Cameron C. Wick

A multi-institutional analysis of tracheotomy complications.

To define the prevalence of tracheotomy tube complications and evaluate risk factors (RFs) associated with their occurrence.

Endolymphatic sac tumors

Endolymphatic sac tumors (ELST) are slow-growing, locally aggressive, low-grade malignancies that originate from the epithelium of the endolymphatic duct and sac. ELST often present with sensorineural hearing loss, tinnitus, and vertigo, which may mimic Meniere disease. Large tumors may present with additional cranial neuropathies. Management is primarily via microsurgical excision. Radiation therapy has a limited role for residual or unresectable disease. Early detection may enable hearing preservation techniques. ELST have an association with von Hippel-Lindau disease.

Surgical and Audiologic Outcomes in Endoscopic Stapes Surgery across 4 Institutions

Objectives To investigate intra- and postoperative outcomes of endoscopic stapes surgery. Study Design Case series with chart review. Setting Four tertiary care otologic centers. Subjects and Methods Sixty-five subjects 18 years and older who underwent endoscopic stapes surgeries were analyzed. Variables analyzed included surgical techniques and intraoperative findings. Outcomes measured included postoperative hearing and complications to date. Results Fifty-one patients met inclusion and exclusion criteria. The average patient age was 48.1 years (range, 26-87 years), with 60.0% female patients. Patients had a median follow-up of 5.13 months (range, 0.8-57.4 months). Of the subjects, 71.7% required scutum removal. The chorda tympani nerve was manipulated in 94.0% of subjects and transected in 12.0%. At last follow-up visit, the median air-bone gap decreased from 34.5 dB hearing level (HL) preoperatively to 9.0 dB HL postoperatively (P < .0001). Ninety percent of subjects had closure of their air-bone gap ≤20 dB HL. Intraoperative complications included tympanic membrane tears in 8.0% of subjects, all of which resolved at first follow-up. Postoperatively, 10.0% of subjects complained of altered taste. Conclusions The present multicentered study of endoscopic stapes surgery demonstrates similar audiometric and postoperative outcomes previously published in the literature, with a median postoperative air-bone gap of 9.0 dB HL. Future prospective endoscopic stapes surgery studies, addressing the need for scutum removal, postoperative taste changes, and pain scores, are merited.

Endoscopic Management of Middle Ear Paragangliomas: A Case Series.

OBJECTIVE To investigate the efficacy and safety of endoscopic middle ear paraganglioma (glomus tympanicum) resection. STUDY DESIGN Case series with chart review. SETTING Multi-institutional tertiary university medical centers. PATIENTS Adult patients with middle ear paragangliomas treated via a transcanal endoscopic approach from 1/2012 to 11/2015. INTERVENTION All tumors were initially approached via a transcanal endoscopic technique. An operating microscope was used only if the tumor could not be adequately visualized or resected with endoscopic techniques alone. MAIN OUTCOME MEASURES The main outcome was completeness of tumor resection via the endoscopic technique. Secondary measures were resolution of pulsatile tinnitus, audiometric outcomes, surgical duration, and surgical complications. RESULTS Endoscopic resection was attempted on 14 middle ear paragangliomas. Thirteen patients (93%) were women with a mean age of 61.6 years. The mean tumor size was 6.2 mm (SD, 3.3). Eleven cases (79%) had complete resection via an exclusive endoscopic approach. The mean surgical duration was 108.1 minutes (SD, 55.6). One case required use of an operating microscope via a transcanal route and two cases required postauricular incisions with mastoidectomy. There were no significant postoperative complications. Two patients (14%) had tympanic membrane perforations repaired intraoperatively without residual perforation on follow-up. All patients had normal postoperative facial nerve function. Pulsatile tinnitus resolved after surgery in all 13 patients who presented with this symptom preoperatively. The mean pure-tone average improved by 5.9 dB (SD, 4.6) after surgery. CONCLUSIONS Endoscopic management of middle ear paraganglioma is safe, feasible, and effective.

