Palate shape is associated with Unilateral Hypoglossal Nerve Stimulation Outcomes.

OBJECTIVE: The aim was to determine the potential association between palate shape and unilateral hypoglossal nerve stimulation (HNS) outcomes. METHODS: Preoperative drug-induced sleep endoscopy (DISE) videos were reviewed and scored by 3 blinded reviewers to determine airway narrowing at the hard-soft palate junction (HP), soft palate genu, and inferior velum, as described by Woodson (2014). Scoring was as follows: 1-open airway, 2-narrow, 3-severe narrowing. Overall palate shape (oblique, intermediate, or vertical) was determined based on prior criteria. Successful surgical treatment was defined by the HNS titration polysomnogram as a reduction of ≥50% in the apnea-hypopnea index (AHI) to <15 events/h. RESULTS: Of 332 adults, the majority was male (77%) with an average BMI of 29.2 ± 3.6 kg/m2 . Overall success rate was 73%. Success rate was lower in patients with vertical palate shape compared with the other shapes (56% vs. 75%, p = 0.029). HP score 3 compared with scores 2 and 1 was associated with lower success rates (60% vs. 76%, p = 0.028), but genu and velum scores were not associated with outcomes. Patients with both HP score 3 and complete oropharyngeal lateral wall-related obstruction had notably worse outcomes (22% vs. 74%, p = 0.026). HP score 3 (OR 0.45, 95%CI 0.22-0.92) and vertical palate shape (OR 0.33, 95%CI 0.15-0.78) were independently associated with lower odds of surgical response after adjustment for DISE findings, age, gender, and BMI. CONCLUSION: Vertical palate shape and narrowing at the hard-soft palate junction are independently associated with lower HNS surgical success rates. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:981-986, 2024.

Pilomatrixoma and its Imitators.

Introduction: Pilomatrixomas are benign neoplasms derived from hair follicle matrix cells. They are among the most common soft tissue head and neck tumors of childhood. Pilomatrixomas are typically isolated, slow-growing, firm, nontender masses that are adherent to the epidermis but mobile in the subcutaneous plane. This clinical presentation is so characteristic that many experienced surgeons will excise suspected pilomatrixomas without prior imaging. We reviewed the results of this approach to determine whether physical examination alone differentiates pilomatrixomas from other similar soft tissue lesions of the pediatric head and neck. Methods: Computerized review of all pilomatrixomas over a 20-year period in a single academic pediatric otolaryngology practice. Results: 18 patients presented to our pediatric otolaryngology practice between 2001 and 2021 with historical and physical findings consistent with pilomatrixoma. Of the 18 patients, 7 were male and 11 were female. Ages ranged from 1.5 to 14 years, with a mean of 7.5 years. Most of the lesions (12) were located in the head and face, while the rest (6) were found in the neck. All patients were treated with complete surgical excision. Pathology confirmed pilomatrixoma in 15 patients. The remaining 3 children were found to have an epidermal inclusion cyst, a ruptured trichilemmal cyst, and a giant molluscum contagiosum lesion, respectively. One additional patient presented with a small lesion of the auricular helix that was thought to be a dermoid cyst, but proved to be a pilomatrixoma on histologic examination. Discussion: As pilomatrixomas are common and have a very characteristic presentation, surgical excision without prior diagnostic imaging will lead to correct treatment in the majority of cases. High resolution ultrasonography can help to confirm the diagnosis preoperatively, but is not definitive in large case series. Most of the cystic lesions that imitate pilomatrixoma will ultimately require surgical excision.

Recurrent angioedema: Experience at a tertiary care urban medical center.

