High Prevalence of Cochlear Nerve Deficiency in Pediatric Patients With Cochlear Aperture Stenosis.

OBJECTIVE: Cochlear nerve deficiency (CND) is a common radiologic finding among unilateral sensorineural hearing loss (USNHL) patients. It is generally detected with magnetic resonance imaging (MRI), which is associated with higher cost, less availability, and possible need for sedation. Therefore, identifying computed tomography (CT) findings, such as cochlear aperture stenosis (CAS), that can reliably predict CND is valuable. Our study aimed to determine the prevalence of CND in pediatric patients with CT-diagnosed CAS. STUDY DESIGN: Retrospective study. SETTING: Tertiary care center. METHODS: We included pediatric patients diagnosed with CAS on temporal bone CT and with available temporal bone MRI. For each patient, an otolaryngologist and a pediatric neuroradiologist measured the cochlear aperture width on CT to confirm CAS (cochlear aperture < 1.4 mm) and assessed the status of the cochlear nerve on MRI. RESULTS: Fifty-five patients, representing 65 ears, had CAS on CT measurement. Median cochlear aperture width in CAS ears was 0.70 mm (interquartile range [IQR]: 0.40-1.05 mm) versus 2.00 mm in non-CAS ears (IQR: 1.80-2.30 mm, P < .001). CND was found in 98.5% (n = 64/65) of CAS ears, while a normal cochlear nerve was found in 1.5% (n = 1/65) of CAS ears. CONCLUSION: CND is highly prevalent among pediatric patients with CAS. This suggests that MRI may not be needed to assess for CND in USNHL patients with CAS, as initial CT may provide sufficient information to determine cochlear implant candidacy. We recommend thoughtful shared decision-making with parents of USNHL patients when determining whether to pursue MRI in the setting of a CAS diagnosis.

Electrode array positioning after cochlear reimplantation from single manufacturer.

OBJECTIVE: To investigate whether revision surgery with the same device results in a change in three key indicators of electrode positioning: scalar location, mean modiolar distance (M¯), and angular insertion depth (AID). METHODS: Retrospective analysis of a cochlear implant database at a university-based tertiary medical center. Intra-operative CT scans were obtained after initial and revision implantation. Electrode array (EA) position was calculated using auto-segmentation techniques. Initial and revision scalar location, M¯, and AID were compared. RESULTS: Mean change in M¯ for all ears was -0.07 mm (SD 0.24 mm; P = 0.16). The mean change in AID for all ears was -5° (SD 67°; P = 0.72). Three initial implantations with pre-curved EAs resulted in a translocation from Scala Tympani (ST) to Scala Vestibuli (SV). Two remained translocated after revision, while one was corrected when revised with a straight EA. An additional five translocations occurred after revision. CONCLUSIONS: In this study examining revision cochlear implantation from a single manufacturer, we demonstrated no significant change in key indicators of EA positioning, even when revising with a different style of electrode. However, the revision EA is not necessarily confined by the initial trajectory and there may be an increased risk of translocation.

Persistent mass after treatment for orbital rhabdomyosarcoma.

PURPOSE: To report a case of orbital rhabdomyosarcoma and highlight the treatment approach to the dilemma of a residual mass. OBSERVATIONS: An eleven-year-old boy was diagnosed with Stage 1, Group III embryonal rhabdomyosarcoma in the orbit. After completing a 24-week treatment regimen of chemotherapy and radiation, imaging showed a large persistent mass with erosion through the medial wall. It was uncertain whether the erosion was due to radiation osteonecrosis or to advancing tumor, creating a treatment dilemma for the providers. A repeat biopsy was planned. During the procedure, the mass was completely excised due to ease of removal, and the biopsy showed completely treated tumor. MRI surveillance at four years follow up showed that the patient remains tumor-free. CONCLUSIONS AND IMPORTANCE: Rhabdomyosarcoma was once a disease with a very poor outcome, but advances in imaging, chemotherapy, and radiation therapy have improved the prognosis of these patients. What was once a surgical disease treated with morbid resection is now predominantly a medical disease diagnosed with biopsy and treated with chemotherapy and radiation. However, such patients may have a residual mass after completing treatment. This situation presents a challenge, as it may not be clear whether the persistent mass is active tumor or treated tumor. This report describes the presentation and management of such a case in the orbit and demonstrates that a residual orbital mass may remain and represent completely treated tumor.

