Endoscopic endonasal recanalization of the obliterated eustachian tube via ureteral stent.

KEY POINTS: Eustachian tube recanalization is a feasible procedure but additional studies are needed to determine its safety. Eustachian tube closure can result from different etiologies and can cause severe symptoms. Ureteral stents have appropriate shape and pliability for placement and long-term healing. Multidisciplinary team approach allows for simultaneous endonasal and otologic approaches.

Nasal Epistaxis Balloons: A Comprehensive MAUDE Database Analysis.

BACKGROUND: While nasal epistaxis balloons are generally seen as safe and routinely utilized by both surgical and nonsurgical providers, the complication profile related to this type of device has not been well defined. OBJECTIVE: The objective of this study was to utilize the FDA MAUDE (Manufacturer and User Facility Device Experience) database to better assess adverse events (AE) related to use of nasal epistaxis balloons. Reports were individually tabulated and events were categorized with special attention to AEs. METHODS: The FDA MAUDE database was queried for all medical device reports (MDR) related to nasal epistaxis balloon devices from January 2012 to November 2022. RESULTS: 19 MDRs met inclusion criteria. 5 MDRs were classified as device related (26.3 %); two events were reported for balloon leak and deflation, two events were reported for device breakage, and one device related event was unknown. 14 MDRs (73.7 %) were classified as patient related. Two documented MDRs were patient deaths due to exsanguination. Additional serious AEs included balloon ingestion and subsequent small bowel perforation (n = 1), cerebrospinal fluid leak (n = 1), skull base violation and intracranial placement of the device (n = 1), and respiratory distress (n = 3). CONCLUSION: Though epistaxis control with nasal balloons is generally seen as a safe procedure, there have been several concerning AEs reported. While two reports of death due to exsanguination were the most severe AEs, multiple other life-threatening AEs were also documented. Increased awareness of associated complications can be used to better counsel patients during the informed consent process as well as providers in their clinical decision making.

Eustachian Tube Balloon Dilation: A Comprehensive Analysis of Adverse Events.

BACKGROUND: Eustachian tube balloon dilation (ETBD) has been Food and Drug Administration (FDA) approved for refractory Eustachian tube dysfunction since 2016. While ETBD is generally seen as safe, the complication profile has not been well defined. OBJECTIVE: The objective of this study was to utilize the FDA manufacturer and user facility device experience (MAUDE) database to better assess adverse events (AE) related to ETBD. METHODS: This is a study of a multiinstitutional database maintained by the U.S. FDA. A database analysis was performed via the collaboration of multiple clinicians at tertiary referral centers. The FDA MAUDE database was queried for all medical device reports (MDR) related to ETBD devices from January 2012 to November 2022. Eighty-eight unique MDR were identified, 16 of which met inclusion criteria. RESULTS: Three MDRs were classified as device-related (18.8%); none resulted in an AE. Thirteen MDRs (81.3%) were patient-related; all were classified as AEs. The most common AE was postoperative subcutaneous emphysema (n = 6, 46.2%). Of the patients with subcutaneous emphysema, there was a wide range of severity. The most severe AE (n = 1, 6.3%) was postoperative stroke secondary to carotid artery dissection. CONCLUSION: Though ETBD is generally seen as a safe procedure, there have been several concerning AEs reported to date. Increased awareness of ETBD complications can serve as a primer for improved patient education and counseling during the informed consent process and aid surgeons in clinical decision-making. Future studies with standardized reporting protocols are warranted to create a central registry for ETBD.

Mesoamerican urbanism revisited: Environmental change, adaptation, resilience, persistence, and collapse.

Urban adaptation to climate change is a global challenge requiring a broad response that can be informed by how urban societies in the past responded to environmental shocks. Yet, interdisciplinary efforts to leverage insights from the urban past have been stymied by disciplinary silos and entrenched misconceptions regarding the nature and diversity of premodern human settlements and institutions, especially in the case of prehispanic Mesoamerica. Long recognized as a distinct cultural region, prehispanic Mesoamerica was the setting for one of the world's original urbanization episodes despite the impediments to communication and resource extraction due to the lack of beasts of burden and wheeled transport, and the limited and relatively late use of metal implements. Our knowledge of prehispanic urbanism in Mesoamerica has been significantly enhanced over the past two decades due to significant advances in excavating, analyzing, and contextualizing archaeological materials. We now understand that Mesoamerican urbanism was as much a story about resilience and adaptation to environmental change as it was about collapse. Here we call for a dialogue among Mesoamerican urban archaeologists, sustainability scientists, and researchers interested in urban adaptation to climate change through a synthetic perspective on the organizational diversity of urbanism. Such a dialogue, seeking insights into what facilitates and hinders urban adaptation to environmental change, can be animated by shifting the long-held emphasis on failure and collapse to a more empirically grounded account of resilience and the factors that fostered adaptation and sustainability.

