Eagle Syndrome: A Rare Case of Atraumatic, Painful Cervical Neck Swelling.

INTRODUCTION: Painful neck swelling is a common emergency complaint but can present diagnostic challenges. Eagle syndrome is a rare clinical entity in which a pathologically elongated styloid process or ossified stylohyoid ligament produces a constellation of symptoms in the head and neck region. CASE REPORT: We present the case of a 50-year-old male with a spontaneous, atraumatic fracture of an elongated styloid process associated with hematoma formation and radiological findings of airway impingement. DISCUSSION: The classic triad for Eagle syndrome consists of unilateral cervicofacial pain, globus sensation, and dysphagia. Diagnosis of Eagle syndrome should be made based on a combination of physical examination and radiological findings. Treatment options vary based on severity of symptoms. CONCLUSION: Although more likely to be an indolent and progressive complaint, providers in the acute care setting should be familiar with Eagle syndrome due to the potential for a spontaneous fracture of an elongated styloid process to cause acute, painful neck swelling and life-threatening airway compromise.

Supraglottoplasty surgery types 1-3: A practical classification system for laryngomalacia surgery.

OBJECTIVE: The objective of this study is to review the published literature on supraglottoplasty techniques for correcting laryngomalacia, and to subsequently provide a standardized classification system. METHODS: Three authors independently and systematically searched Pubmed/MEDLINE and six additional databases for all studies that included descriptions of supraglottoplasty techniques for correcting laryngomalacia. Sub-sites operated on and specific technique descriptions were reviewed, cataloged and subsequently categorized. This data was then used to develop a new classification system. RESULTS: 231 articles were identified, downloaded and reviewed in full text. 53 articles with 1669 patients from the included articles described in detail the supraglottoplasty procedure. 84 articles with 5731 patients had to be excluded secondary to not providing detail about the supraglottoplasty procedure. The resultant data identifies the need for a more standardized reporting of the supraglottoplasty procedure in order to more accurately evaluate technique specific outcomes. Currently 77% of the patients in the literature cannot be assessed for outcomes as they did not describe the details for the procedures. Eight variations of supraglottoplasty and four variations of epiglottis surgery were described. Based on the literature, we consolidated the surgery into the following types: Type 1: Debulking of arytenoids, Type 2: Division of aryepiglottic folds, Type 3: Epiglottis surgery. CONCLUSION: This descriptive review identified 53 articles with 1669 patients from the included articles detailing multiple variations of supraglottoplasty techniques. The new classification supplements a previously established system describing laryngomalacia, and simplifies the supraglottoplasty into three descriptive and logical types of categories. Our classification system would give surgeons a universal language to describe the supraglottoplasty performed, which could improve reporting of techniques, and facilitate future communication and research.

Predictors of Nasal Obstruction: Quantification and Assessment Using Multiple Grading Scales.

UNLABELLED: Objective. To evaluate the association between nasal obstruction and (1) demographic factors, (2) medical history, (3) physical tests, and (4) nasal exam findings. Study Design. CASE SERIES: Methods. Chart review at a tertiary medical center. Results. Two hundred-forty consecutive patients (52.1 ± 17.5 years old, with a Nasal Obstruction Symptom Evaluation (NOSE) score of 32.0 ± 24.1) were included. Demographic factors and inferior turbinate sizes were not associated with NOSE score or Nasal Obstruction Visual Analog Scale (NO-VAS). A significant association was found between higher NOSE score on univariate analysis and positive history of nasal trauma (p = 0.0136), allergic rhinitis (p < 0.0001), use of nasal steroids (p = 0.0108), higher grade of external nasal deformity (p = 0.0149), higher internal nasal septal deviation grade (p = 0.0024), and narrow internal nasal valve angle (p < 0.0001). Multivariate analysis identified the following as independent predictors of high NOSE score: NO-VAS: ≥50 (Odds Ratio (OR) = 17.6 (95% CI 5.83-61.6), p < 0.0001), external nasal deformity: grades 2-4 (OR = 4.63 (95% CI 1.14-19.9), p = 0.0339), and allergic rhinitis: yes (OR = 5.5 (95% CI 1.77-18.7), p = 0.0041). Conclusion. Allergic rhinitis, NO-VAS score ≥ 50, and external nasal deformity (grades 2-4) were statistically significant independent predictors of high NOSE scores on multivariate analysis. Inferior turbinate size was not associated with NOSE scores or NO-VAS.

