Fibrin Glue-Coated Collagen Complex Patch: A Novel Material for Surgical Repair of Spontaneous Temporal Bone Cerebrospinal Fluid Leak and Encephalocele.

OBJECTIVE: To compare outcomes of surgical repair of temporal bone encephalocele and cerebrospinal fluid (CSF) leak using fibrin glue-coated collagen (FGCC) complex patch versus other materials for repair of dura. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care hospital. PATIENTS: Fifty-two adult patients undergoing transmastoid (TM), middle fossa (MF) or combined approach repair of spontaneous MF CSF leak between 2016 and 2020. INTERVENTIONS: Exposure of bony defect via TM approach, MF craniotomy, or combined TM/MF, and repair of the associated dura defect with FGCC complex patch, or other materials (acellular collagen matrix, bovine collagen, autologous fascia, fibrin tissue sealant). MAIN OUTCOME MEASURES: Successful repair without recurrent CSF leak or encephalocele throughout follow-up. Cost of materials used in duraplasty. RESULTS: Sixty-four percent of patients were female. Mean (standard deviation) age at repair was 61.4 (12.1) years. Mean (standard deviation) body mass index was 35.0 (8.3) kg/m 2 . Forty-nine (94%) patients had successful repair without known recurrence of CSF leak or encephalocele over a median follow-up interval of 11.7 months. Average duraplasty material cost was significantly lower with FGCC in comparison with other nonautologous materials (FGCC+: $1259.94, FGCC-: $1652.58; p = 0.004). No significant differences in recurrence risk (FGCC+: 6.9%, FGCC-: 6.9%; p > 0.999) or operative time (FGCC+: 153.7 min, FGCC-: 155.4 min; p = 0.88) were detected based on material used for duraplasty. CONCLUSIONS: All materials studied demonstrate effective and sustained means of repair for MF CSF leak and encephalocele, including in the presence of multiple defects. Use of FGCC for duraplasty produces noninferior surgical results to other nonautologous materials in repair of spontaneous CSF leaks of the temporal bone and may be more cost-effective.

Outcomes of Mastoidectomy With Antibiotic Catheter Irrigation for Patients With Draining Ventilation Tubes.

OBJECTIVES: To evaluate the effectiveness of mastoidectomy with antibiotic catheter irrigation in patients with chronic tympanostomy tube otorrhea. METHODS: A chart review of adult and pediatric patients with persistent tympanostomy tube otorrhea who had failed outpatient medical management and underwent mastoidectomy with placement of a temporary indwelling catheter for antibiotic instillation was performed. Patients were retrospectively followed for recurrent drainage after 2 months and outcomes were categorized as resolution (0-1 episodes of otorrhea or otitis media with effusion during follow-up), improvement (2-3 episodes), or continued episodic (>3 episodes). RESULTS: There were 22 patients and 23 operated ears. Median age was 46 years (interquartile range, IQR = 29-65). The median duration of otorrhea from referral was 5.5 months (IQR = 2.8-12). Following surgery, 14 ears had resolution of drainage, 6 had improvement, and 3 had episodic. The observed percentage of resolved/improved ears (87%) was significant (P = .0005, 95% CI = 67.9%-95.5%). Median follow-up time was 25 months (IQR = 12-59). Pre and postoperative pure tone averages improved (difference of medians = -3.3 dB, P = .02) with no significant difference in word recognition scores (P = .68). Methicillin-resistant Staphylococcus aureus was the most common isolated microbe while no growth was most frequently noted on intraoperative cultures. CONCLUSIONS: Mastoidectomy with antibiotic catheter irrigation may be an effective surgical strategy, and single stage alternative to intravenous antibiotics, for select patients with persistent tube otorrhea who have failed topical and oral antibiotics.

A Cristae-Like Microcompartment in Desulfobacterota.

