Bharat A. Panuganti

Evaluation and management of pruritus and scabies in the elderly population.

Pruritus is the most common dermatologic complaint in individuals older than 65 years. The elderly comprise a demographic that seeks medical attention for itch with greater frequency than other age groups. Managing pruritus in elderly patients represents a unique therapeutic challenge attributable to a range of circumstances that are of particular importance in this population. Topical steroid therapy must be administered carefully, and other forms of treatment, including phototherapy, may be difficult to maintain. The challenge of treating pruritus in the elderly might also stem from communication barriers that prevent definitive identification of the itchs underlying etiology or severity.

Short-Term Morbidity after the Endoscopic Modified Lothrop (Draf-III) Procedure Compared with Draf-IIa

Background The endoscopic modified Lothrop (Draf-III) surgery has improved treatment of recalcitrant frontal sinus disease, with favorable safety and long-term results. However, the short-term clinical and quality-of-life morbidity after Draf-III relative to less-extensive procedures has yet to be investigated. Objective To evaluate the surgical and quality-of-life outcomes, including the burden of follow-up care, in patients who underwent endoscopic modified Lothrop (Draf-III), and compared these results with a less-extensive intervention, the endoscopic frontal sinusotomy (Draf-IIa). Methods A retrospective review of early (<8 weeks) postoperative recovery of patients who underwent Draf-III (2014 to 2016) for chronic rhinosinusitis was conducted and compared with age and radiographically matched Draf-IIa controls. Primary outcomes included perioperative complications, the number of postoperative clinic visits, debridements, and steroid and antibiotic therapy days. Secondary outcomes included the change in the 22-item Sino-Nasal Outcome Test (SNOT-22) scores and/or subscores (domains). Results Thirty-eight patients (19 Draf-III, 19 Draf-IIa) were included. Patients who underwent Draf-III versus Draf-IIa required more postoperative clinic visits (4.9 ±1.7 versus 3.3 ± 0.8; p < 0.05), debridements (4.2 ± 2.0 versus 2.3 ± 0.8; p < 0.05), and antibiotic therapy days (24.4 ± 11.8 versus 15.6 ± 6.3; p < 0.05). The mean (SD) SNOT-22 scores improved for both groups (−12.7 ± 34.5 versus -9.5 ± 20.4; p = 0.74) over the follow-up period, and subscore (domain) analysis demonstrated worsening extranasal symptoms (2.5 ± 3.0 versus -1.5 ± 4.7; p < 0.05) at the first postoperative visit, and less improvement in ear/facial symptoms at the second (−0.5 ± 2.6 versus -3.9 ± 4.7; p = 0.03) and third postoperative visits (−1.1 ± 1.6 versus 3.5 ± 3.3; p = 0.01). Conclusion Draf-III is associated with more postoperative clinic visits, debridements, and antibiotic therapy days. The patients who underwent Draf-III demonstrated worsening of extranasal symptoms at the first postoperative visit and less improvement in the ear/facial score at the second and third visits. Informed consent and counseling patients who may require Draf-III should include a detailed discussion of the burden of postoperative care and recovery.

Efficacy of bone marrow cytologic evaluations in detecting occult cancellous invasion

Determine the accuracy of bone marrow cytologic evaluations in detecting occult cancellous invasion by squamous cell carcinomas (SCCa) beyond the original margins of bone resection that would have gone undetected without the use of intraoperative bone‐marrow margin analysis.

Treating Scars in the Auricle Region

This article provides a review of the surgical and nonsurgical options available to manage a variety of auricular scars. The basics of wound healing are discussed in addition to the etiology of keloids and the cauliflower ear. Many auricular scars can be revised with scar excision techniques, but separate discussions for the treatment of keloids and the cauliflower ear are provided. The management plan for auricular scarring requires appropriate patient counseling regarding the risk of recurrence in keloids, regrowth of scar tissue in cauliflower ears, scar hypertrophy at the line of closure, widening of the scar, and persisting ear contour deformities.

Effects of a Comprehensive Performance Improvement Strategy on Postoperative Adverse Events in Head and Neck Surgery

Objectives We aimed to demonstrate the efficacy of a multifaceted performance improvement regimen to reduce the incidence of adverse events following a spectrum of head and neck surgical procedures. Methods We conducted a chart review of patients who underwent a head and neck procedure between January 1, 2013, and October 30, 2015, at our institution, including 392 patients (450 procedures) before the quality improvement regimen was implemented (October 1, 2013) and 942 patients (1136 procedures) after implementation. Multivariate statistical models were used to investigate the association of clinical parameters and the intervention with postoperative adverse event rate. Results The incidence of adverse events decreased from 12.9% to 7.2% (95% CI, 2.46%-9.38%) after the intervention. Male sex (adjusted odds ratio [ORadj] = 1.57; 95% CI, 1.06-2.31) and the intervention (ORadj = 0.51; 95% CI, 0.35-0.74) were predictive of overall adverse event incidence by univariate and multivariate analyses. Although patient comorbid status, quantified with the Charlson Comorbidity Index, was not found to affect overall adverse event risk, each 1-point increase in index score was associated with a 17% relative increase (ORadj = 1.17; 95% CI, 1.03-1.33) in the odds of a high-grade adverse event. Discussion Comprehensive performance improvement programs can improve perioperative adverse event risk in head and neck surgery. Patient comorbid status and sex are considerations during assessment of the likelihood of high-grade and overall adverse event risk, respectively. Implications for Practice Given the cost of surgical complications, a comprehensive approach to perioperative risk mitigation is warranted.