Neurocognitive outcomes after pediatric adenotonsillectomy for obstructive sleep apnea: A systematic review and meta-analysis.

OBJECTIVE: To provide an up-to-date systematic review and critical appraisal of prospectively performed studies evaluating neurocognitive function in children treated with adenotonsillectomy. DATA SOURCES: PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library. REVIEW METHODS: Searches were performed from inception through September 2, 2015. RESULTS: Nineteen prospective studies (898 adenotonsillectomy patients) met criteria and reported neurocognitive outcomes. The average age of children was 6.6±2.3 years (range 2.5-14 years) and 51.1% were male. Pre- and post-operative data utilizing the Neuropsychological Developmental Assessment score demonstrated an increase from a means±standard deviations of 101.5±14.7 [95% CI 100.0, 103.0] to 108.8±13.4 [95% CI 107.4, 110.2], p-value <0.0001 (375 children, three studies). Pre- and post-operative data utilizing the Stanford-Binet Intelligence Scales (IQ) demonstrated an increase in IQ scores from a means±standard deviations of 97.1±13.8 [95% CI 91.6, 95.4] to 100.7±11.1 [95% CI 100.4, 103.4], p-value <0.0001 (254 children, three studies). The mean pre- and post-adenotonsillectomy apnea-hypopnea index (AHI) decreased from 8.0 to 1.8 (274 children, six studies). CONCLUSIONS: This meta-analysis found an improvement in neurocognitive function and IQ after pediatric adenotonsillectomy, especially in pre-school aged children. However, this must be interpreted with caution as only three studies were performed in pre-school aged children. The decreased effectiveness in older children suggests possibly a threshold age when neurocognitive deficits become irreversible.

Author Self-Citation in the Otolaryngology Literature: A Pilot Study.

OBJECTIVE: To determine the prevalence of author self-citation in the field of otolaryngology. STUDY DESIGN AND SETTING: A retrospective review of bibliographic references in 5 otolaryngology journals. SUBJECTS AND METHODS: Five high-impact otolaryngology journals were reviewed over a 3-month period between January and March 2014 to identify the pattern of author self-citations. Data included study type, otolaryngology topic, authorship, total citations, author self-citations, and country of origin. RESULTS: Nearly two-thirds of articles contained at least 1 self-citation, with an average of 2.6 self-citations per article. Self-citations represented nearly 10% of total citations. Articles with at least 1 self-citation had more authors (5.8 vs 4.9, P < .01) and more citations (30.4 vs 22.2, P < .01) per article than did those without self-citations. There was no difference in self-citation practices between articles originating within the United States and abroad (P = .65). Last authors were the most frequent self-citers and were more likely than lead authors to cite themselves (P < .01). Original reports contained the highest percentage of self-citations per article as compared with reviews and case reports (P < .01). CONCLUSION: Author self-citation in the otolaryngology literature is common and compares similarly to other medical specialties previously studied. Self-citation should not be considered inappropriate, as it is often done to expand on earlier research. Nevertheless, editors, researchers, and readers should be aware of this increasingly recognized phenomenon and its associated potential implications to the process of scientific inquiry.

Supraglottoplasty for laryngomalacia with obstructive sleep apnea: A systematic review and meta-analysis.

