Catherine K. Hart

Olfactory changes after endoscopic pituitary tumor resection.

OBJECTIVES: Given that the transnasal endoscopic approach to the sella involves resection of anatomical structures known to contain olfactory neuroepithelium, the effect of this approach on olfaction was evaluated. STUDY DESIGN: Case series with planned data collection. SETTING: Single tertiary care institution. SUBJECTS AND METHODS: Adults diagnosed with a pituitary mass and scheduled to undergo transnasal endoscopic resection underwent preoperative olfactory evaluation using the University of Pennsylvania Smell Identification Test (UPSIT). Repeat testing was performed at one and three months postoperatively. Paired Student t tests were used to compare preoperative and postoperative scores. RESULTS: A total of 57 consecutive patients were enrolled. Fifty patients (24 males, 26 females) completed olfactory evaluation at one month. Forty-five (23 males, 22 females) completed a three-month evaluation. The average UPSIT score (out of 40) was 31.8 preoperatively, 30.5 at one month, and 32.6 at three months. A significant difference was found between preoperative and one-month scores (P = 0.01) but not three-month scores (P = 0.08). CONCLUSION: A transient difference was found between preoperative and one month UPSIT scores. At three months, no clinically significant difference was found on repeat olfactory testing. Although the transnasal endoscopic approach to the sella removes structures known to contribute to olfactory function, it has no clinically significant effect on olfaction.

Anatomy of the optic canal: a computed tomography study of endoscopic nerve decompression.

Objectives: Endoscopic optic nerve decompression has variable success rates. Our goal was to further delineate the radiographic anatomy of the optic canal to determine whether the variable success can be explained on anatomic principles. Methods: The optic canal dimensions and the degree of optic canal exposure to the sphenoid sinus were measured on sinus computed tomography images of 96 patients. Results: A total of 191 optic canals were analyzed (111 female subjects and 80 male subjects). The average medial canal wall length was 1.48 cm (range, 0.7 to 2.3 cm). The length in male subjects was 1.61 cm (range, 1.1 to 2.3 cm), as compared to 1.39 cm (range, 0.7 to 2.0 cm) in female subjects (p < 0.001). Onodi cells and pneumatized anterior clinoid processes were present on 14 and 16 images, respectively. The average degree of exposure of the optic canal to the sphenoid sinus in optic canals without Onodi cells or clinoid pneumatization was 99.3°, and in optic canals with both Onodi cells and clinoid pneumatization it was 117.7°. The potential area of canal exposed was 0.66 cm2, or 28% of the total surface area. Conclusions: A wide variation in medial canal wall length and exposure of the optic canal to the sphenoid sinus exists on computed tomography images. Variation in medial canal wall length and optic canal exposure may limit the surface area of nerve available for endoscopic optic nerve decompression.

Endoscopic anatomy of the petrous segment of the internal carotid artery.

Background Exposure of the petrous (C2) segment of the internal carotid artery (ICA; petrous carotid) is necessary to treat lesions that have spread from the intracranial space or adjacent sinonasal region. Recent advancements in endonasal-endoscopic approaches to the anterior skull base raise the possibility of extending these approaches beyond the sinonasal cavity. In this cadaveric study, we evaluate the feasibility and extent of exposure of the petrous carotid artery via a combined endoscopic endonasal approach. Methods Endoscopic dissection was performed in four formalin-fixed cadaver heads (eight sides). An endoscopic, endonasal, transmaxillary approach was used to identify the cervical and petrous carotid artery. Results With the endoscopic endonasal, Caldwell-Luc approach, we could visualize the ventral petrous bone after dissecting the contents of the pterygopalatine fossa and infratemporal fossa. Careful dissection allowed exposure of the petrous carotid artery from the upper cervical carotid to the foramen lacerum. Conclusion In this cadaveric study using an endoscopic endonasal approach for exposure of the petrous carotid artery, combination with the transmaxillary-transpterygopalatine-transinfratemporal approaches permitted exposure of the ventral portion of the artery. The anatomy presented will assist experienced endoscopic skull base surgeons in the removal of lesions involving the ventral skull base.

