A Biomechanical Study of Hyoid Bone and Laryngeal Movements During Swallowing Comparing the Blom Low Profile Voice Inner Cannula and Passy-Muir One Way Tracheotomy Tube Speaking Valves.

The aim of this prospective, consecutive, cohort study was to investigate the biomechanical effects, if any, of the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves on movement of the hyoid bone and larynx during swallowing. Ten adult patients (8 male, 2 female) with an age range of 61-89 years (mean 71 years) participated. Criteria for inclusion were ≥18 years of age, English speaking, and ability to tolerate both changing to a Blom tracheotomy tube and placement of a one-way tracheotomy tube speaking valve with a fully deflated tracheotomy tube cuff. Digitized videofluoroscopic swallow studies were performed at 30 frames/s and with each patient seated upright in the lateral plane. A total of 18 swallows (three each with 5 cc bolus volumes of single contrast barium and puree + barium × 3 conditions) were analyzed for each participant. Variables evaluated included larynx-to-hyoid bone excursion (mm), maximum hyoid bone displacement (mm), and aspiration status under three randomized conditions: 1. Tracheotomy tube open with no inner cannula; 2. Tracheotomy tube with Blom valve; and 3. Tracheotomy tube with Passy-Muir valve. Blinded reliability testing with a Pearson product moment correlation was performed on 20 % of the data. Intra- and inter-rater reliability for combined measurements of larynx-to-hyoid bone excursion and maximum hyoid bone displacement was r = 0.98. Intra- and inter-rater reliability for aspiration status was 100 %. No significant differences (p > 0.05) were found for larynx-to-hyoid bone excursion and maximum hyoid bone displacement during swallowing based upon an open tracheotomy tube, Blom valve, or Passy-Muir valve. Aspiration status was identical for all three randomized conditions. The presence of a one-way tracheotomy tube speaking valve did not significantly alter two important components of normal pharyngeal swallow biomechanics, i.e., hyoid bone and laryngeal movements. Aspiration status was similarly unaffected by valve use. Clinicians should be aware that the data do not support placement of a one-way tracheotomy tube speaking valve to reduce prandial aspiration.

Warthin's tumor with superimposed mycobacterium tuberculosis infection.

We report a case of atypical mycobacterium infection in a Warthin's tumor which occurred in a 79-year-old man. The patient had along history of a left parotid mass that underwent rapid growth, became painful, and fistulized. The patient underwent left parotidectomy and neck dissection which showed a Warthin's tumor with areas of necrotizing granulomas. Subsequent culture showed the growth of acid fast bacilli. Consideration of an underlying mycobacterium infection, although rare, is important due to the public health concerns and other treatment needs that such a diagnosis raises.

Revision Zenker diverticulum: laser versus stapler outcomes following initial endoscopic failure.

OBJECTIVES: We used a retrospective chart review to analyze revision endoscopic carbon dioxide (CO2) laser and staple repairs of recurrent Zenker diverticulum (ZD). METHODS: The medical records of patients with recurrent ZD after primary endoscopic repair were selected. The chart data included method of repair (CO2 laser or stapler), demographics (age and sex), defect size (in centimeters), preoperative and postoperative symptoms, and complications. Patients' dysphagia was graded on a modified Functional Oral Intake Scale from 1 to 4 (1 being normal intake and 4 being severely limited intake or gastrostomy tube dependence). Regurgitation was also graded on a 1-to-4 scale (1 being no regurgitation and 4 being aspiration). RESULTS: A total of 148 consecutive patients with ZD were treated with endoscopic repair between 2000 and 2010. Twelve of these patients had revisions after failed primary endoscopic management procedures, all done with the stapler. Eight revision surgeries were performed by CO2 laser, and 4 by stapler repair. No difference was noted in patient age or defect size (laser, 3.06-cm defects; stapler, 2.75-cm defects). The length of hospital stay and the time to oral intake for the patients who had a revision stapler procedure were significantly greater (p values of 0.029 and 0.009) than those for the patients in the primary stapler procedure group. Better postoperative regurgitation scores were noted for patients who had a CO2 laser procedure. CONCLUSIONS: Secondary endoscopic repair for ZD recurrence is an effective treatment method. Better symptom outcomes were observed with secondary CO2 laser repair than with stapler revision. Patients with revision stapling had longer hospital stays and a longer time to oral intake than did patients with primary staple repairs.