OBJECTIVES/HYPOTHESIS: To determine if apnea-hypopnea index (AHI) and lowest oxygen saturation (LSAT) improve following isolated supraglottoplasty for laryngomalacia with obstructive sleep apnea (OSA) in children. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Nine databases, including PubMed/MEDLINE, were searched through September 30, 2015. RESULTS: A total of 517 studies were screened; 57 were reviewed; and 13 met criteria. One hundred thirty-eight patients were included (age range: 1 month-12.6 years). Sixty-four patients had sleep exclusive laryngomalacia, and in these patients: 1) AHI decreased from a mean (M) ± standard deviation (SD) of 14.0 ± 16.5 (95% confidence interval [CI] 10.0, 18.0) to 3.3 ± 4.0 (95% CI 2.4, 4.4) events/hour (relative reduction: 76.4% [95% CI 53.6, 106.4]); 2) LSAT improved from a M ± SD of 84.8 ± 8.4% (95% CI 82.8, 86.8) to 87.6 ± 4.4% (95% CI 86.6, 88.8); 3) standardized mean differences (SMD) demonstrated a small effect for LSAT and a large effect for AHI; and 4) cure (AHI < 1 event/hour) was 10.5% (19 patients with individual data). Seventy-four patients had congenital laryngomalacia, and in these patients: 1) AHI decreased from a M ± SD of 20.4 ± 23.9 (95% CI 12.8, 28.0) to 4.0 ± 4.5 (95% CI 2.6, 5.4) events/hour (relative reduction: 80.4% [95% CI 46.6, 107.4]); 2) LSAT improved from a M ± SD of 74.5 ± 11.9% (95% CI 70.9, 78.1) to 88.4 ± 6.6% (95% CI 86.4, 90.4); 3) SMD demonstrated a large effect for both AHI and LSAT; and 4) cure was 26.5% (38 patients with individual data). CONCLUSION: Supraglottoplasty has improved AHI and LSAT in children with OSA and either sleep exclusive laryngomalacia or congenital laryngomalacia; however, the majority of them are not cured. Laryngoscope, 126:1246-1255, 2016.

Rhinology and medical malpractice: An update of the medicolegal landscape of the last ten years.

OBJECTIVES/HYPOTHESIS: Malpractice claims pertaining to rhinological procedures are a potentially important source of information that could be used to minimize the risk of future litigation and improve patient care. STUDY DESIGN: A retrospective review of a publicly available database containing jury verdicts and settlements. METHODS: The LexisNexis Jury Verdicts and Settlements database was reviewed for all lawsuits and out-of-court adjudications related to the practice of rhinology. Data including patient demographics, type of surgery performed, plaintiff allegation, nature of injury, outcomes, and indemnities were collected and analyzed. RESULTS: Of 85 cases meeting inclusion criteria, 42 were decided by a jury and 43 were adjudicated out of court. Endoscopic sinus surgery was the most commonly litigated surgery. The plaintiff was favored when the eye was injured (P = 0.0196), but the defendant was favored when neuropsychological injuries (P = 0.0137) or recurrent/worsened symptoms (P = 0.0050) were cited. No difference was found when death or skull base injuries occurred. When lack of informed consent was an allegation, the defendant was favored (P = 0.0001). A payout was made in two-thirds of cases overall, but the defendant was favored in two-thirds of cases decided by a jury. Payments were significant for both out-of-court settlements ($1.3 million) and jury verdicts ($2 million). CONCLUSIONS: Endoscopic sinus surgery remains the most commonly litigated rhinology procedure and has the potential to result in large payouts. Meticulous dissection, recognition of complications, and documentation of informed consent remain paramount for providing optimal patient care.

Medication associated with hearing loss: 25 years of medical malpractice cases in the United States.

OBJECTIVES: Many medications have the potential for ototoxicity. To potentiate management of this risk, this study examines malpractice litigation trends of lawsuits involving hearing loss associated with medication use. As experts in hearing loss, it may benefit otolaryngologists to be familiar with this information. STUDY DESIGN: Retrospective review. SETTING: All US civil trials. SUBJECTS AND METHODS: Court records of legal trials from 1987 to 2012 were obtained from 2 major computerized databases. Data were compiled on the demographics of the defendant and plaintiff, use of otolaryngologists as expert witnesses, medication used, legal allegations, verdicts, and judgments. RESULTS: Forty-six unique cases met inclusion criteria and were selected for review. Antibiotics (72%), specifically aminoglycosides (47%), were the most common medications cited as causing hearing loss. Eleven (22%) cases were resolved through a settlement before a verdict was reached. Verdicts in favor of the plaintiffs (37%) were awarded an average of $1,134,242. Pediatric patients were more likely to have outcomes in their favor (P = .03) compared to adults. Of the cases found in favor of the plaintiff, the most common reasons cited were inappropriate medication, dose, or duration (59%); failure to properly monitor (39%); and failure to choose a less toxic medication (18%). CONCLUSIONS: Physicians must be aware of the potential effects of the medications they prescribe. An understanding of potential drug interactions, proper monitoring, and appropriate substitution with less toxic medications are important to improve patient care. Analyzing litigation trends may be used to prevent future lawsuits and improve physician awareness.

