Brian Dunham

The Histologic Relationship of Preauricular Sinuses to Auricular Cartilage

OBJECTIVE To conduct a meta-analysis of the cost-utility of the cochlear implant in adults. DATA SOURCES MEDLINE literature search, review of article bibliographies, and consultation with experts. STUDY SELECTION Studies that reported (1) data on adults (age > or = 18 years) with bilateral, postlingual, profound deafness; (2) a health-utility gain from cochlear implantation on a scale from 0.00 (death) to 1.00 (perfect health); (3) a cost-utility ratio in terms of dollars per quality-adjusted life-year (QALY); and (4) at least 1 conventional statistical parameter (ie, SD, 95% confidence interval [CI], or P value). DATA EXTRACTION From each study, we extracted the number of subjects, study design, health-utility instrument used, health-utility associated with profound deafness, health-utility gain from cochlear implantation, cost-utility of cochlear implantation, and reported statistical parameters. DATA SYNTHESIS Weighted averages were calculated using a statistical weight of 1 per variance. Pooling 9 reports (n = 619), the health-utility of profoundly deaf adults without cochlear implants was 0.54 (95% CI, 0.52-0.56). Pooling 7 studies (n = 511), the health-utility of profoundly deaf adults after cochlear implantation was 0.80 (95% CI, 0.78-0.82). This improvement of 0.26 in health-utility resulted in a cost-utility ratio of

Diagnosis and treatment of pediatric vallecular cysts and pseudocysts

12,787 per QALY. CONCLUSIONS Profound deafness in adults results in a substantial health-utility loss. Over half of that loss is restored after cochlear implantation, yielding a cost-utility ratio of

Coblation for Tonsillectomy: An Evidence-Based Review

12,787 per QALY. This figure compares favorably with medical and surgical interventions that are commonly covered by third-party payers in the United States today.

Prevention and correction of temporal hair loss in rhytidectomy.

OBJECTIVE To review the experience at a childrens hospital diagnosing and treating vallecular cysts. SECONDARY OBJECTIVES To determine if cyst type, operative mode, or ages are risk factor(s) for recurrence. METHODS Chart review of eleven children with vallecular cysts and pseudocysts from 1997 to 2009. RESULTS The most common presenting symptoms were stridor (8/12, 67%), respiratory distress (7/12, 58%), and feeding difficulties (4/12, 33%). Symptoms of gastroesophageal reflux disease were present in 67% of patients and 17% carried a concurrent diagnosis of laryngomalacia. Eleven of twelve patients required operative intervention, the majority of which were transoral endoscopic procedures. Three patients (3/11, 27%) had recurrences. Two of these patients required only a second procedure, but one patient required multiple procedures. Fifty percent (2/4) of the patients 2 years or older experienced a recurrence, whereas only 14% (1/7) of the patients less than 2 years old had a recurrence, a difference which was not statistically significant (p=0.49). Pseudocysts tended to recur more frequently than vallecular cysts. (p=0.13). Surgical approach (marsupialization versus total excision) did not affect recurrence rate. One patient with a small, asymptomatic cyst was observed and continues to be symptom-free. There were no surgical complications. CONCLUSIONS Vallecular cysts and pseudocysts are rare congenital lesions of the upper aerodigestive tract. Vallecular pseudocysts tended to recur more than vallecular cysts in our series. Surgery is the treatment of choice for symptomatic patients; smaller cysts may be followed closely.

Anatomical dissection and modified Sihler stain of the lower branches of the facial nerve.

Coblation technology (Arthrocare Corp., Sunnyvale, Calif., USA) allows for tonsillectomy using plasma-mediated ablation. This review presents the evidence to date with respect to surgical and recovery measures, in order to promote an objective discussion of this surgical technology.

A novel transnasal transsphenoidal speculum: a design for both microscopic and endoscopic transsphenoidal pituitary surgery

Routine incisions in the temporal area for rhytidectomy often remove hair-bearing skin anterior to the ear. This results in a cosmetic deformity, making the surgical intervention clearly visible. This is especially problematic for revision rhytidectomy or for patients with naturally high hairlines. This article describes a systematic approach to the temporal hairline and introduces a novel, hair-bearing, transposition flap that corrects iatrogenic loss of the preauricular tuft of hair.

