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1.
Int J Pediatr Otorhinolaryngol ; 133: 109967, 2020 Feb 23.
Artigo em Inglês | MEDLINE | ID: mdl-32120133

RESUMO

OBJECTIVE: Laryngomalacia is the most common cause of infant stridor, and obstructive sleep apnea (OSA) is sometimes found concurrently in patients with laryngomalacia. OSA has been shown to improve after surgical treatment of laryngomalacia, but the majority of laryngomalacia patients have spontaneous resolution of symptoms. It is unknown whether their comorbid OSA also resolves. This study seeks to define the incidence of OSA in laryngomalacia and assess for resolution of OSA with polysomnography data. METHODS: Retrospective cohort study at a tertiary care academic medical center. All pediatric patients with diagnoses of laryngomalacia or stridor were reviewed, and patients with laryngomalacia confirmed by Otolaryngologist exam were included. All patients with laryngomalacia were recommended to undergo polysomnography. RESULTS: A total of 108 patients had laryngomalacia confirmed by an Otolaryngologist. Of those patients, 56 completed a polysomnogram, and 44 (79%) were diagnosed with OSA. Among the OSA patients, 34 had no surgery, 5 underwent supraglottoplasty, and 5 underwent adenoidectomy or adenotonsillectomy. Follow-up polysomnograms were performed for 9 non-surgical patients, 4 supraglottoplasty patients, and 4 adenoidectomy or adenotonsillectomy patients. Mean change in AHI was -2.81 without surgery, -8.18 after supraglottoplasty, and -2.94 after adenoidectomy or adenotonsillectomy. CONCLUSION: OSA is often present in patients who have laryngomalacia, and the proportion in this population was higher than previous reports. The only significant predictor for obstructive sleep apnea was race, specifically Black/African American. Among patients with follow-up polysomnograms, the largest OSA improvement was in supraglottoplasty patients, but all patients improved.

2.
Laryngoscope ; 2019 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-31365133

RESUMO

OBJECTIVE: Perceived gender identity is correctly assigned when a combination of physical and vocal attributes become congruent. Several voice feminization procedures have gained popularity, but current evidence of their impact on vocal feminization is limited to case series. This study establishes an ex vivo porcine phonatory model to evaluate the ideal extent of anterior glottic web formation in relation to frequency elevation and airway patency. METHODS: Six fresh porcine larynges were obtained and fitted with arytenoid adduction sutures. Compressed air was passed through the larynges, and the vocal folds were adducted to induce phonation. Vocal fold length, posterior glottic width, fundamental frequency, and sound pressure intensity were measured as the vocal folds were progressively shortened as per the anterior glottic web surgical technique. RESULTS: The average fundamental frequency prior to web formation was 109.7 Hz. The maximum frequency achieved after web formation was 403.7 Hz, and the web proportions varied from 11.8% to 61.0% of the length of the membranous vocal folds. The glottic cross-sectional area showed an expected inverse linear relationship to the length of the glottic web. Creation of an anterior glottic web caused consistent elevation of pitch, but there was a gradual plateau of effect with increased length of the web. CONCLUSION: The ex vivo porcine larynx is demonstrated as an effective, available, and low-cost model for further study of vocal pitch elevation surgical techniques. We demonstrate that in addition to progressively reducing the cross-sectional area of the airway, additional benefit from increased web length is limited. LEVEL OF EVIDENCE: NA Laryngoscope, 2019.