Contemporary management of pediatric lateral sinus thrombosis: a twenty year review.

OBJECTIVES: A case of pediatric otogenic lateral sinus thrombosis is reported, followed by a substantive literature review. DESIGN: 104 patients were reviewed, culled from published case reports from 1993 to 2011 on the PubMed database. METHODS: All full text case reports on the PubMed database from 1993 to 2011 with patients less than or equal to 16 years of age that outlined specific treatments were included. RESULTS: 73% of patients were male and average age of presentation was 7.7 years. The most common symptoms were fever, headache, and otalgia, while the most common signs included otorrhea and neck stiffness. CT scans had a sensitivity of 87% and MR studies had a sensitivity of 100%. Single bacterial organisms were isolated in 46% of cases, with beta hemolytic streptococcus, streptococcus pneumoniae, and staphylococcus aureus being most common. Management included broad spectrum antibiotics (100%), mastoidectomy (94%), manipulation of the thrombosed sinus (50%), and anticoagulation (57%). The mortality rate was one in 104 patients. Morbidities occurred in 10% of patients and included cranial nerve palsy, sensorineural hearing loss, stroke, and septic hip joint. CONCLUSION: Lateral sinus thrombosis is a rare but treatable complication of otologic disease in the pediatric population, warranting a high index of suspicion. Management should include broad spectrum antibiotics and surgical removal of all perisinus infection. Anticoagulation is not definitively associated with improved outcomes and warrants further investigation.

Use of intravenous immunoglobulin to treat chronic bilateral otomastoiditis in the setting of rituximab induced hypogammaglobulinemia.

The temporal bone may be affected by a variety of systemic pathology because the disease nature, location, and extent determine the symptoms. Middle ear and mastoid infections may be the initial clinical manifestation of autoimmune and acquired immunodeficiency disorders. Rituximab, an anti-CD20 chimeric antibody, has become increasingly popular as a therapeutic agent for patients with a wide range of autoimmune disorders refractory to standard treatments. Normal levels of immunoglobulin levels are usually maintained during and after rituximab therapy, and clinical trials to date have shown no statistically significant increase of serious infections among patients with autoimmune diseases being treated with rituximab (Cohen SB, Emery P, Greenwald MW, Dougados M, Furie RA, Genovese MC, et al, for the REFLEX Trial Group. Rituximab for rheumatoid arthritis refractory to anti-tumor necrosis factor therapy: results of a multicenter, randomized, double-blind, placebo-controlled, phase III trial evaluating primary efficacy and safety at 24 weeks. Arthritis Rheum. 2006;54:2793-2806. Edwards JC, Szczepanski L, Szechinski J, Filipowicz-Sosnowska A, Emery P, Close DR, et al. Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis. N Engl J Med. 2004;350:2572-2581). However, there have been several reports of opportunistic infections associated with rituximab (Kelesidis T, Daikos G, et al. Does rituximab increase the incidence of infectious complications? A narrative review. Int J Infect Dis 2011;15:e2-e16. Teichmann LL, Woenckhaus M, Vogel C, et al. Fatal Pneumocystis pneumonia following rituximab administration for rheumatoid arthritis. Rheumatology 2008;47:1256-1257), as well as cases of it accelerating the presentation of hypogammaglobulinemia (Diwakar L, Gorrie S, et al. Does rituximab aggravate pre-existing hypogammaglobulinaemia? J Clin Pathol 2010;63:275-277). Humoral immune defects can cause persistent acute and serous otitis media, with the development of chronic suppurative otitis media refractory to medical and surgical therapy (Sasaki CT, Askenase P, Dwyer J, et al. Chronic ear infection in the immunodeficient patient. Arch Otolaryngol 1981;107:82). Here, we describe the first presentation, diagnostic workup, and treatment with intravenous immunoglobulin of chronic bilateral otomastoiditis in the setting of rituximab-induced hypogammaglobulinemia.

