Christopher T. Wootten

Management of Cerebrospinal Fluid Leakage From Cochleostomy During Cochlear Implant Surgery

Objectives: The objectives of this retrospective review were to determine the incidence of cerebrospinal fluid (CSF) otorrhea from the cochleostomy during cochlear implant surgery, to recognize patients at risk, and to determine the appropriate preoperative, postoperative and intraoperative management.

Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea

OBJECTIVES In this study we determine the subjective and objective outcomes of pediatric patients with refractory OSA undergoing drug-induced sleep endoscopy (DISE)-directed surgical treatment. METHODS 31 consecutive children with OSA following TA underwent DISE. 26 completed DISE-directed operative management of the level(s) of ongoing upper airway obstruction. Pre- and postoperative OSA were assessed through a detailed history (of nighttime symptoms (NS) and daytime symptoms (DS)), physical examination, and polysomnography. RESULTS Age ranged 5-18 years (mean 9.7 ± 3.4). Fourteen of 26 had trisomy 21 (51%). Operations were performed in the following frequencies: lingual tonsillectomy (LT) (22), midline posterior glossectomy (MPG) (16), revision adenoidectomy (11), inferior turbinate submucosal resection (7), uvulopalatoplasty (2), and supraglottoplasty (2). Overall, 92% reported subjective improvement. NS improved from 5.8 ± 2.9 preoperatively to 2.1 ± 2.5 postoperatively (p<0.05), while DS improved from 2.1 ± 1.3 preoperatively to 0.6 ± 1.1 postoperatively (p<0.05). Seventeen patients completed preoperative polysomnography, while only 11 of them also completed postoperative polysomnography. Mean OAHI fell from 7.0 (±5.8) events/hr to 3.6 (±1.8) events/hr (t-test, p=0.09). CONCLUSIONS Individualized, multilevel, DISE-directed operative therapy was associated with substantial improvement in subjective measures of sleep.

Evolving Therapies to Treat Retroglossal and Base-of-Tongue Obstruction in Pediatric Obstructive Sleep Apnea

OBJECTIVE To describe our experience treating retroglossal and base-of-tongue collapse in children and young adults with obstructive sleep apnea using combined genioglossus advancement (Repose THS; MedtronicENT, Jacksonville, Florida) and radiofrequency ablation of the tongue base. DESIGN Retrospective institutional review board-approved analysis of 31 operations. SETTING Tertiary pediatric medical center. PATIENTS Thirty-one patients with a mean age of 11.5 years (age range, 3.1-23.0 years). INTERVENTIONS Combined genioglossus advancement and radiofrequency ablation. MAIN OUTCOME MEASURES Preoperative and postoperative polysomnographic data were evaluated for each patient. Success of surgery was determined using the criteria of a postoperative apnea-hypopnea index of 5 or fewer events per hour, without evidence of hypoxemia (oxygen saturation as measured by pulse oximetry), and without prolonged hypercarbia (end-tidal carbon dioxide). RESULTS Thirty-one patients who underwent genioglossus advancement were analyzed. Nineteen (61%) had Down syndrome. The overall success rate was 61% (19 of 31) (58% [12 of 19] success among patients with Down syndrome and 66% [7 of 12] success among patients without Down syndrome). Overall, the mean apnea-hypopnea index improved from 14.1 to 6.4 events per hour (P < .001); the mean nadir oxygen saturation as measured by pulse oximetry during apnea improved from 87.4% to 90.9% (P = .07). CONCLUSIONS Pediatric obstructive sleep apnea refractory to adenotonsillectomy that is due to retroglossal and base-of-tongue collapse remains difficult to treat. However, most patients in this analysis benefited from combined genioglossus advancement and radiofrequency ablation.

Management of brain herniation and cerebrospinal fluid leak in revision chronic ear surgery.

Objectives/Hypothesis: Brain herniation and cerebrospinal fluid (CSF) leakage into the middle ear and mastoid are rare but described complications of chronic ear disease. This paper will discuss the presentation and management of brain herniation and/or CSF leak encountered in revision chronic ear surgery.

Disease homogeneity and treatment heterogeneity in idiopathic subglottic stenosis

Idiopathic subglottic stenosis (iSGS) is a rare and potentially life‐threatening disease marked by recurrent and progressive airway obstruction frequently requiring repeated surgery to stabilize the airway. Unknown etiology and low disease prevalence have limited the ability to characterize the natural history of iSGS and resulted in variability in surgical management. It is uncertain how this variation relates to clinical outcomes.

Prevention of pressure ulcers after pediatric tracheotomy using a Mepilex Ag dressing

Skin irritation and ulceration beneath the tracheostomy tube or ties secondary to pressure and shearing forces on the skin frequently complicate pediatric tracheotomy in the immediate postoperative period. The aim of this study is to determine the effectiveness of Mepilex Ag dressings in reducing posttracheotomy wound complications.

Spontaneous remission of primary hyperparathyroidism: a case report and meta-analysis of the literature.

