Management of traumatic laryngotracheal separation: Case series and review.

Laryngotracheal separation injuries are a rare but serious condition, as survival from such injuries relies on proper airway management. As a result, recommendations for management have been based on small case reports and expert opinion. We reviewed our last 10 years of experience with managing laryngotracheal separation injuries and identified 6 cases for chart review. Awake tracheostomy or videolaryngobronchoscopy was used in each case to initially obtain the airway. Surgical repair was then performed immediately using nonabsorbable monofilament suture or a miniplate, and a low fenestrated tracheostomy was placed. All of our patients who followed up were decannulated, eating regular diets, and had satisfactory voice quality at 3 months postoperatively. Review of the literature revealed that, while management strategies have changed over time, treatment still varies widely depending on surgeon preference and the details of each injury. Outcomes from our series suggest that our described techniques and management strategies can be used with good outcomes. We believe that this is due to securing a safe airway, early surgical intervention with no unnecessary tissue dissection, effective reconstruction of the airway, and the fenestrated tracheostomy technique.

Possible Skull Base Erosion After Prolonged Frontal Sinus Stenting.

Frontal sinus stenting is widely used with the goal of maintaining nasofrontal duct patency after sinus surgery. The general recommendation is to leave stents in place for 6 months; however, prolonged stenting up to 6 years has been reported with no complication. We present the first reported case of frontal sinus posterior table and skull base erosion following prolonged frontal sinus stenting. A 57-year-old female presented with chronic sinusitis and nasal obstruction. Imaging revealed pansinusitis with retained stents in each frontal sinus that were placed 8 years prior. On the right, there was an area of skull base erosion at the tip of the stent. The patient underwent functional endoscopic sinus surgery with polypectomy. The stents were removed, revealing posterior table erosion on the right side but intact mucosa. Two months after surgery, there were no signs or symptoms of cerebrospinal fluid leak or other complications. Recent literature has suggested that prolonged stenting is safe; however, this case highlights a complication with potentially serious outcomes that can result from prolonged stenting. We recommend stent removal once stable nasofrontal duct patency has been achieved. If prolonged stenting is utilized, patients should be closely monitored and consideration should be given to periodic imaging to evaluate stent position.

Sound levels with aural suctioning: Effects of suction size, canal moisture, and distance from the eardrum.

OBJECTIVE: To determine sound levels resulting from aural suctioning of the external auditory canal. METHODS: Unweighted decibels (dB) and A-weighted decibels (dBA) sound pressure level measurements were recorded using a retrotympanic microphone in cadaveric human temporal bones. Sound measurements were made with common otologic suctions, size 3, 5, and 7 French, within the external ear canal at the tympanic membrane, 5, and 10 mm from the tympanic membrane in the dry condition. In the wet condition, the ear canal was filled with fluid and completely suctioned clear to determine sound effects of suctioning liquid from the ear canal. RESULTS: Sound levels generated from ear canal suctioning ranged from 68.3 to 97 dB and 62.6 to 95.1 dBA. Otologic suctions positioned closer to the tympanic membrane resulted in louder sound levels, but was not statistically significant (P > .05). Using larger diameter suctions generated louder dB and dBA sound levels (P < .001) and the addition of liquid in the ear canal during the suction process generated louder dB and dBA sound levels (P < .001). CONCLUSIONS: Smaller caliber suction sizes and nonsuctioning techniques should be utilized for in-office aural toilet to reduce noise trauma and patient discomfort. LEVEL OF EVIDENCE: 5.

Posttraumatic Cranial Suture Diastasis in Pediatric Temporal Bone Fractures.

OBJECTIVE: Only a handful of case reports exist describing posttraumatic sutural diastasis in the calvarium and none report concurrent temporal bone involvement. We aim to describe diastasis along the temporal bone suture lines in the setting of temporal bone trauma and to identify clinical sequelae. STUDY DESIGN: Retrospective case review. SETTING: Tertiary Level 1 trauma center. PATIENTS: Forty-four patients aged 18 and younger who suffered a temporal bone fracture from 2013 to 2018 were identified. Diastasis and diastasis with displacement at the occipitomastoid, lambdoid, sphenosquamosal and petro-occipital sutures, and synchondroses were determined. MAIN OUTCOME MEASURES: The presence of temporal bone suture and synchondrosal diastasis following temporal bone trauma. Diastasis was defined as sutural separation of a distance greater than 1 mm in comparison to the contralateral side. RESULTS: Using our diastasis diagnostic criteria, diastasis occurred in 41.5% of temporal bone fractures. Transverse fracture types were significantly associated with diastasis (p ≤ 0.001). Lower Glasgow Coma Scale (GCS) and loss of consciousness (LOC) were associated with the presence of diastasis with displacement and diastasis (p = 0.034 and p = 0.042, respectively). Otic capsule violation was more common in fractures with diastasis but did not reach statistical significance. There were two cases of cerebrospinal fluid otorrhea and three deaths in cases that featured diastasis. CONCLUSION: Our findings indicate that diastasis is a positive predictor for higher disruptive force injuries and more severe outcomes and complications. Posttraumatic temporal bone suture diastasis may represent a separate clinico-pathologic entity in addition to the usual temporal bone fracture classification types.