Anatomical Parameters and Growth of the Pediatric Skull Base: Endonasal Access Implications.

Objectives Endoscopic endonasal anterior skull base surgery has expanding use in the pediatric population, but the anatomy of pediatric patients can lead to limitations. This study aims to characterize the important anatomical implications of the pediatric skull base using computed tomography (CT) scans. Design This study is designed as retrospective analysis. Setting The study setting comprises of tertiary academic medical center. Participants In total, 506 patients aged 0 to 18 who had undergone maxillofacial and or head CTs between 2009 to 2016 were involved. Methods Measurements included piriform aperture width, nare to sella distance (NSD), sphenoid pneumatization, olfactory fossa depth, lateral lamella cribriform plate angles, and intercarotid distances (ICD) at the superior clivus and cavernous sinus. These patients were then subdivided into three age groups adjusting for sex. Analysis of covariance (ANCOVA) models were fit comparing between all age groups and by sex. Results Piriform aperture width, NSD, sphenoid sinus pneumatization as measured using lateral aeration and anterior sellar wall thickness, olfactory fossa depth, and ICD at the cavernous sinus were significantly different among all age groups ( p <0.0001). Our results show that mean piriform aperture width increased with each age group. The mean olfactory fossa depth also had consistent age dependent growth. In addition, ICD at the cavernous sinus showed age dependent changes. When comparing by sexes, females consistently showed smaller measurements. Conclusion The process of skull base development is age and sex dependent. During preoperative evaluation of pediatric patients for skull base surgery piriform aperture width, sphenoid pneumatization in both the anterior posterior and lateral directions, and ICD at the cavernous sinus should be carefully reviewed.

Utilizing Virtual Surgical Planning and Patient-Specific Cutting Guides as an Adjunct in Microtia Repair with Autologous Costal Cartilage Graft.

Virtual surgical planning (VSP) has been applied to many aspects of head and neck reconstruction. We describe the use of VSP to create auricular templates in addition to cartilage cutting and suturing guides for microtia repair in two patients with unilateral and bilateral grade 3 microtia. Both patients had satisfactory aesthetic results. This technique allows for increased precision, may decrease operative time, and good cosmetic outcomes.

Skull Base Reconstruction following Surgical Treatment of Sinonasal Malignancies.

Skull base defects following resection of anterior cranial fossa and sinonasal tumors are not uncommon. Advances in endoscopic techniques have allowed for entirely endonasal resection and reconstruction of these tumors. This article discusses techniques in the evaluation and management of anterior skull base defects.

Skull Base Anatomy in Patients with Bilateral Choanal Atresia: A Radiographic Study.

Introduction The risk of skull base injury during choanal atresia repair can be mitigated via thorough understanding of skull base anatomy. There is a paucity of data describing differences in skull base anatomy between patients with coloboma, heart defects, atresia choanae, growth retardation, genital abnormalities, and ear abnormalities (CHARGE) syndrome and those without. Objectives The aim of this study was to measure nasal and skull base anatomy in patients with isolated bilateral choanal atresia (BCA), CHARGE syndrome, and other syndromic congenital anomalies. Methods Retrospective chart review of patients with bilateral choanal atresia and computed tomography of the face between 2001 and 2019 were evaluated. Choanal width, height, mid-nasal height, and skull base slope were measured radiographically. Differences in anatomy between healthy patients, those with CHARGE syndrome, and those with other congenital anomalies were compared. Results Twenty-one patients with BCA and relevant imaging were identified: 7 with isolated BCA, 6 with CHARGE syndrome, and 8 with other congenital anomalies. A t -test indicated insignificant difference in skull base slope, choanal height, choanal width, or mid-nasal skull base height between isolate BCA cases and patients with any congenital anomaly. When comparing CHARGE to isolated BCA cases, mid-nasal height was shorter in CHARGE patients ( p = 0.03). There were no differences in measurements between patients with congenital anomalies excluding CHARGE ( p > 0.05). Two patients in the congenital anomaly group were found to have bony skull base defects preoperatively. Conclusion This study represents the largest description of skull base and nasal anatomy in patients with CHARGE syndrome and BCA. Surgeons should be aware of the lower skull base in CHARGE patients to avoid inadvertent skull base injury.

