John C. Goddard

Effects of endoscopic sinus surgery and delivery device on cadaver sinus irrigation

Objective Assess paranasal sinus distribution of topical solutions following endoscopic sinus surgery (ESS) using various delivery devices. Study Design Experimental prospective study. Subjects and Methods Ten cadaver sinus systems were irrigated with Gastroview before surgery, after ESS, and after medial maxillectomy. Delivery was via pressurized spray (NasaMist), neti pot (NasaFlo), and squeeze bottle (Sinus Rinse). Scans were performed before and after each delivery with a portable CT machine (Xoran xCAT), and blinded assessments were made for distribution to individual sinuses. Results Total sinus distribution was greater post-ESS (P < 0.001). Additional distribution was gained with medial maxillectomy (P = 0.02). Influence of delivery device on distribution was significantly higher with neti pot > squeeze bottle > pressurized spray (P < 0.001). Frontal sinus penetration was greatest after surgery (P = 0.001). Conclusion ESS greatly enhances the delivery of nasal solutions, regardless of delivery device. Pressurized spray solutions in un-operated sinuses provide little more than nasal cavity distribution. Use of squeeze bottle/neti pot post-ESS offers a greatly enhanced ability to deliver solutions to the paranasal sinuses.

Inpatient management of epistaxis: outcomes and cost.

OBJECTIVE: Evaluate treatments for epistaxis. STUDY DESIGN AND SETTING: Retrospective review of Nationwide Inpatient Sample (1998-2000). RESULTS: A total of 9778 admissions with admitting diagnosis “epistaxis” were identified. Among admissions involving 1 treatment, 454 (9.6%) received arterial ligation, 94 (2.0%) embolization, and 4188 (88.4%) nasal packing. There were no differences in length of stay, transfusions, complications, or deaths between groups (all P >0.05). Mean total hospital charges were

Outcomes following Semicircular Canal Plugging.

6,282 for the packing group,

Combined image guidance and intraoperative computed tomography in facilitating endoscopic orientation within and around the paranasal sinuses.

12,805 for the ligation group, and

Bone-Anchored Hearing Device Placement with Translabyrinthine Tumor Removal

17,517 for the embolization group; differences between ligation and packing groups, and embolization and packing groups demonstrated significance (P >0.05). CONCLUSIONS: Nasal packing is used commonly for epistaxis that requires inpatient management. Although embolization and arterial ligation are associated with higher hospital charges, complications, transfusion rates, and lengths of stay are similar. Further studies are needed to quantify other outcome measures, such as recurrence rates and patient quality of life. SIGNIFICANCE: Nasal packing is associated with lower hospital charges and similar complication rates as arterial ligation or embolization. (Otolaryngol Head Neck Surg 2005;132:707-12.)

Translabyrinthine Tumor Removal with Concurrent Bone-Anchored Hearing Aid Placement:

Objectives To examine audiometric outcomes, symptom control rates, and complication rates following semicircular canal plugging for superior semicircular canal dehiscence syndrome. Study Design Retrospective chart review. Setting Private, neurotologic tertiary referral center. Subjects and Methods Patients undergoing semicircular canal plugging for superior semicircular canal dehiscence syndrome from January 1, 2007, to December 31, 2012. Pre- and postoperative audiometry, vestibular testing, operative findings, and clinical symptoms were assessed through chart review. Results A total of 24 ears underwent a canal plugging procedure during the study period for superior canal dehiscence syndrome. Pre- and postoperative air conduction pure-tone averages were 21.1 and 22.5 dB (P = .42, not significant [NS]). The average pre- and postoperative word recognition scores were 95.8% and 95.1% (P = .48, NS). Vestibular evoked myogenic potential data showed reduced thresholds in 7 patients with canal dehiscence. Complications were limited to a single, temporary facial weakness. Complete symptom improvement was noted in 35.7% of all patients, while at least partial symptom improvement was found in over 80% of patients. Conclusion Semicircular canal plugging procedures are associated with excellent hearing outcomes and may reduce preoperative symptoms in patients with superior semicircular canal dehiscence.

Effects of Endoscopic Sinus Surgery and Device on Irrigation

Background The utility of image guidance (image-guided surgery [IGS]) and intraoperative computed tomography (CT) scanning as a tool for less experienced endoscopic surgeons to aid in localization of paranasal sinus and skull base anatomic structures was evaluated. Methods Partial endoscopic dissection was performed on cadaver specimens by three fellowship trained rhinologists. Anatomic sites within and around the sinuses were tagged with radio-opaque markers. Otolaryngology residents identified tagged anatomic sites using four successive levels of technology: endoscopy alone (simulating outpatient clinic), endoscopy plus preoperative CT (simulating endoscopic sinus surgery [ESS] without IGS), endoscopy plus IGS registered to preoperative CT (simulating current ESS with IGS), and endoscopy plus IGS registered to real-time intraoperative CT. Responses were graded as follows: consensus rhinologist answer (4 points), close answer without clinically significant difference (3 points), within anatomic region but definite clinical difference (2 points), outside of anatomic region (1 point), no answer (0 points). Results Eleven residents participated. Of 20 specific anatomic sites, IGS-intraoperative CT provided the most accurate anatomic identification at 16 sites. For 8 sites, IGS-intraoperative CT had a significantly higher score than endoscopy alone (p < 0.05; eta2 = 0.29-0.67). For 6 sites, IGS-preoperative CT scan had a significantly higher score than endoscopy alone (p < 0.05; eta2 = 0.30-0.67). All participants found that IGS-intraoperative CT scan made them most comfortable in identifying anatomy. Conclusion Combined IGS and intraoperative CT scan technology may be an instructional adjunct for less experienced paranasal sinus surgeons for dissection and evaluation of unfamiliar or distorted anatomy.

