the face of the COVID-19 pandemic, medical care must be judiciously allocated to treat the most severe conditions while minimizing the risk of long-term sequelae and ensuring patient, physician, and health care worker safety. IMPLICATIONS FOR PRACTICE: The COVID-19 pandemic will have a profound short- and long-term impact on health care worldwide. Although the full repercussions of this disease have yet to be realized, the outlined recommendations will guide otolaryngologists in the treatment of pediatric patients in the face of an unprecedented global health crisis.

Cavernous sinus thrombosis secondary to allergic fungal sinusitis.

Cavernous sinus thrombosis (CST) is a rare and serious complication secondary to invasive fungal sinusitis, but rarer still in cases of allergic fungal sinusitis. Current recommendations for cavernous sinus thrombosis are controversial, especially regarding anticoagulation, secondary to the rarity of the diagnosis. Early surgical debridement and intravenous antibiotics are crucial to prevent mortality and decrease morbidity. Because thrombosis is thought to be caused by a bacterial superinfection, which follows a response to Aspergillus, antifungals may not be necessary. Despite the controversy, most physicians opt to treat with anticoagulation.

Acute Invasive Fungal Rhinosinusitis: Frozen Section Histomorphology and Diagnosis with PAS Stain.

Acute invasive fungal rhinosinusitis (AIFRS) is a fulminant infection in immunocompromised patients requiring rapid diagnosis (DX), frequently made on frozen section (FS) of sinonasal biopsies, followed by prompt surgical debridement. However, FS interpretation is often difficult and DX sometimes not possible. In this study we sought to characterize reasons for misinterpretation and methods to improve diagnostic accuracy. The FS slides from 271 biopsies of suspected AIFRS in a 16-year period were reviewed and the morphologic features evaluated for their utility in DX. Recurring specific patterns of necrosis were identified, which to our knowledge have not been described in the literature. Although they provide strong evidence for AIFRS, identifying fungus consistently in necrotic tissue is essential for DX. Clues to identifying fungus and pitfalls in misidentification were identified, but even with expert knowledge of these, a gap in accurate DX remained. The key to FS DX of AIFRS is to improve fungus identification in necrotic tissues. Methods had been sought in the past to stain fungus at FS without consistent success. The Periodic Acid Schiff's Reaction for Fungi was modified by our histopathology department for use on frozen tissue (PASF-fs) resulting in effective staining of the fungus. It stained fungus on all 62 positive slides when applied retrospectively over hematoxylin and eosin (H&E) stained FSs and used prospectively at FS for DX. Although knowledge of histologic morphology on FS is important, the crucial value of this study is the novel use of PASF-fs to identify fungus in the DX of AIFRS.

Prevention of complications in revision endocrine surgery of the head & neck.

Revision cervical endocrine surgery increases risks for injury to important adjacent structures, possibly resulting in hoarseness and postoperative hypocalcemia. With anatomic knowledge and appropriate use of meticulous dissection techniques, the surgeon strives to minimize morbidity. Technologic advances have provided tools to aid in these difficult cases and maintain the thoroughness of resection while reducing morbidity. The judicious use of preoperative imaging can assist the surgeon in identifying the precise location of disease, thus reducing unnecessary dissection and risk to surrounding structures, while still performing complete resections.

Head and Neck Manifestations of Systemic Disease.

Systemic diseases commonly managed by the Internist may have presentations within the head and neck. Awareness of these manifestations, sometimes as the presenting signs or symptoms of systemic disease, may aid the Internist in diagnosis and management. The Otolaryngologist may be helpful in assisting in the evaluation of these patients and in some cases providing targeted symptomatic therapy. Some systemic processes can generate emergent airway events, and early engagement of the otolaryngologist is of value.

Frozen Section as a Rapid and Accurate Method for Diagnosing Acute Invasive Fungal Rhinosinusitis.

Objective Identify methods to improve the frozen-section diagnosis of acute invasive fungal rhinosinusitis. Study Design Biopsies with frozen section for suspected acute invasive fungal rhinosinusitis were reviewed to identify causes for missed diagnoses and evaluate methods for potential improvement. Setting All aspects of the study were performed at the Penn State Milton S. Hershey Medical Center. Subjects and Methods All frozen sections performed for suspected acute invasive fungal rhinosinusitis between 2006 through 2017 were reviewed with their diagnoses compared to the final diagnoses. Sensitivity and specificity were determined for each biopsy specimen to evaluate the diagnostic method and for each patient for its effectiveness on outcome. Causes for frozen-section failures in diagnosis were identified. A periodic acid-Schiff stain for fungus (PASF) was modified for use on frozen tissue (PASF-fs) and applied both retrospectively and prospectively to frozen sections to determine its ability to identify undetected fungus and improve diagnostic sensitivity. Results Of 63 biopsies positive for acute invasive fungal rhinosinusitis, 51 were diagnosed on frozen section, while 61 were identified by including the novel PASF-fs stain, reducing the failure rate from 19% to 3%. Of 41 cases that were positive, 34 were diagnosed on frozen section. Of the 7 that were not, 5 were identified by including the PASF-fs, reducing the failure rate from 17% to 5%. Conclusions Frozen section interpretation of biopsies for suspected acute invasive fungal rhinosinusitis using a PASF-fs stain should enable a rapid and accurate diagnosis with improved outcomes by shortening the time to surgery.

