Pediatric Head and Neck Dog Bites in the United States: A NEISS Database Investigation of Risk Factors and Escalation of Care.

Pediatric patients experience increased morbidity secondary to head and neck dog bites. The authors examined risk factors among pediatric head and neck dog bite patients and which factors are associated with admission to inform prevention efforts. All patients who suffered head and neck dog bites from 2013-2022 in the National Electronic Injury Surveillance System (NEISS) database were reviewed. Demographics among discharged and escalation of care (EOC) patients were compared using multinomial logistic regression (MLR), and linear regression was employed to analyze yearly emergency room (ER) visit incidence. Among 949 pediatric patients, 57.2% were male, 43.4% were 2-6 years old, and 77.7% sustained face or mouth injuries. Attacks were commonly provoked (60.5%), occurred in the home (82.3%), and involved a dog known to the patient (61.7%). The most common dog breed involved was Pitbull (33.1%). MLR revealed increased EOC among patients with neck injury (OR=11.82, SE=0.68, P<0.001), orbital injury (OR=12.91, SE=0.55, P<0.001), unprovoked attacks (OR=2.67, SE=0.16, P<0.001), and those under 2 years old (OR=1.83, SE=0.19, P=0.002). There was a significant yearly rise in the number of pediatric head and neck dog bites (model coefficient=6.467, SE=1.40, P=0.002). Overall, increased caution around particular dog breeds in households with children under 2 years old may decrease head and neck dog bite injuries. While pediatricians should perform general safety education, enhanced knowledge of risk factors is essential for proper inpatient counseling by surgical specialists.

Predicting Recidivism for Acquired Cholesteatoma: Evaluation of a Current Staging System.

OBJECTIVE: Assess the utility and prognostic capabilities of the European Academy of Otology and Neurotology (EAONO) and Japanese Otological Society (JOS) cholesteatoma classification system, specifically for retraction pocket cholesteatoma. STUDY DESIGN: Retrospective. SETTING: Tertiary referral hospital. PATIENTS: Adults and children with retraction pocket cholesteatoma. INTERVENTIONS: Primary and planned second-look tympanoplasty with mastoidectomy. MAIN OUTCOME MEASURES: Incidence of recurrent or residual cholesteatoma at planned second-look surgery. Independent variables of age, gender, size of canal defect, and mucosa status were assessed. Additionally, the cholesteatoma classification, stage, and extent according to the EAONO/JOS system were recorded during the primary surgery. RESULTS: A total of 125 cases were included. Twelve (9.6%) cases had recidivism over an average time of 7.5 months: the recurrence rate was 4% (n = 5), residual rate was 5% (n = 6), and one patient had both recurrent and residual disease (0.8%). Residual cholesteatoma occurred more frequently in children (p = 0.04, RR = 7.9 [1.0, 63.6]). Supratubal recess (S1) disease was associated with both recurrent cholesteatoma (p = 0.04, RR = 5.9 [1.3, 27.2]) and recidivism (p = 0.01, RR = 4.2 [1.5, 11.9]). Larger canal defects also showed an association with residual disease (p = 0.017). CONCLUSION: Younger patients and those with large ear canal defects tend to have residual disease at second-look surgery. Supratubal recess disease is also associated with recurrence. Despite the utility of the EAONO/JOS classification and staging system for cholesteatoma description and type, the prognostic value remains uncertain.

Ethnic disparity in skin complications following bone-anchored hearing aid implantation.

