The Utility of a "Second-Look" Debridement Following Endonasal Skull Base Surgery in the Pediatric Population.

Background Sinonasal debridement is typically performed in the weeks following endonasal skull base surgery (ESBS). In the pediatric population, this second-look procedure may require general anesthesia; however, there is currently little evidence assessing the benefit of this practice. Methods This was a multicenter retrospective study of pediatric patients (age <18 years) undergoing a planned second-look debridement under general anesthesia following ESBS. Intraoperative findings, interventions performed, and perioperative complications were reviewed. Multivariate regression analysis was performed to identify associations between intraoperative findings and clinical factors. Results We reviewed 69 cases of second-look debridements (age mean 8.6 ± 4.2 years, range: 2-18 years), occurring a mean of 18.3 ± 10.3 days following ESBS. All abnormal findings were noted in patients age ≤12 years. Synechiae were noted in 8.7% of cases, bacterial rhinosinusitis in 2.9%, and failed reconstruction with cerebrospinal fluid leak in 4.5% (two cases of flap malposition and one case of flap necrosis). All failed reconstructions were noted following expanded endonasal cases for craniopharyngioma, and in each case, a revision reconstruction was performed during the second-look surgery. Synechiae were not significantly associated with younger age, revision cases, or cases with reconstructive flaps. There were no perioperative complications. Conclusion Second-look debridement under general anesthesia may be useful in the identification and intervention of sinonasal pathology following endoscopic skull base surgery, particularly in children ≤12 years old or those with pedicled flap reconstructions. Larger controlled studies are warranted to validate this practice and refine indications and timing of this second procedure.

Caloric function as a predictor of cochlear implant performance.

OBJECTIVES: Changes in vestibular function have been demonstrated following cochlear implantation (CI). The functional impact of these changes on CI performance has not been well-studied. We sought to assess whether caloric changes postimplantation could predict CI performance. METHODS: Retrospective review of a prospectively collected database at a tertiary care hospital. Patients who underwent CI over a 22-year period (1999-2021) and had videonystagmography (VNG) testing pre- and postimplantation were included. Caloric responses were compared pre- versus post-implantation, and assessed for their ability to predict CI performance as evaluated using AzBio +10 decibels signal-to-noise ratio (dB S/N) scores. RESULTS: 43 CI recipients were included. There was a significant difference in the average maximal slow-phase velocity in response to caloric irrigation in the implanted ear pre- versus post-operatively (21.2 vs. 18.5 deg/s; p = 0.02). Controlling for age and pre-implantation speech recognition performance, pre- and post-implantation caloric responses in the implanted ear significantly predicted CI performance at 0-6 months and >6 months post-implantation. Caloric changes following implantation were not significantly correlated with CI performance. CONCLUSION: CI impacts vestibular function as evidenced by changes in caloric responses. Vestibular function pre- and possibly post-CI may be clinically useful metrics for predicting some proportion of CI performance variability.

Cochlear Implant Outcomes in the Chinese-Speaking Adult Population: A Systematic Review.

OBJECTIVE: The purpose of this study is to perform a systematic review of speech perception outcomes in the Chinese-speaking adult cochlear implant (CI) population. DATABASES REVIEWED: PubMed, EMbase, and Scopus. METHODS: A comprehensive English literature search was performed with MeSH search terms, keywords, and phrases. Literature written in a language other than English was not included. Full-text articles were screened by two blinded reviewers and adjudicated by a third. Relevant outcomes and demographic data were extracted. Qualitative summaries were performed of the demographics and assessment tools. Speech perception outcomes were assessed with quantitative measures. RESULTS: Forty-four studies (n = 467) notable for marked heterogeneity in speech perception assessment utilized and reporting of relevant patient demographics were included. Mean duration of deafness among studies reporting this metric was 10.27 years (range, 0.08-49; SD, 7.70; n = 250), with 80% of subjects reporting >5 years' duration of deafness and only 19 subjects (7.6%) with <1 year of deafness preimplantation. A summary of the most commonly used assessments is provided. CONCLUSION: Within the English-language literature, there is marked heterogeneity and lack of standardization regarding speech perception outcomes, tests utilized, and reported patient demographics in the Chinese-speaking adult CI population. Most Chinese-speaking CI users for whom data were available had prolonged duration of deafness before implantation. This study may serve as an initial reference for providers counseling Chinese-language CI candidates and who may be interested in adopting these tests, while highlighting the need for continued efforts to measure speech perception outcomes after CI for tonal language speakers.

Predictive Ability of First-Side Cochlear Implant Performance in Adult Sequential Bilateral Cochlear Implantation.