3.
J Voice ; 2019 Jul 23.
Artigo em Inglês | MEDLINE | ID: mdl-31350114

RESUMO

OBJECTIVE: Vocal cord paralysis may result from surgical complications, trauma, tumor, or unknown causes. When both cords are affected, paramedian fixation can lead to life-threatening obstruction. Current treatments, including tracheostomy, cordotomy, and arytenoidectomy, compromise speech and swallow function to maintain a safe airway. To preserve all three critical laryngeal functions, Otolaryngologists need a solution for bilateral vocal cord paralysis that restores motion. This study uses implantable electromagnet technology to create dynamic vocal cord movement in a proof-of-concept, preliminary model. METHODS: A prototype was constructed from a neodymium disk magnet and cylindrical solenoid electromagnet coupled to a battery and 3-way switch. The disk magnet was implanted in an ex vivo porcine larynx model lateral to the arytenoid, affixed with suture. The electromagnet was seated in a window cut in the thyroid cartilage. RESULTS: By driving current in two directions through the electromagnet, the vocal cord was successfully moved towards and away from the electromagnet. The neutral vocal fold opening was 5.8 mm, and the maximal opening was 7.7 mm, representing a 31.4% increase in the cross-sectional area of the glottis. CONCLUSION: This model demonstrated proof of concept of a magnetic laryngeal reanimation device. The full device will include a respiratory effort sensor and implantable processor to time the action of the magnets with respirations. There is currently no effective treatment to re-establish vocal cord motion in patients with vocal cord paralysis. This system has the potential to give patients with bilateral vocal cord paralysis a surgical option to restore vocal cord motion.

4.
Am J Otolaryngol ; 40(4): 536-541, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31036419

RESUMO

PURPOSE: As imaging technology improves and more thyroid nodules and malignancies are identified, it is important to recognize factors associated with malignancy and poor prognosis. Vitamin D has proven useful as a prognostic tool for other cancers and may be similarly useful in thyroid cancer. This study explores the relationship of Vitamin D to papillary thyroid carcinoma stage while accounting for socioeconomic covariates. MATERIALS AND METHODS: The medical records of all patients who underwent thyroidectomy at one institution between 2000 and 2015 were reviewed. Subjects with non-papillary thyroid cancer pathology, prior malignancy, and without Vitamin D levels were excluded. The remaining 334 patient records were examined for cancer stage, Vitamin D levels, Vitamin D deficiency listed in history, and demographic and comorbid factors. RESULTS: Vitamin D laboratory values showed no significant relationship to cancer stage (p = 0.871), but patients with Vitamin D deficiency documented in the medical record were more likely to have advanced disease (28.6% versus 14.7%; p = 0.028). The patients with documented Vitamin D deficiency also had lower 25-hydroxyvitamin D nadirs (21.5 ng/mL versus 26.5 ng/mL, p = 0.008) and were more likely to be on Vitamin D supplementation (92.6% versus 41.8%, p < 0.001). CONCLUSIONS: The results suggest that Vitamin D deficiency may have value as a negative prognostic indicator in papillary thyroid cancer and that pre-operative laboratory evaluation may be less useful. This is important because Vitamin D deficiency is modifiable. While different racial subgroups had different rates of Vitamin D deficiency, neither race nor socioeconomic status showed correlation with cancer stage.


Assuntos
Resultados Negativos , Câncer Papilífero da Tireoide/patologia , Neoplasias da Glândula Tireoide/patologia , Tireoidectomia , Deficiência de Vitamina D , Adulto , Idoso , Biomarcadores Tumorais/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Fatores Socioeconômicos , Câncer Papilífero da Tireoide/etiologia , Neoplasias da Glândula Tireoide/etiologia , Vitamina D/sangue , Deficiência de Vitamina D/complicações
5.
Laryngoscope ; 2019 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-31112319

RESUMO

OBJECTIVES/HYPOTHESIS: Electronic health records have brought many advantages but also placed a documentation burden on the provider during and after the clinic visit. Some otolaryngologists have countered this challenge by employing clinical scribes. This project aimed to better understand the influence of scribes on patient experience in the otolaryngology clinic. STUDY DESIGN: Retrospective cohort survey study. METHODS: Patients presenting to the otolaryngology clinic for new and follow-up appointments were recruited to complete surveys about their experience. RESULTS: A total of 153 patients completed the survey, and 96 of those patients (62.7%) interacted with a scribe. Patient satisfaction was not significantly associated with participation of the scribe (P = .668). Similarly, patient rating of their physician on a scale of 1 to 10 was not associated with scribe involvement (P = .851). The patients who did interact with a scribe responded that the scribe positively impacted the visit 77.1% of the time. Participation of a resident, primary language other than English, and use of interpreter were associated with lower satisfaction (P = .004, P < .001, and P < .001, respectively). CONCLUSIONS: There are no published data on the effect of scribes on patient experience in the otolaryngology clinic. In other specialties, scribes have been demonstrated as having a positive effect on provider satisfaction, clinical productivity, and patient perception. These data demonstrate that patient satisfaction was neither impaired nor improved by the presence of the scribe in this clinic. In light of benefits demonstrated by prior studies, these findings support the conclusion that scribes are a useful adjunct in providing high-level otolaryngology care. LEVEL OF EVIDENCE: 4 Laryngoscope, 2019.