Deep plane face lifting for midface rejuvenation.

The deep-plane midface lift offers many advantages in midface rejuvenation. Anatomic analysis of aging and embryologic evidence both support surgical facial "degloving" in the sub-SMAS plane and resuspension of the platysma/SMAS unit. This approach offers more complete repositioning of facial soft tissue compared with nonsurgical techniques, delivering accurate, direct treatment of deeper anatomic aspects of facial aging. The well-vascularized deep-plane flap minimizes complications. Outcomes can be maximized because tension exists "invisibly," only at the fascia level. Consistent, natural,and long-lasting aesthetic results are achieved.

Verbal communication with the Blom low profile and Passy-Muir one-way tracheotomy tube speaking valves.

OBJECTIVE: To investigate physiologic parameters, voice production abilities, and functional verbal communication ratings of the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves. STUDY DESIGN: Case series with planned data collection. SETTING: Large, urban, tertiary care teaching hospital. SUBJECTS AND METHODS: Referred sample of 30 consecutively enrolled adults requiring a tracheotomy tube and tested with Blom and Passy-Muir valves. Physiologic parameters recorded were oxygen saturation, respiration rate, and heart rate. Voice production abilities included maximum voice intensity in relation to ambient room noise and maximum phonation duration of the vowel/a/. Functional verbal communication was determined from randomized and blinded listener ratings of counting 1-10, saying the days of the week, and reading aloud the sentence, "There is according to legend a boiling pot of gold at one end." RESULTS: There were no significant differences (p>0.05) between the Blom and Passy-Muir valves for the physiologic parameters of oxygen saturation, respiration rate, and heart rate; voice production abilities of both maximum intensity and duration of/a/; and functional verbal communication ratings. Both valves allowed for significantly greater maximum voice intensity over ambient room noise (p<0.001). CONCLUSIONS: The Blom low profile voice inner cannula and Passy-Muir one-way speaking valves exhibited equipoise regarding patient physiologic parameters, voice production abilities, and functional verbal communication ratings. LEARNING OUTCOMES: Readers will understand the importance of verbal communication for patients who require a tracheotomy tube; will be able to determine the differences between the Blom low profile voice inner cannula and Passy-Muir one-way tracheotomy tube speaking valves; and will be confident in knowing that both the Blom and Passy-Muir one-way tracheotomy tube speaking valves are equivalent regarding physiological functioning and speech production abilities.

Esophageal perforation caused by edible foreign bodies: a systematic review of the literature.

OBJECTIVES/HYPOTHESIS: Presentation of a case of esophageal perforation caused by ingestion of a foreign body that was difficult to visualize endoscopically, and systematic review of the current literature with a focus on available diagnostic modalities and missed diagnoses. DATA SOURCES: MEDLINE (1946-2014). REVIEW METHODS: We conducted a systematic review of MEDLINE for cases and studies of esophageal perforation due to foreign bodies. RESULTS: A systematic review of esophageal perforations caused by foreign bodies revealed 40 studies that included 168 patients. Neck/chest pain, odynophagia, and dysphagia were the most common presenting symptoms--each occurring in the majority of patients. Where reported, diagnostic sensitivity of lateral neck X-rays was 56%, and computed tomography (CT) scan was 100%. Nine of 168 cases specifically mentioned a missed diagnosis. Very few studies reported a failure to visualize the foreign object at the time of primary rigid or flexible esophagoscopy. No studies reported nonvisualization of the foreign body at the time of open surgery. CONCLUSION: Esophageal perforations due to foreign bodies are rare but carry potentially devastating complications. Delays in diagnosis are common, and no standard diagnostic algorithm exists. Lateral neck X-rays are an easy but insensitive screening test. Laryngoscopy is an excellent screening test but not always diagnostic. CT is a more sensitive diagnostic method, which can also help guide management based on the detection of complications. Although seldom described, if an object is not visualized at the time of endoscopic or surgical intervention, follow-up CT may be useful in determining the persistence of effects of the perforation or the foreign body.

The deep-plane approach to neck rejuvenation.