OBJECTIVE: To determine the demographics, presentation, management, and outcomes of patients with recurrent angioedema. To compare the findings to patients with ACE inhibitor related angioedema. METHODS: Retrospective case series with chart review of patients who presented to a tertiary-care hospital between January 2010 and December 2017 with two or more episodes of angioedema. Excluded were patients with anaphylactic reaction, medication induced angioedema, or angioedema secondary to an infectious etiology. A group of 88 patients who presented during the same time period with ACE inhibitor related angioedema was used as a control. Statistical analysis was conducted using a two-tailed Fisher exact test and a multivariate logistical regression model to determine significant associations. RESULTS: Ninety-one patients were identified; 61 met the selection criteria and had 217 total episodes of angioedema episodes presenting to the emergency department. Fifty percent were Caucasian or Hispanic. The average number of episodes was 3.5 (range: 2-23). The lips and tongue were the most commonly affected sites (37% and 39%). The larynx and floor of mouth were least likely to be involved (7% and 6%). Only 1 patient was found to have C1 esterase inhibitor deficiency. Twenty-eight percent of patients had asthma, allergic rhinitis, food allergies, or atopic dermatitis. Only 11% of episodes required airway intervention. No patients required airway intervention after admission. CONCLUSION: Recurrent angioedema was primarily idiopathic, was less severe than ACE inhibitor angioedema, and was associated with an atopic history. There was less frequent worsening of symptoms after admission, and recurrences occurred more frequently are at the same anatomic subsite. LEVEL OF EVIDENCE: IV.

Air Pollution and Angioedema.

OBJECTIVE: To identify environmental factors that may precipitate angioedema. STUDY DESIGN: Case series with chart review. SETTING: An urban tertiary care medical center. SUBJECTS AND METHODS: After institutional review board approval was obtained, a chart review of all patients who presented to Temple University Hospital with angioedema from January 2012 to December 2014 was performed. Patient demographics and hospital course were gathered. Environmental data on the dates of presentation, including precipitation, humidity, and air pollution, were obtained from regional Environmental Protection Agency online data banks and used for statistical analysis. RESULTS: In total, 408 patients, representing 450 episodes of angioedema, met the inclusion criteria for the study. Most patients were female (58%), African American (74%), and on an angiotensin-converting enzyme inhibitor (ACE-I) upon presentation (61%). Days with unhealthy levels of air pollution were associated with an increased likelihood of angioedema presentation (odds ratio [OR], 1.82; confidence interval [CI], 1.01-3.30; P = .046). Subgroup analysis revealed that elevated ground-level ozone was the primary air pollutant significantly associated with angioedema presentations (OR, 4.95; CI 1.92-12.76; P = .0009). Higher ground-level ozone was also associated with ACE-I angioedema presentations (P = .017) but not with non-ACE-I angioedema presentations (P = .86). Air quality was not predictive of angioedema severity or need for intubation. CONCLUSION: Angioedema is a complex, multifactorial disease resulting in potentially life-threatening complications. This is the first study to demonstrate that higher levels of air pollution, specifically ground-level ozone, are associated with significantly increased rates of angioedema episodes, although not severity.

Clinical Value of Tc99m-MIBI SPECT/CT Versus 4D-CT or US in Management of Patients With Hyperparathyroidism.

Localization of parathyroid adenomas for treatment of primary hyperparathyroidism can be challenging. This retrospective study compared single-photon emission computed tomography/computed tomography (SPECT/CT), 4D-CT, and US studies in detection of adenomas prior to surgery. A retrospective chart review was performed on all consecutive patients with parathyroid adenoma presenting to an urban tertiary care medical center. A total of 58 patients (45 female, 13 male) underwent surgery for parathyroid adenoma. Patients aged 28 to 80 years (mean: 58.8) with parathyroid hormone levels ranging from 42 to 424 pg/mL (mean: 168). All patients underwent preoperative SPECT/CT with 20 mCi technetium-99m MIBI (99mTc-MIBI). Fifty-three patients had additional US imaging and 14 patients had 4D-CT scans. Additionally, 34 patients had injection of 20 mCi 99mTc-MIBI on the day of surgery. Pathological correlation was performed. Comparing SPECT/CT versus 4D-CT resulted in sensitivity (77% vs 80%), specificity (71% vs 75%), and accuracy (77% vs 79%). Ultrasound was less sensitive with similar specificity (44%, 86%, respectively). Combination of SPECT/CT and 4D-CT increased sensitivity to 88%, specificity to 100%, and accuracy to 89%. Combining SPECT/CT with US resulted in sensitivity of 85%, specificity of 83%, and accuracy of 85%. Intraoperative localization substantially improved in patients who received preoperative injections. The SPECT/CT remains the best imaging modality for preoperative localization of parathyroid adenomas with high sensitivity. Combining SPECT/CT with US resulted in increased sensitivity and accuracy. For suspicion of ectopic cases or suspicion of unidentifiable adenoma with negative scintigraphy, addition of 4D-CT is recommended. Intraoperative localization and adjunctive imaging may improve surgical management of patients with hyperparathyroidism.