The Safety Profile of Liposomal Bupivacaine Use in Septorhinoplasty.

Objective: To evaluate the safety profile, including adverse drug reactions and operative complications, of liposomal bupivacaine (LB) use for local anesthesia during functional septorhinoplasty. Study Design: Retrospective review. Subject and Methods: A database query was conducted for patients >18 years of age who underwent septorhinoplasty from January 1, 2019, to August 1, 2020. Adverse drug reactions and postoperative outcomes were compared between patients who received locally administered LB and patients who received standard local anesthetic at the completion of the surgery. Results: A total of 95 cases were included in our data analysis. No significant differences were found in adverse reactions overall (6.3% vs. 3.1%, p = 0.51) or complications, including rate of infection (3.2% vs. 3.1%, p = 1), cartilage warping (1.6% vs. 0%, p = 1), graft resorption (0% vs. 0%, p = 1), septal hematoma (0% vs. 0%, p = 1), and need for revision surgery (4.8% vs. 3.1%, p = 1) between LB and control groups. Conclusion: LB demonstrated an acceptable safety profile when compared with standard local anesthetics during septorhinoplasty, with no significant difference in systemic or local adverse drug reactions or postoperative complications.

Novel Use of the Buccal Fat Pad for Sinocutaneous Fistulae Closure and a Review of Reconstructive Options.

BACKGROUND: Sinocutaneous fistulae (SCF) are abnormal communications between the paranasal sinuses and the overlying skin. They may be difficult to manage due to facial geometry, scar contraction, and poor tissue vascularity. We describe a novel use of the buccal flap and review the literature to examine management options for this disease process. METHODS: A PubMed/MEDLINE literature search was performed for studies published between January 1, 1950 and April 29, 2020 that describe management strategies for SCF. The clinical record, imaging, and operative reports were reviewed of the case in which the buccal fat flap was used in reconstruction. RESULTS: A total of 359 articles were retrieved. After removing duplicate articles, non-English studies, animal studies, duplicate articles and studies that mentioned SCF without specific mention of management strategies, 51 articles were reviewed. Management paradigms throughout the articles include (1) removal of infection, (2) ensuring patency of sinus outflow tracts, (3) tensionless multilayered closure using well vascularized tissue, and (4) prevention or minimization of future risk factors for fistula formation. CONCLUSION: This article informs surgeons on reconstructive options for sinocutaneous fistulae including a novel description of the buccal fat flap.

Color Change of Intranasal Fluorescein Cannot Detect Cerebrospinal Fluid Leaks.

BACKGROUND: The color change of topical intranasal fluorescein has been used to confirm the presence of cerebrospinal fluid (CSF) during endoscopic endonasal surgery. We aimed to validate the use of topical intranasal fluorescein for CSF detection. METHODS: Blood, CSF, saliva, and normal saline were combined with decreasing fluorescein concentrations (from 10% to 0.1%). The solutions were photographed in high definition on nasal pledgets and in 1.5-mL Eppendorf tubes. The color difference (ΔE) was objectively measured via the International Commission on Illumination coordinates. Four otolaryngologists who were unaware of the study parameters also evaluated the samples for perceptible color differences. The human eye cannot detect color differences at an International Commission on Illumination ΔE of <5. RESULTS: All otolaryngologists agreed a color difference could be seen with blood across all fluorescein concentrations. However, a perceptible color difference between the experimental samples that excluded blood was not appreciable. Objectively, the ΔE was <5 on average for all nonblood samples when mixed with 5% and 10% fluorescein in the Eppendorf experiment. The ΔE for the nonblood samples was >5 for the remaining tested. Similarly, the average ΔE for the nonblood samples in the pledget experiment was >5 across all fluorescein concentrations. The blood ΔE was consistently >50 throughout all fluorescein concentrations in the Eppendorf experiment and >20 throughout the pledget experiment, correlating with the subjective ease of discernment between blood and the control sample in both groups. CONCLUSIONS: Color change alone is not sufficient to determine a difference between CSF, saliva, and saline. Blood, however, is readily identified using this method. Adjunct characteristics, in addition to the color change, are necessary to properly identify an active CSF leak.

Juvenile nasopharyngeal angiofibroma: National practice patterns and resource utilization via HCUP KID.

