Endoscopic surgical field clarity index: An artificial intelligence-based measure of transnasal endoscopic surgical field quality.

KEY POINTS: Clear visualization during transnasal endoscopic surgery (TNES) is crucial for safe, efficient surgery. The endoscopic surgical field clarity index (ESFCI) is an artificial intelligence-enabled measure of surgical field quality. The ESFCI allows researchers to evaluate interventions to improve visualization during TNES.

Primary Intraosseous Granular Cell Tumor of the Sphenoid and Central Skull Base in a Pediatric Patient.

BACKGROUND: Granular cell tumors occur in all ages and many anatomic sites. In the craniofacial region, they typically arise in soft tissue, not bone. We present a primary intra-osseous granular cell tumor of the sphenoid and central skull base arising in a 12- year- old girl. CASE REPORT: A 12-year-old female with sickle cell disease and Jeavons syndrome presented with seizures. Imaging and partial resection revealed an expansile benign granular cell tumor (GCT) involving the sphenoid body, pterygoid process, and central skull base. The disease has remained stable after 36-month follow up. DISCUSSION: GCT primarily involving the osseous sphenoid/skull base has not been previously reported in a child. Although mostly benign, some are aggressive, with malignant transformation in 1-2%. Surgery is the mainstay of treatment, but in the skull base this may be limited by adjacent critical structures. Decision-making is guided by anatomic extent, histology, and clinical behavior.

Shared Surgical Decision Making in the Era of COVID-19: Lessons From Hurricane Katrina.

The COVID-19 pandemic has challenged every surgical discipline. Lessons learned from Hurricane Katrina have informed our department's management of the current crisis. That experience impressed upon us a profound appreciation for shared decision making in the face of scarce resources, an evolving clinical context, and potential harm to patients and health care workers. To that end, we have formed a Resource Utilization Committee to prospectively review all nonemergent surgical cases during the current crisis. This has allowed "state-of-the-pandemic" otolaryngologic care in a real-time, collaborative, and high-information setting. In addition, to protect our patients and health care workers, it has influenced our institution's thoughtful application of COVID testing and the use of personal protective equipment.

Hypoglossal Nerve Palsy After Anterior Cervical Spine Surgery: A Case Report and Literature Review.

CASE: A 37-year-old man was found to have hypoglossal nerve palsy after undergoing anterior cervical spine surgery at C3-C5, an injury that would cause him severe disability and further complications. CONCLUSION: Knowledge of the hypoglossal nerve is crucial for cervical spine surgery even at lower levels (C4-C7), including variations in its course and potential displacement during the induction of anesthesia.

Retro-Auricular Thyroidectomy: An Open Approach.

Distant access robot-assisted thyroidectomy has gained popularity in recent years. Adoption of distant access procedures has been limited by cost, need for specialized training and expertise. We report our preliminary clinical experience with our modification of the retro-auricular thyroidectomy approach that allows adequate exposure for thyroid lobectomy without robotic or endoscopic assistance. This is a retrospective chart review of ten patients who have undergone retro-auricular thyroidectomies in the absence of robotic or endoscopic assistance. Ten patients were identified to have undergone this procedure over an 18-month period. All patients were female with average age 36 years (range 27-52). Six were right sided and 4 were left sided procedures. The average gland size was 4.2 cm (range 3.7-6 cm). The average nodule size was 2.1 cm (range 1.1-3.5 cm). The average operative time was 91 min (range 76-114 min). All patients had benign pathology on final histopathology. There were no conversions to open cervical thyroidectomy. Two patients had vocal cord paresis that resolved spontaneously. The average postoperative follow up was 3 months (range 1-7 months). Our technique for retro-auricular thyroidectomy is a safe, reproducible, and cost effective option for remote access thyroidectomy.

The hospital otolaryngologist: The louisiana state university experience.

OBJECTIVES/HYPOTHESIS: To describe the implementation and impact of a hospital otolaryngologist in an academic medical center setting. Our hypothesis was that the hospital otolaryngologist would increase productivity of the Louisiana State University (LSU) faculty otolaryngologists and provide more timely access to inpatient otolaryngology services. STUDY DESIGN: Retrospective clinical and administrative database review. METHODS: A comparative database review was performed with data from the year predating the initiation of the hospitalist program (2013) to the first full year after initiation of the program (2014). A clinical database review including diagnoses and procedures was also performed. RESULTS: Overall outpatient clinic relative value units for the aggregated LSU faculty increased 16% (despite the fact that the direct outpatient contribution of the hospital otolaryngologist was negligible). Overall capture of inpatient consult codes increased 128%. The hospital otolaryngologist was responsible for 84.5% of inpatient consult codes. There was a 100% increase in outpatient consult codes for the LSU faculty, of which <1% was attributed to the otolaryngology hospitalist. No significant impact was seen on length of stay over the study interval. Clinical database review of the first 2 years of the program showed 3,707 total encounters with postoperative encounters the most common. Four hundred fifty-four inpatient procedures were logged. The most common surgical procedure was tracheostomy. CONCLUSIONS: The otolaryngology hospitalist program is a viable clinical and economic model. LEVEL OF EVIDENCE: NA Laryngoscope, 1851-1857, 2018.