Manikin Laryngoscopy Motion as a Predictor of Patient Intubation Outcomes: A Prospective Observational Study.

BACKGROUND: The goal of this study was to determine whether motion parameters during laryngoscopy in a manikin differed with experienced operators versus novice trainees and whether motion measurements would predict trainee outcomes when intubating patients. METHODS: Motion, force, and duration of laryngoscopy on a manikin were compared in two separate experiments between beginning anesthesiology residents (CA1) and anesthesiologists with more than 24 months of anesthesiology training (CA3 or attendings). In one experiment, CA1 residents were also evaluated for the percentage of their laryngoscope path that followed the route used by attending anesthesiologists. The residents were then observed for patient intubation outcomes for 4 weeks after manikin testing. The relationship between manikin test metrics and patient intubation outcomes was analyzed by multilevel modeling. RESULTS: CA1 residents positioned the laryngoscope blade farther right and with less lift than did experienced anesthesiologists. Endpoint position was 0.6 ± 0.3 cm left of midline for residents (n = 10) versus 2.7 ± 0.3 cm for advanced anesthesiologists (n = 8; P = .0003), and 15.6 ± 0.8 versus 17.7 ± 0.2 cm above the table surface, respectively (P = .033). On average, only 74 ± 6% of the CA1 laryngoscopy trajectory coincided with the Attending Route (P < .001 versus 100%). For each percentage point increase in Attending Route match, residents' odds of intubating a patient's trachea improved by a factor of 1.033 (95% confidence interval [CI] 1.007-1.059, P = .040), and their rate of failed laryngoscopy attempts decreased by a factor of 0.982 (0.969-0.996, P = .045). DISCUSSION: Laryngoscopy motion in manikins may predict which trainees can complete a patient intubation successfully in a few attempts. The assessment could help determine readiness for intubating patients with indirect supervision.

Early detection of squamous cell carcinoma in carcinogen induced oral cancer rodent model by ratiometric activatable cell penetrating peptides.

OBJECTIVES: Ratiometric cell-penetrating-peptides (RACPP) are hairpin-shaped molecules that undergo cleavage by tumor-associated proteases resulting in measurable Cy5:Cy7 fluorescence ratiometric change to label cancer in vivo. We evaluated an MMP cleavable RACPP for use in the early detection of malignant lesions in a carcinogen-induced rodent tumor model. METHODS: Wild-type immune-competent mice were given 4-nitroquinoline-oxide (4NQO) for 16weeks. Oral cavities from live mice that had been intravenously administered MMP cleavable PLGC(Me)AG-RACPP were serially imaged from week 11 through week 21 using white-light reflectance and Cy5:Cy7 ratiometric fluorescence. RESULTS: In an initial study we found that at week 21 nearly all mice (13/14) had oral cavity lesions, of which 90% were high-grade dysplasia or invasive carcinoma. These high-grade lesions were identifiable with white light reflectance and RACPP Cy5:Cy7 ratiometric fluorescence with similar detectability, Area Under Curve (AUC) for RACPP detection was 0.97 (95% Confidence interval (CI)=0.92-1.02, p<0.001), sensitivity=89%, specificity=100%. In a follow up study, oral cavity lesions generated by 4NQO were imaged and histologically analyzed at weeks 16, 18 and 21. In this study we showed that RACPP-fluorescence detection positively identified 15 squamous cell carcinomas (in 6 separate mice) that were poorly visible or undetectable by white light reflectance. CONCLUSIONS: RACPP ratiometric fluorescence can be used to accurately detect carcinogen-induced carcinoma in immunocompetent mice that are poorly visible or undetectable by white light reflectance.

