Jason A. Brant

Unilateral Cochlear Nerve Deficiency in Children

Objective Cochlear nerve deficiency (CND) is increasingly diagnosed in children with sensorineural hearing loss (SNHL). We sought to determine the prevalence of CND, its imaging characteristics, and correlations with audiologic phenotype in children with unilateral SNHL. Design Case series with chart review. Setting Tertiary pediatric hospital. Subjects/Methods In 128 consecutive children with unilateral SNHL who underwent high-resolution magnetic resonance imaging, the diameters, area, and signal intensity of the cochlear nerve (CN) were measured and normalized to the ipsilateral facial nerve. Presence of CND was determined by comparison to normative data. Relationships among hearing loss severity, progression, and nerve size were investigated. Results Cochlear nerve deficiency was present in 26% of children with unilateral SNHL. Its prevalence was higher (48%) in severe to profound SNHL, especially when in infants (100%). Width of the bony cochlear nerve canal (BCNC) correlated strongly with relative CN diameter, density, and area (R = 0.5); furthermore, a narrow BCNC (<1.7 mm) strongly predicted CND. Severity of hearing loss modestly correlated with nerve size, although significant variability was observed. Progression never occurred unless there were other inner ear malformations, whereas in the non-CND group, it occurred in 22%. Ophthalmologic abnormalities were very common (67%) in CND children, particularly oculomotor disturbances. Conclusion Cochlear nerve deficiency is a common cause of unilateral SNHL, particularly in congenital unilateral deafness. Width of the BCNC effectively predicts CND, a finding useful when only computed tomography imaging is available. In an ear with CND, hearing can be expected to remain stable over time. Diagnosis should prompt evaluation by an ophthalmologist.

Association of Clinical Risk Factors and Postoperative Complications With Unplanned Hospital Readmission After Head and Neck Cancer Surgery

Importance Unplanned hospital readmission is costly and in recent years has become a focus of health care legislation intended to reduce health care expenditures. Greater understanding of which perioperative complications are associated with hospital readmission after surgery for head and neck cancer is needed to reduce unplanned readmissions. Objective To determine which clinical risk factors and complications are associated with 30-day unplanned readmission after surgery for malignant neoplasms of the head and neck. Design, Setting, and Participants This retrospective longitudinal claims analysis included data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from January 1, 2012, to December 31, 2014. Patients undergoing surgery for malignant tumors of the head and neck were included; those with a primary diagnosis of thyroid malignant disease and those undergoing free autologous tissue transfer were excluded. Main Outcomes and Measures Clinical risk factors and complications were analyzed for association with unplanned hospital readmission using multivariable regression analysis. Statistical significance was determined using P < .05. Results A total of 7605 patients (5007 men [65.8%]; mean [SD] age, 64.2 [0.2] years) were identified and included for analysis. Overall, 1472 complications occurred in 912 cases. Three hundred eighty-eight patients (5.1%) had an unplanned readmission, which was lower than the previously published overall readmission rate for noncardiac surgical procedures in the NSQIP (6.8%). Clinical factors that were independently associated with unplanned readmission were age (adjusted odds ratio [AOR], 1.12; 95% CI, 1.03-1.22), diabetes (AOR, 1.60; 95% CI, 1.01-2.43), preoperative dyspnea at rest (AOR, 2.89; 95% CI, 1.40-5.55) and with moderate exertion (AOR, 1.48; 95% CI, 1.01-2.11), long-term use of corticosteroids (AOR, 2.45; 95% CI, 1.63-3.58), disseminated cancer (AOR, 1.57; 95% CI, 1.14-2.20), and a contaminated wound (AOR, 2.05; 95% CI, 1.05-3.7). When specific complications were examined, superficial incisional surgical site infection (SSI) (AOR, 2.02; 95% CI, 1.14-3.40), deep incisional SSI (AOR, 2.57; 95% CI, 1.26-5.03), organ or space SSI (AOR, 13.27; 95% CI, 6.57-26.61), wound disruption (AOR, 3.58; 95% CI, 1.95-6.31), pneumonia (AOR, 3.39; 95% CI, 1.88-5.96), deep vein thrombosis (AOR, 5.60; 95% CI, 1.90-15.25), pulmonary embolism (AOR, 20.72; 95% CI, 7.86-55.68), urinary tract infection (AOR, 2.66; 95% CI, 1.00-6.34), stroke (AOR, 12.42; 95% CI, 3.99-36.50), sepsis (AOR, 2.64; 95% CI, 1.27-5.30), and septic shock (AOR, 4.12; 95% CI, 1.10-15.81) were all associated with 30-day unplanned hospital readmission. Conclusions and Relevance This study evaluated clinical factors and postoperative complications to determine which ones were associated with 30-day unplanned hospital readmission among patients undergoing surgery for malignant tumors of the head and neck. Further understanding of which complications are associated with unplanned readmission after head and neck surgery will allow for improved risk stratification and development of postoperative care protocols to reduce unplanned hospital readmission.

