Pott's Puffy Tumor in an Inflammatory Bowel Disease Patient on Anti-TNF Therapy.

BACKGROUND Anti-TNF-alpha therapies were the first class of biologics to be used in treatment of moderate to severe IBD. Immunosuppression status that develops from using anti-TNF-a therapies increases the risk of serious and opportunistic infections. We present here a rare case of serious infection that developed in an IBD patient while on anti-TNF therapy. CASE REPORT Our patient was a 14-year-old boy with a history of chronic sinusitis and ulcerative colitis who had been on infliximab therapy for the last 3 years. He presented with facial swelling and worsening constant frontal headache. Imaging showed frontal scalp subgaleal abscess, mild frontal calvarial early osteomyelitis, bilateral preseptal cellulitis, and acute and chronic paranasal sinus disease. He was treated with intravenous antibiotics and underwent sinus surgery with incision and drainage of the forehead abscess. He recovered well and resumed his infliximab infusions 3 weeks after the surgery. CONCLUSIONS PPT is a serious complication of untreated sinusitis. IBD patients on biologics can have higher risk of developing such complications because of their decreased ability to fight infections. Although the risk of serious infections declines significantly after the first year of using biologics, physicians should keep a low threshold for investigating symptomatic patients for serious infections, as they require prompt intervention. Despite the potential complications from using biologics, the benefits of this therapy in IBD patients outweigh the risks.

Interdisciplinary care of children with trisomy 13 and 18.

Children with trisomy 13 and 18 (previously deemed "incompatible with life") are living longer, warranting a comprehensive overview of their unique comorbidities and complex care needs. This Review Article provides a summation of the recent literature, informed by the study team's Interdisciplinary Trisomy Translational Program consisting of representatives from: cardiology, cardiothoracic surgery, neonatology, otolaryngology, intensive care, neurology, social work, chaplaincy, nursing, and palliative care. Medical interventions are discussed in the context of decisional-paradigms and whole-family considerations. The communication format, educational endeavors, and lessons learned from the study team's interdisciplinary care processes are shared with recognition of the potential for replication and implementation in other care settings.

Laryngoscopy and Bronchoscopy in an Infant With a Congenital Laryngeal Web Complicated by Bilateral Pneumothoraces: A Case Report.

Neonates with laryngeal webs pose unique challenges to the anesthesiologist. We present a 2-day-old neonate with aphonia and stridor who underwent microdirect laryngoscopy. Intraoperatively, a Cohen type 4 laryngeal web was diagnosed not immediately amenable to resection. Therefore, the decision was made for endotracheal intubation and subsequent tracheostomy. After endotracheal intubation, there was acute respiratory compromise and oxygen desaturation that improved moderately after urgent tracheostomy. A chest radiograph revealed a large pneumothorax. Our experience suggests that in the presence of high-grade laryngeal webs, the possibility of intraoperative development of pneumothorax should be considered if respiratory difficulties are encountered.

Medical malpractice and transoral robotic surgery: Evaluation and some preemptive thoughts.

Medical malpractice is costly and disruptive, and it is important to prevent. We conducted a study with the objective to look at medical malpractice in robotic surgery overall, to evaluate reasons for litigation, and to comment on possible strategies to avoid litigation with transoral robotic surgery. We used the Westlaw computerized database to identify all state and federal verdict summaries in medical malpractice cases. We found 17 cases alleging malpractice that involved the use of robotic surgery. In all, the plaintiffs in 6 cases (35%) contended that an open rather than a robotic approach should have been used, 5 (29%) alleged negligent credentialing, 4 (24%) alleged training deficiencies, 2 (12%) alleged manufacturing problems, and 1 (6%) charged that robotic surgery should have been performed instead of open surgery (1 case involved two of these allegations). In 11 cases (65%), plaintiffs charged that robotic surgery contributed to an undesirable outcome, and in 6 cases (35%) they raised concerns about informed consent. In all, only 5 of the 17 lawsuits (29%) resulted in plaintiff verdicts or settlements; damages ranged from $95,000 to $7.5 million. We believe the courts should not play a major role in establishing safety guidelines for the introduction of new technology such as robotic surgery. Instead, training and credentialing guidelines should be established by appropriate national associations and societies to assist hospitals in doing so.

Chronic cervical esophageal foreign bodies in children: surgical approach after unsuccessful endoscopic management.

OBJECTIVES: We reviewed the surgical management of chronic cervical esophageal foreign bodies (CCEFBs) in a pediatric population after failed endoscopic retrieval. METHODS: A descriptive analysis via a retrospective chart review of patients with CCEFBs who failed initial endoscopic management was performed between 2008 and 2013. Details were recorded regarding presenting symptoms, time from symptom onset to diagnosis of the CCEFB, surgical approach, and complications. RESULTS: Three patients with CCEFBs unsuccessfully managed with endoscopy were identified. The range of ages at diagnosis was 14 months to 4.5 years. The foreign bodies (FBs) were present for at least 1 month before diagnosis (range, 1 to 10 months). Respiratory symptoms were predominant in all cases. Neck exploration with removal of the FB was performed in each case. Complications included esophageal stricture necessitating serial dilations (patient 1), left true vocal fold paresis that resolved spontaneously (patient 3), and tracheoesophageal fistula with successful endoscopic closure (patient 3). No long-term sequelae were experienced. CONCLUSIONS: A high index of suspicion is required to recognize CCEFBs in children with respiratory distress. Although endoscopic management remains the first-line treatment, it may fail or may not be possible because of transmural FB migration. In this setting, neck exploration with FB removal is a safe and effective alternative.