BACKGROUND: Juvenile nasopharyngeal angiofibroma (JNA) is a locally aggressive benign vascular tumor that typically afflicts young adolescent males. Historically removed via open approaches, these tumors are now being removed endoscopically. As the modern healthcare setting emphasizes value, efficient utilization of resources may lead to decreased cost while maintaining or improving patient outcomes. OBJECTIVE: The objective of this study was to investigate how perioperative management of juvenile nasopharyngeal angiofibromas (JNAs) influence overall cost. We specifically investigate the effect of approach type (open, endoscopic, or combined) with regards to cost and length of stay. We also delineated practice patterns, analyzed safety profiles, and characterize clinical outcomes. METHODS: The 2016 Healthcare Cost and Utilization Project Kids' Inpatient Database (HCUP-KID) was queried to identify males aged <21 years with an ICD-10-CM diagnosis code of D10.6 (benign neoplasm of nasopharynx) and ICD-10-PCS codes to determine whether an open, endoscopic or combined approach was performed. Univariate statistical analysis and multivariable logistic regression were performed to examine the effects of demographics, patient characteristics, procedure type, and complications on length of stay (LOS) and cost. RESULTS: A total of 89 male patients were analyzed with a mean age of 14.8 years (range 8-20 years). Mean LOS was 3.4 days. Mean total charges were $128,780. Comparing open (n = 16), endoscopic (n = 65), and combined (n = 8) approaches, there was a significant difference in the need for fresh frozen plasma (p = 0.02) and packed red blood cell (pRBC) (p = 0.03) transfusion but no difference in preoperative embolization (p > 0.05) between approach types. LOS was associated with age (p = 0.02), pRBC transfusion (p = 0.04) and septal deviation (p = 0.03). Charges varied with LOS (p < 0.001) on linear regression analysis but not with other variables in this dataset. CONCLUSION: Approach type for JNA appears to be unrelated to LOS or charges in this multi-site, population-based analysis. However, septal deviation, pRBC transfusion, and young age are associated with increased LOS in patients undergoing JNA resection.

Surgical Margin Determination in the Era of HPV-Positive Oropharyngeal Cancer.

OBJECTIVES/HYPOTHESIS: The goal of head and neck cancer surgery is the complete resection of tumor with a cuff of healthy tissue. A 5-mm margin is optimal but not always achievable in the oropharynx. We aimed to identify a consensus of definition and management of close margins for human papilloma virus (HPV)-associated oropharyngeal cancer without other risk factors. STUDY DESIGN: Descriptive survey. METHODS: A survey of the American Head and Neck Society (AHNS) was conducted to evaluate the abovementioned objectives by presenting hypothetical scenarios and asking questions regarding management. RESULTS: One-hundred fifty-five AHNS members completed the survey (18% response rate). Close margins were defined as <5 mm, <3 mm, and <1 mm by 27.7%, 32.3%, and 32.3% of respondents. There was no significant difference in margin determination with experience level (P = .186). In an HPV-positive tumor with close margins, 51% chose postoperative observation. The remainder chose adjuvant radiation (22.6%), chemoradiation (1.9%), or re-excision of the wound bed (19.4%). There was no association between postoperative close margin management and experience level (P = .80). CONCLUSION: Heterogeneity exists in the definition and management of close margins in HPV-mediated oropharyngeal carcinoma (OPSCC). Establishing a standard regarding close margins in HPV-mediated OPSCC may allow for the optimization of outcomes and help define best practices. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:E2650-E2654, 2021.

Outpatient Sistrunk procedure: A retrospective analysis.

OBJECTIVE: The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a Sistrunk procedure via either same day surgery or overnight observation. METHODS: A retrospective review of patients undergoing Sistrunk procedures between January 1, 2008 to January 1, 2019 was performed. 76 cases were identified for review. Bivariate and multivariable analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation >90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement. RESULTS: No patients had life-threatening adverse events. There was no difference in complication rates between same day discharge (17%) and overnight observation (23%, p = 0.47). Otolaryngologists were more likely to admit patients overnight (88% vs. 14%, p = 0.042) as well as place a drain (97% vs. 24%, p < 0.001) when compared to pediatric surgeons. Drain placement was associated with overnight observation (73% vs. 3%, p < 0.001). Multivariable logistic regression demonstrated drain placement (OR 21.9, 95%CI (2.5-189.7), p = 0.005) and otolaryngologist as operative surgeon (OR 11.7, 95%CI (2.8-48.2), p < 0.001) as strong predictive variables for overnight observation. There was no association between other investigated variables and adverse events or overnight stay. CONCLUSION: Same day Sistrunk operations are safe in select healthy patients. Overnight observation appears to be driven by drain placement and surgeon practice patterns.

Feasibility of same day surgery for pediatric second branchial cleft anomalies.