Prevalence, variability, and predictors of sinus surgery in pediatric patients with cystic fibrosis.

INTRODUCTION: Chronic rhinosinusitis is common among individuals with cystic fibrosis (CF) and has an impact on quality of life. Sinus surgery is a treatment option, but minimal literature exists regarding prevalence and indications. METHODS: Using the linked CF Foundation Patient Registry (CFFPR) - Pediatric Health Information Systems (PHIS) database, we investigated variability in receipt of surgery, predictors of surgery, and time to first surgery. We included individuals less than 18 receiving care between 2006 and 2015 at a CF Foundation care program that is also a PHIS-participating-hospital. We used logistic regression to examine predictors of receipt of surgery and a Kaplan-Meier curve to examine time to first surgery among those born 2005-2007. RESULTS: There were 11,545 children and adolescents and 2156 (18.7%) received at least one surgery. Variation in number of surgeries was observed across hospitals (median: 63 [IQR, 33-110]). There was an inconsistent pattern between receipt of surgery and markers of disease severity; those receiving surgery having increased odds of treatment use and pulmonary exacerbations and decreased odds of lower lung function and body mass index. Among the cohort of young children, 159 (14%) had at least one surgery with a median age at first surgery of 5.6 (IQR, 3.9-7.0). CONCLUSIONS: The use of sinus surgery is frequent, but variable, among children and adolescents. Clinical factors are associated with receipt of surgery, but further understanding is needed on other factors that impact variability in use. Our study indicates the need for additional evaluation of the management of CF-related CRS and indications for surgery.

Chronic rhino-sinusitis treatment in children with cystic fibrosis: A cross-sectional survey of pediatric pulmonologists and otolaryngologists.

OBJECTIVES: Children with cystic fibrosis (CF) have a high incidence of chronic rhinosinusitis (CRS); however, no clinical care guidelines currently exist for the management of CRS in these patients. As a result, there is variation in the treatment of CRS in children, especially when it comes to the frequency of surgery for nasal polyposis. METHODS: A 28-question survey was sent to pediatric otolaryngologists (POs) and pulmonologists (PPs) who care for pediatric CF patients. Questions assessed the level of agreement that practitioners had with various approaches to CRS care in pediatric CF patients. RESULTS: Responses from 114 POs and 50 PPs were included in our final analysis. Each group demonstrated significantly different approaches to the medical and surgical management of CRS in pediatric CF patients. POs prefer multi-modal approach while PPs prefer single-modal approaches. With respect to medical management, PPs incline towards IV antibiotics while POs tend toward oral steroids. CONCLUSION: POs and PPs strongly agree that CRS has an impact on overall disease state and quality of life of pediatric CF patients. However, POs and PPs significantly differ in their approach to treating CRS, demonstrating a potential need for clinical care guidelines for the management these common sequelae of CF.

Update on sinus disease in children with cystic fibrosis: advances in treatment modalities, microbiology, and health-related quality-of-life instruments.

PURPOSE OF REVIEW: There is a lack of consensus with regards to the diagnosis and treatment of sinus disease in children with cystic fibrosis. Here, we review literature from the past 18 months in order to highlight the way forward in this contentious field. RECENT FINDINGS: Most of the literature (from the past 18 months) on sinus disease in pediatric cystic fibrosis focused on treatment approaches, bacteriology and immunology, and health-related quality-of-life (HRQOL) instruments. Quality studies have demonstrated that functional endoscopic sinus surgery (FESS) is as safe in children with or without cystic fibrosis; that the microbiology of the paranasal sinus in children with cystic fibrosis is different than that of their lungs; and, that HRQOL instruments may prove useful in determining sinonasal disease severity in children with cystic fibrosis. SUMMARY: Medical and surgical approaches appear to be viable in the treatment of sinonasal disease in pediatric cystic fibrosis; the microbiology and immunology of pediatric cystic fibrosis is proving more complex and nuanced than initially believed; and, HRQOL instruments show promise in reconciling differences between observable and clinically relevant sinus disease in pediatric cystic fibrosis patients.

Tympanic Membrane Perforation Repair Using Porcine Small Intestinal Submucosal Grafting.