Concordant Oral and Vaginal Human Papillomavirus Infection in the United States.

IMPORTANCE: Human papillomavirus (HPV) is a common infection in adults, with tropism for sites in the head and neck and the genital tracts. To date, few studies have addressed concurrent infection in these sites. OBJECTIVE: To understand the prevalence, characteristics, and concordance of HPV infections in the oral and vaginal regions. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective analysis of cross-sectional survey data from the National Health and Nutrition Examination Survey, 2009-2012. The database was reviewed for all women aged 18 to 69 years with available oral and vaginal HPV DNA screening data. The study was performed from August 1, 2014, to November 1, 2014. Data analysis was performed from November 1, 2014, to June 30, 2015. MAIN OUTCOMES AND MEASURES: Logistic regression models were constructed to identify factors associated with infection. Covariates for multivariate analysis included age, income to poverty ratio, number of prior sexual partners, number of prior oral sex partners, and having recent oral sex partners. Dual infection was defined as having an infection of any serotype in both the oral and vaginal HPV regions. Concordant infection was defined as an infection of matching serotype in both locations. RESULTS: A total of 3463 women were identified (mean [SD] age, 37.5 [12.1] years). Racial distribution was 1341 white (38.7%), 786 black (22.7%), 554 Mexican American (16.0%), 378 other Hispanic (10.9%), and 404 self-identified as other (11.7%). Vaginal HPV infection was present in 1586 (45.2%) and oral HPV infection in 141 (4.1%). Dual infection was identified in 107 (3.0%) of all patients, and concordant infection was observed in 41 (1.1%). The prevalence of dual infection was 75.9% in those with oral infection and 6.8% in those with vaginal infection. On multivariate analysis, age (30-50 years) and higher income to poverty ratios had negative associations with dual and concordant infections. A new sexual partner within the last year was positively associated with dual infection (odds ratio, 2.28; 95% CI, 1.03-5.02; P = .04). More than 2 oral sex partners in the past year was positively associated with concordant infection (odds ratio, 3.43; 95% CI, 1.06-11.06; P = .04). CONCLUSIONS AND RELEVANCE: This analysis reveals the importance of several demographic factors (age and socioeconomic status) and behavioral factors (oral sex practices) in the development of dual and concordant HPV infection in women. Notably, other sexual behaviors, other sexually transmitted infections, sexual orientation, and number of lifetime sexual partners did not demonstrate any significant associations. Women with multiple oral sex partners and oral HPV infection have a high likelihood of having concurrent vaginal HPV infection.

Lymph Node Yield as a Predictor of Survival in Pathologically Node Negative Oral Cavity Carcinoma.

OBJECTIVE: Even after a pathologically node-negative (pN0) neck dissection for oral cavity squamous cell carcinoma (SCC), patients may develop regional recurrence. In this study, we (1) hypothesize that an increased number of lymph nodes removed (lymph node yield) in patients with pN0 oral SCC predicts improved survival and (2) explore predictors of survival in these patients using a multivariable model. STUDY DESIGN: Case series with chart review. SETTING: Administrative database analysis. SUBJECTS AND METHODS: The SEER database was queried for patients diagnosed with all-stage oral cavity SCC between 1988 and 2009 who were determined to be pN0 after elective lymph node dissection. Demographic and treatment variables were extracted. The association of lymph node yield with 5-year all-cause survival was studied with multivariable survival analyses. RESULTS: A total of 4341 patients with pN0 oral SCC were included in this study. The 2 highest lymph node yield quartiles (representing >22 nodes removed) were found to be significant predictors of overall survival (22-35 nodes: hazard ratio [HR] = 0.854, P = .031; 36-98 nodes: HR = 0.827, P = .010). Each additional lymph node removed during neck dissection was associated with increased survival (HR = 0.995, P = .022). CONCLUSION: These data suggest that patients with oral SCC undergoing elective neck dissection may experience an overall survival benefit associated with greater lymph node yield. Mechanisms behind the demonstrated survival advantage are unknown. Larger nodal dissections may remove a greater burden of microscopic metastatic disease, diminishing the likelihood of recurrence. Lymph node yield may serve as an objective measure of the adequacy of lymphadenectomy.