The Management of Spontaneous Otogenic CSF Leaks: A Presentation of Cases and Review of Literature.

Objective The types of otogenic cerebrospinal fluid (CSF) fistulae were previously classified into defects through, adjacent to, or distal to the otic capsule. This article presents cases of the three different types of spontaneous CSF fistulae and reviews pertinent literature. We examine the management of the different types of otogenic CSF leaks with modern audiovestibular testing, imaging, and surgical techniques. Design Case series and review of the literature. Setting Academic tertiary neurotologic referral practice. Participants Four patients identified through a retrospective search. Main outcome measures Resolution of CSF leak and absence of meningitis. Results Surgical intervention was performed on the four cases described in this series; none had a return of CSF otorrhea in the postoperative period or meningitis. Conclusions Otogenic CSF fistulae may lead to life-threatening infection and in congenital forms are typically not diagnosed unless meningitis has occurred. Rapid and proper recognition, work-up, and treatment of such leaks decrease the risk of permanent neurologic sequelae as well as recurrent meningitis.

Mucosal melanoma of the middle ear cavity and Eustachian tube: a case report, literature review, and focus on surgical technique.

OBJECTIVE: To present a case of mucosal melanoma of the Eustachian tube with a focus on surgical technique and to review the literature on treatment of mucosal melanoma of the head and neck, and review cases involving the middle ear and/or Eustachian tube. PATIENT: A 67-year-old man was diagnosed with mucosal melanoma of the middle ear and Eustachian tube. INTERVENTION: The patient underwent primary surgical resection including transtemporal/transpetrosal approach, endoscopic nasopharyngectomy, infratemporal fossa dissection, temporomandibular joint resection, ipsilateral neck dissection (levels II-IV), and superficial parotidectomy. RESULTS: The patient was discharged on postoperative Day 7 with a very good functional status. He did have early dysphagia and dysarthria as a result of the VII to XII anastomosis for facial nerve reconstruction, which did require PEG tube placement. However, at 4 months after surgery, the patient was eating solid foods and returning to normal activities. He received radiation therapy postoperatively. There has been no evidence of tumor recurrence at 8 months after treatment. CONCLUSION: The standard treatment of head and neck mucosal melanoma is primarily surgical. Surgical removal of mucosal melanoma in the Eustachian tube/middle ear can present challenges in achieving microscopically negative margins. However, gross tumor resection with postoperative radiotherapy has been shown to improve locoregional control.

Neurotology telemedicine consultation.

The opportunity to treat neurotologic patients when the patient and physician are in separate locations is an important clinical delivery mechanism. The authors developed their applications of neurotologic telemedicine in the aftermath of Hurricane Katrina and found this to be an effective way to deliver clinical care, develop a clinical neurotology practice, and train residents and fellows and to manage a growing neurotologic clinical practice remotely. This article outlines the technical requirements, current uses, clinical applicability, and implementation details of the Our Lady of the Lake - LSU neurotology telemedicine program; administrative issues surrounding telemedicine; and future considerations.

Diagnostic and interventional sialendoscopy: a preliminary experience.

OBJECTIVES/HYPOTHESIS: To review our preliminary experience with diagnostic and therapeutic sialendoscopy for the management of non-neoplastic disorders of the salivary gland. STUDY DESIGN: Retrospective chart review. METHODS: Thirty-three consecutive patients undergoing 36 sialendoscopy procedures performed at a tertiary medical center from July 2008 to July 2010 were included. RESULTS: The mean age of presentation was 43 years (range, 7-74 years), and 61% of patients were male. Indications included sialolithiasis (47%; 17 of 36), recurrent sialadenitis (44%, 16 of 36), and Sjögren's syndrome (8%; three of 36). Successful endoscopy was performed in 97% (35 of 36). A papillotomy for access was necessary in 25% (nine of 36). In patients with sialolithiasis (n = 17), the mean size of the stones was 7.3 mm (range, 1-20 mm). Complete stone removal was achieved in 76% (13 of 17) of cases. Endoscopic stone removal was possible in 29% (five of 17), and a combined approach technique was required in 47% (eight of 17). Seventy-two percent (26 of 36) of patients had complete resolution of symptoms after sialendoscopy, with 19% (seven of 36) having partial resolution of symptoms. Patients with partial improvement of symptoms had a mean duration of improvement of 4.7 months. The overall complication rate was 22% (eight of 36). The major and minor complication rates were 3% (one of 36) and 19% (seven of 36), respectively. CONCLUSIONS: Sialendoscopy is safe and effective in managing non-neoplastic salivary gland disorders with low rates of major complications. Knowledge of options to navigate the rate-limiting steps, like dilation of the papilla and careful case selection, are key to successful outcomes.