Endoscopic Lateral Cartilage Graft Tympanoplasty

Objective To describe a novel technique for lateral graft tympanoplasty. Study Design Case series with chart review. Setting Tertiary care university hospital. Subjects and Methods Pediatric and adult patients with tympanic membrane perforations deemed unfavorable for a medial graft technique due to the perforation characteristics or myringitis. Results Between 2014 and 2016, 34 ears from 31 patients underwent a transcanal endoscopic lateral cartilage graft tympanoplasty. The mean age was 24.4 years (range, 6-71 years), and 22 patients (65%) were younger than 18 years. All patients had tympanic membrane perforations. Eighteen patients (53%) had total or near-total perforations, leaving a minimal anterior remnant, and 16 patients (47%) had extensive myringitis. A bisected tragal cartilage-perichondrium shield graft was used in 33 patients (97%). The mean (SD) follow-up length was 9.8 (5.7) months. Initial perforation closure rate was 88.2% (30/34). Three of the persistent perforations underwent a revision endoscopic medial graft tympanoplasty with successful closure, leaving a final closure rate of 97.1% (33/34). Five patients (15%) required topical therapy for postoperative myringitis. Mean (SD) pure-tone average and air-bone gap significantly improved by 11.5 (10.7) dB (P < .001) and 11.4 (10.6) dB (P < .001), respectively. Twenty-seven patients (79%) closed their air-bone gap within 20 dB. Conclusion Transcanal endoscopic lateral cartilage graft tympanoplasty is feasible, and initial data support favorable outcomes. Further data are necessary for evaluation of long-term results and efficacy comparisons.

Petroclival Chondrosarcoma: A Multicenter Review of 55 Cases and New Staging System

Objective: To analyze clinical outcomes after treatment of petroclival chondrosarcoma and to propose a novel staging system. Study Design: Retrospective case review, 1995 to 2015. Setting: Multicenter study. Patients: Consecutive patients with histopathologically proven petroclival chondrosarcoma. Intervention(s): Microsurgery, endoscopic endonasal surgery, radiation therapy, observation. Main Outcome Measures: Disease- and treatment-associated morbidity, recurrence, mortality. Results: Fifty-five patients (mean age 42 years; 56% women) presenting with primary or recurrent petroclival chondrosarcoma were analyzed. The mean duration of follow-up was 74 months. Among 47 primary cases, the most common presenting symptoms were headache (55%) and diplopia (49%) and the mean tumor size at diagnosis was 3.3 cm. Subtotal resection was performed in 33 (73%) patients and gross total resection in 12 (27%). Adjuvant postoperative radiation was administered in 30 (64%) cases. Preoperative cranial neuropathy improved in 13 (29%), worsened in 11 (24%), and remained stable in 21 (47%) patients; notably, 11 preoperative sixth nerve palsies resolved after treatment. Nine recurrences occurred at a mean of 42 months. The 1-, 3-, 5- and 10-year recurrence-free survival rate for all 45 patients who underwent primary microsurgery with or without adjuvant radiation therapy was 97%, 89%, 70%, and 56%, respectively. Higher tumor stage, larger categorical size (<4 versus ≥4 cm), lack of adjuvant radiation, and longer duration of follow-up were associated with greater risk of recurrence. The overall mortality rate was 2% for patients presenting with primary disease. Analyzing the cohort of 17 cases with 20 recurrences, 3 received salvage surgery alone, 5 radiation therapy alone, 11 multimodality treatment, and one patient has been observed. Tumor control was ultimately achieved in 15 of 17 patients with recurrent disease. One patient (6%) with grade 3 petroclival chondrosarcoma died as a result of rapidly progressive disease within 6 months of salvage treatment. The overall mortality rate was 6% for patients with recurrent disease. Conclusion: Gross total or subtotal resection with adjuvant radiation provides durable tumor control with minimal morbidity in most patients. Surgery may improve preoperative cranial nerve dysfunction, particularly in the case of cranial nerve 6 paralysis.

IgG4-related disease causing facial nerve and optic nerve palsies: Case report and literature review

IgG4-related disease (IgG4-RD) is increasingly being recognized as an entity effecting the head and neck region. Although most commonly seen with salivary gland or paranasal sinus involvement, IgG4-RD may also involve the temporal bone and skull base. We report a rare care of a 61-year-old female with IgG4-RD presenting as synchronous lesions of the middle ear and middle cranial fossa with polyneuropathy of cranial nerves II, VI, and VII. Initial histopathological evaluation of her resected ear mass suggested a benign inflammatory process but no specific diagnosis. Her symptoms progressed over 10months prompting re-evaluation of the specimen and consideration of the IgG4-RD diagnosis. Key pathologic features included prominent lymphoplasmacytic population, storiform fibrosis, obliterative phlebitis, and IgG4 specific staining. The patient was treated with high-dose intravenous and oral steroids but was transitioned to azathioprine secondary to steroid-induced myopathy. Radiographic studies before and after treatment reveal marked improvement of the intracranial and extracranial disease. Correspondingly, her cranial neuropathies resolved. A high degree of clinical suspicion is necessary to diagnosis IgG4-RD. The diagnosis can be supported by elevated serum IgG, elevated IgG index, and pathognomonic histopathological findings. Primary treatment is with corticosteroids. However, immunotherapy using azathioprine or rituximab can be utilized in recurrent disease or patients with steroid intolerance.