Computed Tomography Anatomy of the Optic Canal

Objective (1) Analyze the radiographic anatomy of the optic canal in relationship to the sphenoid sinus. (2) Understand the role variation in optic canal anatomy may have in the variability of outcomes in optic nerve decompression. Methods Fine cut computed tomography images of the sinuses were obtained with an IRB waiver. Optic canal dimensions were measured on sinus computed tomography images of 96 patients. 191 optic canals were analyzed (111 females, 80 males). Student T-test calculations were performed for statistical analysis on computer software. Results The average medial canal wall length was 1.48 centimeters (range 0.7–2.3). The length in males was 1.61 centimeters (1.1–2.3) as compared to 1.39 centimeters (0.7–2.0) in females (p=8.0–7). The average degree of exposure of the optic canal exposed to the sphenoid sinus was 101.3 degrees (56–176). The degree of exposure was 105.6 in males versus 98.2 in females (p=.01). The potential area of canal exposed to the sphenoid sinus was 0.66 centimeters squared or 28% of the total surface area. The potential area exposed to the sphenoid sinus in males was 0.76cm2 (28%) and 0.58 centimeters squared (27%) in females. Conclusions A wide range in medial canal wall length and exposure of the bony optic canal to the sphenoid sinus exists on CT images. The variation in medial canal wall length and in optic canal exposure to the sphenoid sinus may contribute to the variability in success rates of endoscopic optic nerve decompression for optic neuropathy.

Short- versus Long-term Stenting in Children with Subglottic Stenosis Undergoing Laryngotracheal Reconstruction:

Objectives Suprastomal stents are routinely used in laryngotracheal reconstruction (LTR) to stabilize grafts and provide framework to sites of repair. However, the duration of stenting varies according to patient history and physician preference. We examined outcomes of short- versus long-term stenting in children with subglottic stenosis (SGS) undergoing LTR. Study Design Case series with chart review. Setting Tertiary care pediatric hospital. Subjects and Methods Thirty-six children <18 years old who underwent double-stage LTR for SGS from January 2012 to January 2015 were included. Demographic data, stenosis grade, and decannulation rates were compared between children with short-term stenting (≤21 days; n = 14) and those with long-term stenting (>21 days; n = 22). Results No significant difference between groups was seen for sex, age, race, or previous repair. Children in the short-term group were stented for 10.9 ± 4.9 days, compared with 44.0 ± 10.6 for those long-term (P < .0001). A similar number of children with short- versus long-term stents had grade 3/4 stenosis preoperatively (71.4% vs 77.2%). Although time to decannulation was not significantly different, 72.7% of children with long-term stents were decannulated, as opposed to 35.7% with short-term stents (P = .03). After adjusting for grade at surgery and age, children with long-term stents had 4.3 greater odds (95% CI, 1.0-18.3) of decannulation than children with short-term stents. Conclusions Children with long-term stenting were more likely to be successfully decannulated. Although long-term stenting improved outcomes for children with SGS, additional research is needed to better define ideal candidates for short- versus long-term stenting.

Posttonsillectomy Hemorrhage in a Pediatric Jehovah’s Witness and the Decision to Transfuse:

A 7-year-old male presented for adenotonsillectomy for chronic tonsillitis. The family was Spanish speaking and Jehovah’s Witness, and a specific request to avoid blood transfusions was made. Adenotonsillectomy was performed as an outpatient without event. On postoperative day (POD) 1, the patient presented to the emergency department (ED) with hematemesis. The patient was taken to the operating room (OR) for control of pharyngeal bleeding. Intraoperative blood loss was 400 mL, and he was transferred to the intensive care unit (ICU) intubated. Postoperative hemoglobin was 5.8 g/dL, with normal coagulation profiles. Hematology was consulted, and iron and transexamic acid were started. Discussion was made with the family and the Jehovah’s Witness liaison committee regarding recommendation for transfusion, which the family refused. On POD 2, the patient required an additional OR trip for hemorrhage control with a postoperative hemoglobin of 5.2 g/dL. The patient had another bleeding event on POD 5 and again went to the OR. Hemoglobin was 5.3 g/dL, and after difficulty controlling the hemorrhage, the anesthesiologist and the otolaryngologist jointly decided to administer 3 units of packed red blood cells to the child. The hemorrhage was controlled, and postoperatively, the child had a hemoglobin of 15.9 g/dL with no additional bleeding. The Cincinnati Children’s Hospital Medical Center IRB exempted this case report from review.

Development of a survival animal model for subglottic stenosis: Survival Animal Model for Subglottic Stenosis

To develop a reproducible survival animal model for subglottic stenosis.

