Courtney B. Shires

Body mass index as an indicator of obstructive sleep apnea in pediatric Down syndrome

OBJECTIVE Our objective was to determine if higher body mass index (BMI) increases the likelihood of, obstructive sleep apnea (OSA) in pediatric Down syndrome (DS) patients. METHODS We performed a, retrospective chart review of 63 DS patients evaluated by overnight polysomnography from December 1995 to February 2005. Patients aged less than 2 years were excluded. Remaining patients were grouped, according to presence (n=19) or absence (n=33) of OSA based on apnea hypopnea index (AHI). OSA, and non-OSA DS groups were age matched while blinded to patient attributes other than age and OSA, status. Patients without appropriate age matches were excluded. We recorded various patient information, including age, sex, height, weight, number of apneas, number of hypopneas, respiratory distress index (RDI), apnea-hypopnea index (AHI), lowest oxygen saturation during sleep, mean oxygen saturation, number of arousals per hour, and mean time spent in REM sleep. We calculated BMI using the, standard kg/m(2) formula and converted this into a Z-score. RESULTS Fifty-two DS patients were analyzed with average age of 9.3+/-4.5 years (10.2+/-4.2 in 33 OSA patients, 7.8+/-4.3 in 19 non-OSA patients). There were 28 males and 24 females. The OSA group mean BMI Z-score was 2.09+/-0.94, and the non-OSA group Z-score was 1.4+/-1.40. The Z-scores for BMI were statistically significant between OSA and non-OSA patients with p=0.03 by t-test. CONCLUSIONS When age and sex adjusted, BMI has a statistically significant association with the presence of OSA in Down syndrome patients. The incidence of OSA also increases with increasing age in this population.

Management of suprastomal tracheal fibroma: Introduction of a new technique and comparison with other techniques

OBJECTIVE Suprastomal tracheal granuloma/fibroma (SSTGF) is a common cause of failure to decannulate following pediatric tracheostomy. Because larger lesions obstruct the trachea, it is necessary to remove them prior to decannulation. Various methods have been described for the management of these obstructing tracheal lesions, including the KTP laser, Nd-YAG laser, sphenoid punch, optical forceps, microsuspension laryngoscopy with an articulated arm (MSLAA), and external excision. A hollow core guide fiber for the CO(2) laser has been developed that can be advanced to better approximate targeted tissues and minimize thermal spread using a near-contact method. METHODS A retrospective chart review was performed of 30 children under the age of 7 years (21M, 9F) with SSTGF who underwent treatment by either external excision (n=10), MSLAA (n=10), or CO(2) laser vaporization by fiberoptic laser carrier (n=10). The medical charts were reviewed for excision techniques and outcomes. RESULTS Mean operative time for external excision was 34.9min (SD=10.2min), for MSLAA was 16.3min (SD=4.8min), and for fiberoptic CO(2) laser carrier was 19.3min (SD=7.1min). Mean hospital time postoperatively for external excision was 24h (SD=510min), for MSLAA was 3.3h (SD=37.7min), and for fiberoptic CO(2) laser carrier was 3.9h (SD=46.3min). Need for additional procedures was seen in 60% of external excision procedures, 70% of MSLAA procedures, and in 30% of fiberoptic CO(2) laser carrier procedures. Immediate postoperative decannulation was possible in 10% of the external excision group, 20% of the MSLAA group, and 40% of the fiberoptic CO(2) laser carrier group. CONCLUSIONS The new technique of using a fiberoptic carrier for the CO(2) laser to treat children with SSTGFs is comparable to more traditional techniques of SSTGF removal when considering the need for additional procedures, postoperative hospital stay, and percentage of immediate postoperative decannulation and provides another useful tool in the armamentarium of the surgeon in treating SSTGFs.