OBJECTIVE: To evaluate the use of porcine small intestinal submucosal grafts for tympanic membrane repair. PATIENTS: Adult and pediatric patients with tympanic membrane perforations with and without chronic otitits media, and perforations after removal of cholesteatoma. INTERVENTION: Endoscopic or microscopic tympanic membrane repair using porcine small intestinal submucosal grafts (Biodesign). MAIN OUTCOME MEASURE(S): Perforation closure, bone and air pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS) were recorded as outcome measures. RESULTS: Thirty-seven patients were included with a mean age of 25.4 years (range, 6-75), 57% men. Twenty-six cases (70%) were performed endoscopically and 34 (92%) had concomitant cartilage grafting. Three patients (8%) had postoperative pinpoint (<1% surface area) perforation, and two patients (5%) had postoperative perforation, with an overall success rate of 86.5%. The mean improvement in air-bone gap was 7.6 dB and (p = 0.006). There were no statistically significant differences in closure rates when comparing primary versus revision cases, endoscopic versus microscopic cases, size of perforation, cholesteatoma, concomitant mastoidectomy, age, tobacco exposure, or comorbid diabetes mellitus. Patients with concomitant cartilage graft were more likely to be successful when compared with those without cartilage graft (p = 0.04). CONCLUSIONS: Porcine small intestinal submucosal grafts are effective in the repair of the tympanic membrane. These grafts are an excellent choice in total endoscopic cases as it avoids incisions necessary for allograft harvest.

Nasal saline irrigation in pediatric rhinosinusitis: A systematic review.

OBJECTIVE: To determine the efficacy of nasal saline irrigation (NSI) in reducing symptoms and improving quality of life in pediatric patients with acute (ARS) or chronic (CRS) rhinosinusitis. DATA SOURCES: We searched the PubMed/MEDLINE and Embase electronic databases (indexed January, 1950 through April, 2017). REVIEW METHODS: Studies assessing the efficacy of NSI in pediatric patients with ARS or CRS were selected for analysis. Outcome measures, including symptom scores and parental surveys, were analyzed. Two independent reviewers evaluated each abstract and article. RESULTS: Of the 272 articles identified using our search strategy, only 1 study, focusing on the use of NSI in pediatric ARS, met all inclusion criteria. No studies investigating NSI in pediatric CRS were included for analysis. In general, studies demonstrated significant improvement of symptom scores with the use of NSI in pediatric rhinosinusitis; but, the use of varied outcome measures, control treatments, and NSI delivery made including studies and drawing conclusions difficult. No quantitative meta-analysis could be performed. CONCLUSION: NSI may provide benefit for ARS in children; however, additional high-quality studies with defined outcome measures are needed to determine the quantitative efficacy of this therapy in the pediatric patients with rhinosinusitis-especially in pediatric CRS.

Correlation of intraoperative parathyroid hormone levels with parathyroid gland size.

OBJECTIVES: To study the relationship of intraoperative intact parathyroid hormone levels (iPTH) with parathyroid adenoma weight and volume in patients with primary hyperparathyroidism. METHODS: Retrospective evaluation of consecutive patients undergoing minimally invasive parathyroidectomy with iPTH measurement. Data collected include preoperative serum calcium, ionized calcium, and serum parathyroid hormone (PTH) levels, iPTH levels at baseline, 5 minutes, and 10 minutes, and parathyroid adenoma weight. Adenoma volume was calculated using an equation for the volume of a spheroid object. RESULTS: Thirty patients underwent minimally invasive parathyroidectomy with iPTH measurement for a single parathyroid adenoma between March 2004 and January 2006. There were 8 men and 22 women, with a mean age of 59.3 (range 26-92) years. A significant correlation between preoperative serum calcium and ionized calcium levels and parathyroid adenoma weight was identified (P = .0008 and P = .03, respectively). A significant correlation was also shown between baseline iPTH measurements and parathyroid adenoma volume (P = .03). There was no correlation between baseline iPTH levels and parathyroid adenoma weight. There was a significant correlation between parathyroid adenoma weight and percentage decrease of iPTH levels at 10 minutes compared to baseline (P = .04). CONCLUSION: Preoperative serum calcium and baseline iPTH levels may be useful in predicting parathyroid adenoma weight and volume, respectively. Adenoma weight may relate to the percentage decrease of iPTH levels at the 10-minute postparathyroidectomy interval.