Factors affecting access to head and neck cancer care after a natural disaster: a post-Hurricane Katrina survey.

BACKGROUND: Our aim was to survey the factors affecting access to cancer care in patients with head and neck cancer after Hurricane Katrina. METHODS: In this cross-sectional survey, 207 patients with head and neck cancer were identified post-Hurricane Katrina, but only 83 patients completed the questionnaires and were analyzed. Clinical, demographic, and socioeconomic data were recorded. Chi-square test and t test were used for comparisons. RESULTS: Patients who felt that there was a lack of access to cancer care would have sought treatment earlier had they had better access to cancer care (chi-square[1] = 32; p < .0001). Patients who felt that there was a lack of access to cancer care also had difficulty receiving treatment (chi-square[1] = 48; p < .0001). Availability of transportation affected access to cancer care in patients with early-stage cancers (chi-square[1] = 4; p < .035). CONCLUSION: In the postdisaster environment, patients who felt the lack of access to cancer care post-Hurricane Katrina would have sought treatment earlier with better access to cancer care. These patients also reported difficulty obtaining cancer treatment. Availability of transportation affected access to cancer care in patients with early-stage cancers. Clinical, demographic, and socioeconomic factors did not influence access to cancer care.

Transoral resection of a retropharyngeal myxoma: a case report.

This study was conducted to describe a retropharyngeal myxoma and discuss clinical concerns regarding this pathology and a retropharyngeal site of occurrence. We present a case report and review of literature. A 71-year-old woman presented with mild right neck pressure for 3 weeks. Imaging studies and head neck examination confirmed a 5.3 × 3.1 × 1.0 cm retropharyngeal mass with no communication to the vertebral column but was intimately involved with the pharyngeal mucosa. A transoral fine needle aspiration biopsy suggested a possible spindle cell neoplasm. A presurgical swallowing consultation was obtained. A transoral excision of the tumor was possible with no intraoperative complications. Histopathology was a cellular myxoma. Postoperative dysphagia required swallowing therapy and nasogastric tube feeding for 2 weeks before oral intake was possible. The patient has no evidence of clinical or radiological recurrence more than 1 year after surgical intervention. We present the second case of a myxoma in the retropharynx reported in English literature. Transoral excision was safe, feasible, and cosmetically appealing option in our patient. Additional clinical data are required to valid its safety and utility as an approach to tumors in the retropharynx. Postoperative dysphagia can be significant and consequently we recommend preoperative swallowing evaluation and counseling.

Treatment of nasopharyngeal papillomatosis with coblation: a case series.

BACKGROUND: Nasopharyngeal papillomatosis is uncommon. Access and visualization make excision difficult, increasing the risk for recurrence. We present a novel technique for excision of nasopharyngeal papillomatosis. METHODS: A case series of 3 patients with recurrent papilloma of the nasopharynx (NP) were treated with endoscopic transnasal coblation. We used an Arthrocare EVac 70 Coblator (setting: coblation-9, coagulation-5). RESULTS: Using transnasal endoscopic coblation, we performed complete excision in 3 patients with recurrent papilloma of the NP (4 total procedures). There were no complications. One patient had a minor recurrence, which was successfully re-excised with the same technique. CONCLUSION: Nasopharyngeal papillomas can be difficult to excise. Multiple techniques have been described using a transoral approach, with no reported complications. However, surgical access to the entire NP is more challenging with a transoral approach. Also, bleeding and poor visualization secondary to bleeding can be encountered with these techniques. These problems were not encountered with transnasal coblation. The absence of eschar and decreased collateral thermal damage make coblation preferable to cauterization or laser excision. This proposed technique enables more complete visualization and removal of disease, which may reduce recurrence rates.

Retro-auricular video-assisted "gasless" thyroidectomy: feasibility study in human cadavers.