Some Alphaproteobacteria contain intracytoplasmic membranes (ICMs) and proteins homologous to those responsible for the mitochondrial cristae, an observation which has given rise to the hypothesis that the Alphaproteobacteria endosymbiont had already evolved cristae-like structures and functions. However, our knowledge of microbial fine structure is still limited, leaving open the possibility of structurally homologous ICMs outside the Alphaproteobacteria. Here, we report on the detailed characterization of lamellar cristae-like ICMs in environmental sulfate-reducing Desulfobacterota that form syntrophic partnerships with anaerobic methane-oxidizing (ANME) archaea. These structures are junction-bound to the cytoplasmic membrane and resemble the form seen in the lamellar cristae of opisthokont mitochondria. Extending these observations, we also characterized similar structures in Desulfovibrio carbinolicus, a close relative of the magnetotactic D. magneticus, which does not contain magnetosomes. Despite a remarkable structural similarity, the key proteins involved in cristae formation have not yet been identified in Desulfobacterota, suggesting that an analogous, but not a homologous, protein organization system developed during the evolution of some members of Desulfobacterota. IMPORTANCE Working with anaerobic consortia of methane oxidizing ANME archaea and their sulfate-reducing bacterial partners recovered from deep sea sediments and with the related sulfate-reducing bacterial isolate D. carbinolicus, we discovered that their intracytoplasmic membranes (ICMs) appear remarkably similar to lamellar cristae. Three-dimensional electron microscopy allowed for the novel analysis of the nanoscale attachment of ICMs to the cytoplasmic membrane, and these ICMs are structurally nearly identical to the crista junction architecture seen in metazoan mitochondria. However, the core junction-forming proteins must be different. The outer membrane vesicles were observed to bud from syntrophic Desulfobacterota, and darkly stained granules were prominent in both Desulfobacterota and D. carbinolicus. These findings expand the taxonomic breadth of ICM-producing microorganisms and add to our understanding of three-dimensional microbial fine structure in environmental microorganisms.

Systematic Review and Meta-analysis of Endoscopic vs Microscopic Stapes Surgery for Stapes Fixation.

OBJECTIVE: To systematically review the current literature regarding the operative outcomes of stapes surgery for stapes fixation via the endoscopic and microscopic approaches. DATA SOURCES: PubMed, Embase, and Web of Science. REVIEW METHODS: An electronic search was conducted with the keywords "endoscop* or microscop*" and "stapes surgery or stapedectomy or stapedotomy or otosclerosis or stapes fixation." Studies were included if they compared endoscopy with microscopy for stapes surgery performed for stapes fixation and evaluated hearing outcomes and postoperative complications. Articles focusing on stapes surgery other than for stapes fixation were excluded. RESULTS: The database search yielded 1317 studies; 12 remained after dual-investigator screening for quantitative analysis. The mean MINORS score was 18 of 24, indicating a low risk of bias. A meta-analysis demonstrated no statistically significant difference between the groups with regard to operative time, chorda tympani nerve manipulation or sacrifice, or postoperative vertigo. There was a 2.6-dB mean improvement in the change in air-bone gap in favor of endoscopic stapes surgery and a 15.2% increased incidence in postoperative dysgeusia in the microscopic group, but the studies are heterogeneous. CONCLUSIONS: Endoscopic stapes surgery appears to be a reasonable alternative to microscopic stapes surgery, with similar operative times, complications, and hearing outcomes. Superior visibility with the endoscope was consistently reported in all the studies. Future studies should have standardized methods of reporting visibility, hearing outcomes, and postoperative complications to truly establish if endoscopic stapes surgery is equivalent or superior to microscopic stapes surgery.

Surgical Management of Sialorrhea: A Systematic Review and Meta-analysis.

OBJECTIVE: Chronic sialorrhea commonly occurs in patients with neurodevelopmental disorders. While conservative management can provide sufficient symptom control, surgical intervention is often required. One of the most common procedures utilized is submandibular gland excision (SMGE), with or without parotid duct ligation or rerouting (PDL or PDR). This study aims to compare these surgical approaches and their outcomes. DATA SOURCES: PubMed, Web of Science, and Embase. REVIEW METHODS: This systematic review includes studies of patients with chronic sialorrhea treated with SMGE alone or SMGE plus PDR or PDL and reports on postintervention outcomes and complications. Two independent investigators assessed study eligibility, rated quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data. RESULTS: Of 3186 studies identified, 21 met inclusion criteria, with 708 patients: 103 underwent SMGE alone (15%); 299 (42%), SMGE and PDL; and 306 (43%), SMGE plus PDR. Overall, a majority of patients had significant improvement, with very good to excellent control of symptoms after surgery: SMGE, 82% (95% CI, 73%-89%); SMGE and PDL, 79% (95% CI, 73%-85%); and SMGE and PDR, 85% (95% CI, 75%-92%). Importantly, there was no significant difference in outcomes with the addition of PDL or PDR. Reported complications included sialocele, parotitis, dental caries, and dry mouth. CONCLUSION: Our systematic review identified consistent positive outcomes with SMGE for patients with chronic sialorrhea but no additional benefit when PDR or PDL was performed as a concurrent procedure.

Management of Type 1 Laryngeal Clefts: A Systematic Review and Meta-analysis.