Clinical chronic rhinosinusitis outcomes in pediatric patients with cystic fibrosis.

Objectives: Chronic rhinosinusitis and nasal polyposis are common conditions in cystic fibrosis (CF). Approximately 2-3% of pediatric CF patients per year have sinus disease requiring surgery. It has been well established that there is a significant negative impact on quality of life associated with chronic rhinosinusitis (CRS) in the non-CF patient population. However, the impact of CRS on the pediatric CF population remains uncertain. The purpose of this article is to review the current state of outcome measures for CRS in pediatric CF patients. Data Sources: PubMed and EMBASE literature review. Methods: PubMed and EMBASE electronic databases were searched using Boolean searches that incorporated mesh headings and plain language for quality of life, symptom evaluation, pediatric patients, and sinusitis/rhinosinusitis. Studies were included if the study primarily evaluated a pediatric Cystic Fibrosis-Chronic Rhinosinusitis (CF-CRS) population and the primary outcome measure was quality of life evaluation. Results: The search yielded 34 unique articles. A total of 7 articles met inclusion criteria. Conclusions: Despite the high frequency of chronic rhinosinusitis in the pediatric CF patient population, its impact on quality of life is not well understood. Currently there is a lack of a validated disease specific quality of life instruments available to assess the impact of CRS on the pediatric CF patient population. Level of Evidence: 5.

Characteristics of superior orbital subperiosteal abscesses in children.

OBJECTIVES/HYPOTHESIS: Superior pediatric orbital subperiosteal abscesses (SPAs) are less common than medial ones, and clinical features specific to patients with superior SPAs have not been well defined. Clinical characteristics between patients with superior and medial SPAs are compared to determine whether superior location is a risk factor for surgical intervention. STUDY DESIGN: Retrospective cohort study. METHODS: The target population consisted of patients diagnosed with an SPA and seen by the pediatric otolaryngology service at a tertiary children's hospital between January 2010 and October 2014. Imaging characteristics including proptosis, hypoglobus, intraorbital air, and abscess volume as well as treatment interventions were reviewed. RESULTS: Forty patients between 5 and 17 years of age treated for an orbital SPA were identified. Thirteen patients were identified as having superior SPAs; 27 had medial SPAs. The average ages in the two groups were 10.92 and 9.26 years, respectively. The odds ratio for surgical treatment per each increasing year of age was 1.5 (P = .004). The proportion of patients requiring surgery was significantly different between the groups (12/13 superior vs. 13/27 medial, P = .01). The predominant organism group cultured in surgical patients was Streptococcus anginosus (8/24, 29.17%). Superior SPA patients had significantly more proptosis, hypoglobus, and abscess volume on computed tomography scan. CONCLUSIONS: Patients with superior SPAs may present with more advanced disease, leading to a higher rate of characteristics such as proptosis, hypoglobus, and intraorbital air, factors that would predispose to surgical drainage. We found that abscess volume was the most predictive of surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:735-740, 2017.

Evaluating the sinus and Nasal Quality of Life Survey in the pediatric cystic fibrosis patient population.

INTRODUCTION: The Sinus and Nasal Quality of Life Survey (SN-5) is a validated quality of life (QOL) questionnaire for chronic rhinosinusitis in patients age 2-12. Its utility in the cystic fibrosis (CF) has been studied, but not yet validated. The purpose of this study is to determine the effectiveness of the SN-5 for evaluation of sinonasal symptoms in the pediatric CF population. METHODS: This retrospective study analyzed SN-5 surveys completed between 2012 and 2015 by pediatric CF patients and caregivers. Baseline and follow-up overall QOL scores and specific symptom scores were obtained from surveys completed in the three-year span. Non-parametric statistics were conducted to identify differences in survey data. RESULTS: A total of 165 patients completed baseline and follow-up surveys. The overall QOL of the patient cohort did not change over the duration of the study (p = 0.660). Thirty-seven patients indicated higher overall QOL, with all five symptom scores showing significant improvement. Analysis by age group showed that QOL was significantly correlated with all five symptoms for children ages 0-4. In patients 5-12 years, overall QOL was only correlated with sinus infection (r = -0.3090, p = 0.01). QOL was significantly correlated with sinus infection (r = -0.2903, p = 0.04) and allergy symptoms (r = -0.5644, p < 0.01) in patients >12 years of age. CONCLUSION: There remains a need for a validated CRS QOL tool for children with CF. Though the SN-5 has previously been described as a potential instrument, our data suggest that it may be more valuable in children ages 0-4.