6.
Head Neck ; 41(5): E79-E81, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30582245

RESUMO

BACKGROUND: The most common head and neck paraganglioma is the carotid body paraganglioma. Treatment of carotid body tumors is primarily surgical, and uncontrolled growth leads to cranial nerve deficits and more morbid resection. METHODS: A 60-year-old man was referred for evaluation of carotid body tumor, and workup revealed an internal carotid artery (ICA) aneurysm within the known mass. RESULTS: Interventional Radiology performed angiogram and stenting across aneurysm with interval dramatic reduction in size of mass, and surgery was avoided altogether. CONCLUSIONS: Surgical resection is indicated for carotid body paragangliomas when the patient can tolerate the surgery and when the tumor was not very advanced. This patient had a small tumor that initially appeared easily resectable. Failure to detect the ICA aneurysm before resection may have resulted in devastating vascular injury and possible stroke or death. Identification of underlying vascular pathology is essential for safe treatment and should be prioritized, especially considering this case.

7.
Int J Pediatr Otorhinolaryngol ; 107: 25-30, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29501306

RESUMO

OBJECTIVES: Congenital cholesteatoma (CC) occurs less commonly than acquired cholesteatoma (AC), and bilateral CC (BCC) is even more rare with only 38 such cases having been reported in the past 42 years. Because of the rarity of this condition, providers confronted with cases of BCC may find it difficult to treat while balancing complete removal of disease, optimal hearing outcomes, and minimized surgical burden in the pediatric patient. This review alerts physicians that BCC occurs, highlights past presentations and management strategies, describes the considerations in treatment and offers an algorithm helpful in the management of BCC. METHODS: Review of a single case with extensive review of published reports from 1975 to 2017 pertaining to management of BCC. RESULTS: A five-year-old boy presented with bilateral congenital cholesteatoma. Tympanomastoidectomy was performed to remove cholesteatoma in the left ear then in the right ear months later. Ossicular chain reconstruction was deferred in both cases. Second look procedures revealed persistent cholesteatoma in both ears. In the descriptions of the 38 published BCC cases, the extent and location of the CC varied widely as did the approach to management. In the 18 cases that had descriptions of surgical management, four had second look procedures. In the 16 reports that described extent of cholesteatoma, 12 had the first of two or more operations on the ear with more extensive cholesteatoma. CONCLUSIONS: Risks are increased for recidivism/recurrence and hearing impairment in children with BCC compared to children with unilateral CC. We present a novel algorithm for management of BCC that recommends surgery for cholesteatoma removal first in the more severely affected ear and delayed OCR for both ears. Simultaneous surgery may be considered in certain cases.


Assuntos
Colesteatoma da Orelha Média/cirurgia , Colesteatoma/congênito , Mastoidectomia/métodos , Pré-Escolar , Colesteatoma/cirurgia , Audição , Perda Auditiva/etiologia , Perda Auditiva/cirurgia , Testes Auditivos , Humanos , Masculino , Mastoidectomia/efeitos adversos , Ventilação da Orelha Média/métodos , Recidiva , Cirurgia de Second-Look , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Timpanoplastia
8.
Laryngoscope ; 127(12): 2784-2789, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28639701

