Will nasal airway surgery improve my sense of smell? A prospective observational study.

BACKGROUND: The effect of nasal airway surgery on olfaction has not been well established. The goal of this study is to assess changes in olfaction after septoplasty with inferior turbinate reduction through both objective and patient-reported measures. METHODS: Prospective, observational study was conducted of patients with nasal airway obstruction presenting between July 2017 and October 2019 who underwent septoplasty with inferior turbinate reduction. Nasal airflow was characterized with the Nasal Obstruction Symptom Evaluation (NOSE) scale and an 11-point ease-of-breathing (EOB) Likert scale, and olfaction with an 11-point olfactory Likert scale and the 40-item University of Pennsylvania Smell Identification Test (UPSIT), pre- and postoperatively. Pearson correlations were used to assess the relationship between measures of nasal obstruction and olfaction. RESULTS: Among 80 patients, mean NOSE scores improved from 67.4 preoperatively to 19.6 postoperatively (p < 0.001). EOB Likert scores improved from a mean of 3.9/10 to 8.1/10 after surgery (p < 0.001). Olfactory Likert scores improved from a baseline of 6.1/10 preoperatively to 7.9/10 after surgery (p < 0.001). No statistically significant difference was noted in UPSIT testing pre- versus postoperatively. A moderate correlation was noted between the degree of change in NOSE scores and improved olfactory Likert scores (r = 0.51, p < 0.001), and similarly between the degree of change in EOB Likert scores and improved olfactory Likert scores (r = 0.55, p < 0.0001). CONCLUSIONS: Based on our data, subjective tests of olfaction may improve with nasal airway surgery in some patients. Changes in olfaction best correlate with the extent to which surgery can improve subjective nasal obstructive symptoms.

Prevalence and Management of Laryngomalacia in Patients With Pierre Robin Sequence.

OBJECTIVE: To characterize the prevalence and presentation of laryngomalacia and efficacy of supraglottoplasty (SGP) in a cohort of patients with Pierre Robin Sequence (PRS). DESIGN: Retrospective cohort study. SETTING: Tertiary-care children's hospital. PATIENTS, PARTICIPANTS: Consecutive patients with PRS born between January 2010 and June 2018. MAIN OUTCOME MEASURES: Chart review included demographics, comorbid airway obstruction including laryngomalacia, timing of surgical interventions, clinical symptoms, sleep study data, and modified barium swallow study data.126 patients with PRS were included; 54% had an associated syndrome, 64% had an overt cleft palate, and 22% had a submucous cleft palate. 64/126 were noted to have laryngomalacia (51%). Patients with concurrent PRS and laryngomalacia were significantly more likely to have submucous cleft palate (P = .005) and present with aspiration with cough (P = .01) compared to patients with PRS without laryngomalacia. Patients with concurrent laryngomalacia and PRS showed a significant decrease in apnea-hypopnea index (AHI) and obstructive AHI (OAHI) after mandibular distraction, with a median AHI and OAHI improvement of 22.3 (P = .001) and 19.8 (P = .002), respectively. Patients who underwent only SGP did not show significant improvement in these parameters (P = .112 for AHI, P = .064 for OAHI).The prevalence of laryngomalacia in our PRS cohort was 51%. Patients with PRS and laryngomalacia are more likely to present with overt aspiration compared to patients with PRS without laryngomalacia. These data support that laryngomalacia does not appear to be a contraindication to pursuing MDO.

Primary versus secondary closure of tracheocutaneous fistula in pediatric patients.

OBJECTIVE: Up to 50% of pediatric patients have a persistent tracheocutaneous fistula (TCF) after tracheostomy decannulation. Classically these fistula tracts were excised and completely closed in a multilayered fashion, but recently closure by secondary intention has become the standard of care. However, variations in postoperative care still exist. The primary objectives of this study were to compare outcomes between patients who had a primary closure versus closure by secondary intention after excision of a TCF in children with a tracheostomy placement at one year old or less and to determine if closure by secondary intention will be equally efficacious compared to traditional primary closure. METHODS: Patients ages 0-21 years who had a primary or secondary closure of a TCF at a tertiary care children's hospital following decannulation of a tracheostomy tube were reviewed and those with a tracheostomy placement ≤1 year old were included. Demographic information, comorbidities, and surgical information were extracted from inpatient and outpatient charts. Mann-Whitney U test, Fisher's Exact test, and logistic regression to compare outcomes across the two TCF surgical groups. RESULTS: A total of 64 patients met inclusion with primary closures in 25 (39.1%) patients and secondary closures in 39(60.9%) patients. Patients who underwent secondary closure had a significantly shorter surgery duration (p < .001), shorter ICU length of stay (p < .001), and shorter postop LOS (p < .001). There were no differences in cardiac complications, respiratory complications, and the need for additional closure surgery between the two techniques, p > .05. Time from decannulation to TCF in months increased with primary closure, p = .010. CONCLUSION: Closure of tracheocutaneous fistula by secondary intention is safe and effective and can allow for shorter hospital stays in children with a tracheostomy placement at a year old or less.

Self-directed Learning in Otolaryngology Residents' Preparation for Surgical Cases.