Pediatric post-tonsillectomy hemorrhage in the setting of post-transplantation immunosuppression.

INTRODUCTION: Long-term immunosuppressants form an integral part of therapy for post-transplantation patients. Immunosuppressants may also have an anticoagulant effect, and little is known about their effects on bleeding risk after adenotonsillectomy. Our objective was to investigate whether there is an increased observed rate of post-tonsillectomy hemorrhage in a population of pediatric patients on long-term immunosuppressants after solid organ transplantation, compared to healthy controls. METHODS: This was a retrospective chart review of pediatric patients with a history of renal or heart transplant undergoing adenotonsillectomy at our institution between 2000 and 2014. All patients underwent tonsillectomy with monopolar electrocautery. Retrieved data included perioperative medications, occurrence of post-operative bleeding and associated treatment. For comparison, we obtained a population of age-matched controls with no history of immunosuppression who underwent the same procedure. RESULTS: A total of 34 patients meeting criteria were identified, of which 3 (8.82%) suffered a postoperative bleed. Forty-seven controls were obtained, with a total of 2 (4.26%) postoperative hemorrhages (p = 0.65). Two of the post-transplantation patients who bled postoperatively required cauterization in the operating room. None of the controls required surgical treatment. The incidences of postoperative bleeding requiring surgical treatment were 5.88% and 0%, respectively (p = 0.17). CONCLUSION: We failed to demonstrate an increased risk of bleeding after undergoing adenotonsillectomy in our cohort of post-transplantation pediatric patients on chronic immunosuppression. Future research, likely requiring a multi-institutional effort, could stratify by immunosuppressive agent to elucidate bleeding risk with specific medications.

Inter-hospital variation in the frequency of sinus surgery in children with cystic fibrosis.

BACKGROUND: Chronic rhinosinusitis and nasal polyposis are common conditions in cystic fibrosis (CF). Approximately 2-3% of pediatric CF patients per year have sinus disease requiring surgery. The purpose of this study was to evaluate the variation of sinus surgery rates in pediatric CF patients across multiple US pediatric hospitals. METHODS: The Pediatric Health Information System (PHIS) compiles inpatient administrative data from 42 pediatric hospitals. We conducted a retrospective analysis of PHIS for the period January 1, 2008 to January 1, 2011 to evaluate frequency of sinus surgery at each hospital. We identified CF patients and sinus surgery during inpatient encounters using ICD-9 codes. Demographic data and data for each hospital on hospital size, number of pediatric otolaryngologists, average FEV1, and percentage of patients meeting minimum care guidelines were collected. Twenty-nine hospitals were included in analysis using mixed-effects logistic regression models for occurrence of sinus surgery. RESULTS: We identified 5,194 CF patients, accounting for 18,788 unique encounters among 29 hospitals. 880 patients underwent 1,397 sinus operations. Total number of CF patients at each institution ranged from 39 to 364 and total number of sinus surgeries ranged from 4 to 205, over the 3-year period. Variation in the rate of sinus surgery with hospital encounter was observed (1-24%). Hospital-average lung function (P = 0.56), number of otolaryngologists (P = 0.65) were not found to be predictors of sinus surgery. The size of the CF center (P = 0.01), hospital size (P = 0.05), and age at admission (P ≤ 0.0001) were associated with an increased frequency of sinus surgery. However, with multivariable analysis, only size of the CF center and age of admission remained statistically significant predictors of surgery with admission. CONCLUSIONS: There is large variation in the incidence of sinus surgery for CF in 29 of the largest freestanding pediatric hospitals. This study highlights remarkable variation in clinical practice and underscores the need for further research into the indications and benefits of sinus surgery in pediatric patients with CF. Pediatr Pulmonol. 2015; 50:231-235. © 2014 Wiley Periodicals, Inc.

