Twice as Nice: How Doubling Otolaryngology Rotation Time Affects the Intern Experience Nationwide.

OBJECTIVES: Describe the current state of otolaryngologic residency training with recent changes to the program requirements by the Accreditation Council for Graduate Medical Education (ACGME) which increased the amount of time on intern year otolaryngology rotations from 3 to 6 months. METHODS: A cross-sectional study was performed and recruitment was done via personalized email sent to program coordinators of 113 ACGME-accredited otolaryngology training programs within the Unites States. The message requested a breakdown of the amount of time and specialty in which first year otolaryngologic residents rotated. Interval follow ups were sent at 3 and 6 months for coordinators who had not responded. RESULTS: Response rate was 79.7% (90/113). General surgery and surgical intensive care unit were the two most common non-otolaryngologic rotations (92.2% and 96.6% respectively) while ophthalmology and radiation oncology were the least common at 7.8% each. All first year residents spend time on an inpatient otolaryngologic rotation, while 30.7% spend time on outpatient rotations. The most common subspecialties were head and neck oncology (40.0%) followed by pediatric otolaryngology (36.0%). CONCLUSIONS: Otolaryngologic training continues to become more slanted towards specialty-specific training and a concurrent reduction in "off-service" rotations. General inpatient services still predominate the intern year both inter- and intra-departmentally. These data provide insight into the training environment of the otolaryngologic trainees set to graduate residency for the first time this year.

Targeting the unfolded protein response in head and neck and oral cavity cancers.

Many FDA-approved anti-cancer therapies, targeted toward a wide array of molecular targets and signaling networks, have been demonstrated to activate the unfolded protein response (UPR). Despite a critical role for UPR signaling in the apoptotic execution of cancer cells by many of these compounds, the authors are currently unaware of any instance whereby a cancer drug was developed with the UPR as the intended target. With the essential role of the UPR as a driving force in the genesis and maintenance of the malignant phenotype, a great number of pre-clinical studies have surged into the medical literature describing the ability of dozens of compounds to induce UPR signaling in a myriad of cancer models. The focus of the current work is to review the literature and explore the role of the UPR as a mediator of chemotherapy-induced cell death in squamous cell carcinomas of the head and neck (HNSCC) and oral cavity (OCSCC), with an emphasis on preclinical studies.

Benign and Malignant Oral Lesions in Children and Adolescents: An Organized Approach to Diagnosis and Management.

Oral lesions in children encompass a wide range of etiologies, including idiopathic entities as well as those related to an underlying systemic illness. In addition, oral masses include benign entities harboring locally destructive behavior and even malignancies in rare cases. Thorough patient history and detailed and efficient physical examination are critical for determining which lesions can be closely observed versus those require further diagnostic work-up. Understanding normal oral cavity anatomy is crucial for performing appropriate evaluation. This review describes the appropriate diagnostic and therapeutic strategies for oral cavity lesions and reviews the broad differential diagnosis of oral cavity masses.

Trends in management of obstructive sleep apnea in pediatric patients with Down syndrome.

INTRODUCTION: Residual obstructive sleep apnea (OSA) after adenotonsillectomy (T&A) is a common problem in children with Down Syndrome (DS). Our objective was to describe trends in surgical and medical management of OSA in pediatric patients with DS, and to present an algorithmic approach to managing these children. METHODS: Retrospective case series of children with DS seen at a tertiary care medical center between 1/2008-6/2016 who underwent polysomnography (PSG) after having a T&A performed for sleep disordered breathing (SDB). RESULTS: Sixty-five patients met inclusion criteria. The mean age at T&A was 4.8 years and 52.0% were male. The mean apnea-hypopnea index (AHI) was 23.2 events/hour for patients who had pre-T&A PSGs. The mean AHI was 10.7 events/hour after T&A. Twenty-three patients (35.4%) underwent at least one additional surgical procedure after T&A; 5 (7.7%) patients had ≥ two additional procedures. The most common additional surgical procedures were revision adenoidectomies (n = 8) and lingual tonsillectomies (n = 13). Fifteen (23.1%) patients underwent at least one drug-induced sleep endoscopy (DISE) to help direct selection of surgical site/s. CONCLUSIONS: Residual OSA is common after T&A in children with Down syndrome and can be managed by additional surgical interventions in many instances with successful reduction of the AHI. DISE has become part of a standard algorithm for managing persistent OSA in children with Down syndrome after T&A.