Sphenopalatine Artery Ligation A Cadaver Anatomic Study

Objective. To clarify endoscopic anatomy of the sphenopalatine artery (SPA) in relation to intranasal endoscopic landmarks using a human cadaver model and to simplify the surgical approach to SPA ligation. Study Design. Prospective anatomic study from November to December 2009. Setting. University of Tennessee Health Science Center Gross Anatomy Lab. Subjects. Fifty human cadaveric sagittally sectioned heads. Methods. The cadaveric nasal cavities were examined using a 0° endoscope, and the SPA and foramen were identified. The number of nasal cavities in which a transnasal approach successfully revealed the SPA foramen was compared with those that required maxillary antrostomy. The distance from the posterior edge of the maxillary natural ostium to the anterior edge of the SPA foramen was measured. Results. Successful ligation of the SPA via a lateral nasal wall incision was achieved in 45 of 50 specimens (90%). The mean distance from the posterior edge of the maxillary natural ostium to the anterior edge of the SPA foramen was 23.79 mm (95% confidence interval, 22.03-25.55). Conclusion. The method of performing SPA ligation via lateral nasal wall incision alone was successful in 90% of human cadaveric heads. Maxillary antrostomy revealed the SPA in the remainder. No specimen required uncinectomy. The mean distance from the maxillary natural ostium to SPA foramen was more than 2 cm. The routine use of maxillary antrostomy and uncinectomy is not needed to locate the SPA in most nasal cavities and moreover produces unnecessary mucosal trauma in the often medically fragile or coagulopathic patient.

Lower Face-Lift with Extensive Neck Recontouring

Difficult anatomy and advanced aging continue to pose a challenge to the face-lift surgeon. We present a thorough analysis of the patient with respect to relevant vascular anatomy, as well as our techniques used to address advanced cases, including compartment communication and submental suspension platysmaplasty.

Chemical face peeling.

Chemexfoliation is an excellent method to reduce facial rhytids. For 25 years, we have used the traditional formula as described by T. J. Baker but with a moist healing technique rather than a tape mask. We have found the peel to be inexpensive and easy to perform, with results that are excellent and consistent, with minimal side effects.

Histopathological and Postoperative Behavioral Comparison of Rodent Oral Tongue Resection Fiber-Enabled CO2 Laser versus Electrocautery

Objective To compare operative time and hemostasis of fiber-enabled CO2 laser (FECL) energy to that of the electrocautery (EC) technique for oral tongue resection, to compare return to oral intake and preoperative weight after FECL and EC resection, and to compare histologic changes in adjacent tissue after FECL and EC resection. Study Design Prospective animal study. Setting Research laboratory. Subjects and Methods The CO2 laser fiber and the Bovie cautery were each used to resect the anterior tongue in 15 adult rats. Fixative perfusion and killing were performed on postoperative day 0 (n = 10), 3 (n = 10), or 7 (n = 10). Body weight, food intake, and water intake were recorded daily for 3- and 7-day survival rats. After preparation for histologic analysis, the tongue tissue was graded with a mucosal wound-healing scale (MWHS). Results A higher incidence of intraoperative bleeding and shorter operative times were noted in the EC group. No statistically significant difference in postoperative food or water intake between the EC and FECL groups was noted. The FECL group returned to baseline weight by postoperative day 6. MWHS scores were lower in the EC group by postoperative day 3 and lower in the FECL group by postoperative day 7. Conclusions Both EC and FECL are effective for resection of the tongue in rats. EC has the advantage of shorter operative time and lower MWHS scores by postoperative day 3; FECL has the advantages of less intraoperative bleeding, faster return to baseline body weight, and lower MWHS score by postoperative day 7.

Effects of Sensory or Motor Nerve Deafferentation on Oromotor Function in Mice

Objective. To investigate the effect of sensory or motor nerve damage to the tongue using a mouse model. Study Design. Animal study. Setting. Research laboratory. Subjects and Methods. Adult male and female mice from inbred strains B6 (n = 19) and D2 (n = 25). Following lick training, bilateral lingual–chorda tympani nerve cuts (LX) (n = 6 B6, n = 7 D2), unilateral hypoglossal nerve cuts (HX) (n = 7 B6, n = 9 D2), or sham surgery (n = 6 B6, n = 9 D2) was performed. Mice were lick tested postsurgically with both water and sucrose (4 days total). Following testing, post mortem dissections and microscopic analysis of tongue papillae were performed. Results. In both strains, HX and LX mice demonstrated a significant reduction in volume per lick (VPL) in the surgical groups relative to shams. Neither motor nor sensory nerve transection affected local lick rate. In most LX mice in both strains, taste papillae were reduced compared with HX or sham mice. Conclusion. Mice of either strain with either a sensory or a motor nerve injury have a significant loss of VPL during ingestion of either a neutral (water) or preferred (sucrose) stimulus. This reduction in VPL reflects a deficit in licking. Lick rate was not affected by deafferentation. A reduction in fungiform papillae following LX but not HX mice was noted.