To transfuse or not to transfuse? Jehovah's Witnesses and postoperative hemorrhage in pediatric otolaryngology

OBJECTIVESnDiscuss the ethical issues in the management of postoperative hemorrhage in pediatric patients whose parents are Jehovahs Witnesses (JW) and 2) Describe a framework for shared decision making in this population.nnnMETHODSnA recall review of pediatric otolaryngology patients with parents of the JW faith and postoperative hemorrhage was performed over a year long period at a single institution. The literature on transfusions for JW minors was reviewed.nnnRESULTSnTwo patients were identified. The first patient had a severe post-tonsillectomy hemorrhage requiring multiple emergency operative interventions. The child developed a hemoglobin of 5.2u202fg/dl and received an emergent transfusion against parents wishes. The child subsequently did not require further intervention. The second patient hemorrhaged after a supraglottoplasty and was administered erythropoietin and iron infusion but did not require transfusion (hemoglobin nadir 7.9u202fg/dl). In both cases hematology was consulted, and extensive discussion with the families and the JW Hospital Liaison Committee occurred.nnnCONCLUSIONSnThe risks of hemorrhage should be discussed with JW parents of patients undergoing even routine otolaryngologic surgery. In these cases, early shared decision making with family, the JW Hospital Liaison committee, and hematology was pursued regarding mutually acceptable interventions. Aggressive non-transfusion based resuscitation was carried out to minimize the likelihood of transfusion. In the first case, danger to the patients life eventually necessitated transfusion in accordance with the patients best interest and previous case law. A defined framework involving all stake-holders, including Pastoral Care, in the event of postoperative hemorrhage is critical.

Association of Reduced Delay in Care With a Dedicated Operating Room in Pediatric Otolaryngology

Importance Obtaining sufficient operating room time for inpatient consults requiring an operative intervention is a persistent challenge for otolaryngologists. Objective To examine the institution of an otolaryngology-specific operating room (OR) for unscheduled (add-on) cases for its association with time from initial consultation to surgery and, secondarily, to determine utilization of a dedicated block of time. Design, Setting, and Participants Retrospective review of medical records of a tertiary care pediatric hospital for patients treated between January 1, 2015, and March 31, 2016; analysis was concluded by June 2016. Included were all patients undergoing inpatient otolaryngology consultations who required nonemergency operative procedures. Interventions In August 2015, a once-weekly 5-hour block of OR time dedicated to inpatient otolaryngology consults was instituted. Prior to this, cases were placed on an add-on list shared between all surgical services. Main Outcomes and Measures It was hypothesized that institution of a dedicated block of OR time would decrease the time from initial consultation to operative intervention and would be utilized at a high rate. Operating room utilization was calculated by dividing scheduled OR time by actual OR time utilized. Time from initial consultation to OR intervention was compared before and after the institution of the dedicated OR block. Results A total of 316 inpatient add-on pediatric cases (including 108 patients from the intensive care unit [ICU]) were scheduled during the study period. The most common cases were microlaryngoscopy/bronchoscopy (79%) and tracheostomy (8%). Mean (SD) time between consultation and OR intervention was 7.8 (1.6) days prior to establishing the add-on OR and 4.4 (1.3) days after it was established (absolute difference of 3.4 days; 95% CI, 3.1-3.7 days). Mean (SD) time between consultation and OR intervention was 7.4 (5.0) days for ICU patients prior to intervention and 5.6 (3.0) days after intervention (absolute difference of 1.8 days; 95% CI, 1.6-2.0 days). Total utilization of the OR block time was 74%, and adjusted utilization was 86%. There was a 15% drop in the number of unscheduled add-on cases after the intervention (from 10 cases/mo to 8.5 cases/mo; absolute difference of 1.5 cases; 95% CI, 1.1-1.9 cases). Conclusions and Relevance Instituting a dedicated otolaryngology add-on OR was associated with significantly reduced time between initial consultation and operative care, by approximately 3 days, decreased the number of unscheduled add-on cases, and was utilized at a high level.

A randomized controlled trial of Velcro versus standard twill ties following pediatric tracheotomy

Tracheotomy is a common procedure. A reliable method of securing the tracheotomy tube is essential to minimize accidental decannulation. However, skin breakdown has been reported in ∼30% of patients. We sought to evaluate rates of skin‐related complications and accidental decannulation with the use of Velcro ties compared to twill ties.