Extensive surgical and comprehensive postoperative medical management for cystic fibrosis chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis has a major impact on the quality of life of patients with cystic fibrosis (CF) and may contribute to progression of chronic lung disease. Despite multiple sinus surgeries, maxillary sinus involvement is a recurrent problem. The modified endoscopic medial maxillectomy (MEMM) permits debridement in the clinic, improves mucus clearance with nasal irrigations, and increases access for topical delivery of therapeutics. However, clinical outcomes of aggressive sinus surgery with regimented postoperative medical treatment have not been systematically evaluated. METHODS: CF patients completed the 22-Item Sinonasal Outcome Test questionnaires before sinus surgery (and bilateral MEMM) and at sequential postoperative visits. Objective measures included Lund-Kennedy endoscopic score and pulmonary function tests (forced expiratory volume at 1 second percent [FEV(1)%] predicted). Culture-directed antibiotic therapy, prednisone, and topical irrigations were initiated postoperatively. RESULTS: Twenty-two patients (mean age, 26.5 years; 4.9 prior sinus operations) underwent MEMM and sinus surgery. Symptom scores were significantly reduced at 60 days (primary outcome, 64.7 ± 18.4 presurgery versus 27.5 ± 15.3 postsurgery; p < 0.0001) and up to a year postoperatively (27.6 ± 12.6; p < 0.0001). Endoscopic scores were also reduced after surgery (10.4 ± 1.1 presurgery versus 5.7 ± 2.4 [30 days], 5.7 ± 1.4 [60 days], 5.8 ± 1.3 [120 days], and 6.0 ± 1.1 [1 year]; p < 0.0001)]. There were no differences in FEV(1)% predicted up to 1 year postoperatively, but hospital admissions secondary to pulmonary exacerbations significantly decreased (2.0 ± 1.4 versus 3.2 ± 2.4, respectively; p < 0.05). CONCLUSION: Prospective evaluation indicates sinus surgery with MEMM is associated with marked improvement in sinus disease outcomes. Additional studies are necessary to confirm whether this treatment paradigm is associated with improved CF pulmonary disease.

Free flap reconstruction of lateral mandibular defects: indications and outcomes.

OBJECTIVE: To compare outcomes following osteocutaneous radial forearm and fibula free flap reconstruction of lateral mandibular defects. STUDY DESIGN: Retrospective case-controlled study. SETTING: Historical cohort study. SUBJECTS AND METHODS: All patients who underwent free flap reconstruction of lateral mandibular defects from 1999 to 2010 were included in this study. Patients were classified into 2 groups based on type of reconstruction: (1) osteocutaneous radial forearm (n = 73) and (2) fibula free flap reconstruction (n = 51). Patient characteristics, length of hospital stay, recipient and donor site complications, and long-term outcomes including postoperative diet were evaluated. RESULTS: Most patients were male (68%) and presented with advanced T-stage (71%) squamous cell carcinoma (94%) involving the alveolus (21%), retromolar trigone (23%), or oral tongue (21%). Median length of hospital stay was 8 days (range, 4-22 days). The recipient site complication rate approached 27% and included infection (n = 11), mandibular malunion (n = 9), exposed bone or mandibular plates (n = 9), and flap failure (n = 5). Most patients demonstrated little to no trismus following reconstruction (94%) and were able to resume a regular or edentulous diet (73%). No difference in complication rates or postoperative outcomes was seen between osteocutaneous radial forearm and fibula free flap groups (P > .05). One patient underwent dental implantation following osteocutaneous radial forearm free flap reconstruction. No patients from the fibula free flap group underwent dental implantation. CONCLUSION: The osteocutaneous radial forearm and fibula free flap provide equivalent wound healing and functional outcomes in patients undergoing lateral mandibular defect reconstruction.

Evolving materials and techniques for endoscopic sinus surgery.

Functional endoscopic sinus surgery was initially introduced as a minimally invasive procedure to treat chronic rhinosinusitis (CRS) in patients for whom medical management failed. Sinus surgery has been deemed an extremely effective part of the overall management of chronic sinus disease with symptomatic improvement in the vast majority of patients. At the forefront, technologic advances have been critical in advancing endoscopic sinus surgical procedures. With the introduction of improved optics and lighting, advanced instrumentation, and image-guided surgical navigation, the limitations of endoscopic procedures have been significantly reduced. Endoscopic techniques have evolved to include the management of both malignant and benign neoplasms of the sinuses and anterior skull base. This article highlights some of the newest advances in technology, materials, and medical/surgical techniques used in endoscopic sinus and skull base procedures and illustrates how they advance overall patient care to help minimize morbidity and complications.