Foxtail Ingestion in an Asymptomatic Child: A True Emergency?:

F oreign body ingestion is commonly seen in the pediatric population. The most frequently implicated age range is 6 months to 5 years, and the most frequently ingested objects are coins. Decisions regarding intervention are based on the characteristics of the foreign body (eg, batteries for their corrosive potential, sharp objects for their perforation risk) and their location. Although corrosive entities, such as button batteries, should prompt immediate removal, the management of more atypical ingestions is less definitive. We present the case of an otherwise healthy 3year-old girl who arrived in our emergency department several hours after reportedly swallowing a foxtail. She demonstrated no clinical signs of acute pain or respiratory distress but complained of irritation in her throat. Given the history of a foreign body ingestion with a specific concern for a foxtail being present, the otolaryngology service was consulted for urgent evaluation and removal. This submission was reviewed and approved by the University of California– San Diego Human Research Protections Program (June 29, 2017). A ‘‘foxtail’’ is a plant dispersal unit, usually manifesting as a spikelet or cluster of grass that is ubiquitous in the western United States. Indeed, different plant species produce grasses known colloquially as ‘‘foxtails,’’ but their common detrimental potential is due to their indiscriminate barb-laced tips. The dangers of foxtail ingestions are widely recognized by veterinarians and commonly conveyed to dog owners, as foxtails have been reported to become burrowed in dogs’ nasal turbinates or gastrointestinal tracts when ingested, where they have the potential to traverse deeper and cause serious foreign body reactions/infections, perforations, and even death. The mechanism is associated with the conformation of the foxtail’s barbs and sharp leading edge, which results in a one-way trajectory through soft tissue. Flexible nasolaryngoscopy in our patient clearly revealed the foxtail overlying over the epiglottis (Figure 1), with no evidence of associated laryngopharyngeal mucosal injury. Tongue depression allowed adequate visualization of the head of the foxtail, which was promptly removed with a pair of large alligator forceps. The patient’s father reported that the girl ingested 2 foxtails. Given that only 1 was identified via nasolaryngoscopy, a gastroenterologist was recruited to perform an upper gastrointestinal endoscopy, the result of which was negative. Upon most recent inquiry (approximately 5 months following the ingestion), the patient is well and without associated complications. Despite never being reported in humans and based on the reported theoretical risk, the possibility of foxtail ingestion should prompt at least consideration of comprehensive

Opioid prescribing practices in patients undergoing surgery for oral cavity cancer: Opioids After Oral Cavity Surgery

Opioids have been overprescribed after general and orthopedic surgeries, but prescribing patterns have not been reported for head and neck surgery. The objectives of this retrospective review are to describe postoperative opioid prescriptions after oral cancer surgery and determine which patients receive higher amounts.

Cytoreductive Surgery and Normothermic Intraperitoneal Chemotherapy for Signet Ring Cell Appendiceal Adenocarcinoma With Peritoneal Metastases in the Setting of Cirrhosis

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are combined to treat peritoneal surface malignancies (PSM). The objective of cytoreduction is to eradicate macroscopic disease, while HIPEC addresses residual microscopic disease. Currently, there are no protocols guiding treatment of cirrhotic patients with PSM. We report the case of a cirrhotic patient with signet ring cell (SRC) appendiceal adenocarcinoma who underwent normothermic, as opposed to hyperthermic intraperitoneal chemotherapy (IPC). A 50-year-old woman with compensated class A cirrhosis and chronic hepatitis B and C underwent a right hemicolectomy in 2007 and adjuvant chemotherapy in 2008 for appendiceal SRC adenocarcinoma. In 2011, she was found to have peritoneal disease after a laparotomy. She subsequently experienced intolerance to chemotherapy, with stable disease on serial restaging. In light of her cirrhosis, the decision was made to perform CRS and IPC without hyperthermia to treat her residual disease. In 2012, she underwent CRS (omentectomy, total abdominal hysterectomy, left salpingo-oophorectomy) and IPC with mitomycin C. Thirty-day postoperative morbidity included delayed abdominal closure (Clavien-Dindo Grade IIIb), prolonged ventilator support (IIIa), vasopressor requirements (II), and confusion (II). The patient’s liver function remained stable. Eight months later, she had evidence of recurrence on computed tomography. Twenty-two months later, she developed an extrinsic compression secondary to evolving disease, requiring a palliative endoscopic stent. The patient expired from her disease 29 months after her CRS and IPC. The criteria guiding selection of suitable candidates for CRS continues to evolve. Concomitant compensated cirrhosis in patients with PSM should not constitute a reason independently to exclude CRS with intraperitoneal chemotherapy, given the oncologic benefits of the procedure.

Chronic sialadenitis with sialolithiasis associated with parapharyngeal fistula and tonsillolith

Sialolithiasis is a common salivary pathology, suggested to affect over 1% of the population by postmortem studies. An uncommon complication of sialadenitis and sialolithiasis is the formation of fistulous tracts to other cervicofacial compartments. Submandibular gland sialocutaneous and sialo-oral fistulae have been sparsely described, but a sialo-pharyngeal fistula manifesting as a tonsillolith has yet to be described. We present an unusual case of a 35-year-old male presenting with recalcitrant neck pain and a presumed tonsillolith in the background of chronic submandibular sialadenitis, subsequently demonstrating a salivary fistula through the parapharyngeal space. We offer a thorough review of the literature to highlight the possibility of migratory sialolithiasis and its complications.

Isolated sphenoid sinus opacifications: a systematic review and meta-analysis: Isolated sphenoid sinus opacifications

Isolated sphenoid sinus opacifications (ISSOs) represent a relatively uncommon disease with the potential for serious complications. To better understand this disease, we performed a systematic review to further characterize the underlying pathologies, associated symptoms, and treatment outcomes of patients with ISSOs.