BACKGROUND: In recent years, there has been a surge of interest in developing alternative surgical approaches to the thyroid gland with a focus on cosmesis. Approaches can be either complete endoscopic approaches using CO(2) insufflation or endoscopy-assisted approaches. We describe a novel approach for thyroidectomy via a retro-auricular incision without gas insufflation using endoscopic assistance. METHODS: Six fresh human cadavers were utilized. Four head and neck specimens were used to assess the retro-auricular approach and the creation of surgical space in the lower neck. Three hemithyroidectomy in two fresh human cadavers procedures were performed via a retro-auricular approach. The end-point of the study was successful removal of the hemithyroid gland with preservation of the recurrent laryngeal nerve. RESULTS: In all cases, the retro-auricular flap and subplatysmal plane could be achieved without difficulty. Three hemithyroid specimens were successfully removed in two cadaveric specimens using the retro-auricular approach with endoscopic guidance. Thyroid gland resection with identification and preservation of the recurrent laryngeal nerve could be achieved in all three procedures (100%). CONCLUSION: The retro-auricular approach or the "Walvekar approach" permits adequate working space and an excellent endoscopic surgical view for removal of the ipsilateral hemithyroid gland with an option for a bilateral approach using a "gasless technique."

Telemedicine-assisted neurotology in post-Katrina Southeast Louisiana.

OBJECTIVE: This study evaluates technical requirements, privacy and legal constraints, reimbursement considerations, and overall feasibility of a new telemedicine neurotologic patient care delivery model in post-Katrina, Southeast Louisiana. METHODS: This study is a retrospective review of the first year of a telemedicine neurotology practice with limited on-site neurotology physician availability (3-days monthly) with a full-time on-site audiologist, a full-time specialty-trained nurse practitioner, full-time neurosurgery on-site availability, and full-time otolaryngology on-site availability. RESULTS: A combined "store-and-forward" and "real-time" telemedicine delivery model was implemented for a new neurotology practice. Technical requirements include secure data transfer, real-time video-streaming, high-quality video otoscopy and microscopy, infrared video eye movement visualization and recording, remote visualization of radiologic imaging studies, and formalized diagnostic algorithms for patient evaluation. Telemedicine patient evaluations occur with the patient in Baton Rouge, LA, while the examining neurotologist is linked through a secure, commercially available communication connection in Pittsburgh, PA. Specifically designed consent forms and bilocation licensing and liability insurance coverage were required. Third-party payers were consulted before implementation to assure adherence to local reimbursement requirements. During the first 12 months of operation, 450 patient encounters were accomplished purely through telemedicine, with an additional 800 on-site patient visits and 150 operative procedures, including 24 neurotologic skull base procedures. CONCLUSION: Telemedicine is a viable delivery model for neurotology care delivery. Planning and implementation of such a model requires systematic considerations of medical, nursing, information systems, legal, reimbursement, and management parameters. Although the authors' initial motivation for this model was the resource-restricted, post-Katrina health care environment in South Louisiana, this delivery model has wider applicability in otolaryngology, other medical specialties, humanitarian outreach, and medical education. Prospective assessment of clinical outcomes and patient satisfaction is ongoing for objective validation of this delivery model.

Applicability of the pittsburgh staging system for advanced cutaneous malignancy of the temporal bone.

The objectives are to evaluate the applicability of the Pittsburgh staging system (PSS) (designed for primary temporal bone malignancies) to advanced periauricular cutaneous malignancies with temporal bone involvement and to study treatment outcomes and prognostic factors predicting recurrence-free survival. Ten patients with advanced periauricular cutaneous malignancy with temporal bone involvement were identified. Patients with primary temporal bone or parotid gland malignancies were excluded. All patients were clinically T4 at presentation by the American Joint Committee on Cancer (AJCC) staging system. Using Pittsburgh staging, six were T1 (stage I) and four were T4 (stage III). The mean follow-up was 13.6 months (3 to 24 months). Patients with basal cell carcinoma were managed with wide local excision and lateral temporal bone resection (WLE/LTBR) without adjuvant therapy. Two of three (66%) are alive and free of disease; one patient died of other causes. Treatment for squamous cell carcinoma patients involved multimodality therapy. Kaplan-Meier survival curves show a worse prognosis in terms of disease-specific survival for patients with higher-staged PSS tumors. This did not reach statistical significance. The PSS may provide additional prognostic information on advanced cutaneous malignancies of the temporal bone over the more widely used AJCC staging system. However, further prospective multicenter studies with larger sample size are required to validate our findings. Basal cell carcinoma was well controlled with WLE/LTBR alone without adjuvant therapy, whereas squamous cell carcinoma required multimodality therapy: WLE/LTBR and postoperative radiation with or without chemotherapy.

Surgical approaches to the submandibular gland: a review of literature.

