Christopher G. Larsen

Esthesioneuroblastoma: endoscopic nasal and anterior craniotomy resection.

Objectives/Hypothesis The objective was to illustrate the use of endoscopic techniques as an evolving surgical modality in excision of esthesioneuroblastoma. The authors advocate this method with excision with anterior craniotomy for removal of cribriform plate or anterior cranial fossa tumor extension.

Endoscopic techniques in resection of anterior skull base/paranasal sinus malignancies.

Objective: The objective of this study was to examine the role of endoscopic approaches to the resection of anterior skull base and paranasal sinus malignancies at one tertiary care medical center.

Salivary endoscopy in a pediatric patient with HLA-B27 seropositivity and recurrent submandibular sialadenitis☆

Patients with human leukocyte antigen (HLA)-B27 seropositivity have a genetic predisposition to form spondyloarthropathies, especially ankylosing spondylitis. Other related inflammatory or autoimmune disorders include reactive arthritis, uveitis, psoriatic arthritis, and Crohns disease. Although juvenile recurrent parotitis is not uncommon, recurrent submandibular sialadenitis is rare in pediatric patients. Sialadenitis is typically caused by salivary stones, infection, or duct stricture. To our knowledge, there has not been report of HLA-B27 positivity and recurrent sialadenitis described previously. We describe a patient with HLA-B27 seropositivity and multiple episodes of left submandibular sialadenitis who underwent diagnostic and therapeutic sialendoscopy. Previous treatment included antibiotics, sialogogues, warm compresses, and hydration before he underwent definitive sialendoscopy treatment at a tertiary care medical center. Salivary endoscopy showed salivary stasis and sludging within the left submandibular gland duct, with no salivary stones. Topical steroid was applied to the duct. At one year following his surgery, he has not had any recurrent episodes of sialadenitis. HLA-B27 seropositivity is associated with many inflammatory disorders; we report a case in which the patient had coexisting recurrent sialadenitis. In the pediatric population, sialadenitis is traditionally managed with antibiotics and supportive care, however our patient underwent salivary endoscopy. Sialendoscopy is an emerging modality that potentially avoids radiation exposure from CT or sialography and should be considered as another preferred treatment option. More investigation is required to prove a possible correlation between existing HLA-B27 and the propensity to develop this clinical problem.

Histoplasmosis presenting as upper airway obstruction.

Once considered a rare disease, histoplasmosis is now one of the most common endemic mycotic diseases in the United States, especially in the Ohio and Mississippi River Valleys and the Central United States. Clinical manifestations of histoplasmosis infection are usually seen in immunocompromised hosts. Disease severity may range from fulminate multi-organ disease to single mucosal ulcers. Head and neck manifestations of disseminated histoplasmosis are not uncommon and include oropharyngeal nodules and ulceration. In this case report we discuss an unusual presentation of a laryngeal histoplasmosis lesion masquerading as an ulcerative supraglottic mass and subacute life-threatening upperairway obstruction. Although the otolaryngeal manifestations of histoplasmosis are well described, there were no case reports of subacute airway obstruction identified in our literature review.

Pediatric Salivary Disorders

Pediatric sialadenitis accounts for up to 10% of all salivary gland pathology and is most commonly in the parotid gland. Many factors contribute to salivary gland disease in children such as viral parotitis and juvenile recurrent parotitis being the two most common. Other etiologies include bacterial infections, congenital or traumatic duct obstruction, autoimmune disease, and genetic defects. Viral sialadenitis is most commonly due to paramyxovirus. However, clinicians must distinguish this from a mumps infection in order to monitor for systemic complications. Juvenile recurrent parotitis is typically biphasic in age distribution, occurring between ages 2–6 and at the start of puberty. This is a clinical diagnosis aided with the use of ultrasonography, and patients must have a minimum of two episodes to be diagnosed. The specific etiology is not completely understood, although may be linked to immune deficiency, genetics, or allergy. Bacterial sialadenitis primarily occurs in children younger than 2 months and is distinguished from other diseases of the salivary gland by the presence of pus. The most common bacterial etiology is Staphylococcus areas. Progression to abscess formation, although rare, should be evaluated with ultrasound as this can lead to respiratory compromise. If an abscess is nonresponsive to antimicrobials and remains chronic, mycobacterial infection should be ruled out. Finally, salivary stones occur most frequently in the submandibular gland, are diagnosed via ultrasound, and can be successfully removed with sialendoscopy in pediatric patients.