Predictors of length of stay, reoperation, and readmission following total laryngectomy

To identify relevant patient and surgical risk factors associated with prolonged length of stay, return to the operating room, and readmission within 30 days following total laryngectomy using the American College of Surgeons National Quality Improvement Program (ACS‐NSQIP)

Use of free tissue transfer in head and neck cancer surgery and risk of overall and serious complication(s): An American College of Surgeons–National Surgical Quality Improvement Project analysis of free tissue transfer to the head and neck

The purpose of this article was to assess the rates of head and neck free tissue transfer and variables available in the American College of Surgeons – National Surgical Quality Improvement Project (ACS–NSQIP) dataset to predict overall and serious complications.

Advances in Nano-based inner ear delivery systems for the treatment of sensorineural hearing loss.

ABSTRACT Sensorineural hearing loss (SNHL) is one of the most common diseases, accounting for about 90% of all hearing loss. Leading causes of SNHL include advanced age, ototoxic medications, noise exposure, inherited and autoimmune disorders. Most of SNHL is irreversible and managed with hearing aids or cochlear implants. Although there is increased understanding of the molecular pathophysiology of SNHL, biologic treatment options are limited due to lack of noninvasive targeted delivery systems. Obstacles of targeted inner ear delivery include anatomic inaccessibility, biotherapeutic instability, and nonspecific delivery. Advances in nanotechnology may provide a solution to these barriers. Nanoparticles can stabilize and carry biomaterials across the round window membrane into the inner ear, and ligand bioconjugation onto nanoparticle surfaces allows for specific targeting. A newer technology, nanohydrogel, may offer noninvasive and sustained biotherapeutic delivery into specific inner ear cells. Nanohydrogel may be used for inner ear dialysis, a potential treatment for ototoxicity‐induced SNHL. Graphical abstract Figure. No Caption available.

Safety of transoral surgery for oropharyngeal malignancies: An analysis of the ACS NSQIP.

Minimally invasive transoral surgical approaches for the resection of oropharyngeal tumors offer unique opportunities to achieve oncologically sound results while reducing treatment‐related morbidity. The objective of this study is to characterize the mortality and complication rates of transoral oncologic resections in a large, prospective, de‐identified national dataset from multiple hospitals.

Reoperation following Adult Tonsillectomy Review of the American College of Surgeons National Surgical Quality Improvement Program

Objective Tonsillectomy remains a common procedure in adults; however, there are few population-level data evaluating risk factors for reoperation. Study Design Retrospective review of national database. Setting American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), 2005-2013. Subjects and Methods The ACS-NSQIP was queried for patients undergoing tonsillectomy ± adenoidectomy as their primary procedure (CPT 42821 or 42826). Demographic information and indications were reviewed along with complications and reoperation rates. Results In total, 12,542 cases met inclusion criteria. Patients were predominantly female (66.4%) and white (70.8%), with mean age of 30 ± 12 years (range: 16-90+). Thirty-day mortality was 0.03%, and 4.8% of patients experienced at least 1 complication, including reoperation (3.6%). Risk of complications was associated with male sex (P < .0001; odds ratio [OR], 1.7), diabetes (P = .0002; OR, 2.1), and presence of a bleeding disorder (P = .002; OR, 3.2). Risk factors for reoperation were similar, in addition to older age (P = .002; OR, 0.986). Complications other than reoperation were correlated with older age (P = .001; OR, 1.02) and diabetes (P = .001; OR, 2.59). Procedures were done mostly for infectious/inflammatory (70.4%) versus hypertrophic (16.4%) indications. Indication had no significant effect on the rate of reoperation. Most reoperations occurred after postoperative day 1 (86%; mean, 6.4 ± 4.2 days). Conclusion This review of a large validated surgical database provides an overview of the rates of, and risk factors for, complications and reoperations following tonsillectomy in the adult population.