Emergent treatment of button batteries in the esophagus: evolution of management and need for close second-look esophagoscopy.

OBJECTIVES: The evolving epidemiology of pediatric button battery ingestion is alarming. Currently, assessment of the degree of damage relies heavily on the initial esophagoscopy in a manner similar to the management of caustic ingestion. We have noted that use of this classic approach may delay the return to normal oral intake. Using several cases treated at our institution, we illustrate the value of "close second-look esophagoscopy" (CSLE) in expediting a return to normal oral intake after button battery ingestion. METHODS: We present a retrospective case series. RESULTS: Five patients (11 to 18 months of age) with button batteries trapped in the cervical esophagus were recently managed at our institution. The batteries were lodged in the esophagus for durations ranging from 6 hours to 4 months. Three cases of initial grade III circumferential necrotic injury were downgraded to grade IIa after a CSLE performed 2 to 4 days after removal, and their management was appropriately changed. CONCLUSIONS: The injury and healing of cases of button batteries in the proximal esophagus appear to be variable; caustic injury, electrical mucosal damage, and direct pressure are thought to be several contributory factors. Performing a CSLE within 2 to 4 days after battery removal may provide more useful prognostic information. In certain cases, downgrading of the injury may facilitate an earlier return to an oral diet, use of fewer diagnostic tests, and a shorter hospital stay. The utility and timing of imaging, management of diet and medications, and acceptable follow-up plans are discussed within the context of guiding future research.

RNA interference of transforming growth factor-ß 2 in human respiratory fibroblasts.

OBJECTIVE: Transforming growth factor-ß2 (TGF-ß2) is a principal cytokine of interest in the pathogenesis of scar formation and is a potential target for future molecular-based adjunctive therapies. The authors hypothesize that interfering RNA (RNAi) can be used to modulate TGF-ß2 production in cultured human respiratory fibroblasts. STUDY DESIGN: Basic science. Setting. Laboratory. SUBJECTS AND METHODS: RNAi constructs targeted to the TGF-ß2 transcript were complexed with microsomal lipids and applied to human fibroblasts in cell culture. Transfection efficiency and cell viability were measured by fluorescence microscopy. Messenger RNA (mRNA) for TGF-ß2 was measured 48 hours posttransfection using real-time quantitative PCR. The quantity of TGF-ß2 protein produced with increasing concentrations of RNAi was measured using enzyme-linked immunosorbent assay. The function of RNAi-treated fibroblasts was tested using a wound-healing assay. RESULTS: Transfection efficiency of more than 80% was achieved with minimal induced cell death. Treated cells showed selective knockdown of 80% of TGF-ß2 mRNA, which was confirmed with negative controls. As the concentration of RNAi was increased, an incremental decrease in TGF-ß2 protein was measured. CONCLUSION: RNAi technology is an effective means of localized and transient gene silencing in cultured human fibroblasts. Transfection can be achieved using microsome complexed RNAi with minimal induced cell death. This preliminary result shows promise for future in vitro studies.

Head and neck ultrasound in the pediatric population.

Ultrasound, as a diagnostic modality, has been developing rapidly. High-resolution ultrasound machines have been reduced to the size of a laptop computer. Ultrasound can be adopted by otolaryngologists for use within the clinic and the operating room. Ultrasound offers several advantages to the pediatric patient population. It is well tolerated and adds a degree of precision to the physical examination. It can be done repeatedly as lesions evolve and treatment is performed. It is valuable for guidance and therapeutic treatment of lesions in the operating room. It is likely that ultrasound use will continue to rapidly grow and evolve as a tool within the field of otolaryngology.

Acute rise in methicillin-resistant Staphylococcus aureus infections in a coastal community.