In a minority of patients, primary hyperparathyroidism spontaneously remits either by autoinfarction or by hemorrhage into or around the adenoma. We describe a case of autoparathyroidectomy occurring in a 63‐year‐old man 9 years after three parathyroid glands were removed during a total thyroidectomy. This case is compared with 50 previously reported cases of autoparathyriodectomy, and a meta‐analysis is performed.

Tracheotomy in the First Year of Life: Outcomes in Term Infants, the Vanderbilt Experience

OBJECTIVE: In an era emphasizing critical care of preterm infants, we characterize the indications and outcomes of tracheotomies performed in the first year of life in term infants compared to preterm infants. METHODS: Retrospective study of 127 tracheotomies performed in the first year of life at a tertiary-care childrens hospital between 1988-2004. RESULTS: Mean gestational ages of the term and preterm groups were 38.97 and 29.71 weeks, respectively (P < 0.001). Indications for tracheotomy were upper airway abnormalities in 53% for the term group. The number of subsequent airway procedures required was 1.39 in the term group, achieving decannulation in 36.3%, with a 20.5% mortality rate. CONCLUSION: Compared to preterm infants, the term decannulation rate was favorable, as chronic lung disease was uncommon. However, non-tracheotomy-related mortalities remained high. SIGNIFICANCE: Tracheotomies are often performed for relief of upper airway obstruction, and congenital and acquired comorbidities not related to tracheotomy are associated with adverse outcomes in term infants. EBM rating: C-4 ©2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. All rights reserved.

Pediatric Endoscopic Cholesteatoma Surgery

Objectives (1) To describe and review a single center’s pediatric endoscopic cholesteatoma experience, including surgical and audiologic outcomes. (2) To assess the most common locations of residual cholesteatoma following endoscopic removal. Study Design Case series with chart review. Setting Tertiary otologic referral center. Subjects Patients <19 years of age who underwent cholesteatoma removal with either endoscopic or microscopic visualization. Methods In a comparison of patients who underwent total endoscopic ear surgery (TEES), combined endoscopic-microscopic surgery, or microscopic surgery, analyzed outcomes included locations and incidence of recurrent and residual cholesteatoma, complications, and audiometric testing. Results Sixty-six patients (mean age, 10.9 years; range, 4-18 years; 43.4% female) with 76 ears met inclusion criteria. The average overall follow-up was 18.8 months (range, 6.7-48.3). Forty-seven (61.8%) ears underwent microscopic removal of cholesteatoma; 29 (38.1%) ears underwent combined endoscopic-microscopic removal; and 8 (10.5%) ears underwent TEES removal. Significantly more mastoidectomies were completed in microscopic cases as compared with endoscopic cases (P = .049). Though second-look procedures occurred in 15 (51.7%) endoscopic cases and 10 (21.3%) microscopic cases (P = .006), the rate of residual disease was 20.0% and 40.0% in endoscopic and microscopic cases, respectively (P = .38). When controlling for preoperative hearing, only the air-bone gap for TEES demonstrated significant improvement (P = .009). No complications were noted. Conclusion The present report describes our experience with pediatric endoscopic cholesteatoma surgery, demonstrating similar hearing outcomes, rates of recurrence and residual disease, and complication rates as compared with traditional microscopic techniques.

Findings on MR Sleep Studies as Biomarkers to Predict Outcome of Genioglossus Advancement in the Treatment of Obstructive Sleep Apnea in Children and Young Adults

OBJECTIVE Genioglossus advancement, an operation to pull the tongue anteriorly, is a treatment of obstructive sleep apnea (OSA) secondary to glossoptosis. MRI predictors to identify which children will benefit from genioglossus advancement would be helpful for planning. We reviewed imaging findings on MR sleep studies as biomarkers to predict success or failure of genioglossus advancement in the treatment of OSA in children and young adults. MATERIALS AND METHODS Twenty-eight patients who had undergone genioglossus advancement and preoperative MRI were identified. For each subject, genioglossus advancement, which was performed to treat OSA, was categorized as a success or failure on the basis of polysomnography and clinical criteria. Static and dynamic cine MR sequences were retrospectively evaluated for multiple parameters including measurements of the size of the tongue and of the bony confines of the supraglottic airway, the ratio of tongue size to bony confines size, static size and dynamic changes of the retroglossal airway, tonsil size, and soft palate thickness. Radiologists were blinded to the outcome of genioglossus advancement (i.e., success or failure category). Numeric biomarkers were compared in an analysis-of-covariance model adjusting for patient age. RESULTS Genioglossus advancement was successful for the treatment of OSA in 17 patients and failed in 11 patients. The relative size of the tongue (tongue-bony confines ratio) was larger in patients with a successful surgical outcome than in those for whom the procedure failed (mean ratio, 0.51 vs 0.46; p = 0.023). Smaller adenoids were associated with a successful outcome (mean size of adenoids, 9.1 vs 12.4 mm; p = 0.049). No other biomarker-including absolute tongue size and airway size or dynamic airway motion-was significant. CONCLUSION The relative (not absolute) tongue size and small size of the adenoid tonsils on MRI were predictors of success of genioglossus advancement for the treatment of glossoptosis causing OSA. These findings may be helpful in guiding surgical decision making in children with OSA.