Management of Epistaxis in Children and Adolescents: Avoiding a Chaotic Approach.

This article provides an organized foundation that facilitates the management of acute epistaxis and an understanding of features that merit further diagnostic workup. Prompt management, including measures such as holding pressure and using nasal packing, takes precedence over comprehensive diagnostic workup. Severe, recurrent, and posteriorly based bleeds should prompt consideration of alternate interventions and expert consultation.

Analysis of Factors Associated With Rhytidectomy Malpractice Litigation Cases.

IMPORTANCE: This study investigates the financial burden of medical malpractice litigation associated with rhytidectomies, as well as factors that contribute to litigation and poor defendant outcomes, which can help guide physician practices. OBJECTIVE: To comprehensively evaluate rhytidectomy malpractice litigation. DATA SOURCES AND STUDY SELECTION: Jury verdict and settlement reports related to rhytidectomy malpractice litigations were obtained using the Westlaw Next database. Use of medical malpractice in conjunction with several terms for rhytidectomy, to account for the various procedure names associated with the procedure, yielded 155 court cases. Duplicate and nonrelevant cases were removed, and 89 cases were included in the analysis and reviewed for outcomes, defendant specialty, payments, and other allegations raised in proceedings. Data were collected from November 21, 2015, to December 25, 2015. Data analysis took place from December 25, 2015, to January 20, 2016. RESULTS: A total of 89 cases met our inclusion criteria. Most plaintiffs were female (81 of 88 with known sex [92%]), and patient age ranged from 40 to 76 years (median age, 56 years). Fifty-three (60%) were resolved in the defendant's favor, while the remaining 36 cases (40%) were resolved with either a settlement or a plaintiff verdict payment. The mean payment was $1.4 million. A greater proportion of cases involving plastic surgeon defendants were resolved with payment compared with cases involving defendants with ear, nose, and throat specialty (15 [36%] vs 4 [24%]). The most common allegations raised in litigation were intraoperative negligence (61 [69%]), poor cosmesis or disfigurement (57 [64%]), inadequate informed consent (30 [34%]), additional procedures required (14 [16%]), postoperative negligence (12 [14%]), and facial nerve injury (10 [11%]). Six cases (7%) involved alleged negligence surrounding a "lifestyle-lift" procedure, which tightens or oversews the superficial muscular aponeurosis system layer. CONCLUSIONS AND RELEVANCE: In this study, although most cases of rhytidectomy malpractice litigation were resolved in the defendant's favor, cases resulting in payments created substantial financial burden for the defendants. Common factors cited by plaintiffs for pursuing litigation included dissatisfaction with cosmetic outcomes and perceived deficits in informed consent. These factors reinforce the importance of a comprehensive, preoperative informed consent process in which the specific potential risks and outcomes are presented by the surgeon to the patient to limit or avoid postsurgical allegations. Intraoperative negligence and facial nerve injury were significantly more likely to result in poor defendant outcomes. LEVEL OF EVIDENCE: NA.

Establishing a danger zone: An anatomic study of the lingual artery in base of tongue surgery.

OBJECTIVES/HYPOTHESIS: To contrast the changes in measurement of the hypoglossal/lingual artery neurovascular bundle (HLNVB) to constant surface landmarks in the base of tongue (BOT) during surgically simulated retraction versus resting anatomic position, and to identify a safe zone for BOT robotic surgery to avoid injury to the HLNVB. STUDY DESIGN: Human cadaver study. METHODS: Five fresh-frozen head and neck complexes were obtained, and seven HLNVBs were dissected. A microcaliper was used to measure the distance from the HLNVB to constant surface landmarks in resting and surgically simulated positions using a Feyh-Kastenbauer retractor. RESULTS: Measurements from foramen cecum to palatoglossus muscle (P < 0.042) was significantly different when comparing anatomical to surgically simulated positions. Importantly, the location of the lingual artery in reference to the surface landmarks measured was dramatically altered with tongue retraction. With retraction, the branches of the dorsal lingual artery were not encountered posterior to a horizontal line between midway circumvallate papilla (mCVP). CONCLUSION: Measurements of the HLNVB to surface landmarks in the BOT differs significantly between resting and a surgically simulated tongue position. The dorsal branch of the lingual artery seems more superficial in the BOT than previously described. A safe zone may exist posterior to an imaginary horizontal line between mCVP; however, further studies are needed to confirm this. LEVEL OF EVIDENCE: NA Laryngoscope, 127:110-115, 2017.

