Amanda L. Stapleton

Congenital cholesteatoma: predictors for residual disease and hearing outcomes.

OBJECTIVE To determine predictive factors for residual disease and hearing outcomes of surgery for congenital cholesteatoma (CC). DESIGN Retrospective record review of surgery for CC from January 1, 1998, through December 31, 2010. The initial extent of CC was staged using the system as defined by Potsic et al. SETTING Tertiary care childrens hospital. PATIENTS Eighty-one children (82 ears) underwent a total of 230 operations for CC. The mean (SD) age was 5.3 (2.9) years, and the mean follow-up was 4.3 years. INTERVENTION Initial and subsequent operations for CC and audiologic evaluations. MAIN OUTCOME MEASURES Statistical analyses were performed to determine factors associated with increased residual disease for CC and poorer hearing outcomes. RESULTS Higher initial stage of disease, erosion of ossicles, and removal of ossicles were significantly associated with increased likelihood of residual CC (46%, 50%, and 51%, respectively; P < .001). More extensive disease at initial surgery was associated with poorer final hearing outcomes (P < .05). Other significant findings included CC medial to the malleus (41.5%) or incus (54.3%), abutting the incus (51.3%) or stapes (63%), or enveloping the stapes (50%); all patients had increased residual disease (all P < .05). Excellent audiometric results (air-bone gap of ≤20 decibel hearing level) were obtained in 63 (77%) of the 82 ears. CONCLUSIONS More extensive initial disease, ossicular erosion, and the need for ossicular removal were associated with residual disease. On the basis of our data, the best chance for completely removing CC at initial surgery involves removing involved ossicles if they are eroded, if the CC is abutting or enveloping the incus or stapes, if the CC is medial to the malleus or incus, or if the matrix of the CC is violated. These results may help guide surgeons to achieve the best results for their patients.

Perioperative incidence and management of hyponatremia in vWD patients undergoing adenotonsillectomy

To analyze the incidence and severity of hyponatremia in patients receiving synthetic desmopressin (DDAVP) in the perioperative setting of oropharyngeal surgery in the treatment of von Willebrand disease and to propose a standardized protocol for perioperative fluid resuscitation and postoperative sodium monitoring after DDAVP administration.

Risk factors for cerebrospinal fluid leak in pediatric patients undergoing endoscopic endonasal skull base surgery

OBJECTIVES To determine the risk factors associated with cerebrospinal fluid (CSF) leak following endoscopic endonasal surgery (EES) for pediatric skull base lesions. METHODS Retrospective chart review of pediatric patients (ages 1 month to 18 years) treated for skull base lesions with EES from 1999 to 2014. Five pathologies were reviewed: craniopharyngioma, clival chordoma, pituitary adenoma, pituitary carcinoma, and Rathkes cleft cyst. Fishers exact tests were used to evaluate the different factors to determine which had a statistically higher risk of leading to a post-operative CSF leak. RESULTS 55 pediatric patients were identified who underwent 70 EESs for tumor resection. Of the 70 surgeries, 47 surgeries had intraoperative CSF leaks that were repaired at the time of surgery. 11 of 47 (23%) surgeries had post-operative CSF leaks that required secondary operative repair. Clival chordomas had the highest CSF leak rate at 36%. There was no statistical difference in leak rate based on the type of reconstruction, although 28% of cases that used a vascularized flap had a post-operative leak, whereas only 9% of those cases not using a vascularized flap had a leak. Post-operative hydrocephalus and perioperative use of a lumbar drain were not significant risk factors. CONCLUSIONS Pediatric patients with an intra-operative CSF leak during EES of the skull base have a high rate of post-operative CSF leaks. Clival chordomas appear to be a particularly high-risk group. The use of vascularized flaps and perioperative lumbar drains did not statistically decrease the rate of post-operative CSF leak.

The impact of nasal surgery on sleep quality: a prospective outcomes study.

Objective (1) Evaluate the impact of nasal airway surgery on sleep quality using validated outcome measurements, (2) compare the utility of Epworth Sleepiness Scale (ESS) versus Pittsburgh Sleep Quality Index (PSQI) as a reflection of sleep quality, and (3) identify perioperative variables that might correlate with a beneficial effect of nasal surgery on sleep quality. Study Design Prospective outcome study of patients with symptomatic nasal obstruction undergoing nasal airway surgery. Setting Academic medical center. Methods Patients completed the Nasal Obstruction Symptom Evaluation (NOSE) scale, ESS, PSQI, and Ease-of-Breathing and Sleep Quality Likert scales preoperatively and 3 months postoperatively. A nonparametric analysis compared pre- and postoperative values, and associations were examined using Spearman correlations. Results Sixty-one patients completed the study. Mean NOSE scores decreased significantly from 68.2 preoperatively to 17.5 three months after surgery. Mean ESS scores and PSQI scores improved (P < .0001) over that same interval (7.5 to 5.3 and 7.8 to 4.6, respectively). There was a correlation seen between the degree of change in both NOSE scores and Ease-of-Breathing scores and the change in sleep quality measured using the PSQI or Sleep Quality Likert scores. The PSQI correlated better with Sleep Quality Likert scores than the ESS. Overall, 86.9% of subjects reported subjective improvement in sleep quality postoperatively. Conclusion In patients undergoing nasal airway surgery there may be a secondary improvement in subjective sleep quality. The degree of change in sleep quality correlates with the severity of nasal obstruction preoperatively and the degree of improvement in obstruction with surgery.

The Costs of Skull Base Surgery in the Pediatric Population

Objectives To determine the costs of endoscopic endonasal surgery (EES) for pediatric skull base lesions. Methods Retrospective chart review of pediatric patients (ages 1 month to 19 years) treated for skull base lesions with EES from 1999 to 2013. Demographic and operative data were recorded. The cost of care for the surgical day, intensive care unit (ICU), floor, and total overall cost of inpatient stay were acquired from the finance department. Results A total of 160 pediatric patients undergoing EES for skull base lesions were identified. Of these, 55 patients had complete financial data available. The average total inpatient and surgical costs of care were

Endoscopic endonasal surgery for benign fibro‐osseous lesions of the pediatric skull base

34, 056 per patient. Angiofibromas were the most costly:

The role of tympanostomy tubes in surgery for acquired retraction pocket cholesteatoma

59,051 per patient. Fibro-osseous lesions had the lowest costs:

The Natural Growth Rate of Residual Juvenile Angiofibroma

10,931 per patient. The average ICU stay was 1.8 days at

The Role of Tympanostomy Tubes in Surgery for Acquired Retraction Pocket Cholesteatoma

4,577 per ICU day. The average acute care stay was 3.4 days at

Prospective Outcomes Study of the Impact of Nasal Surgery on Sleep Quality

1,961 per day. Overall length of stay was 4.5 days. Three cerebrospinal fluid leaks (4%) and two cases of meningitis (3%) occurred. One tracheostomy was required (1.5%). Conclusions EES is a cost-effective model for removal of skull base lesions in the pediatric population. Costs of care vary according to pathology, staged surgeries, length of ICU stay, and need for second operations.