Piezoelectric BoneScalpel osteotomies in osteocutaneous free flaps

INTRODUCTION The use of ultrasonic technology is not a novel concept amidst surgical specialties. Dentistry was at the foreground of early ultrasonic adaptation with reports in the late 1950s that highlighted its selective ability to cut dento-osseous structures during root canals. Since then, considerable advancements have been made in ultrasonic technology, and many other surgical specialties have incorporated the use of ultrasonic bone scalpels into their practice. The scientific literature has abundant reports demonstrating the versatile use of ultrasonic technology in oral-maxillo-facial surgery, plastic surgery, neurosurgery, and otolaryngology-head and neck surgery. Ultrasound is a cyclic sound pressure with a frequency greater than the upper limit of human hearing, typically 20,000 Hz and above. Using an ultrasonic frequency, these devices transfer their mechanical energy to the molecules in tissue causing them to deform. This process is termed piezoelectric effect, with piezooriginating from Greek, meaning ‘‘to squeeze or press.’’ Along the ultrasonic spectrum, low-frequencies have a selectivity for densely packed, mineralized tissue while higherfrequencies (i.e., Harmonic scalpel) have a propensity for separating soft-tissue. The widespread adaptation of the low-frequency ultrasonic technology is secondary to its minimal learning curve, improved tactile control compared to oscillating saws or rotating burrs, and the preservation of adjacent soft tissue. The harvesting of osteocutaneous free flaps presents a unique challenge to the reconstructive surgeon, specifically the creation of a precise osteotomy often adjacent to a flap’s vital vascular pedicle. Traditional osteotomy instruments are the oscillating saw and rotational burr, which produce considerable vibration and torque respectively. Case reports do exist of flap complications secondary to soft tissue damage, while dissecting the flap’s pedicle and creating osteotomies. Although rare and likely underreported, involuntary injury to critical perforators among all free flap types has been reported at 1.5%. In addition to tactile control and soft tissue protection, surgical reports indicate that low-frequency ultrasonic technology has reduced osteotomy blood loss and bone necrosis compared to traditional osteotomy methods. There have been very few reports of this technology being used for osteocutaneous free flaps, in which the above features would provide a distinct advantage. The Misonix BoneScalpel Ultrasonic Osteotome is a piezoelectric device that offers a low-frequency ultrasonic energy selective to mineralized tissue. Working at 22.5 kHz (22,500 strokes per second), it has disposable blades that can produce a precise linear osteotomy as thin as 0.5 mm, and with an insertion depth up to 20 mm. With these factors in mind, we sought to characterize how the BoneScalpel Ultrasonic Osteotome may benefit the harvesting of different osteocutaneous free flaps used to reconstruct bony defects. The goal of this preliminary report is to describe a future role of piezoelectric technology in the setting of osteocutaneous free-flap osteotomies.

Endoscopic Infracochlear Approach for Drainage of Petrous Apex Cholesterol Granulomas: A Case Series.

OBJECTIVE To describe the feasibility and technical nuances of a transcanal endoscopic infracochlear approach for drainage of petrous apex cholesterol granulomas. STUDY DESIGN Retrospective case review. SETTING Tertiary care university hospital. PATIENTS A 32-year-old man with bilateral petrous apex cholesterol granulomas and a 54-year-old man with a left-sided petrous apex granuloma each with symptoms necessitating surgical intervention. INTERVENTIONS Transcanal endoscopic infracochlear approach for drainage of the cholesterol granulomas. MAIN OUTCOME MEASURES Operation efficacy, corridor size, and perioperative morbidity. RESULTS All three cholesterol granulomas were successful drained without violating the cochlea, jugular bulb, or carotid artery. The dimensions of the infracochlear surgical corridor measured 5 mm × 6 mm, 3.5 mm × 3.5 mm, and 6 mm × 4 mm, respectively. All corridors facilitated visualization within the cyst and allowed lyses of adhesions for additional cyst content eradication. All patients had resolution of their acute symptoms. Two of the three subjects had serviceable hearing before and after their procedures. One patient required revision surgery 2-months after their initial procedure secondary to recurrent symptoms from acute hemorrhage within the cyst cavity. The infracochlear tract in this patient was noted to be patent. CONCLUSIONS A transcanal endoscopic infracochlear approach is feasible for the management of cholesterol granuloma. The surgical access was wide enough to introduce the endoscope into the petrous apex cavity in each case. Further studies are needed to compare the efficacy and perioperative morbidity versus the traditional postauricular transtemporal approaches.

Contemporary management of carotid blowout syndrome utilizing endovascular techniques

To illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS).