Augmented Reality Microscopy in the Management of Cerebellopontine Lesions and Microvascular Decompression: A Pilot Study.

Objective: To evaluate whether augmented reality microscopy surgical fluorescence technology, already Food and Drug Administration approved for vascular neurosurgery, can aid in lateral skull base surgery during cerebellopontine (CPA) tumor resection and microvascular decompression. Study Design: Pilot prospective uncontrolled observational cohort study. Setting: An academic tertiary care hospital. Patients: Those who underwent retrosigmoid craniotomy for CPA tumor resection or microvascular decompression for hemifacial spasm, trigeminal neuralgia or pulsatile tinnitus. 11 patients were recruited: 4 underwent CPA tumor resection and 7 underwent microvascular decompression. Interventions: Augmented reality microscopy with fluorescence imaging was utilized to visualize vascular flow intraoperatively. A postoperative surgeon questionnaire was administered to assess the intraoperative efficacy of this technology. Main Outcome Measures: Efficacy of technology in aiding with CPA tumor resection and microvascular decompression. Results: For all 7 microvascular decompression cases, surgeons agreed that the technology aided in identifying areas where disease was affecting tissues with no cases of vascular occlusion identified. In 3 of the 4 CPA tumor resection cases, surgeons agreed that the technology identified areas of vascular flow within the CPA and the tumor. Vascular patency of the sigmoid-transverse sinus was also confirmed. No significant adverse effects were noted except 1 instance of severe-to-profound sensorineural hearing loss. Conclusions: Our study shows that the augmented reality fluorescence technology works during lateral skull base surgery as it can confirm intraoperative vascular integrity. Our data also suggest that this technology may improve visualization of ambiguous vasculature and blood flow to diseased tissue.

Clinical practice guideline: tympanostomy tubes in children--executive summary.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tympanostomy Tubes in Children. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 12 recommendations developed address patient selection, surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes.

Clinical practice guideline: Tympanostomy tubes in children.

OBJECTIVE: Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type. PURPOSE: The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. ACTION STATEMENTS: The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (8) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) and symptoms that are likely attributable to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).

Prospective clinical investigation of the relationship between idiopathic benign paroxysmal positional vertigo and bone turnover: a pilot study.

OBJECTIVE/HYPOTHESIS: Idiopathic benign paroxysmal positional vertigo (BPPV) is a strong indicator of decreased bone density (osteopenia/osteoporosis) in postmenopausal women, and there is a correlation between BPPV and serum levels of biochemical markers of bone turnover. STUDY DESIGN: Prospective pilot clinical trial. METHODS: Two groups of postmenopausal women were recruited. The BPPV group consisted of 16 women with a diagnosis of BPPV. The OSTEO group consisted of 13 women with history of osteopenia/osteoporosis. Dual-energy x-ray absorptiometry scan results were compared, along with serum levels of ionized calcium (iCa), vitamin D, aminoterminal propeptide of protocollagen type I (P1NP), and aminoterminal telopeptides of collagen (sNTX). RESULTS: Prevalence of decreased bone mass density among BPPV subjects was 81%, and prevalence of BPPV among OSTEO subjects was 31%. BPPV subjects had higher P1NP levels. Multiple regression analysis showed that among BPPV subjects, there was positive correlation between P1NP and sNTX and a negative correlation between P1NP and vitamin D level. Age was positively correlated with serum levels of both biomarkers among the BPPV subjects. T score, serum iCa, and serum vitamin D levels did not appear to correlate with presence of BPPV. CONCLUSIONS: Idiopathic BPPV subjects have a high prevalence of osteopenia/osteoporosis. Levels of biochemical markers of bone turnover correlate with presence of BPPV. Our results, based on a sample of U.S. subjects, support an association between idiopathic BPPV and disorders of bone turnover.

Anosmia: loss of smell in the elderly.

More than 35 million people in the United States are aged 65 years or older. Of people aged more than 80 years, 62% to 80% have a significant reduction in their sense of smell, which can adversely affect their safety and nutritional status. This article reviews the anatomy of smell and discusses the known and theorized etiologies of smell loss in the elderly population.

Polyglycolic acid/poly-L-lactic acid copolymer use in laryngotracheal reconstruction: a rabbit model.