A Review of Hard Palate Fracture Repair Techniques.

PURPOSE: Hard palate trauma is a relatively infrequent occurrence compared with other craniofacial injuries. Several techniques of hard palate fracture repair have been described. To date, there is no consensus on the optimal management of this type of fracture. The purpose of this study was to compile and analyze studies describing hard palate fracture repair techniques with outcomes data. MATERIALS AND METHODS: A systematic review of the Medline, Scopus, and Web of Science databases was performed for articles describing hard palate fracture repair techniques. RESULTS: Eight articles were ultimately included in the review. Of the collective 310 fractures reported, postoperative malocclusion occurred in 21 of 235 cases (8.9%) and other complications occurred in 13 of 299 cases (4.3%). The most important variability in technique was the method of palatal vault stabilization. Three studies described wiring techniques, 3 described internal fixation techniques, and 2 described external fixation techniques. Studies describing internal fixation techniques reported higher rates of wound complications. Proponents of rigid internal fixation believe that this technique provides better fracture reduction. External fixation techniques appear to impart low rates of wound complications, but their overall effectiveness remains in question. CONCLUSIONS: Hard palate fractures are associated with high rates of malocclusion and wound complications. The most established methods of palatal vault stabilization are closed reduction with wiring and internal plate fixation. Depending on the fracture type, patient comorbidities, and associated injuries, either technique might be preferable in a given circumstance.

Predictors of high-risk and low-risk oral HPV infection in the United States.

OBJECTIVES/HYPOTHESIS: Determine predictors of high-risk and low-risk oral HPV infection in the United States. STUDY DESIGN: Retrospective analyses of National Health and Nutrition Examination Survey cross-sectional data of U.S. population from 2009 to 2012. METHODS: Database queried for subjects aged 18 to 69 with oral rinse human papillomavirus (HPV) DNA data. Logistic regression identified factors associated with high-risk and low-risk infection. Covariates included age, gender, ethnicity, income-to-poverty (IP) ratio, sexual orientation, human immunodeficiency virus infection, other sexually transmitted infections, lifetime sexual partners, and lifetime oral sex partners. RESULTS: In total, 9,256 subjects were identified with mean age of 42.1 years. Oral HPV infection was present in 8.1% (N = 747); 55.7% were high-risk and 55.3% were low-risk types, including 11% with both. Oral infection had a negative association with female gender (odds ratio [OR] 0.3, P < 0.001), IP ratio ≥ 3 (OR 0.7, P = 0.02), and one lifetime oral sex partner (OR 0.7, P = 0.03). Increasing oral sex behavior (6-21+ lifetime partners) was positively associated with oral HPV (OR 1.4-3.0, P = 0.03). Low-risk infection had negative associations with female gender (OR 0.4, P < 0.001) and non-Hispanic white ethnicity (OR 0.6, P = 0.02), IP ratio ≥ 3 (OR 0.6, P = 0.01), and positive association with > 20 sexual partners (all sex OR 1.7, P = 0.04; oral sex OR 1.9, P = 0.02). Predictors of high-risk HPV infection included male gender and increasing oral sex partners. CONCLUSION: Increasing oral sex partners is positively associated with oral HPV infection; female sex and higher socioeconomic class are negatively associated. The risk-factor profiles for high-risk and low-risk HPV types are distinct, with similar trends related to sexual behaviors. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1365-1372, 2016.

Early bronchiolitis obliterans syndrome shows an abnormality of perfusion not ventilation in lung transplant recipients.