Retropharyngeal thymus and parathyroid gland: a case report.

Cervical ectopic thymus occurs when thymic tissue arrests during its embryologic descent through the neck to the upper mediastinum. Most often it presents as an asymptomatic neck mass. Rarely does it present with airway compromise, particularly in neonates. A neonate presented with a retropharyngeal mass causing dynamic upper airway obstruction, mimicking a venolymphatic malformation. Ultimately this proved to be aberrant ectopic thymus with an associated parathyroid gland. While there have been isolated reports of thymus or parathyroid in the retropharyngeal space, none of the prior reports found both within the same patient.

Hearing loss resulting in malpractice litigation: what physicians need to know.

OBJECTIVES/HYPOTHESIS: To evaluate the relationship between hearing loss and malpractice litigation. STUDY DESIGN: Retrospective study evaluating state and federal civil malpractice litigation pertaining to physician treatment and patient hearing loss in the United States during a 10-year period (2001-2011). METHODS: A Westlaw search of the computer database Jury Verdicts-All for 2001-2011 was performed using the search terms "hearing loss" and "malpractice." This database includes jury verdicts, judgments, and settlements. RESULTS: Niney-four cases were analyzed. There were 53 verdicts favorable for the defense (56%), 28 verdicts favorable for the plaintiff (30%), and 12 settlements. One case resulted in a mistrial. Settlements ranged from $42,500 to $12,500,000, and verdicts ranged from $0 to $8,784,000. The average payout for adult plaintiffs was less ($549,157) than the payout for minors ($1,349,121). The average payout for a surgical case was $579,098, compared to $960,048 for medical etiology of hearing loss. Otolaryngologists were the most frequently sued treating physician for hearing loss; the second most common defendant was pediatricians (eight cases). In the 13 cases in which an otolaryngologist was sued, there were nine defense verdicts and four verdicts in plaintiffs' favor. The average indemnity for an otolaryngologist was $313,230. CONCLUSIONS: Otolaryngologists are successful in most (70%) hearing loss litigation brought against them. This is true regardless of whether the allegations are of medical error or include operative procedures. Pediatric patients received more favorable jury verdicts when litigating malpractice claims than their adult counterparts, and the payouts were highest when there was alleged birth trauma and/or meningitis. Finally, the severity and degree of hearing loss sustained correlate with higher payouts.

Medical malpractice and sinonasal disease.

OBJECTIVE: Sinonasal disease is a common diagnosis that is encountered by nearly all specialties. This study examines medical malpractice trends in sinonasal disease. METHODS: One hundred fifty-two malpractice cases involving sinonasal disease between 1988 and 2005 were obtained from a computerized legal database. RESULTS: Defendants prevailed in 62 percent of the cases with a median monetary award of $650,000. Younger patients prevailed at a higher rate than did older patients (50% vs 35%), and men had a higher median award than did women ($1.0 million vs $314,000). These results approached but did not reach statistical significance (P = 0.09, P = 0.06). Otolaryngologists were the most commonly sued specialty (56%). The most common complications of endoscopic sinus surgery included cerebrospinal fluid leak, orbital trauma, and anosmia. Cancer plaintiffs received the highest median award of $1.5 million. CONCLUSIONS: Physicians must be diligent in forming differential diagnoses, and surgeons must ensure informed consent is obtained and documented. Future studies should continue to identify risk management strategies and areas for malpractice reform.

Hearing loss in Union Army veterans from 1862 to 1920.

OBJECTIVES: To examine the prevalence of hearing loss (HL) in Union Army (UA) veterans by year, birth cohort, and occupation, and to compare Civil War pension and contemporary disability programs by examining monthly dollar awards. STUDY DESIGN: A retrospective review of medical records for 17,722 UA veteran pension applicants, a subset of some 35,000 soldiers retrieved randomly from the Military Archives. METHODS: The diagnosis of HL was based on review of medical records, which used gross measurements because of the unavailability of audiometric testing. RESULTS: One third (5,891 or 33%) of pensioners sampled received compensation for HL. The veterans with HL suffered predominantly from left-sided HL (4,091 or 70%), which is consistent with noise-induced HL in a right-handed individual firing a rifle. Comparison of civilian occupations reveals minimal variation in prevalence of HL. Civil War pensions for unilateral HL averaged $134.04 per year, representing nearly one third of the average annual income in 1890. Bilateral HL received nearly twice that amount. Today, military veterans receive $1,248 annually for unilateral loss and $27,288 annually for bilateral loss. Social Security disability benefits are granted only for bilateral HL, with an average 60-year-old individual receiving $11,400 per year. CONCLUSION: HL was a common disability among UA Civil War veterans, with noise exposure a likely etiology for the HL. The differing levels of compensation for HL may reflect differing perceptions on the incapacitating effects of HL.