OBJECTIVES: To characterize the nature of surgical preparation among otolaryngology residents nationwide, determine the self-rated effectiveness and efficiency of case preparation practices, and identify potential means for educational improvement. METHODS: A survey examining the study objectives was developed and distributed to otolaryngology residents nationwide. Survey response data were submitted to descriptive analysis and comparative analyses between junior and senior residents. Literature regarding case preparation among otolaryngology residents was reviewed. RESULTS: Among 108 resident respondents, the most commonly used resources included textbooks (86.1%), surgical education websites (74.1%), and surgical atlases (66.7%). Time was the primary limitation (cited by 84.3%) and convenience the predominant factor influencing resource selection (92.5%). On a 5-point Likert scale, mean scores regarding effectiveness and efficiency of case preparation were 3.53 ± 0.68 and 3.19 ± 0.88, respectively. Senior residents compared to junior residents were more likely to rate their preparation as effective (3.75 ± 0.54 vs 3.40 ± 0.72, P = .008) and efficient (3.45 ± 0.85 vs 3.03 ± 0.86, P = .02). CONCLUSION: Otolaryngology residents do not consistently rate their case preparation as effective or efficient. While there appears to be progress in self-directed learning throughout residency, room for improvement remains, with potential avenues for such improvement explored here.

Dietary Reversal Ameliorates Short- and Long-Term Memory Deficits Induced by High-fat Diet Early in Life.

A high-fat diet (HFD), one of the major factors contributing to metabolic syndrome, which is associated with an increased risk of neurodegenerative diseases, leads to insulin resistance and cognitive impairment. It is not known whether these alterations are improved with dietary intervention. To investigate the long-term impact of a HFD on hippocampal insulin signaling and memory, C57BL6 mice were placed into one of three groups based on the diet: a standard diet (control), a HFD, or a HFD for 16 weeks and then the standard diet for 8 weeks (HF16). HFD-induced impairments in glucose tolerance and hippocampal insulin signaling occurred concurrently with deficits in both short- and long-term memory. Furthermore, these conditions were improved with dietary intervention; however, the HFD-induced decrease in insulin receptor expression in the hippocampus was not altered with dietary intervention. Our results demonstrate that memory deficits due to the consumption of a HFD at an early age are reversible.

The role of endoplasmic reticulum stress in hippocampal insulin resistance.

Metabolic syndrome, which includes hypertension, hyperglycemia, obesity, insulin resistance, and dyslipidemia, has a negative impact on cognitive health. Endoplasmic reticulum (ER) stress is activated during metabolic syndrome, however it is not known which factor associated with metabolic syndrome contributes to this stress. ER stress has been reported to play a role in the development of insulin resistance in peripheral tissues. The role of ER stress in the development of insulin resistance in hippocampal neurons is not known. In the current study, we investigated ER stress in the hippocampus of 3 different mouse models of metabolic syndrome: the C57BL6 mouse on a high fat (HF) diet; apolipoprotein E, leptin, and apolipoprotein B-48 deficient (ApoE 3KO) mice; and the low density lipoprotein receptor, leptin, and apolipoprotein B-48 deficient (LDLR 3KO) mice. We demonstrate that ER stress is activated in the hippocampus of HF mice, and for the first time, in ApoE 3KO mice, but not LDLR 3KO mice. The HF and ApoE 3KO mice are hyperglycemic; however, the LDLR 3KO mice have normal glycemia. This suggests that hyperglycemia may play a role in the activation of ER stress in the hippocampus. Similarly, we also demonstrate that impaired insulin signaling is only present in the HF and ApoE 3KO mice, which suggests that ER stress may play a role in insulin resistance in the hippocampus. To confirm this we pharmacologically induced ER stress with thapsigargin in human hippocampal neurons. We demonstrate for the first time that thapsigargin leads to ER stress and impaired insulin signaling in human hippocampal neurons. Our results may provide a potential mechanism that links metabolic syndrome and cognitive health.

The Role of Oxidized Cholesterol in Diabetes-Induced Lysosomal Dysfunction in the Brain.

Abnormalities in lysosomal function have been reported in diabetes, aging, and age-related degenerative diseases. These lysosomal abnormalities are an early manifestation of neurodegenerative diseases and often precede the onset of clinical symptoms such as learning and memory deficits; however, the mechanism underlying lysosomal dysfunction is not known. In the current study, we investigated the mechanism underlying lysosomal dysfunction in the cortex and hippocampi, key structures involved in learning and memory, of a type 2 diabetes (T2D) mouse model, the leptin receptor deficient db/db mouse. We demonstrate for the first time that diabetes leads to destabilization of lysosomes as well as alterations in the protein expression, activity, and/or trafficking of two lysosomal enzymes, hexosaminidase A and cathepsin D, in the hippocampus of db/db mice. Pioglitazone, a thiazolidinedione (TZD) commonly used in the treatment of diabetes due to its ability to improve insulin sensitivity and reverse hyperglycemia, was ineffective in reversing the diabetes-induced changes on lysosomal enzymes. Our previous work revealed that pioglitazone does not reverse hypercholesterolemia; thus, we investigated whether cholesterol plays a role in diabetes-induced lysosomal changes. In vitro, cholesterol promoted the destabilization of lysosomes, suggesting that lysosomal-related changes associated with diabetes are due to elevated levels of cholesterol. Since lysosome dysfunction precedes neurodegeneration, cognitive deficits, and Alzheimer's disease neuropathology, our results may provide a potential mechanism that links diabetes with complications of the central nervous system.