Guidelines for radiographic imaging of cranial neuropathies.

Disruption of the complex pathways of the 12 cranial nerves can occur at any site along their course, and many, varied pathologic processes may initially manifest as dysfunction and neuropathy. Radiographic imaging (computed topography or magnetic resonance imaging) is frequently used to evaluate cranial neuropathies; however, indications for imaging and imaging method of choice vary considerably between the cranial nerves. The purpose of this review is to provide an analysis of the diagnostic yield and the most clinically appropriate means to evaluate cranial neuropathies using radiographic imaging. Using the PubMed MEDLINE NCBI database, a total of 49,079 articles' results were retrieved on September 20, 2014. Scholarly articles that discuss the etiology, incidence, and use of imaging in the context of evaluation and diagnostic yield of the 12 cranial nerves were evaluated for the purposes of this review. We combined primary research, guidelines, and best practice recommendations to create a practical framework for the radiographic evaluation of cranial neuropathies.

End-organ radiographic manifestations of cranial neuropathies: A concise review.

BACKGROUND: Cranial neuropathies are a spectrum of disorders associated with dysfunction of one or more of the twelve cranial nerves and the subsequent anatomic structures they innervate. OBJECTIVE: The purpose of this article is to review radiographic imaging findings of end-organ aberrations secondary to cranial neuropathies. METHOD: All articles related to cranial neuropathies were retrieved through the PubMed MEDLINE NCBI database from January 1, 1991 to August 31, 2014. These manuscripts were analyzed for their relation to cranial nerve end-organ disease pathogenesis and radiographic imaging. RESULTS: The present review reveals detectable end-organ changes on CT and/or MRI for the following cranial nerves: olfactory nerve, optic nerve, oculomotor nerve, trochlear nerve, trigeminal nerve, abducens nerve, facial nerve, vestibulocochlear nerve, glossopharyngeal nerve, vagus nerve, accessory nerve, and hypoglossal nerve. CONCLUSION: Radiographic imaging can assist in the detailed evaluation of end-organ involvement, often revealing a corresponding cranial nerve injury with high sensitivity and diagnostic accuracy. A thorough understanding of the distal manifestations of cranial nerve disease can optimize early pathologic detection as well as dictate further clinical management.

Case-Logging Practices in Otolaryngology Residency Training: National Survey of Residents and Program Directors.

Objective (1) Evaluate the consistency and manner in which otolaryngology residents log surgical cases. (2) Assess the extent of instruction and guidance provided by program directors on case-logging practices. Study Design Cross-sectional national survey. Setting Accreditation Council for Graduate Medical Education otolaryngology residency programs in the United States. Subjects and Methods US otolaryngology residents, postgraduate year 2 through graduating chiefs as of July 2016, were recruited to respond to an anonymous questionnaire designed to characterize surgical case-logging practices. Program directors of US otolaryngology residency programs were recruited to respond to an anonymous questionnaire to elucidate how residents are instructed to log cases. Results A total of 272 residents and 53 program directors completed the survey, yielding response rates of 40.6% and 49.5%, respectively. Perceived accuracy of case logs is low among residents and program directors. Nearly 40% of residents purposely choose not to log certain cases, and 65.1% of residents underreport cases performed. More than 80% of program directors advise residents to log procedures performed outside the operating room, yet only 16% of residents consistently log such cases. Conclusion Variability in surgical case-logging behaviors and differences in provided instruction highlight the need for methods to improve consistency of logging practices. It is imperative to standardize practices across otolaryngology residency programs for case logs to serve as an accurate measure of surgical competency. This study provides a foundation for reform efforts within residency programs and for the Resident Case Log System.

Acute Invasive Fungal Rhinosinusitis: A 15-Year Experience with 41 Patients.