Hypoglossal nerve stimulation for obstructive sleep apnoea in a patient with previous tongue laceration

Upper airway stimulation of the tongue using an implantable neurostimulator has recently been approved for select patients with moderate to severe obstructive sleep apnoea (OSA) and intolerance to continuous positive airway pressure therapy. Effective implantation depends on the integrity of the hypoglossal nerve as well as the tongue musculature, notably the genioglossus. Prior trauma to either of these structures may be viewed as a relative contraindication to implantation. We describe a case of successful right hypoglossal nerve implantation in a patient with a history of left cardiac pacemaker placement and severe left penetrating tongue trauma with decreased mobility from contracture and deviation mimicking a hypoglossal nerve palsy. Preoperative and postoperative apnoea–hypopnoea index values were 52/hour and 5/hour, respectively. Prior soft tissue trauma to the tongue may not necessarily preclude surgical candidacy for upper airway stimulation in patients with OSA.

Steroid Versus Antibiotic Drops in the Prevention of Postoperative Myringotomy Tube Complications

Objectives: To determine the incidence of early postoperative tympanostomy tube insertion otorrhea and obstruction in pediatric patients receiving antibiotic ear drops with or without steroid perioperatively. Methods: A retrospective chart review was performed on patients who underwent outpatient myringotomy and tube placement. Patients from June 2013 to February 2014 received ciprofloxacin/dexamethasone perioperatively while patients from May 2014 to April 2015 received ofloxacin. Statistical analysis was performed to compare outcomes between the cohorts. Results: One hundred thirty-four patients received topical ciprofloxacin/dexamethasone, and 116 patients received topical ofloxacin. The rate of postoperative otorrhea was 5.2% for the ciprofloxacin/dexamethasone group and 8.2% for the ofloxacin group. Tube obstruction was seen in 6.0% of the ciprofloxacin/dexamethasone group and 5.2% in the ofloxacin group. Neither outcome had a statistically significant difference (P = .21 and .85, respectively). There was no difference in the rate of effusion at the time of tube placement between the 2 cohorts (P = .16), and this included subgroup analysis based on effusion type (mucoid, purulent, serous). Patients with a mucoid effusion at the time of surgery were more likely to experience otorrhea/obstruction than patients with dry ears (odds ratio = 2.23, P = .02). Conclusion: No significant difference in the incidence of immediate postoperative tympanostomy tube otorrhea or obstruction was seen between the antibiotic-steroid and antibiotic alone cohorts, regardless of effusion type. Overall, patients with mucoid effusions are more likely to develop tube otorrhea or obstruction at follow-up. Cost-effective drops should be used when prescribing topical therapy to prevent complications after ear tubes.

Tinnitus perception in patients after vagal nerve stimulator implantation for epilepsy