OBJECTIVE: Endoscopic surgical management or injection laryngoplasty of type 1 laryngeal clefts in pediatric patients is used in those who do not respond to conservative treatment. This study compares conservative treatment, endoscopic surgical repair, and injection laryngoplasty for the management of type 1 laryngeal clefts. DATA SOURCES: PubMed, Web of Science, and Embase. REVIEW METHODS: This systematic review included studies of patients with type 1 laryngeal clefts who were managed with conservative treatment, injection laryngoplasty, or endoscopic repair, and all studies reported postintervention outcomes. Two independent investigators assessed study eligibility, rated the quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data. RESULTS: Of the 1209 studies identified, 27 met inclusion criteria. There were 543 patients with type 1 laryngeal clefts represented in the studies, with outcomes reported for 537. Conservative therapy had a 52% (95% CI, 37%-66%; I2 = 63%) success rate at improving symptoms, while endoscopic repair had a significantly higher percentage resolution of symptoms (70%; 95% CI, 59%-79%; I2 = 62%, P < .001) as compared with conservative treatment (51%; 95% CI, 36%-65%; I2 = 62%) or injection laryngoplasty (36%; 95% CI, 20%-57%; I2 = 70%). The quality scores of the studies ranged from 7 to 12 out of 16. CONCLUSION: Our systematic review demonstrated significant improvement and resolution of symptoms for patients with type 1 laryngeal clefts treated with endoscopic repair as compared with other modalities. More prospective and controlled studies comparing treatment strategies with validated instruments to measure outcomes are necessary to determine their efficacy in the management of type 1 laryngeal clefts.

Robotic versus conventional neck dissection: A systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review is to compare the perioperative outcomes of robotic versus conventional neck dissection in patients with head and neck malignancy. METHODS: An electronic search of PubMed, Web of Science, and EMBASE databases was conducted. We included studies with direct comparisons of robotic and open neck dissections and performed dual, independent data extraction for primary outcomes of nodal yield, recurrence rate, subjective cosmetic assessment, operative time, length of stay, and rates of perioperative complications. Data were pooled using random effects meta-analysis to determine the standardized mean difference (SMD), absolute risk difference (RD), and 95% confidence intervals (CI). RESULTS: Eleven comparative studies comprising 225 robotic and 430 open neck dissections met the final selection criteria. All studies had low to moderate risk of bias. Robotic surgery improved cosmesis (SMD 1.15, 95% CI 0.73 to 1.56) but also increased operative time (SMD 1.94, 95% CI 1.25 to 2.63). Total nodal yield, pathological nodal yield, recurrence rate, rates of perioperative complications, and length of stay were not significantly different between the two groups, and the 95% CIs suggested that false negative results were unlikely. The results remained consistent after stratification by pathology and robotic technique. CONCLUSION: Although robotic neck dissection may offer similar perioperative outcomes compared to conventional neck dissection, it requires significantly more operative time. Whereas cosmesis was found to be superior among the robotic cohort, this must be viewed cautiously given the nonvalidated measurement tool that was used and the inherent reporting bias associated with it. Laryngoscope, 129:1587-1596, 2019.

Quality-of-Life Outcomes following Surgical Treatment of Ménière's Disease: A Systematic Review and Meta-analysis.

OBJECTIVE: Several surgical interventions are offered to patients with Ménière's disease (MD) who fail medical management. Although outcomes have historically been reported according to American Academy of Otolaryngology-Head and Neck Surgery guidelines, patient-reported outcome measures (PROMs) are increasingly used to evaluate treatments. This study reviews PROMs used to assess surgical treatments for MD and compares the effect of each intervention based on PROM scores. DATA SOURCES: PubMed, EMBASE, CINAHL, and Web of Science. REVIEW METHODS: This is a systematic review and meta-analysis of English-language studies that reported PROMs for surgical treatments of MD. Two independent investigators assessed study eligibility, rated the quality using Methodological Index for Non-Randomized Studies (MINORS), and abstracted data for comparative analysis. A random-effects model was used for meta-analysis of pooled data. RESULTS: Of 148 unique studies identified, 11 satisfied inclusion criteria. The Ménière's Disease Outcome Questionnaire (MDOQ) was the most commonly used survey. Interventions included intratympanic gentamicin, vestibular nerve section, endolymphatic sac surgery, and labyrinthectomy. Pooled analysis of 8 studies that used the MDOQ instrument demonstrated statistically significant improvements in quality of life but did not identify a difference between destructive and nondestructive procedures. CONCLUSION: Although our review shows significant improvements in PROM scores for both destructive and nondestructive interventions, there was no significant difference noted between treatment types. We cannot draw conclusions regarding the comparative effectiveness of specific interventions, and the results do not account for placebo effects or the natural history of the disease. Further investigation with randomized controlled trials should be considered in future studies.

Systematic Review of Voice Outcomes for Injection Laryngoplasty Performed under Local vs General Anesthesia.