RESUMO

OBJECTIVE: Explore relationship between insurance status and survival, determine outcomes that vary based on insurance status, and identify potential areas of intervention. STUDY DESIGN: Retrospective cohort analysis of patients who underwent resection of an upper aerodigestive tract malignancy at a single tertiary care hospital during a 5-year period. METHODS: Patients were categorized into four groups by insurance status: Medicaid or uninsured, Medicare and under 65 years of age, Medicare and 65 years or older, and private insurance. Data were collected from the medical record and analyzed with respect to survival and other outcomes. RESULTS: The final cohort consisted of 860 patients. Survival analysis demonstrated a hazard ratio of 2.1 (95% confidence interval [CI], 1.5-3.0) for the Medicaid/uninsured group when compared to the private insurance group. When adjusted for other variables, mortality was still different across insurance groups (P = 0.002). The following also were different across insurance groups: tumor stage (P < 0.001), American Society of Anesthesiologists score (P < 0.001), length of stay (P < 0.001), and complications (P = 0.021). The Medicaid/uninsured group was most likely to have a complication (odds ratio [OR] = 2.10, 95% CI 1.24-3.56, P = 0.006). CONCLUSION: Medicaid/uninsured patients present with more advanced tumors and have poorer survival than privately insured patients. Insurance status is predictive of tumor stage, comorbidity burden, length of stay, and complications. Specifically, the Medicaid/uninsured group had high rates of tobacco use and alcohol abuse, advanced stage tumors, and postoperative complications. Because alcohol abuse and advanced stage also were predictors of poor survival, they may contribute to the survival disparity for socially disadvantaged patients. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2784-2789, 2017.


Assuntos
Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/cirurgia , Cobertura do Seguro , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Medicaid , Medicare , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Estados Unidos
9.
JAMA Otolaryngol Head Neck Surg ; 142(4): 357-63, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26967008

RESUMO

IMPORTANCE: This study contributes novel data on the association between oral fluid intake before discharge and adverse outcomes following tonsillectomy in pediatric patients. These data contribute to evidence-based, safe, and cost-effective decision making regarding discharge. OBJECTIVE: To determine whether the quantity of oral fluid intake before discharge is associated with adverse outcomes following tonsillectomy in pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort analysis was conducted using the electronic medical records of 1183 pediatric patients undergoing tonsillectomy between September 24, 2012, and June 5, 2015, at a tertiary care academic medical center. Exclusion criteria included age 18 years or older, overnight admission, and missing data on fluid intake. The final cohort comprised 473 patients. Data analysis was conducted from July 8 to August 23, 2015. EXPOSURES: All patients underwent tonsillectomy by 1 of 7 attending surgeons at our institution. All patients were given intravenous fluids and analgesia in the postanesthesia care unit before being admitted to the pediatric inpatient floor for monitoring before discharge. MAIN OUTCOMES AND MEASURES: The primary outcome measured was presentation to the emergency department within 2 weeks after tonsillectomy with a related complication. We also recorded hospital readmissions and returns to the operating room for related complications. The primary diagnosis was noted for each complication. RESULTS: Among 473 patients (235 male; mean [SD] age, 7.2 [3.5] years), oral fluid intake after tonsillectomy ranged from 0.7 to 66.7 mL/kg, with a mean (SD) intake of 18.2 (10.8) mL/kg. Mean (SD) time to discharge was 6.96 (1.91) hours (range, 1.68-14.25 hours). Overall, 31 patients (6.6%) presented to the emergency department for a related complication after tonsillectomy. No correlation was found between oral fluid intake after tonsillectomy and presentation to the emergency department (odds ratio, 1.03; 95% CI, 0.98-1.08; P = .29). CONCLUSIONS AND RELEVANCE: This study suggests that oral fluid intake before discharge is not predictive of presentation to the emergency department after tonsillectomy within the ranges studied and at this institution. Therefore, discharge criteria based strictly on thresholds for oral fluid intake may be unnecessary. Further study at multiple institutions using a wider range of fluid intake volumes or a large-scale randomized clinical trial is needed before conclusions can be generalized.