OBJECTIVES: To describe a 15-year single-institution experience of 41 cases of acute invasive fungal sinusitis (AIFRS), identify clinical indicators predictive of AIFRS, and discuss our approach to these high-acuity patients. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center; The Pennsylvania State University Hershey Medical Center. SUBJECTS AND METHODS: A retrospective review was performed for AIFRS consultations between September 1999 and March 2014. Variables reviewed included underlying condition, presenting symptoms, absolute neutrophil count, disease extent on examination, radiographic findings, medical treatment, biopsy results, surgical treatment, and outcomes. Univariate analysis was performed to determine variables significantly associated with AIFRS. Outcome measures were assessed and patient assessment algorithm developed. RESULTS: Of 131 patients evaluated, 41 were diagnosed with AIFRS; 92.7% had an underlying hematologic malignancy. Disease predictive variables included absolute neutrophil count <500/µL (P < .0001; sensitivity = 78%), mucosal abnormalities of middle turbinate (P < .0001; specificity = 88%) and septum (P < .0001; specificity = 97%), and specifically, necrosis of the middle turbinate (P < .0001; specificity = 97%). Twenty-five AIFRS patients (61%) survived until discharge; 25% (n = 10) expired secondary to AIFRS infection explicitly. CONCLUSION: This series represents one of the largest single-institution experiences of AIFRS published to date. Timely diagnosis is necessary to improve patient outcomes and limit morbidity. Maintaining a high index of suspicion in at-risk patient populations, followed by prompt evaluation and management, is crucial in suspected AIFRS. The presence or absence of certain findings appear to correlate with biopsy results and may aid in appropriately gauging clinical suspicion for the presence of AIFRS.

Multifocal inverted papillomas in the head and neck.

Inverted papilloma is a rare benign neoplasm that usually originates in the lateral nasal wall. It can be a locally aggressive lesion and invade nearby structures. While primarily a nasal neoplasm, cases of an inverted papilloma involving the temporal bone, pharynx, nasopharynx, and lacrimal sac have been reported. We describe the case of a 67-year-old man with a history of nasal inverted papilloma who presented with a recurrent nasal mass and a large mass on the left side of his upper neck. The patient's history included inverted papillomas in multiple locations: the temporal bone, the sinonasal tract, and the nasopharynx. The new neck mass raised a concern for malignant degeneration and metastasis, but pathology demonstrated that it was a benign inverted papilloma. No clear etiology for the new neck lesion was evident except for an origin in salivary gland tissue. However, there was no physical connection between the neck mass and the submandibular gland identifiable on pathologic evaluation. This case illustrates the need for an aggressive primary resection to minimize local recurrence, as well as adequate surveillance to address recurrences early. Given the potential for multicentricity, patients with a typical sinonasal inverted papilloma should undergo a complete head and neck examination as part of their follow-up.

Acoustic analysis of upper airway obstruction in the excised human larynx.

Upper airway obstruction is an emergency that requires quick and decisive intervention. Stridor is the sound created by airflow through a partially obstructed airway, and has been described to vary with the site and degree of obstruction. This study sought to determine the sound characteristics of stridor in the excised human larynx. Five fresh cadaver human larynges were harvested and subjected to obstructions at supraglottic, glottic, and subglottic subsites. Subglottic pressure, airflow, and audio signal were recorded. Data were analyzed on the basis of laryngeal obstruction subsite and the degree of laryngeal resistance. Visual inspection demonstrated certain trends in peak spectral energy depending on the site and, more significantly, the amount of obstruction. Statistical analysis of spectral waveforms showed better correlation with the amount of obstruction than with the site of obstruction. In summary, the frequency distribution of stridor produced in an excised human larynx was influenced by the amount of laryngeal resistance, but not by the site of airway obstruction.

Pathologic fracture of the mandible secondary to traumatic bone cyst.

The traumatic bone cyst (TBC) is an uncommon and poorly understood lesion. First described in 1929, TBCs lack an epithelial lining, typically occur during the second decade of life, and are most frequently located in the jaw. Although the majority of TBCs are asymptomatic, rarely a TBC can cause a pathologic fracture of the mandible. We present a case of an adolescent suffering a sports-related pathologic mandible fracture secondary to a traumatic bone cyst.

Perioperative care in functional endoscopic sinus surgery: a survey study.

BACKGROUND: Functional endoscopic sinus surgery (FESS) is largely viewed as the standard of care in the treatment of chronic rhinosinusitis (CRS) refractory to medical treatment. While there is an understanding regarding the importance of some form of routine postoperative FESS care, no consensus currently exists regarding what the specific management routine should include. The authors of this survey study did not intend to examine the efficacy of such treatment protocols, but rather to determine and report on the current practice patterns of perioperative FESS care among otolaryngologists. METHODS: This survey study was designed in accordance with and approved by our institutional review board. The online-based survey was designed using the online product SurveyMonkey®. A total of 859 otolaryngologists were identified and email addresses were obtained from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) website directory. Responses were collected anonymously. RESULTS: Our survey response rate was 32%. Multiple parameters of the otolaryngologists' perioperative care were collected. Among the data, some consistent patterns emerged: 93.2% of respondents use nasal saline irrigations postoperatively; 86.8% of otolaryngologists surveyed prescribe antibiotics in the immediate postoperative period; and office-based endoscopic sinus debridements are performed by a majority (87.9%) of those surveyed. CONCLUSION: This survey study demonstrates that current practices in perioperative FESS care can vary widely among otolaryngologists, and are not uniformly based on evidence-based outcomes research. Despite the lack of absolutes regarding the specific perioperative care in FESS, practice patterns emerge from the data regarding typical perioperative management among current otolaryngologists.