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Emerging Trends in Tonsillectomy

Objective. To describe the tonsillectomy techniques and management used by practicing otolaryngologists in the United States. Study Design. Anonymous 18-question postal survey of pediatric and general otolaryngologists on their current tonsillectomy practices. Setting. Tertiary academic medical center. Subjects and Methods. Current preoperative, perioperative, and postoperative practices in tonsillectomy were queried with multiple-choice and open-ended questions. Pediatric otolaryngologists and general otolaryngologists were compared. Results. Eighty percent of respondents perform subcapsular (total tonsillectomy) dissection. Most otolaryngologists trained with either monopolar cautery (52%) or cold steel (42%). The Coblator (ArthroCare ENT, Austin, Texas) is the most common single instrument used for tonsillectomy (27.5%), followed by monopolar cautery (26%), but in combination with other instruments, monopolar cautery was still more common (33.5%) than coblation (28.9%). Coblation was more common among private practice and general otolaryngologists. The majority of those surveyed do not use intraoperative local anesthesia, but most do use intraoperative steroids (67%). Compared with generalists, pediatric otolaryngologists were less likely to use coblation, were less likely to use local anesthetic, managed postoperative pain slightly differently, and were more likely to recommend diet ad libitum after surgery. Otolaryngologists were more likely to admit medically compromised patients postoperatively. Conclusions. Coblation is becoming a more commonly used instrument for tonsillectomy. Pediatric otolaryngologists perform more tonsillectomies than do general otolaryngologists and manage their patients differently.

Impact of the pediatric tonsillectomy and polysomnography clinical practice guidelines

OBJECTIVE To evaluate the effect of the recently published guidelines on Tonsillectomy in Children and Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children on physician practice patterns. STUDY DESIGN Cross-sectional survey. METHOD Survey of members of the American Academy of Otolaryngology-Head and Neck Surgery. SETTING Academic tertiary referral center. RESULTS A total of 280 physicians completed the survey, with a response rate of 41.7%. 93% of respondents had read the clinical practice guidelines. Many respondents had completed a pediatric otolaryngology fellowship (46%). A large group of physicians (46%) continue to prescribe antibiotics within 24h after surgery. One-third of respondents stopped prescribing antibiotics because of the guidelines. Discord between severity of symptoms and tonsil size was the most common reason cited for ordering a polysomnogram prior to tonsillectomy (76%). The most common reason cited for admission post-tonsillectomy was age less than 3 (40%). Less than half of physicians prescribe NSAIDs for pain control (43.8%) despite its safety profile, and only 23% reported that the guidelines influenced their use of NSAIDs postoperatively. Most respondents use intra-operative steroids (90%) as recommended. CONCLUSION The guidelines are intended to provide evidence based direction in tonsillectomy practices and improve referral patterns for polysomnography prior to tonsillectomy. The majority of the surveyed otolaryngologists reviewed these guidelines and some have changed their practice secondary to the guidelines. However, many physicians continue to prescribe post-operative antibiotics and do not use NSAIDs.

Surgical anatomy of the supraglottic larynx using the da Vinci robot

Transoral robotic surgery (TORS) has facilitated organ‐preserving surgery of the larynx. It has also presented a change in the surgical perspective. We performed cadaveric dissections using the robot to highlight the vascular and muscular anatomy of the supraglottic larynx.

Traumatic dislocation of intact mandibular condyle into middle cranial fossa

INTRODUCTION A 10-year-old girl presented to the Emergency Department with temporomandibular joint pain, malocclusion, and trismus after a bicycle accident. METHODS CT of the temporal bones showed displacement of the right mandibular condyle into the middle cranial fossa with small intraparenchymal hemorrhage. The condyle was reduced using closed reduction technique and the patient was placed in maxillomandibular fixation. RESULTS Complete reduction of the displaced condyle with resultant normal occlusion and persistent bony defect in the temporal bone. CONCLUSION In early follow-up assessments the patient has had complete resolution of symptoms with residual bony defect from the site of fracture in the temporal bone.

Molecular and Genetic Markers of Follicular-Cell Thyroid Cancer: Etiology and Diagnostic and Therapeutic Opportunities

