Jacob E. Smith

Intracranial complications before and after endoscopic skull base reconstruction.

Background Endoscopic skull base reconstruction (ESBR) has been widely accepted in the management of cerebrospinal fluid (CSF) leaks. However, it is not the CSF leak itselfbut the potential for life-threatening intracranial complications (ICCs) that is of primary clinical concern. The risk of developing complications, such as meningitis, in a skull base defect is unknown. Many ESBR are multilayered soft tissue repairs, and long-term prevention of ICCs is not well described. Methods Retrospective chart review and telephone consultation was used to assess patients who had an ESBR from 2002 to 2008. The incidence of an ICCs (meningitis, cerebral abscess, and pneumocephalus) and associated risk factors were assessed before and after surgery. Results One hundred six patients underwent ESBR (mean age (∓SD), 47.7 ∓ 18.5 years; range, 2–78 years) with 95.3% long-term follow-up (mean, 19.9 ∓ 16.3 months). ICCs occurred in 21.7% of patients at presentation, in 2.8% of patients during the perioperative period (<2 weeks), and in one patient (0.9%) during the postoperative period. Risk factors for presenting with an ICC and meningitis were revision cases performed elsewhere (χ2 = 9.10; p = 0.007) and leaking encephaloceles (χ2 = 5.98; p = 0.014). Factors not associated with increased ICC were an active CSF leak at presentation (χ2 = 3.03; p = 0.082) and previous radiotherapy. Conclusion ESBR offers an excellent long-term option in preventing subsequent ICC with low perioperative complications. ESBR is robust with delayed (>2weeks) CSF leakage occurring in only 1.9% regardless of etiology. The presence of identifiable risk factors for ICC may guide the surgeon in determining the urgency of ESBR.

Histological comparison of implanted cadaveric and porcine dermal matrix grafts

OBJECTIVES: Histological comparison of human-based (AlloDerm) and porcine-based (ENDURAGen) dermal matrices regarding tissue incorporation and neovascularization as potential soft tissue augmentation materials. STUDY DESIGN: In vivo, rat model. METHODS: Subcutaneous implantation of 1-mm thick, 1 cm X 1 cm pieces of AlloDerm, ENDURAGen, and meshed ENDURAGen was performed in 24 Sprague Dawley rats. Implant materials were harvested at 4 (n = 12) and 8 weeks (n = 12). Histological quantification of soft tissue ingrowth and microvascular density was performed following hematoxylin-eosin staining and CD34 immunohistochemistry, respectively. RESULTS: AlloDerm showed significantly greater soft tissue in-growth and microvascular density compared with both ENDURAGen and meshed ENDURAGen at 4 and 8 weeks (P < 0.001). CONCLUSIONS: Although these results may differ in human host tissues, AlloDerm seems to be a more suitable dermal matrix implant than ENDURAGen for cases in which tissue incorporation and neovascularization are sought for the optimal outcome based on this animal model.

Effectiveness of Pillar palatal implants for snoring management

Objective: Determine patient factors associated with the success and complications of using the Pillar palatal implants for snoring management. Study Design: Retrospective series of 79 consecutive adult patients receiving Pillar implants for snoring management between January 2005 and December 2007. Multiple regression analysis was used to determine factors associated with initial and final bed partner satisfaction with the snoring result, and factors associated with Pillar-related complications. Results: A total of 64 of 79 (81%) bed partners reported snoring improvement in patients after initial Pillar implantation; however, only 31 (39%) were satisfied with the level of reduction. Following secondary procedures, the number of satisfied bed partners improved to 52 (66%). Factors associated with final bed partner satisfaction included lower initial apnea-hypopnea index (AHI) (P = 0.029), Friedman tongue position I or II (P = 0.008), and shorter follow-up time (P = 0.001). Sixteen patients (20%) experienced procedure-related complications. Factors associated with Pillar complications included female gender (P = 0.001) and placement under general anesthesia (P = 0.009). Conclusions: Initial AHI values and tongue position scores are important determinants of final snoring success. Pillar implants placed in women and under general anesthesia may have a higher risk of poor placement and extrusion.

Clinical course following endoscopic repair of type 1 laryngeal clefts

OBJECTIVES Treatment of type I laryngeal clefts (T1LCs) remains controversial. We present our experience with 16 endoscopic T1LC repairs to evaluate the effect of patient characteristics and surgical technique on outcomes. METHODS A retrospective study was performed. Diagnosis of T1LC was made by interarytenoid palpation during operative microlaryngoscopy. Two surgeons performed endoscopic repair using either microflap reconstruction or laser demucosalization and reapproximation. All patients received preoperative and postoperative modified barium swallow (MBS) studies. Improved MBS at 3-5 months determined success of repair. Factors contributing to success of repair were analyzed statistically. RESULTS No intraoperative complications occurred. One T1LC repair dehisced after 3 months. Overall, 11 of 16 repairs (68.8%) were successful. Mean age at repair was 23.3 months. Length of stay for microflap repair was significantly shorter than for laser reapproximation (0.89 days vs. 4.6 days, p<0.001, two-tail t-test). The difference in patient age between failures and successes (21.3 months vs. 24.2 months) was non-significant (p=0.661, two-tail t-test). Success for the nine patients receiving microflap reconstruction (77.8%) vs. the seven receiving laser reapproximation (57.1%) is comparable (p=0.596, Fishers exact test). No correlation between comorbidities and failure was found (p>0.05, Fishers exact test). CONCLUSIONS This series matches the largest reported series of endoscopic T1LC repairs. Success rates were lower than in previously reported studies, and comorbidities were higher. However, comorbidities did not contribute to surgical failure. No difference in outcome was seen between the two endoscopic techniques. Microflap repair may require a shorter hospital stay.

Effectiveness of Pillar Implants in Snoring Management

Objective Determine the effectiveness and complications of Pillar implants for snoring management in the course of routine clinical practice. Methods Retrospective series of adult patients receiving Pillar implants for snoring management between January 2005 and December 2007. Outcomes include procedure-related complications and patient satisfaction with snoring control. Results A total of 58 males and 12 females with an average age of 56 years (range, 33 to 74 years) underwent placement of Pillar implants for socially disruptive snoring. 21 patients were snorers, whereas 49 had mild to moderate degrees of sleep apnea. 41 patients were treated with 3 implants, and 24 patients received 4 or more implants. The procedure was performed in the outpatient setting in 47 cases and in the operating room in 23 cases. Complications included poor placement requiring removal (5 patients), and implant extrusion (4 patients). Complications were more common with implants placed in the OR, compared to the outpatient office (p=0.004). Of the patients with sufficient 3-month follow-up, 35/54 (65%) reported reduction in snoring, however only 28/54 (52%) were completely satisfied with the level of snoring reduction. When the satisfied patients were compared to dissatisfied patients, there were no noted differences in mean age, diagnosis of OSA, the use of adjunctive nasal surgery, or the number of implants placed. Conclusions Pillar implants offer satisfactory snoring reduction in approximately 50% of patients. Additional study is needed to determine factors that increase the probability of success. Implants placed under general anesthesia have a higher risk of poor placement and extrusion.