Congenital Malformations of the Nose and Nasopharynx

Background: The cervical branch of the facial nerve and the muscles it supplies play a role in perioral function and neck aesthetics. Paralysis of the cervical branch in some patients may result in lip depressor deficiency and an asymmetric smile. It is unclear whether this is the result of platysmal weakness alone, or attributable to coinnervation of the lip depressor muscles by the cervical and marginal mandibular branches of the facial nerve. The purpose of this study was to provide a detailed description of the anatomy and function of the cervical branch to assist surgeons operating in the face and neck. Methods: Anatomical dissection of the marginal mandibular and cervical branches was performed in 20 hemifacial human cadaver specimens. The modified Sihler stain was used to stain the extramuscular and intramuscular nerve branches in eight specimens. The course, branching patterns, and neuromuscular relationships of the cervical and marginal mandibular branches were examined. Results: Multiple cervical branches were identified in 85 percent of specimens, and an anastomosis with the transverse cervical cutaneous nerve was documented consistently. A communication between the marginal mandibular and cervical branches was identified in seven specimens, and coinnervation of the depressor anguli oris by intramuscular cervical branch ramifications was seen in one. Conclusions: A detailed description of the anatomy of the cervical branch is provided. Coinnervation of the lower lip depressors by the cervical branch remains a plausible explanation for the lower lip deformity attributed to cervical branch paralysis in some patients.

Pediatric tracheostomy in conjoined twins: multidisciplinary approach.

Over the last several years minimally invasive surgical approaches to the sella turcica and parasellar regions have undergone significant change. The transsphenoidal approach to this region has evolved from a sublabial transnasal, to transnasal, to pure endonasal approaches with the increasing popularity of endoscopic over microscopic techniques. Endoscopic and microscopic techniques individually or in combination have their own unique advantages, and the preference of one over the other awaits further technological refinements and surgical experience. In parallel with this evolution in techniques for transsphenoidal surgery, the authors designed an adaptable versatile speculum for the endonasal/transnasal transsphenoidal approach to the sella turcica and parasellar regions that can be used equally effectively with a microscope or an endoscope. The development of this instrument and its unique features are described, and its initial clinical use is summarized. This transnasal transsphenoidal speculum has interchangeable blades, unique blade angulations, and independent blade opening mechanisms and allows safe, optimal exposure in all patients regardless of the size and anatomical aberrations of individual nasal and endonasal regions. An attached endoscope carrier further allows it to be used interchangeably with microscopic or endoscopic techniques without having to remove the speculum; likewise, a single surgeon can use both hands without need of an assistant. A forehead headrest component adds further stabilization. This device has been used successfully in 90 transsphenoidal procedures.

Infectious complications and ventilation tubes in pediatric cochlear implant recipients

This chapter provides embryologic and clinical descriptions, photographs, and illustrations of the more common congenital anomalies of the nose and nasopharynx. The authors present the topics in sections based on the underlying pathology. These sections include malformations that occur because the nose failed to form properly (such as arhinia, polyrhinia, and nasal colomboma), those that resulted in midline nasal and nasopharyngeal malformations (such as choanal atresia and craniopharyngioma), and those that resulted in congenital nasopharyngeal or nasal midline masses (such as epignathi, Thornwaldt cysts, dermoids, gliomas, and encephaloceles).

Don’t hang your coat here

Tracheostomy for definitive airway management in conjoined twins is a challenge for the surgeon, anesthesiologist, and support staff. A carefully choreographed multidisciplinary approach is required. A literature search finds few reports on tracheostomy in conjoined twins. We report our experience with tracheostomy with 5.5-month-old conjoined omphalopagus twins who were attached facing each other. Initial planning led to a careful rehearsal of infant positioning focused on optimizing anterior cervical exposure. A postoperative tracheostomy care plan was also addressed. Each twin was assigned his own anesthetic team and equipment early in his life to provide consistent care for the anticipated multiple surgical procedures throughout his hospital stay. Issues addressed in this report include transportation, intubation, intraoperative airway management, the mechanical ventilatory pattern of two individuals sharing a common diaphragm, and the pharmaceutical management of two children with partially shared vascular supply.