OBJECTIVES: Sound processor loading after implantation of a bone-anchored hearing aid is often delayed by skin-site complications. This study examined the frequency of skin-site complications in various ethnic groups and determined factors that may lead to higher rates of skin-site complications resulting in delayed processor loading. METHODS: Adult, English-speaking patients who underwent implantation of a bone-anchored hearing aid between 2007 and 2010 were reviewed. Demographic data including ethnicity, tobacco use, diabetes mellitus, immunosuppression, and long-term steroid use were determined. Major and minor skin-site complications and the time to processor loading were recorded. RESULTS: The mean time to processor loading was 9.5 weeks, and the mean follow-up time was 23 months. There were no cases of osseointegration failure. African American patients had a significantly higher rate of major skin-site complications (p < 0.005) and a longer time to processor loading (mean, 17.6 weeks; p < 0.05) than the other ethnic groups. There was no significant difference in minor skin complication rates. There was no correlation between diabetes mellitus, long-term immunosuppression, or tobacco use and skin-site complications. CONCLUSIONS: Skin complications can delay processor loading following implantation of a bone-anchored hearing aid. There is a higher rate of major skin-site complications in African American patients, and these often delay processor loading. The risk of skin-site complications is not correlated with smoking, diabetes mellitus, or immunosuppression. An increased risk of skin-site complications is an important consideration for preoperative counseling.

Management outcomes of facial nerve tumors: comparative outcomes with observation, CyberKnife, and surgical management.

OBJECTIVES: Primary facial nerve tumors (FNTs) present in varying ways. In this study, the authors present their institutional experience with the management of facial nerve tumors, including their recommendations for available therapies such as observation, microsurgical decompression or removal, and stereotactic radiation. They emphasize the auditory and facial nerve function outcomes. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Retrospective review of all cases of FNT seen at the authors' tertiary care academic medical center over a 10-year period (2002-2011). The clinical presentation, treatment modality, and outcome parameters of cochlear and facial nerve function were assessed. RESULTS: Twelve patients were identified. House-Brackmann grades on presentation were 4 grade I, 2 grade II, 2 grade III, 1 grade IV, and 3 grade V, with 2 grade V patients declining to grade VI shortly after presentation. Seven patients presented with serviceable hearing and 4 with nonserviceable hearing. Treatment options/arms included observation with serial clinicoradiological review (2 cases), stereotactic radiation with the CyberKnife (3 cases), wide fallopian canal decompression (3 cases), microsurgical excision and repair (3 cases), and biopsy followed by observation (1 case). At the end of the review period, facial nerve function was stable in 8 patients, improved in 3, and declined in 1, and none had documented worsening of hearing based on American Academy of Otolaryngology--Head and Neck Surgery Foundation classification. CONCLUSIONS: Management of FNT is largely based on the clinicoradiological picture. Each treatment arm is different, but overall auditory and facial function can be maintained.

Endoscopically assisted intratumoral embolization of juvenile nasopharyngeal angiofibroma using Onyx.

Juvenile nasopharyngeal angiofibromas are vascular tumors that may make resection difficult and potentially dangerous. Preoperative embolization is frequently used to decrease surgical morbidity and blood loss. Embolization has typically been performed via a transarterial route using a variety of embolic materials. The authors present a case in which endoscopic assistance was used for direct transnasal tumor puncture and intratumoral embolization using the liquid embolic agent Onyx. In this case there was excellent infiltration of the parenchymal vasculature with complete angiographic obliteration. There were no complications related to the embolization. The tumor was resected with minimal blood loss. To the authors' knowledge, there have been no previous reports of this novel direct intratumoral embolization technique using endoscopic guidance.

Differences in cochlear nerve cross-sectional area between normal hearing and postlingually deafened patients on MRI.