This article provides the facial plastic surgeon with anatomic and embryologic evidence to support the use of the deep-plane rhytidectomy for optimal treatment of the aging neck. An anatomic basis is established that demonstrates this technique's ability to maximize neck rejuvenation through its direct relationship to midface soft-tissue mobilization. A detailed description of the procedure, aimed at providing safe and consistent results, is presented with insights into anatomic landmarks, technical nuances, and alternative approaches to facial variations.

Endoscopic resection of an anterior skull-base Schwannoma.

Sinonasal Schwannomas represent less than 4% of all head and neck Schwannomas. These neural sheath tumors arise from the ophthalmic and maxillary divisions of the trigeminal nerve, as well as autonomic nerves from sympathetic fibers of the carotid plexus and parasympathetic fibers of the sphenopalatine ganglion. Patients commonly present with nonspecific symptoms such as nasal obstruction, epistaxis, and anosmia. Nasal endoscopy usually reveals a unilateral polypoid mass. Diagnostic imaging with computed tomography (CT) and magnetic resonance (MR) is typically nonspecific. Diagnosis may be delayed due to the masquerade of common sinonasal conditions, such as allergic rhinitis and chronic rhinosinusitis. We report a case involving a 51-year-old male with an anterior skull-base Schwannoma that was excised endoscopically. Clinical features, imaging characteristics, histopathology, and treatment of sinonasal Schwannomas are discussed.

Laser versus stapler: outcomes in endoscopic repair of Zenker diverticulum.

OBJECTIVES/HYPOTHESIS: To analyze a single surgeon's experience with endoscopic CO(2) laser and stapler repair of Zenker diverticulum (ZD) by comparing dysphagia and regurgitation outcomes. STUDY DESIGN: Retrospective chart review of 148 patient charts. METHODS: Medical records of all patients receiving endoscopic repair of ZD with either CO(2) laser (61 patients) or stapler (67 patients) were reviewed. Additional data included demographics (age and sex), size (cm), preoperative and postoperative symptoms, need for revision, and complications. Symptoms of dysphagia were graded based on a modified Functional Oral Intake Scale 1 to 4 scale (1 = normal intake; 4 = severely limited/G-tube dependent). Regurgitation was also graded on a 1 to 4 scale (1 = no regurgitation; 4 = aspiration events). RESULTS: We noted no difference in patient age or defect size (laser, 3.26 cm; stapler, 3.53 cm; P .135). Significant differences were noted in return trips to the operating room for failed procedures (laser, 0; stapler, 7; P = .009), length of stay (laser, 3.19 days; stapler, 1.29 days; P < .001), time to oral intake (laser, 3.01 days; stapler, 1.22 days; P < .001). Significant improvement occurred in laser and staple patient symptom scales following surgery (P < .001). Laser dysphagia and regurgitation scores showed greater improvement when compared to stapler scores (P < .001). CONCLUSIONS: Endoscopic CO(2) laser and staple methods are effective in treating ZD. The laser can have greater efficacy and result in lower recurrence rates. Both methods are analyzed and compared.

Transcervical double mandibular osteotomy approach to the infratemporal fossa.

BACKGROUND: In this study, we propose an alternative to the traditional transmandibular lower lip and chin splitting approach for exposing high infratemporal fossa and parapharyngeal space lesions involving the carotid canal and jugular foramen. METHODS: We present 2 cases of high skull base tumors removed transcervically with anterior and posterior segmental mandibulotomies preserving the mental nerve without the use of a lip or chin incision. RESULTS: Making the posterior osteotomy in an inverted L configuration is necessary so that the coronoid process does not prevent rotation of the mandible out of the visual field. Both patients had complete tumor resection with access to the carotid canal and jugular foramen and functional preservation of the mental nerve and marginal branch of the facial nerve. Neither patient had malocclusion or other dental complications from the approach. CONCLUSIONS: This novel technique is useful for providing excellent access to high infratemporal fossa or parapharyngeal space tumors. It avoids the traditional chin or lip incision and preserves the mental and facial nerves and is a useful procedure in the armamentarium of skull base/cerebrovascular neurosurgeons.