PURPOSE Vagal nerve stimulation in conjunction with sound therapy has been proposed as a treatment for subjective tinnitus. The purpose of this study is to retrospectively review the effect of VNS on perception of tinnitus in epilepsy patients. We explore the incidence of tinnitus and its perceived reduction in patients requiring implantation of VNS for medically refractory seizures. MATERIALS AND METHODS A phone survey was conducted in adult patients with prior VNS implantation. A questionnaire including the visual analog scale (VAS) of tinnitus loudness was used to determine the presence and severity of tinnitus. RESULTS Out of the 56 patients who had completed the phone survey, 20 (35%) reported the presence of pre-operative tinnitus. The tinnitus positive group was significantly older (p = 0.019). Of the 20 pre-operative tinnitus positive patients, all patients continued to have tinnitus post-operatively. Four (20%) noted no changes in VAS of tinnitus loudness while 16 (80%) had at least a one-point decrease. The mean difference between pre- and post-operative VAS of loudness was 2.05, with a standard deviation of 1.84 and this was statistically significant (p < 0.001). CONCLUSIONS In this study, we evaluate the potential of vagal nerve stimulation to alter the perception of tinnitus in patients with refractory epilepsy. Eighty percent of patients noted some level of subjective tinnitus improvement after VNS implantation. Given this finding, there may be a potential additional benefit to the use of VNS in patients with epilepsy.

Upper Airway Surgery for the Treatment of Obstructive Sleep Apnea: Surgical Outcomes and the Effect on CPAP

Objective: 1) Elucidate the efficacy of upperairway surgery for the treatment of obstructive sleep apnea/hypopnea syndrome(OSAHS). 2) Observe the change in polysomnography, continuous positive airway pressure (CPAP) therapy, and sleepiness following upper airway surgical intervention. 3) Objectively measure CPAP compliance using smart card CPAP devices. Method: Surgical and clinical records were reviewed on patients (N =51) who underwent upper airway surgery for the treatment of moderate-severe OSAHS from January 2008 to June 2010 at an urban tertiary-care center. Outcome measurements recorded pre and postoperatively include BMI, Epworth sleepiness score, CPAP settings and compliance, and polysomnography. Results: Data was collected and is currently undergoing analysis in a collaborative effort between the otolaryngology and pulmonology departments at our tertiary care center. A unique requirement for this study is the use of smart card CPAP devices on all patients allowing an objective measure of CPAP compliance. All patients underwent traditional uvulopalatopharyngoplasty (UPPP), lateral pharyngoplasty or expansion sphincter pharyngoplasty. Additionally, patients underwent turbinate reduction (N = 29), septoplasty (N = 20) and base of tongue reduction (N = 16). Initial analysis indicates a significant improvement in polysomnographic data and CPAP compliance. There does not appear to be problems associated with air-leak postoperatively. Conclusion: Mucosa-sparing pharyngoplasty and multilevel upper airway surgery are effective treatment options for moderate-severe OSAHS. These surgical interventions can significantly reduce CPAP pressure settings and improve CPAP compliance. All patients undergoing CPAP therapy should be required to use smart card devices in order to objectively measure compliance.

S186 – Necessity of Drain Placement for Thyroplasty

Objectives Review the complication rate and drain output characteristics during the immediate postoperative period for open thyroplasty via anterior neck approach with drain placement. Methods A retrospective cohort review of patients requiring open thyroplasty at 2 academic medical centers in the Midwestern United States between 1/1/1997 and 6/30/2007. Charts of patients receiving a thyroplasty were selected by CPT code and reviewed for rates of postoperative hemorrhage, hematoma formation, seroma formation, and upper airway compromise. Drain output quantities were examined, where available. Results Charts of 107 patients and 112 total procedures were reviewed. 18 procedures were excluded from this series due to simultaneous performance of other procedures. One (1/94) patient developed postoperative hematoma with upper airway obstruction. Hematoma evacuation was performed and the patient was subsequently discharged in stable condition. Average patient age was 59.3 years. Postoperative drain output was recorded as “minimal” in 58/94 (62%) of cases. Average drain output was 17.7 mL for those which were recorded. Hospital stay was less than 24-hours for 89/94 (95%) of cases. Conclusions In this series, patients having undergone open thyroplasty have had little to no drain output prior to the discontinuation of the drain. This, as well as the low rate of overall complication associated with this procedure, would support the opinion that such drains may be unnecessary in these cases.