OBJECTIVE: Predictors of second-side cochlear implant performance have not been well studied. We sought to assess whether speech recognition scores from first-side cochlear implant (CI1) could predict second-side cochlear implant (CI2) scores in sequential bilaterally implanted adults. STUDY DESIGN: Retrospective review using a prospectively collected database. SETTING: Academic tertiary care hospital. PATIENTS: Fifty-seven adults with postimplantation speech recognition testing performed at least 12 months after CI2. INTERVENTION: Sequential bilateral CI. MAIN OUTCOME MEASURES: CI2 performance at ≥12 months as measured using consonant-nucleus-consonant (CNC) words and AzBio sentences in quiet and +10 dB signal-to-noise ratio (S/N). RESULTS: CI1 performance scores at ≥12 months were independently associated with CI2 performance scores at ≥12 months for CNC words (ß = 0.371 [0.136-0.606], p = 0.003), AzBio sentences in quiet (ß = 0.614 [0.429-0.80], p < 0.0001), and AzBio +10 dB S/N (ß = 0.712 [0.459-0.964], p < 0.0001). CI1 scores on AzBio in quiet at 0 to 6 months were also independently associated with CI2 AzBio in quiet scores at ≥12 months (ß = 0.389 [0.004-0.774], p = 0.048). Hearing loss etiology and duration, age at implantation, interval between CI1 and CI2, duration of hearing aid use, and preimplantation speech recognition testing scores were not consistently associated with CI2 scores at ≥12 months. CONCLUSIONS: CI1 performance is an independent predictor of second-side performance as measured ≥12 months postimplantation. This may be a clinically useful metric when considering adult sequential bilateral implantation.

Introducing Surgical Equity into Contemporary Medical Education: Results From Operation Equity, a Pilot Curriculum.

OBJECTIVE: To date, education about health equity for early-stage healthcare trainees is largely situated outside of surgical disciplines. This study aims to evaluate the effectiveness of a surgical equity curriculum offered to a voluntary group of medical and graduate students. DESIGN: Mixed-methods cohort study from January to June 2021. Pre- and post-course surveys measured domains of attitudes, self-reported confidence, and knowledge via 5-point Likert scale and multiple-choice questions. Paired t tests were used to analyze quantitative responses. Qualitative responses were studied via iterative thematic analysis. SETTING: At the University of Pennsylvania in Philadelphia, PA which provides tertiary level, institutional care, 10, interdisciplinary 1.5-hour sessions were held over 1 semester, teaching surgical equity topics that spanned the peri-operative continuum. PARTICIPANTS: Twenty-four medical and graduate students from across the University of Pennsylvania enrolled. Twenty completed both surveys. RESULTS: From pre- to post-course, students improved across all domains. Students improved in their self-rated ability to identify strategies to talk about sensitive health topics with patients (pre: 20%, post: 90%) and identify strategies to address healthcare disparities in surgery (pre: 10%, post: 90%). Qualitatively, from pre- to post-course, more students could articulate the role of bias and identify opportunities for surgeons to engage in surgical equity. The course strengthened any pre-existing interest in surgical equity, and for 1 student, created interest in a surgical career where it had not previously existed. Many also expressed greater resolve to provide patient-centric care. CONCLUSIONS: Formal curricula can improve students' ability to advocate for surgical equity. A similar framework may fill a need for medical students interested in health equity and surgical careers at other institutions.

Management of Chronic Sialadenitis due to Sjogren's Syndrome and Radioactive Iodine Therapy Using Sialendoscopy.

INTRODUCTION: Sialendoscopy is a minimally invasive technique for the management of salivary gland disease. This work characterizes its utility for treating chronic sialadenitis due to Sjogren's syndrome and radioactive iodine (RAI) therapy. METHODS: A single-center, retrospective review of patients undergoing sialendoscopy between March 2013 and May 2019 for the treatment of chronic sialadenitis due to Sjogren's or prior RAI therapy was performed. RESULTS: Thirty-four patients with Sjogren's and 25 patients who received RAI were identified, undergoing a total of 86 procedures. Median age at presentation was 53 years with mean follow-up time of 14.3 months. Seventy-two procedures were performed on the parotid gland, four on the submandibular gland, and ten on both glands. Corticosteroid injection and duct dilation were performed most commonly. Sixteen patients required repeat procedure. All patients were symptomatically improved at follow-up visit. DISCUSSION/CONCLUSION: These results support the idea that sialendoscopy offers symptomatic benefit for patients with chronic sialadenitis due to Sjogren's or RAI.

Sialendoscopy for sialodocholithiasis following submandibular gland excision: six variations on a theme.

Sialendoscopy is a minimally invasive technique that facilitates the diagnosis and treatment of sialolithiasis. This case series presents the novel use of sialendoscopy to treat sialodocholithiasis in six patients with a non-functional or surgically absent submandibular gland by a single surgeon at the University of Pennsylvania Health System between March 2013 and December 2019. The four female and two male patients had a median age of 56 years and mean follow-up of 16.2 months (range 1-44.5). All stones were successfully removed using sialendoscopy, and in 5 patients a combined approach was utilized. All patients remain asymptomatic at last clinical follow-up. We conclude that sialendoscopy is a viable, minimally invasive method for managing sialodocholithiasis in patients with prior submandibular gland excision or atretic gland. It is also useful as an assistive tool when approaching complex transcervical or transoral procedures in previously instrumented patients.