The Plication Technique to Enhance the Endoscopic Approach to Zenker's Diverticulum.

Endoscopic stapler approaches to Zenker's diverticulum often yield a persistent diverticulum and recurrent dysphagia up to 20%. A novel technique to reduce the postoperative diverticulum is described. Eight consecutive patients with Zenker's diverticulum who underwent endoscopic stapler diverticulotomy had adjunctive endoscopic plication of the diverticulum wall to functionally reduce the residual diverticulum size. On postoperative esophagram, there was no visible diverticulum in 4 of 7 patients (57%). The remaining 3 patients had a reduction in common wall of 76%, 50%, and 40% with a mean postoperative size of 1.0 cm. All patients had resolution or significant improvement in dysphagia. There were no complications or recurrences at a mean follow-up of 6.3 months. As an adjunct to endoscopic treatment of Zenker's diverticulum, the plication technique can reduce diverticulum size. Further studies will determine if the plication technique affects long-term recurrence of endoscopic stapler approaches.

Discrepancy Between Neurosurgery Morbidity and Mortality Conference Discussions and Hospital Quality Metric Standards.

OBJECTIVE: Medical institutions use quality metrics to track complications seen in hospital admissions. Similarly, morbidity and mortality (M&M) conferences are held to peer review complications. The purpose of this study was to compare the complications identified in a cohort of patients within 30 days of neurosurgical intervention with those captured in a cohort of M&M conferences. METHODS: All complications that occurred within 30 days of surgery were obtained for patients admitted to the neurosurgical service between May and September 2013. All patients discussed in M&M conference between August 2012 and February 2015 were included in a second data set. Complications were subdivided into 4 categories and compared between the 2 cohorts. RESULTS: A total of 749 postoperative complications were identified, including 52 urinary tract infections, 52 pneumonias, 15 deep vein thromboses, 19 strokes, 75 seizures, 25 wound infections, 6 cardiac arrests, and 162 reoperations. Eighty-five M&M cases were reviewed, identifying 9 strokes, 3 seizures, 8 wound infections, 13 hematomas, 7 intraoperative errors, and 11 postoperative deaths. The M&M cohort showed higher rates of neurologic complications (P < 0.0001) and surgical complications (P < 0.0001). The neurosurgical admission cohort showed higher rates of general medical adverse events (P = 0.0118) and infectious complications (not surgical wound related, P = 0.0002). CONCLUSIONS: Both neurosurgical service inpatient complications and complications discussed in M&M provide valuable opportunities for identifying areas in need of quality improvement. As the United States moves toward an outcomes reimbursement model, neurosurgical programs should adjust M&M conferences to reflect both technical operative complications as well as more common complications.

A novel technique for unilateral supraglottoplasty.

OBJECTIVES: Traditional supraglottoplasty for pediatric laryngomalacia is most commonly conducted with either CO2 laser or cold steel instruments. While the procedure enjoys high success rates, serious complications such as excessive bleeding, supraglottic stenosis and aspiration can occur. Unilateral coblation supraglottoplasty may reduce this risk, but data on respiratory and swallowing outcomes are lacking. This study reports our experiences with unilateral coblation supraglottoplasty. METHODS: Pediatric patients with severe congenital laryngomalacia who underwent unilateral supraglottoplasty at a single institution from 2013 to 2016 were retrospectively reviewed. Bipolar radiofrequency ablation (Coblation) was utilized with partial arytenoidectomy, aryepiglottoplasty, and advancement of mucosal flaps. Outcome measures included apnea-hypopnea index (AHI), weight-by-age percentile, and decannulation rate. RESULTS: Twelve patients were included with an average age of 13.1 months (range 2-28 months). In patients without tracheostomy, 88% had complete resolution of respiratory symptoms, while the remainder had significant improvement. In patients without gastrostomy tubes, there was an average increase in weight-age percentile of 6.1, 7.8, and 15.3 points at 1, 3, and 6 months postoperatively, respectively. Three patients had complete polysomnography data with a mean preoperative AHI of 19.3 and postoperative AHI of 4.0. Three of four patients with tracheostomy have been decannulated at a mean follow-up of 1.5 years. There were no early or late postoperative complications and no revision supraglottoplasty. CONCLUSION: Unilateral supraglottoplasty with bipolar radiofrequency ablation can improve respiratory symptoms and decrease OSA severity in severe congenital laryngomalacia. This technique is safe and can lead to substantial improvement in AHI in patients with OSA.