Exposure to cigarette smoke condensate reduces calcium activated chloride channel transport in primary sinonasal epithelial cultures.

OBJECTIVES/HYPOTHESIS: The cystic fibrosis transmembrane conductance regulator (CFTR) serves as a predominant Cl(-) transport conduit in airway epithelium and is inhibited by cigarette smoke in vitro and in vivo. Activation of secondary Cl(-) transport pathways through calcium-activated Cl(-) channels (CaCC) has been postulated as a mechanism to bypass defects in CFTR-mediated transport. Because it is not known whether CaCCs are also inhibited by tobacco exposure, the current study was designed to investigate the effect of cigarette smoke condensate (CSC) on CaCC transport. STUDY DESIGN: In vitro study. METHODS: Well-characterized primary murine nasal septal epithelial (MNSE) and human sinonasal epithelial (HSNE) cultures were exposed to CSC in Ussing chambers. We monitored CaCC short-circuit current through stimulation of P2Y purinergic receptors with uridine triphosphate or adenosine triphosphate and selective inhibition of the CFTR-dependent secretory pathway. Characterization of CaCC current was also accomplished in primary airway cells derived from transgenic CFTR(-/-) (knockout) murine models. RESULTS: Change in CaCC-mediated current (DeltaI(SC) representing transepithelial Ca-mediated Cl(-) secretion in muA/cm(2)) was significantly decreased in CSC-exposed wild type MNSE when compared to controls (32.8 +/- 4.6 vs. 47.5 +/- 2.3; respectively; P < .02). A similar effect was demonstrated in CFTR(-/-) MNSE cultures (33.4 +/- 2.8 vs. 38.6 +/- 2.0; P < .05>. HSNE cultures also had a significant reduction in I(SC) (16.1 +/- 0.6 vs. 22.7 +/- 0; P = .008). CONCLUSIONS: CSC affects multiple pathways fundamental to airway ion transport, including both cyclic adenosine monophosphate and calcium activated Cl(-) transport. Inhibition of Cl(-) transport may contribute to common diseases of the airways, such as chronic rhinosinusitis and chronic obstructive pulmonary disease.

Functional outcomes of fibula and osteocutaneous forearm free flap reconstruction for segmental mandibular defects.

OBJECTIVE/HYPOTHESIS: To demonstrate that the osteocutaneous radial forearm free flap provides equivalent functional outcomes and improved morbidity compared to the fibular free flap in mandibular reconstruction. STUDY DESIGN: Retrospective review. METHODS: There were 168 patients requiring free flap reconstruction of segmental mandibular defects between January 2001 and December 2008. Mean follow-up was 31 months for fibula free flap (FFF) (n = 117) and 20 months for osteocutaneous radial forearm free flaps (OCRFFF) (n = 51), reflecting an increasing use of forearms. RESULTS: OCRFFF were more commonly used in older patients (mean 63.7 years vs. 59 years, P = .03). The majority (96.2%) of reconstruction was for malignant pathology. Flap failure was 3.4% for the fibula group and 3.9% in the forearm group. Malunion was infrequent (2.0% OCRFFF, 6.0% FFF, P = .26). Donor site complications were higher in the FFF group (4.3%) versus none in the OCRFF group (P = .13). Despite a high rate of long-term survival in this patient population (75% at 5 years for carcinoma), dental implants were rarely placed (2.3% of patients) and were more common in forearm than fibula free flaps. Functional outcomes demonstrated no significant difference between groups with respect to oral diet (FFF 72.6% vs. OCRFFF 79.1%, P = .49) or retained enterogastric feeding tube (20.9% OCRFFF vs. 27.4% FFF, P = .49). CONCLUSIONS: Osteocutaneous radial forearm flaps provide comparable functional outcomes with less morbidity compared to fibula free flaps for selected segmental mandibulectomy defects. The overall dental implantation rate was low and more commonly performed in osteocutaneous radial forearm flaps compared to fibula flaps.