Assessment of music experience after cochlear implantation: A review of current tools and their utilization.

OBJECTIVE: To provide an overview of the current available music assessment tools after cochlear implantation (CI); to report on the utilization of music assessments in the literature; to propose potential future directions in music assessment after CI. METHODS: A thorough search was performed in PubMed, Embase, and The Cochrane Library through October 31, 2020. MeSH search terms, keywords, and phrases included "cochlear implant," "cochlear prosthesis," "auditory prosthesis," "music," "music assessment," "music questionnaire," "music perception," "music enjoyment, and "music experience." Potentially relevant studies were reviewed for inclusion, with particular focus on assessments developed specifically for the cochlear implant population and intended for widespread use. RESULTS/CONCLUSIONS: Six hundred and forty-three studies were screened for relevance to assessment of music experience among cochlear implantees. Eighty-one studies ultimately met criteria for inclusion. There are multiple validated tools for assessment of music experience after cochlear implantation, each of which provide slightly differing insights into the patients' subjective and/or objective post-activation experience. However, no single assessment tool has been adopted into widespread use and thus, much of the literature pertaining to this topic evaluates outcomes non-uniformly, including single-use assessments designed specifically for the study at hand. The lack of a widely accepted universal tool for assessment of music limits our collective understanding the contributory and mitigating factors applicable to current music experience of cochlear implantees, and limits our ability to uniformly evaluate the success of new implant technologies or music training paradigms.

Nuances and Management of Hilar Submandibular Sialoliths With Combined Transoral Robotic Surgery-Assisted Sialolithotomy and Sialendoscopy.

OBJECTIVE: To describe the management, technical nuances, and success rates of transoral robotic surgery (TORS)-assisted sialolithotomy. STUDY DESIGN: Retrospective database review. SETTING: Quaternary academic medical center. METHODS: Between the months of January 2015 and May 2019, patients with hilar submandibular gland stones underwent 2 main variations of TORS-assisted sialolithotomy and sialendoscopy: (1) TORS followed by sialendoscopy for patients with palpable predominantly single stones and (2) either sialendoscopy followed by TORS and sialendoscopy or sialendoscopy followed by TORS only for patients with nonpalpable or multiple stones. Clinical charts were reviewed to collect data, including stone size (imaging review, intraoperative measurement), palpability, duration of operation, TORS variation, operative challenges, symptom improvement, gland preservation rate, and complications. RESULTS: Thirty-seven patients were identified. Patients were 26 to 80 years old (mean, 57.2 years), and 40.5% were female. Twenty-four patients (64.9%) underwent TORS followed by sialendoscopy; 10 (27.0%), sialendoscopy followed by TORS and sialendoscopy; and 3 (8.1%), sialendoscopy followed by TORS only. The mean stone size was 12.4 mm (range, 4-28 mm). Eleven patients had multiple stones with a mean 4 stones per patient (range, 2-9). Procedural success was 91.9% (34/37) at a mean follow-up of 34.2 weeks (range, 1.4-262.1), and the gland preservation rate was 97.3% (36/37). No patients reported symptoms of lingual nerve injury at 3-month follow-up. CONCLUSION: TORS combined with sialendoscopy for hilar submandibular gland sialolithiasis allows for improved visualization of critical anatomy, tissue manipulation, and operative flexibility. In our experience, the operative success rate is high, and duration of surgery compares favorably with conventional combined hilar approaches.

Robotic Management of Salivary Glands.

There are numerous salivary gland pathologies for which robotic surgery can provide benefit. This article reviews the primary indications for use of transoral robotic surgery for salivary gland neoplasms. It also discusses transoral and retroauricular robotic approaches for pathology of the submandibular gland and prestyloid parapharyngeal space. These approaches have the advantage of avoiding a visible scar and are additionally minimally invasive in other ways as well. Robotic surgery offers advantages in several different modules of salivary gland surgery, similar to those it offers for oropharyngeal cancer, including improved optics, manual dexterity, and teamwork.

Single-port transoral robotic combined approach with sialendoscopy for sialolithiasis: Case report and review of the literature.

BACKGROUND: The da Vinci single-port (SP) is utilized in transoral robotic surgery (TORS) procedures for malignant oropharyngeal tumors. We report a case utilizing the da Vinci SP in TORS for sialolith removal. METHODS AND RESULTS: A 75-year-old male with chronic right submandibular gland (SMG) sialadenitis underwent combined da Vinci SP TORS approach with sialendoscopy for multiple SMG sialoliths. We were unable to find a previous report of using the da Vinci SP in TORS for SMG sialolith removal. CONCLUSION: The da Vinci SP has been utilized in a combined TORS approach with sialendoscopy for SMG sialolith removal. The da Vinci SP's additional arm provides improved retraction, enabling optimal visualization, dissection, and preservation of important structures such as the lingual nerve.