OBJECTIVES: Surgical excision of the submandibular gland (SMG) is commonly indicated in patients with neoplasms, and non-neoplastic conditions such as chronic sialadenitis, sialolithiasis, ranula and drooling. Traditional SMG surgery involves a direct transcervical approach. In the recent past, alternative approaches to SMG excision have been described in effort to offer minimally invasive options or better cosmetic results. The purpose of this article is to describe the surgical approaches to the SMG and present relevant surgical anatomy via cadaveric dissection and a systematic review of literature to compare and contrast each technique. STUDY DESIGN: Cadaveric dissection with fresh human cadaver heads followed by a review of the literature. METHODS: Cadaver heads were dissected via both the transcervical and transoral approaches to the submandibular gland with the use of endoscopic assistance when indicated. Key landmarks and anatomic relationships were recorded via photo documentation. A review of the literature was conducted using a Medline search for approaches to SMG excision, including indications, results and complications. RESULTS: While the traditional SMG excision remains a direct transcervical approach, many other methods of excision are described that include open, endoscopic, and robot assisted resections. The approaches vary from being transcervical, submental, transoral or retroauricular. CONCLUSIONS: Alternative approaches to the SMG are feasible but should be tailored to the individual patient based on factors such as pathology, patient preferences, availability of technology, and the experience and skill of the surgeon.

Positron emission tomography-computed tomography surveillance for the node-positive neck after chemoradiotherapy.

OBJECTIVES/HYPOTHESIS: To review our results with positron emission tomography and computed tomography fusion imaging (PET-CT) surveillance of the postchemoradiotherapy neck in patients with advanced head and neck squamous cell carcinoma. STUDY DESIGN: Retrospective. METHODS: Four hundred twenty-eight patients with advanced head and neck squamous cell carcinoma were treated with nonsurgical therapy from September 2002 to March 2007 and followed with post-treatment PET-CT surveillance of the neck. Fifty-two patients meeting inclusion criteria were analyzed. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PET-CT were determined. RESULTS: Ten patients had a positive post-treatment PET-CT for residual neck disease, and 42 patients had negative scans. The NPV and PPV were 100% and 40%, respectively. The sensitivity, specificity, and accuracy were 100%, 87.5%, and 88%, respectively. CONCLUSIONS: Planned neck dissection can be deferred with a negative post-treatment PET-CT. Assuming a complete response at the primary site and a negative PET-CT scan, there may be a role for serial PET-CT surveillance in patients with residual palpable cervical lymphadenopathy. Laryngoscope, 2009.

Post-Katrina: study in crisis-related program adaptability.

OBJECTIVE: To discuss disaster planning, didactic reorganization, and clinical realignments useful in rebuilding academic otolaryngology residency programs after disaster. SUMMARY: We describe our reorganization and analysis of objective measures in resident education before and after Hurricane Katrina. Post-Katrina, the number of full-time faculty and part-time clinical instructors/gratis faculty has decreased (4 vs 9 and 36 vs 43, respectively), but the number of part-time LSU faculty (private-academic partnership) has increased (0 vs 3) with overall improved resident supervision. Resident complement decreased by 9.3%. Surgical case loads are essentially unchanged. Reorganization of the didactic schedule has increased attendance and maintained examination scores above national averages. Establishment of two new practice sites provided an adequate number of patients for residency training. CONCLUSION: Poststorm reorganization has maintained or exceeded pre-Katrina performance standards. Establishment of communication and data retrieval proved irreplaceable and demand advance preparation.

Transnasal endoscopic removal of orbital, ethmoid sinus, and anterior skull base foreign body with mucocele formation.

OBJECTIVES: 1. Case report of foreign body and associated orbitoethmoid and skull base mucocele following orbital blowout fracture repair. 2. Literature review of orbital fracture repair complications and endoscopic removal of paranasal sinus and anterior skull base foreign body. DESIGN: Case report and literature review. SETTING: Tertiary-care academic otolaryngology practice. RESULTS: Foreign body involvement of the orbit, paranasal sinuses, and skull base are relatively rare entities. In contrast, orbital blowout fractures are relatively common facial fractures. We report skull base involvement of a previously placed orbital floor implant complicated by mucocele formation and exophthalmos. Successful endoscopic removal and decompression of foreign body and associated mucocele were accomplished. Review of orbital floor fracture repair complications and paranasal sinus and skull base foreign body endoscopic removal were also performed. CONCLUSIONS: Transnasal endoscopic removal of complicated foreign bodies involving the orbit, paranasal sinuses, and anterior skull base can be successfully accomplished given appropriate patient selection and careful technique.