Assuntos
Ingestão de Líquidos/fisiologia , Serviço Hospitalar de Emergência , Tonsilectomia , Criança , Tomada de Decisões , Registros Eletrônicos de Saúde , Feminino , Seguimentos , Humanos , Masculino , Alta do Paciente/tendências , Readmissão do Paciente/tendências , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Tempo
10.
Surg Radiol Anat ; 38(7): 863-5, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26724831

RESUMO

INTRODUCTION: Successful surgery in the neck is dependent on reliable anatomical relationships between nerves, vessels, and muscles. These landmarks and planes are also essential to avoiding undue morbidity and mortality. Anatomic variants of the hypoglossal nerve are rare, and their incidences are unknown. METHODS: We describe a case of a hypoglossal nerve found coursing superficial to the internal jugular vein in a 52-year-old woman treated with bilateral selective neck dissection for metastatic thyroid malignancy. RESULTS: The vulnerable nerve was protected, and she maintained excellent speech and swallow function post-operatively. CONCLUSIONS: The variant course of the nerve may pose higher risk for injury in neck surgery. Surgeons should be aware of the possibility of aberrant anatomy in this region and exercise extra caution to avoid nerve injury.


Assuntos
Nervo Hipoglosso/anormalidades , Feminino , Humanos , Pessoa de Meia-Idade , Esvaziamento Cervical , Tireoidectomia
11.
Mol Pharm ; 8(5): 1941-54, 2011 Oct 03.
Artigo em Inglês | MEDLINE | ID: mdl-21806015

RESUMO

A combination of biophysical, biochemical, and computational techniques was used to delineate mechanistic differences between the platinum-acridine hybrid agent [PtCl(en)(L)](NO(3))(2) (complex 1, en = ethane-1,2-diamine, L = 1-[2-(acridin-9-ylamino)ethyl]-1,3-dimethylthiourea) and a considerably more potent second-generation analogue containing L' = N-[2-(acridin-9-ylamino)ethyl]-N-methylpropionamidine (complex 2). Calculations at the density functional theory level provide a rationale for the binding preference of both complexes for guanine-N7 and the relatively high level of adenine adducts observed for compound 1. A significant rate enhancement is observed for binding of the amidine-based complex 2 with DNA compared with the thiourea-based prototype 1. Studies conducted with chemical probes and on the bending and unwinding of model duplex DNA suggest that adducts of complex 2 perturb B-form DNA more severely than complex 1, however, without denaturing the double strand and significantly less than cisplatin. Circular and linear dichroism spectroscopies and viscosity measurements suggest that subtle differences exist between the intercalation modes and adduct geometries of the two complexes. The adducts formed by complex 2 most efficiently inhibit transcription of the damaged DNA by RNA polymerase II. Not only do complexes 1 and 2 cause less distortion to DNA than cisplatin, they also do not compromise the thermodynamic stability of the modified duplex. This leads to a decreased or negligible affinity of HMG domain proteins for the adducts formed by either Pt-acridine complex. In a DNA repair synthesis assay the lesions formed by complex 2 were repaired less efficiently than those formed by complex 1. These significant differences in DNA adduct formation, structure, and recognition between the two acridine complexes and cisplatin help to elucidate why compound 2 is highly active in cisplatin-resistant, repair proficient cancer cell lines.


Assuntos
Acridinas/química , Amidinas/química , Antineoplásicos/química , Adutos de DNA/química , Reparo do DNA/efeitos dos fármacos , DNA/metabolismo , Compostos Organoplatínicos/química , Acridinas/metabolismo , Acridinas/farmacologia , Amidinas/metabolismo , Amidinas/farmacologia , Antineoplásicos/metabolismo , Antineoplásicos/farmacologia , Cisplatino/análogos & derivados , Cisplatino/química , Cisplatino/metabolismo , Cisplatino/farmacologia , DNA/química , DNA de Forma B/química , DNA de Forma B/metabolismo , Desenho de Drogas , Proteína HMGB1/metabolismo , Células HeLa , Humanos , Substâncias Intercalantes/química , Substâncias Intercalantes/metabolismo , Substâncias Intercalantes/farmacologia , Cinética , Conformação de Ácido Nucleico/efeitos dos fármacos , Compostos Organoplatínicos/metabolismo , Compostos Organoplatínicos/farmacologia , Isoformas de Proteínas/metabolismo , Relação Estrutura-Atividade , Tioureia/química , Tioureia/metabolismo , Tioureia/farmacologia , Transcrição Genética/efeitos dos fármacos
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