Long-term survival of lung transplant patients is limited, principally because of Bronchiolitis Obliterans Syndrome (BOS). BOS is primarily classified based on airflow obstruction however there is recent data to suggest that the rejection process can lead to a restrictive ventilatory defect with involvement of the pulmonary vasculature. This study evaluates perfusion heterogeneity in different BOS stages by measuring the relative dispersion (RD) of an arterial spin labelling MRI blood flow image. Acinar ventilation heterogeneity (Sacin) was determined using the Multiple Breath Nitrogen Washout technique. In 24 post transplant patients with a range of severity in BOS status, Sacin increased as BOS level rose from stage 0 to stage 3. In contrast, RD-perfusion was not elevated at BOS 1 and 2 combined compared to BOS 0 and becoming elevated only at BOS-3. However, RD-perfusion in BOS-0p was elevated compared to BOS-0, without an increase in Sacin. These results suggest that BOS-0p is different in nature from other BOS stages.

Parametrically adjustable intubation mannequin with real-time visual feedback.

INTRODUCTION: Training for direct laryngoscopy relies heavily on practice with patients. The necessity for human practice might be supplanted to some extent by an intubation mannequin with accurate airway anatomy, a realistic "feel" during laryngoscopy, the capacity to model many patient configurations, and a means to provide feedback to trainees and instructors. The goals of this project were (1) to build and evaluate an airway simulator with realistic dimensions and haptic sensation that could undergo a range of adjustments in several features that affect laryngoscopy difficulty and (2) to develop a system for displaying information on laryngoscopy force and motion in real time. METHODS: The prototype was an existing 2-dimensional (2D) airway model that closely approximated cephalometric measurements of head, neck, and airway anatomy from the dental and surgical literature. The 2D model was extended in a third dimension by adding layers along the coronal axis. An off-the-shelf airway model provided the tongue, pharynx, larynx, and trachea. Adjustability was built into the face, jaw, mouth, teeth, and spine components. A feedback system was constructed with a force- and motion-sensing laryngoscope and motion sensors incorporated in the mannequin head, jaw, and larynx. Anatomic accuracy was assessed by measuring model dimensions. Realism was evaluated by measuring laryngoscopy force and motion compared with laryngoscopy in patients. RESULTS: The extruded 2.5-dimensional model maintained a close conformity to the anatomic measurements present in the original 2D model. The model could be adjusted through multiple settings for face length, jaw length and tension, mouth opening, and dental condition. The laryngoscopy trajectory had a similar shape to laryngoscopy trajectories in patients, but force was greater, on the order of 50 N, compared with roughly 30 N in patients. The movement of the laryngoscope through the mannequin airway could be displayed in real time during the procedure, establishing a means for feedback. CONCLUSIONS: The model incorporates novel features that could aid in developing mastery of the laryngoscopy procedure. Further work is needed to investigate how adjustability and feedback impact the value of laryngoscopy practice on mannequins.

The effect of cross-training with adjustable airway model anatomies on laryngoscopy skill transfer.

BACKGROUND: A problem with learning endotracheal intubation on airway mannequins is poor transfer of direct laryngoscopy skills from model to patient. We developed an airway model with adjustable anatomic features and investigated whether practicing on a model with frequent adjustments improved laryngoscopy skills transfer. METHODS: Fifty-one paramedic students and 18 medical students with minimal previous experience practiced laryngoscopy 25 times with either the novel model with static features, the novel model with variable features, or a Laerdal Adult Intubation mannequin. For the variable group, the configuration changed after every 5 attempts. After training, all subjects performed 10 laryngoscopies on 2 new mannequins to test their competence at skills transfer. A mixed linear model analyzed various predictors of success as a binary outcome, including training group and change in laryngoscopy model. RESULTS: The odds ratio for success after a recent change in mannequin was 0.69 (0.49, 0.96 [95% confidence interval]). Compared with the Laerdal group, subjects with the static trainer did worse (odds ratio 0.46 [0.23, 0.94]), and subjects in the variable group were no different (0.74 [0.36, 1.52]). Change in laryngoscopy model decreased success rate by approximately 30% for all training groups. CONCLUSION: The results verify that proficiency on one model does not guarantee success on another. However, subjects who trained with a laryngoscopy mannequin in multiple configurations did not show better skill transfer than subjects practicing on fixed configuration airway models.