09:30: Expression Patterns in the Injured Cochlea Microenvironment

Objective Translabyrinthine resection of intracranial tumors results in single-sided deafness, which can be treated by surgical and nonsurgical means. Here we describe the first series examining complication and device usage rates among patients receiving a surgically implanted bone-anchored hearing device (BAHD) at the time of translabyrinthine tumor removal. Study Design Case series with chart review. Setting Private tertiary neurotologic referral center. Patients Patients (N = 154) undergoing concurrent BAHD placement and translabyrinthine tumor resection. Intervention Concurrent BAHD placement and translabyrinthine tumor removal. Main Outcome Measures Postoperative complication rates and BAHD usage. Results Of the 154 patients, 121 (78.6%) had no device-related complications. The most common device-related complications were skin overgrowth (8.4%), acute infection (5.2%), and chronic infection (3.2%). The overall and specific complication rates did not differ from published BAHD complication rates. One patient (0.6%) developed a cerebrospinal leak through the surgical site for the device. At the time of last follow-up (mean, 39.8 months), 151 patients (95.0%) were still using their devices. Conclusion Patients undergoing concurrent translabyrinthine tumor removal and BAHD placement exhibit similar device-related complication profiles as patients undergoing standard device placement. Based on these outcomes and the high long-term usage rates, BAHD insertion at the time of translabyrinthine intracranial surgery can be considered a safe and useful procedure.

Transplantation of Mouse Embryonic Stem Cells into the Cochlea of an Auditory-Neuropathy Animal Model: Effects of Timing after Injury

Objectives: (1) Describe the safety profile of performing translabyrinthine tumor removal and bone-anchored hearing aid placement during the same surgical procedure. (2) Describe the overall patient satisfaction of those individuals who underwent the above procedure. Methods: Retrospective review from a tertiary neurotologic referral center of 154 patients who underwent concurrent translabyrinthine tumor resection and bone-anchored hearing device placement between 2004 and 2012. Patient records were reviewed to identify postoperative complication rates and bone-anchored hearing device usage. A Fisher’s exact test was used to compare the qualitative variables and Student t test was used for the quantitative comparison. Results: One hundred twenty-one (78.6%) of 154 patients undergoing concurrent translabyrinthine tumor removal and bone-anchored hearing device placement had no device-related complications. The most common device-related complications were skin overgrowth (8.4%), acute infection (5.2%), and chronic infection (3.2%). The overall and specific complication rates did not statistically differ from published bone-anchored device complication rates (all P < .05). One patient (0.7%) developed a cerebrospinal fluid leak at the placement site of the bone-anchored device. Of the 145 patients with at least 1-year follow-up, 137 (95.5%) were still regularly using their bone-anchored hearing devices. Conclusions: Patients undergoing concurrent translabyrinthine tumor removal and bone-anchored hearing device placement exhibit similar device-related complication profiles as patients undergoing standard device placement. Based on these outcomes and the high long-term usage rates, translabyrinthine intracranial surgery and bone-anchored hearing device insertion can be considered a useful and safe procedure.

Current and Developing Management of Single-Sided Deafness

Objective 1) Assess the effect of endoscopic sinus surgery (ESS) on the distribution of topical solutions to the para-nasal sinuses. 2) Understand differences in topical solution distribution to the para-nasal sinuses using various delivery devices. Methods Ten cadaver sinus systems were irrigated with radio-opaque contrast prior to any surgery, after ESS, and following modified medial maxillectomy. Delivery of contrast was via pressurized spray, neti pot and squeeze bottle techniques for each surgical state. CT scans were performed before and after each irrigation using a portable CT machine. Blinded assessments were made for distribution of contrast within the sinuses. A semi-quantitative grading scale was used to assess contrast distribution to each of 5 sinus regions (maxillary, anterior ethmoid, posterior ethmoid, sphenoid and frontal). Results Total sinus distribution of contrast was significantly greater post-ESS as compared to the un-operated state (p<0.001). Sphenoid and frontal sinus distribution was most affected by surgery. Delivery device influenced contrast distribution, with neti pot and squeeze bottle techniques providing greater distribution than pressurized spray (p<0.001). Frontal sinus penetration was greater post-ESS (p=0.017) and neti pot delivery was the most effective frontal delivery device (p<0.001). Conclusions ESS greatly enhances the delivery of nasal solutions, regardless of delivery device. Limited distribution to the sinuses exists without concomitant ESS, especially for sprays. Squeeze bottle/neti pot use, post-ESS, offers a greatly enhanced ability to deliver solutions to the para-nasal sinuses.