OBJECTIVE: The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a removal of second branchial cleft anomalies (BCA) via either same day surgery or overnight observation. METHODS: A retrospective review of patients undergoing second BCA removal between January 1, 2008 to January 1, 2019 was performed. 40 cases were identified for review. Bivariate analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation >90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement. RESULTS: There were no life-threatening adverse events. Same day discharge was not associated with adverse events (p = 0.24). Overnight observation was associated with a history of preoperative infection (p = 0.003), cyst > 3.0 cm (p = 0.046), operative time > 90 min (p < 0.001), and drain placement (p = 0.001). There was no association between other investigated variables and adverse events or overnight stay. CONCLUSION: Same day discharge following second branchial cleft anomalies appears safe and feasible. Further study is needed to determine the safety profile of same day discharge and etiologies of practice patterns of overnight observation.

Prosthetic Reconstruction of the Maxilla and Palate.

Maxillary defects commonly present following surgical resection of oncologic processes. The use of rotational and free flaps has largely replaced the use of prosthetic options for hard palate and maxillary reconstruction, but prostheses remain a useful tool. Prosthetic devices may be invaluable in patients considered poor candidates for surgical reconstruction secondary to poor vascularity, need for postoperative radiation, or medical comorbidities that place them at high risk for healing following reconstruction. Obturators may also be considered over soft tissue options if oncologic surveillance via direct visualization of the surgical site is warranted.

Economic implications of localization strategies for cerebrospinal fluid rhinorrhea.

BACKGROUND: The direct costs associated with different diagnostic algorithms to localize cerebrospinal fluid (CSF) rhinorrhea have not been described. METHODS: A decision-tree analysis of imaging modalities used to localize CSF rhinorrhea was performed to compare associated direct costs. The primary outcome was cost, which was determined based on reimbursement data published by the Centers for Medicare and Medicaid Services in 2018. The model was parameterized after a literature review of published studies was performed from 1990 to 2018 to estimate the sensitivity CSF rhinorrhea localization of the following radiographic modalities: high-resolution computed tomography (HRCT), magnetic resonance cisternography (MRC), and CT cisternography (CTC). In addition to base case analysis, 1-way sensitivity analyses were also performed to evaluate the robustness of results to changes in model parameters. RESULTS: Among patients with a high suspicion for CSF rhinorrhea, use of HRCT followed by exploration in the operating room if preliminary HRCT was negative was found to be the optimal localization modality from a cost perspective ($172.25). The next least costly algorithm was HRCT followed by MRC ($294.10). Imaging algorithms beginning with CTC were the next least costly modality ($727.37). Sensitivity analyses generally supported HRCT to be the optimal initial radiographic strategy over a wide range of parameter values. CONCLUSION: This work advocates HRCT as first-line modality to localize CSF rhinorrhea from a cost perspective. Although algorithms beginning with MRC were on average $35 more expensive than those starting with CTC, associated risks of CTC were not modeled and may play a role in decision making.

Sinonasal Disease in Total Laryngectomy Patients.

OBJECTIVE: Total laryngectomy (TL) results in complete abolition of nasal airflow, with notable pathologic alterations of the intranasal mucosa, mucociliary clearance, and nasal cycle. Despite these observed morphological changes, it remains unclear whether this subpopulation of patients experiences clinically significant sinonasal disease. The goal of this study was to identify rhinosinusitis in TL patients using radiographic imaging. METHODS: An Institutional Review Board-approved retrospective review (January 2005-July 2017) identified 50 patients who underwent radiographic imaging before and after TL. The Lund-Mackay Staging System (LM) was applied to 197 surveillance computed tomography scans. Surveyed patients also underwent investigation of current sinonasal symptomatology using the SNOT-22 questionnaire. Simple linear regression was modeled to LM scores; tests of statistical significance were estimated via the method of Kenward and Roger. RESULTS: The mean age was 62.4 years, with a 5:1 male-to-female ratio. The mean SNOT-22 score was 27.4 (range, 5-33). A median of 3 scans was obtained, 49% within 12 months after TL. The mean (± standard deviation) postoperative LM score was 2.7 ± 3.97 points (range, 0-19). For every 1 month after TL, postoperative LM was +0.01 point (P = .49). Conversely, for every +1 point in preoperative LM, postoperative LM was +1.08 points (P < .001). Two patients required functional endoscopic sinus surgery after TL for persistent sinonasal disease. CONCLUSIONS: Preoperative sinonasal disease burden likely plays an important role in the development of clinically significant rhinosinusitis in TL patients. Correlating radiographic findings to validated outcome measures remains a critical aspect of determining optimal surgical candidates; this arena is still under investigation in this unique patient cohort.