OBJECTIVE: Describe the incidence of head and neck community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections over a 5-year period at a coastal tertiary medical center. STUDY DESIGN: Retrospective chart review. SUBJECTS AND METHODS: All patients presenting to the otolaryngology service with cultures taken from head and neck infections between 1999 and 2004 were eligible for inclusion. Statistical analysis was used to determine significance of the changing incidence of isolated organisms over the study period. RESULTS: CA-MRSA infections rose from 21% to 64% over the 5-year period. The increasing trend in CA-MRSA infections reached statistical significance from 2003 to 2004. All CA-MRSA isolates were resistant to cefazolin and penicillin, but most were sensitive to clindamycin. CONCLUSIONS: Our data demonstrates a striking increase in the incidence of CA-MRSA. We have tailored our treatment of cutaneous head and neck infections to include empiric treatment for CA-MRSA using clindamycin. Awareness and monitoring of this trend will be important for all practitioners involved in the care of these patients.

Characterization of transforming growth factors beta1 and 2 in ferrets (Mustela putorius furo).

Unwanted scar tissue after surgical procedures remains a central problem in medicine. Nowhere is this problem more evident than within the pediatric airway, where excess scarring, termed subglottic stenosis, can compromise breathing. Recent advances in molecular biology have focused on ways to decrease scar formation through understanding of the wound repair process. Transforming growth factor beta (TFGbeta) plays a central role in this pathway. Ferrets serve as an ideal model for the pediatric airway, and reproduction of subglottic stenosis in ferrets is possible. However, ferret cytokine profiles have not been established. In this study, we characterized the presence and nucleotide sequence of the TGFbeta1 and 2 genes in ferrets by using total RNA isolated from airways. Amino acid sequence homology between human and ferret was determined to be 96.6% for TGFbeta1 and 99.3% for TGFbeta2. Given the nearly total homology between TGFbetas of ferret and human origin, the ferret may serve as an ideal model for future molecular studies.

Pediatric functional endoscopic sinus surgery: frequently asked questions.

Pediatric endoscopic sinus surgery is a controversial procedure that has evolved considerably over the past 2 decades. We present a current review of the literature regarding the treatment of children with refractory sinusitis with a focus on the use of endoscopic sinus surgery. Preoperative evaluation, surgical technique, postoperative care, and unusual applications are discussed.

Xylitol enhances bacterial killing in the rabbit maxillary sinus.

OBJECTIVES: Factors that alter airway surface liquid (ASL) ionic concentrations may influence the course of sinusitis. Xylitol has been shown to effect ASL ionic composition in vitro and to reduce nasal bacterial carriage, otitis media, and dental caries in vivo. We examined the effect of xylitol on experimental sinusitis in the rabbit model. STUDY DESIGN: Prospective randomized controlled study of xylitol, saline, and Pseudomonas aeruginosa administration to the rabbit maxillary sinus. METHODS: P. aeruginosa was administered to the sinuses of 26 New Zealand white rabbits. Saline was placed in the left maxillary sinus and xylitol in the right. The rabbits were randomly assigned to one of three groups: one, simultaneous administration of bacteria and solutions with bacterial analysis at 20 minutes, 11 rabbits; two, preadministration of solutions 1 hour before bacterial infection with analysis at 20 minutes, 11 rabbits; three, established sinusitis, 4 rabbits had daily injections of solutions for 5 days starting 7 days after P. aeruginosa administration. RESULTS: In group 1, 6.96% of injected bacteria were retrieved on the left (saline), whereas 0.095% were retrieved on the right (xylitol) (P = .034). In group 2, 5.64% of inoculum was recovered from the left and 2.89% from the right (P = .188). Group 3 demonstrated evidence of sinusitis with recovery of noninoculate bacteria. with no difference between right and left. CONCLUSIONS: Xylitol reduces experimental sinusitis when administered simultaneously with bacteria. Its effect in established sinusitis is less clear. A role may exist for xylitol in nasal irrigation fluid in human disease.

Pediatric airway reconstruction: principles, decision-making, and outcomes at the University of Iowa hospitals and clinics.

Pediatric airway stenosis challenges the treating surgeon, from the initial evaluation and decision-making process to the final postoperative care and follow-up setting. As our approach to these cases evolves, we must critically evaluate our outcomes in reference to our stated goals. We describe our process in treating this population and critically examine our outcome data from 1990 to the present. Emphasis is placed on selection of procedure and postoperative management.