Thyroid cancer has an increasing incidence in the US population and worldwide, with 95% of the cancers being of follicular cell origin-papillary, follicular, or anaplastic thyroid carcinomas. Both follicular and papillary thyroid cancers portend good survival rates, with estimated 5-year survival amongst differentiated thyroid cancer approaching 97%. On the other hand, the median survival for a patient with anaplastic thyroid carcinoma is measured in months. Despite the optimistic survival rates for papillary and follicular thyroid carcinoma, a subset of this population demonstrates resistance to radioactive iodine, and a proclivity for more aggressive tumors with higher rates of recurrence and metastasis.As there is an increased understanding of the molecular etiology of thyroid cancer, there is also a new interest in alternative treatment methods for those nonresponsive to typical treatment. Multiple signaling pathways have been identified, including the mitogen activated protein kinase pathway, as crucial to thyroid tumor formation and progression. Additionally, particular oncogenes have been identified as prevalent in anaplastic thyroid carcinoma and thought to be involved in the transformation from differentiated to anaplastic histology.We review the current literature and evidence describing the molecular and genetic etiology of non-medullary (follicular cell derived) thyroid carcinomas including papillary, follicular, and anaplastic thyroid carcinoma. Additionally, we evaluate the current literature on emerging and established therapies of molecular and genetic targets in these cancers.

Hyalinizing clear cell adenocarcinoma of the oropharynx

Hyalinizing clear cell adenocarcinoma (HCCA) is a rare salivary gland malignancy. To our knowledge, there are no published reports of primary clear cell carcinoma of the vallecula.

Pathologic fracture of the mandible secondary to traumatic bone cyst.

The traumatic bone cyst (TBC) is an uncommon and poorly understood lesion. First described in 1929, TBCs lack an epithelial lining, typically occur during the second decade of life, and are most frequently located in the jaw. Although the majority of TBCs are asymptomatic, rarely a TBC can cause a pathologic fracture of the mandible. We present a case of an adolescent suffering a sports-related pathologic mandible fracture secondary to a traumatic bone cyst.

The relationship of external and internal sidewall dimensions in the adult Caucasian nose.

Nasal bone length is commonly referenced in the rhinoplasty literature. It has been suggested that short nasal bone length may predispose one to a greater risk of middle vault collapse after rhinoplasty. However, there are limited data available on what constitutes the normal dimensions of these pertinent structures of the nasal sidewall. In addition, no data exist on the gender and ethnic variability of such dimensions. This article reports on measurements of nasal bones and associated structures in adult Caucasian cadavers and their relationships to the nasal sidewall. Furthermore, this study assesses the validity of using surface measurements to approximate the true dimensions of the nasal sidewall structures.

Predictive Factors of Prolonged Hospital Stay in Tonsillectomy Patients

Objective: Tonsillectomy remains one of the most common surgeries performed in the pediatric population. Factors that are predictive of a prolonged stay after tonsillectomy are useful in planning postop care. Method: A retrospective chart review was completed inclusive of all pediatric patients who had tonsillectomy at a tertiary medical center from March 10, 2010, to January 1, 2011. Preoperative variables were analyzed to determine predictors of extended hospital stay (defined as > 24 hours). Results: A total of 210 patients were reviewed. Thirty-three patients (15.7%) had hospital stays greater than 24 hours. Indications for tonsillectomy included obstructive sleep apnea (69.5%), tonsillitis (9.5%), and asymmetry (1.9%). Twenty-eight (84.8%) patients had extended stays for poor oral intake. Fever and respiratory complications accounted for 0.06% respectively. Patients with extended stays were younger (P < .001), weighed less (P < .001), and had higher apnea-hypopnea indices (P = .043). Patients with a history of sickle cell crises or bronchodilator use, along with those who had state funded insurance (P < .05), were more likely to have extended stays. Conclusion: Factors from the history and physical of patients may predict which patients are at higher risk for extended hospital stays after tonsillectomy. Predictors of extended stays include younger and smaller children, those with a prior history of sickle cell crises, those using bronchodilators, and those with state funded health insurance.

Transoral robotic study of the vascular anatomy of the head and neck

We aimed to explore, highlight and accurately identify the vascular anatomy of the oropharynx, hypopharynx and supraglottis utilizing the transoral robotic perspective. This was a case series using anatomic studies of cadaveric specimens. The cadavers were injected with red- and blue-dyed silicone through the arterial and venous systems to define the macro- and microvasculature. Following injection of the specimen, a da Vinci robotic surgical system was engaged to perform a transoral dissection of the oropharynx, hypopharynx and supraglottic regions. Dissection was carried out under high-definition optics. Vascular structures were identified and followed to their terminal branches. We successfully performed transoral robotic dissections of five fresh frozen cadaveric human heads which had been injected with dyed silicone. The injection technique and use of a high-definition magnifying camera allowed us to visualize and identify the vasculature of the head and neck in a unique fashion. The cadaveric model provides an excellent educational tool to aid in training. Additionally, the use of this model and the transoral approach has allowed us to identify vessels which typically may not be visible on routine dissection. We believe this to be very relevant in training and improving performance for safe and bloodless transoral robotic surgery. To our knowledge this is the first study using the transoral robotic approach to examine the vascular anatomy of the oropharynx and larynx.