To exenterate or not? An unusual case of pediatric rhinocerebral mucormycosis.

Rhinocerebral mucormycosis (RM) is a rare, potentially lethal fungal infection. Traditional teaching encourages aggressive surgical resection until viable bleeding tissue is encountered, often leading to orbital exenteration, skull base resection, and cerebral debridement, in addition to systemic antifungal therapy. We present a 2-year-old male with acute lymphocytic leukemia undergoing chemotherapy presenting with RM and unilateral orbital and intracranial involvement. After aggressive sinonasal debridement, systemic antifungal and hyperbaric oxygen therapies, he recovered without need for further aggressive tissue resection. We report the successful management of invasive orbital and intracranial RM without orbital exenteration or cerebral debridement.

Salutary effect of calcium channel blockade following hypoxic and septic insult.

BACKGROUND: Intestinal ischemia and reperfusion is a major problem associated with a high morbidity and mortality following trauma and hemorrhagic shock. Apoptosis is the major mode of cell death following reperfusion. The cytoskeleton damage precedes the apoptotic final microscopic features. Calcium plays a central role in apoptosis. Therefore, we studied whether verapamil could preserve the function of the cytoskeleton in an in vitro intestinal model following hypoxia-reoxygenation (H/R). Our goal was to assess mainly the cytoskeleton functions, which includes IgA transport and the cell monolayer barrier integrity. METHODS: Confluent HT29 intestinal monolayers grown in a two-chamber cell culture system were held under hypoxic (5% CO2) conditions for 90 minutes followed by normoxia (21% O2) (H/R). Cell subsets were exposed to lipopolysaccharide (10 µg/mL) before H/R. Verapamil (8 µM) was added to HT29 cell subsets after H/R treatment. Dimeric IgA was added to the basal compartment, and apical media were sampled at intervals to quantitate IgA transcytosis using enzyme-linked immunosorbent assay. HT29 cells held under normoxic conditions served as controls. HT29 permeability to FD4 was assessed at the end of each experiment. In a separate experiment, HT29 cells were stained for F actin using rhodamine-labeled phalloidin. RESULTS: Intestinal monolayer permeability was increased following treatment with H/R and/or lipopolysaccharide. Verapamil treatment prevented increased permeability in HT29 cells and led to an increase in IgA transport. Disruption of actin microfilaments was demonstrated following H/R insult but was abrogated by the addition of verapamil following H/R insult. CONCLUSION: Reperfusion can lead to both physical and immune derangement of epithelial cell barrier function. Verapamil may be important in preserving gut barrier function. Additional studies including in vivo confirmation in animal shock models are needed to validate these findings.

New paradigms in the pathogenesis of otitis media in children.

Acute otitis media (AOM) is a multifactorial disease with a significant socioeconomic impact. The pathogenesis of AOM is attributed to a variety of well-established internal and extrinsic factors. Recent evidence strongly points to bacterial biofilm formation as an important contributor to this disease entity. The nasopharynx is a likely reservoir for infection with subsequent seeding of pathogens to the middle ear via planktonic shedding. Various modalities have been used to directly detect biofilm formation in the middle ear mucosa of children with AOM. Further insights into this disease may lead to new strategies for prevention and treatment.

Potential role of lycopene in the treatment of hepatitis C and prevention of hepatocellular carcinoma.

Hepatitis C virus (HCV) infection and hepatocellular carcinoma (HCC) are growing health problems around the world. Oxidative stress plays a significant role in the initiation and progression of hepatocellular damage and possibly in the development of HCC in HCV infected patients. In vitro, animal and clinical studies suggest that lycopene, a nonprovitamin A carotenoid and a potent antioxidant, may attenuate the liver injury and possibly prevent the development of HCC. In this article, we discuss the relationship between HCV infection and oxidative stress and review the potential role of lycopene in the treatment of HCV and prevention of HCC.