Anterior Skull Base Reconstruction: Does Fat Preparation Matter?

Abstract Objectives This article aims (1) to determine whether there is any difference in cerebrospinal fluid (CSF) leak rate after anterior skull base autologous fat reconstruction based on how the fat is prepared, and (2) to measure impact on surgical times by reconstruction type. Design Translational animal model surgical technique 3‐arm trial, comparing two different methods of autologous fat skull base reconstruction versus a nonreconstructed control group. Setting Animal study. Subjects Adult Sprague‐Dawley rats. Main Outcome Measures Resolution of CSF rhinorrhea after repair of a surgically created anterior skull base defect. Results Both wet (uncompressed) and dry (compressed) fat reconstruction of an anterior skull base defect demonstrated lower CSF leak rates than nonreconstructed defects. Dry fat reconstruction achieved significance in superiority of controlling CSF leak over no reconstruction (64% success vs. 31%); while wet fat reconstruction trended toward significance (50% vs. 31%). Reconstruction procedure time was longer than nonreconstructed controls, but there was no significant difference between type of fat preparation in surgical time. Conclusions This study demonstrates that drying and compressing the fat graft improves autologous fat reconstruction success for anterior skull base defects, and does not add significantly to surgical time over nonprepared fat.

Anterior skull base duplication requiring delivery via EXIT procedure: A case report

Duplication of the anterior skull base structures is an extremely rare malformation of failed midline blastogenesis. We present the case of a child with an obstructive oral cavity mass diagnosed on prenatal imaging. The child was successfully delivered by EXIT procedure, a tracheotomy was performed, and postnatal imaging demonstrated an array of craniofacial malformations, including complete duplication of the maxilla, pituitary glands, aqueducts of Sylvius, and basilar arteries. The child underwent excision of the duplicate maxilla, resulting in a wide cleft palate that will be repaired at a future date.

Management protocol for primary hyperparathyroidism in a single institution: utility of surgeon performed ultrasound

Background We aimed to: (I) discover preoperative diagnostic studies, intraoperative techniques, and patient factors most predictive of cure within a single hospital system; (II) establish practice guidelines for surgical treatment of primary hyperparathyroidism to maximize outcomes based on this hospital systems performance. Methods A retrospective chart review was undertaken of all parathyroid-related procedures from 01/01/02 to 7/31/15 at the Veterans Administration Hospital. Results Seventy-one patients were eligible and charts available for analysis. Preoperative studies most predictive of cure were a combination of sestamibi parathyroid scan and surgeon performed ultrasound (S-US). When studies did not agree, S-US was most often correct. Intraoperative parathyroid hormone (PTH) rapid assay was helpful in predicting cure, but added an average of 33 minutes to operating room time. Patients who had two corroborating preoperative localizing studies, one of which was S-US, that agreed with intraoperative findings, and who did not undergo intraoperative PTH confirmation enjoyed equal cure rates and shorter operating room times. Successful achievement of normal calcium was high at 95.8%. Vitamin D deficiency was prevalent in this patient population, prompting more aggressive preoperative investigation and replacement. Conclusions A management protocol was developed based on the findings of this study: (I) obtain two preoperative localization studies, one of which is surgeon-performed ultrasound; (II) obtain preoperative vitamin D levels and supplement as indicated; and (III) in select patients who have two strongly corroborating preoperative localization studies, one of which is surgeon performed ultrasound, and intraoperative findings are consistent with the localizing studies, intraoperative PTH (IOPTH) may not be necessary.