Objective To assist otolaryngologists in counseling patients with hoarseness who would benefit from injection laryngoplasty on whether or not to perform the procedure in the office vs the operating room. Data Sources Cochrane library, CINAHL, PubMed, and EMBASE. Review Methods Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting standards of English-language articles that compared voice outcomes for in-office and in the operating room injection laryngoplasty. Two independent investigators assessed study eligibility, rated the quality using Methodological Index for Non-Randomized Studies (MINORS), and abstracted data for comparative analysis. Results Of 689 initial studies, 4 observational, comparative studies met inclusion criteria, with follow-up of 2 weeks to 12 months postinjection. Laryngoplasty was most commonly performed for vocal fold immobility with varied injectable materials (micronized dermis, hyaluronic acid, and calcium hydroxyapatite). Follow-up ranged from 2 weeks to 12 months. Voice outcomes improved in all studies, with comparable improvement for patients injected in the office vs the operating room ( P = .42 to P = .88). Meta-analysis of 3 studies showed no difference in Voice Handicap Index-10 voice outcomes by treatment setting (standardized mean difference -0.11, P = .441), with the 95% confidence interval (-0.405 to 0.176), making it unlikely that anything larger than a small or trivial difference was missed. Conclusion Our systematic review makes it unlikely that meaningful clinical differences exist in postprocedure voice outcomes for injection laryngoplasty in the office vs the operating room.

The double-barreled radial forearm osteocutaneous free flap.

OBJECTIVES/HYPOTHESIS: The radial forearm osteocutaneous free flap (RFOCFF) provides a thin pliable skin paddle with up to 11 cm of bone. A limitation of this flap is the thin bone that is obtained and the lack of suitability for dental implants. A minimum depth of 5 mm and height of 10 mm is required for a bony flap to accept osteointegrated implants. We propose that by double barreling the radial bone, it is possible to reconstruct osseous defects with bone of sufficient caliber to accept dental implants. STUDY DESIGN: Retrospective review of our experience with double-barreled RFOCFF. METHODS: We reviewed all free flaps performed from July 2000 to September 2014 and analyzed patients in whom a radial forearm osteocutaneous flap was used. We then reviewed those who had an osteotomy to form a double-barrel reconstruction. Descriptive data and outcomes were tabulated. RESULTS: A total of 458 osteocutaneous free flaps were performed; 75 were RFOCFF and 18 of these were double barreled. All 18 flaps survived. The reconstructed defect size was between 2.6 and 6.8 cm. One patient had dental implants placed at time of surgery that successfully osteointegrated. Postoperative computed tomography scans were available in nine patients and were used to calculate bone dimensions. Bone depth ranged from 7.91 to 13.22 mm, with a mean of 9.77 ± 1.53 mm. Bone height ranged from 8.42 to 17.81 mm, with a mean of 13.82 ± 3.2 mm. CONCLUSIONS: The double-barreled RFOCFF provides dependable long-lasting bone with adequate bone dimensions to support osteointegrated dental implants. LEVEL OF EVIDENCE: 4.

Documenting immunization of children in a cochlear implant program.

PURPOSE: Assess the effectiveness of an immunization verification protocol (IVP) to achieve and document pneumococcal vaccination of patients with cochlear implants. STUDY DESIGN: Chart review. SETTING: Academic tertiary medical center. PATIENTS: Pediatric patients with cochlear implants (n = 76). OUTCOME MEASURES: 1) Status of pneumococcal immunization for cochlear implant patients, before and after initiation of the IVP; 2) final number of existing cochlear implant patients successfully immunized after institution of the IVP; and 3) effectiveness of communication between our office and patient/parent or pediatrician. RESULTS: Subjects were grouped according to whether their cochlear implantation was performed before (Group 1, n = 63) or after (Group 2, n = 18) initiation of the IVP in September 2010. In the 28 months between IVP initiation and January 2013, the number of fully immunized age-eligible patients increased in Group 1 from 2% (n = 1) to 63% (n = 40). Of 18 subjects in Group 2, 56% (n = 10) were fully vaccinated at the time of surgery, and 94% were fully vaccinated at the conclusion of the study (n = 17). Of all 81 children, complete immunization was documented in 70% (n = 57), incomplete documentation was noted in 16% (n = 13); and 14% (n = 11) were lost to follow-up. CONCLUSION: It is a challenge to achieve and document immunizations recommended for cochlear implantation, even in a relatively small cochlear implant program. In our practice, those patients who were required to document immunizations before surgery had the highest rates of compliance. Access to a vaccination registry and the ability to administer vaccines in the otolaryngology office also improved compliance.