OBJECTIVES: To demonstrate that parasagittal constructive interference in steady state (CISS) magnetic resonance imaging (MRI) can be used to accurately measure cochlear nerve cross-sectional area and thereby evaluate for statistically significant differences in the cochlear nerve cross-sectional areas of postlingually deafened and normal-hearing adults. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care medical center. SUBJECTS AND METHODS: Parasagittal CISS MRIs of postlingually profoundly deafened cochlear implant candidates and normal-hearing patients at a tertiary care academic medical center between 2006 and 2009 were retrospectively identified. Two independent and blinded investigators measured the cochlear nerve height and width and calculated the cross-sectional area [π(H/2)(W/2)] at the fundus of the internal auditory canals. Measurements of both investigators were analyzed for reliability and agreement with an Altman plot, and deafened patient measurements were compared with results of the normal-hearing patients via Wilcoxon rank sum tests. RESULTS: The cochlear nerve cross-sectional area of postlingually deafened patients (mean ± SD = 0.61 ± 0.16 mm(2)) was less than normal-hearing patients (0.94 ± 0.28 mm(2)). The difference was statistically significant (P = .002). There was good agreement between independent observer measurements. CONCLUSION: Parasagittal CISS MRI can be used to measure the cochlear nerve with good interobserver agreement, and there is a significant difference between the cross-sectional area of postlingually deafened and normal-hearing adults. The cross-sectional area may correlate with residual spiral ganglion cells and provide a prognostic indicator for post-cochlear implant performance, which is the focus of our ongoing research.

Early loading after single-stage bone-anchored implantation in adults.

OBJECTIVE: Classically, processor loading after single-stage bone-anchored implantation (BAI) surgery follows a 3-month osseointegration period. The purpose of this study was to examine audiometric outcomes and postoperative complications in adult patients undergoing single-stage BAI with processor loading at less than 6 weeks postoperatively. STUDY DESIGN: Retrospective review. SETTING: Otology clinic in a tertiary care academic center. SUBJECTS AND METHODS: A retrospective review was performed of all adult patients (>18 years) undergoing BAI from 2007 to 2010. Sixty-four patients met inclusion criteria. Fifty-five patients had unilateral hearing loss, including single-sided deafness, conductive hearing loss, or mixed hearing loss. Nine patients had bilateral hearing loss. Patients were divided into groups based on time to processor loading (>12 weeks, <12 weeks, <6 weeks). All patients were loaded with the external processor at less than 6 weeks when possible. Preoperative and postoperative audiometric evaluations were performed. RESULTS: There were no cases of osseointegration failure. All groups showed significant improvement in audiometric testing using their BAI (P < .005), and there were no significant differences between patients loaded at less than 12 weeks and those loaded at less than 6 weeks (P > .05). Major skin complications were seen in 9% of subjects and minor complications in 30%. CONCLUSIONS: Single-stage BAI implantation with early processor loading is safe and effective in adults. All groups demonstrated significant audiometric benefit that was not affected in patients loaded early. Major and minor skin-site complications frequently delayed processor loading, but there were no cases of osseointegration failure in any group.

Endoscopic embolization with onyx prior to resection of JNA: a new approach.

OBJECTIVE: To report a novel pioneering approach of endoscopic embolization (EE) and resection of juvenile nasopharyngeal angiofibroma (JNA) and describe all outcomes and results. METHODS: Four patients presented to the University of Miami with repeated episodes of unilateral epistaxis diagnosed by fiberoptic and radiographic examination as nasal JNA. Subsequently, in conjunction with neurosurgery, endoscopic visualization was provided to perform intratumor needle insertion, through which the liquid embolic agent Onyx was infused to embolize the JNA's under fluoroscopic and endoscopic guidance. The day after EE, endoscopic resection was performed. Operating room time, estimated blood loss (EBL), and other intraoperative and post-operative results are reported and compared to published literature. RESULTS: A total of 4 patients (all males), had EE of JNA and subsequent endoscopic resection between September 2008 and January 2009. Average EBL during surgery was 412.5 ml (range 150-800) with an average operating room time of 228 min (range 95-485). We experienced no bleeding from the tumor or its attachments, only from the approach. Two patients experienced mild numbness in the V2 distribution, which began to resolve one week post-operatively. No other complications were encountered. CONCLUSIONS: This is the first published report of direct endoscopic embolization of JNA with Onyx. Although further studies are needed, it seems to provide a safe, less invasive alternative to traditional embolization and endoscopic resection, but must be done in cooperation with interventional neurosurgery to maximize its safety profile.

The use of a "hybrid" trainer in an established laparoscopic skills program.