OBJECTIVE: To evaluate the tissue response and resorption of the polyglycolic acid/poly-L-lactic acid (PGA/PLLA) implant in laryngotracheal reconstruction and compare its dynamic stability with autologous cartilage grafts. STUDY DESIGN: An interventional, before-after trial. METHODS: Twenty-one white, female, New Zealand rabbits were divided into four groups. Groups A and B underwent laryngotracheoplasty using the PGA/PLLA implants of 3 and 4 mm widths. Group C received autologous ear cartilage grafts. Group D was the control group and did not undergo surgery. The subjects were sedated at 12 months, and the larynges were evaluated in vivo for stability and area measurements by way of endoscopy during spontaneous respiration. The subjects were then killed, the larynges harvested, and the negative intraluminal pressures applied to the laryngotracheal unit were measured in a closed-system apparatus. The larynges were then evaluated for inflammatory reaction and implant resorption by way of histologic analysis. RESULTS: All implanted subjects survived without complications and grew normally. There was no appreciable subglottic collapse during spontaneous respiration under anesthesia. Ex vivo examination of maximum negative intraluminal pressures (-50 cm H2O) in a closed system demonstrated subglottic collapse of 78%, 72%, 61%, and 3% for groups A, B, C, and D, respectively, revealing the inherent weakness in the surgically manipulated airways regardless of grafting material. Histologically, the PGA/PLLA implants were essentially completely resorbed. CONCLUSIONS: PGA/PLLA appears to be a safe and effective synthetic material for use in laryngotracheal reconstruction in the rabbit model while avoiding donor site morbidity and additional operative time. Reconstructed airways maintained adequate strength and patency under physiologic conditions and are comparable with autologous cartilage grafts.

Malignant mimickers: chronic bacterial and fungal infections of the larynx.

Chronic infections of the larynx are notorious "copycats" of squamous cell carcinoma. Patients typically present with a historical picture and symptoms identical to those seen in a neoplastic setting: dyspnea, hoarseness, odynophagia, weight loss, and a history of tobacco and alcohol abuse. Historically, these patients were subject to an extensive resection for what was in reality a benign disease. A better understanding and awareness of these conditions has reinforced the need for a direct laryngoscopy, biopsy, and culture in the evaluation of long-lasting laryngeal lesions; this has led to more appropriate and focused treatment. The clinical mimicry of chronic laryngeal infections will be illustrated in two recent case reports, histoplasmosis and botryomycosis of the larynx, which will lead into a discussion on the differential diagnosis of bacterial and fungal laryngeal infections, their evaluation, and treatment options.

Mohs micrographic surgery vs traditional surgical excision: a cost comparison analysis.

OBJECTIVE: To compare the cost and margin adequacy of Mohs micrographic surgery (Mohs) and traditional surgical excision (TSE) for the treatment of facial and auricular nonmelanoma skin cancer (NMSC). DESIGN: Prospective cost analysis with each patient serving as his or her own control. SETTING: Study was performed from 1999 to 2001 at the University of Connecticut dermatology clinic, a tertiary care referral center. PATIENTS: A total of 98 consecutive patients with a primary diagnosis of NMSC on the face and ears. MAIN OUTCOME MEASURES: The average cost of Mohs and TSE per patient for the treatment and repair of NMSC; adequacy of TSE margins after the initial procedure(because this outcome affects overall cost). RESULTS: Mohs was cost comparable to TSE when the subsequent procedure for inadequate TSE margins after permanent section was Mohs (937 vs 1029 US dollars; P =.16) or a subsequent TSE (937 vs 944 US dollars; P =.53). When facility-based frozen sections were requested for TSE, Mohs was significantly less costly (956 vs 1399 US dollars; P<.001). The cost difference between Mohs and TSE was sensitive to the type of repair chosen. CONCLUSIONS: If the end point is clear margins, Mohs is cost comparable to TSE performed by otolaryngologic surgeons. Some caution is needed when evaluating the cost of facial and auricular NMSC treatment because the choice of repair can significantly affect the cost conclusions.

Anosmia and nasal sinus disease.

Smell loss associated with nasal sinus disease can be a frustrating condition for patients and their physicians. A better understanding of the causes and pathophysiology of olfactory dysfunction can provide a framework from which the physician can plan appropriate treatment and counsel patients as to probable outcomes. This article reviews the pathophysiology of smell loss and the diagnostic paradigms and treatment approaches for the more common causes of anosmia.