Results of Baha® implantation using a small horizontal incision

PURPOSE Techniques for Baha® implantation continue to evolve. The Weber technique, utilizing a 1.5 cm horizontal incision for Baha® implantation is evaluated. METHODS Retrospective review of patients undergoing Baha® implantation by a single surgeon over three years. RESULTS 33 Baha®s implanted in 30 patients. Fourteen used an Inverted J (IJ) incision with an anteriorly-based skin-flap, 13 with the Weber technique (W). Five were not included as other techniques were used. Demographics and weeks to activation (14.58 vs 13.4, p = 0.12) were similar. There were no differences in the number of patients with minor complications (5 vs 2, p = 0.22) or number of minor complications (20 vs 4, p = 0.09). One patient in the IJ Group required operative revision for overgrowth. There were no infections in the IJ Group, and one requiring oral antibiotics in the W Group. Follow-up was longer in the IJ Group (41 vs 13 weeks, p = 0.016), no complications occurred after 14 weeks post-op. Mean operative times were similar (43 vs 39 min, p = 0.59). There were no cases of skin flap necrosis in either group. CONCLUSION A small incision for Baha® implantation proved as effective, without increased complications as a skin-flap based technique.

Complications Associated with Mortality after Head and Neck Surgery.

Objective To determine which complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, correlate with 30-day mortality in surgery for malignancies of the head and neck. Study Design Retrospective review of prospectively collected national database. Setting NSQIP. Subjects and Methods NSQIP data from 2005 to 2014 were queried for ICD-9 codes head and neck malignancies. Multivariate logistic regression was used to examine the correlation of individual complications with 30-day mortality. Results In total, 15,410 cases met criteria with 3499 complications in 2235 cases. After controlling for patient and surgical variables, postoperative pneumonia (P = .02; odds ratio [OR], 2.39; 95% confidence interval [CI], 1.15-4.72), progressive renal insufficiency (P < .001; OR, 21.28; 95% CI, 4.22-87.94), bleeding requiring transfusion (P = .02; OR, 2.10; 95% CI, 1.12-3.84), sepsis (P = .02; OR, 2.86; 95% CI, 1.15-6.46), septic shock (P = .045; OR, 2.87; 95% CI, 0.98-7.81), stroke (P < .001; OR, 19.81; 95% CI, 6.23-56.03), and cardiac arrest (P < .001; OR, 135.59; 95% CI, 65.00-286.48) were independently associated with increased odds of 30-day mortality. Conclusion The NSQIP database has been extensively validated and used to examine surgical complications, yet there is little analysis on which complications are associated with death. This study identified complications associated with increased risk of 30-day mortality following head and neck cancer surgery. These associations may be used as a measure of complication severity and should be considered when using the NSQIP database to evaluate outcomes in head and neck surgery.

Systematic Review of Treatments for Autoimmune Inner Ear Disease.

Objective: To systematically evaluate the evidence for treatment of autoimmune inner ear disease (AIED). Data Sources: Medline/EMBASE, Cochrane Review. Study Selection: Studies reviewed were English language original articles reporting outcome data for subjects with AIED undergoing any treatment other than oral steroids alone with particular emphasis on prospectively collected data. Data Extraction: The full text of articles meeting selection criteria was reviewed for subject inclusion criteria, number of subjects, treatment type and duration, audiologic and vestibular evaluations, blinding, randomization, and follow-up. Data Synthesis: Twelve studies representing 272 subjects met selection criteria and presented prospective data, three of which were randomized and placebo controlled. Low numbers and heterogeneity between studies precluded meta analysis. Conclusions: Clear evidence of an effective treatment for AIED from high-quality prospective trials remains lacking.