OBJECTIVES: Tabletop inanimate trainers have proven to be a safe, inexpensive, and convenient platform for developing laparoscopic skills. Historically, programs that utilize these trainers rely on subjective evaluation of errors and time as the only measures of performance. Virtual reality simulators offer more extensive data collection capability, but they are expensive and lack realism. This study reviews a new electronic proctor (EP), and its performance within the Rosser Top Gun Laparoscopic Skills and Suturing Program. This "hybrid" training device seeks to capture the strengths of both platforms by providing an affordable, reliable, realistic training arena with metrics to objectively evaluate performance. METHODS: An electronic proctor was designed for use in conjunction with drills from the Top Gun Program. The tabletop trainers used were outfitted with an automated electromechanically monitored task arena. Subjects performed 10 repetitions of each of 3 drills: "Cup Drop," "Triangle Transfer," and "Intracorporeal Suturing." In real time, this device evaluates for instrument targeting accuracy, economy of motion, and adherence to the rules of the exercises. A buzzer and flashing light serve to alert the student to inaccuracies and breaches of the defined skill transference parameters. RESULTS: Between July 2001 and June 2003, 117 subjects participated in courses. Seventy-three who met data evaluation criteria were assessed and compared with 744 surgeons who had previously taken the course. The total time to complete each task was significantly longer with the EP in place. The Cup Drop drill with the EP had a mean total time of 1661 seconds (average, 166.10) with 54.49 errors (average, 5.45) vs. 1252 seconds (average, 125.2) without the EP (P = 0.000, t = 6.735, df = 814). The Triangle Transfer drill mean total time was 556 seconds (average, 55.63) and 167.57 errors (average. 16.75) (EP) vs. 454 seconds (non-EP) (average. 45.4) (P = 0.000, t = 4.447, df = 814). The mean total times of the suturing task was 1777 seconds (average, 177.73) and 90.46 errors (average. 9.04) (EP) vs. 1682 seconds (non-EP) (average, 168.2) (P = 0.040, t = 1.150, df = 814). When compared with surgeons who had participated in the Top Gun course prior to EP, the participants in the study collectively scored in the 18.3th percentile with the Cup Drop drill, 22.6th percentile with the Triangle Transfer drill, and 36.7th percentile with the Intracorporeal Suturing exercise. When penalizing for errors recorded by the EP, participants scored collectively in the 9.9th, 0.1th, and 17.7th percentile, respectively. No equipment failures occurred, and the agenda of the course did not have to be modified to accommodate the new platform. CONCLUSIONS: The EP utilized during the Top Gun Course was introduced without modification of the core curriculum and experienced no device failures. This hybrid trainer offers a cost-effective inanimate simulator that brings quality performance monitoring to traditional inanimate trainers. It appears that the EP influenced student performance by alerting them to errors made, thus causing an increased awareness of and focus on precision and accuracy. This suggests that the EP could have internal guidance capabilities. However, validation studies must be done in the future.

Telementoring.

Telementoring began in the 1950s and is an advanced application of telemedicine that involves the removed guidance of a procedure where the student has no or limited experience. In the past 10 to 15 years, telemedicine has been revisited as a result of the healthcare delivery crisis, budgetary concerns, and the impact of managed care. In recent years, telementoring has had a number of successes which have led to further recent telementoring investigations and developments. Telementoring programs were established because it was impractical for specialized minimally invasive surgeons to proctor fellow surgeons during the adoption phase of new techniques. This catalyzed the establishment of formal telementoring procedural guidelines and networks. Efforts have been made in the remote direction of laparoscopic spermatic vein ligations, renal biopsy, nephrectomy, varicocelectomy, fetoscopy, and ophthalmology. Pilot studies in 2000 have statistically validated that telementoring can be as effective as on-site mentoring. In order to successfully conduct telementoring missions, however, it is important to follow a precise algorithm. If a standardized protocol is followed, it will ensure that telementoring is practiced safely and efficiently.