Johnathan D. McGinn

Peritonsillar abscess in children : a 10-year review of diagnosis and management

OBJECTIVE peritonsillar abscess is the most common deep neck infection in adults and children. However, pediatric patients with their smaller anatomy and often inability to cooperate with exam and treatment, provide a challenge. This study reviews the experience over the last 10 years at a childrens hospital in the diagnosis and treatment of pediatric peritonsillar abscess. METHODS a retrospective chart review of 83 children diagnosed with a peritonsillar abscess by the Otolaryngology service over a 10-year period (March 1989-February 1999) were reviewed. Presenting signs and symptoms, physical findings, age, season of presentation, prior pharyngitis history, and prior treatment was collected from the charts. Additionally, diagnostic studies (if any), treatment performed, bacteriology, and outcome/complications were noted. RESULTS due to either an inability to cooperate fully for examination and treatment, or because of an earlier history of significant recurrent pharyngitis or obstructive tonsillar hypertrophy, half of the children required treatment in the operating room. Twenty-six out of 83 (31%) underwent a quinsy tonsillectomy. Length of stay was relatively short (0.9 days). There were no recurrent PTAs in our series, although four children initially treated with incision and drainage required tonsillectomy for persistent symptoms or residual abscess. Ten of those not treated with tonsillectomy (19%) required interval tonsillectomy for recurrent pharyngitis. CONCLUSION limited by the ability to cooperate with treatment, children often require different treatment plans. We offer a treatment algorithm for managing children with PTAs that takes into account their age, level of cooperativeness, co-morbidities and prior history of pharyngitis, PTA or obstructive sleep disorder.

Plating techniques and plate orientation in repair of mandibular angle fractures : An in vitro study

A biomechanical model utilizing polystyrene mandibles was devised to evaluate the fixation efficacy of various plating techniques for repair of mandibular angle fractures. A simple angle fracture was created in the mandible models at a standardized location and was repaired using five different plating techniques. Each experimental group consisted of 15 mandibles, with fracture site, plate placement, load application, and fracture displacement measurement standardized to ensure consistency among experimental groups. Measurement of fracture distraction under load application generated a load deformation curve and corresponding slope for each technique. Comparison of load deformation slopes allowed assessment of fixation stability. When applied with a subapical, medially placed monocortical tension band, bicortical compression plating demonstrated the most stable fracture fixation. The data show that biplanar plate placement in both monocortical noncompression and bicortical compression techniques yields a stronger fixation than monoplanar placement.

Perioperative care in functional endoscopic sinus surgery: a survey study†‡

Functional endoscopic sinus surgery (FESS) is largely viewed as the standard of care in the treatment of chronic rhinosinusitis (CRS) refractory to medical treatment. While there is an understanding regarding the importance of some form of routine postoperative FESS care, no consensus currently exists regarding what the specific management routine should include. The authors of this survey study did not intend to examine the efficacy of such treatment protocols, but rather to determine and report on the current practice patterns of perioperative FESS care among otolaryngologists.

Unintentional parathyroidectomy and hypoparathyroidism in secondary central compartment surgery for thyroid cancer

Unintentional parathyroidectomy is a complication of thyroid surgery. To our knowledge, no study has specifically examined the incidence of inadvertent parathyroidectomy exclusively in patients undergoing secondary central compartment surgery for recurrent or persistent thyroid cancer.

Acute Invasive Fungal Rhinosinusitis A 15-Year Experience with 41 Patients

Objectives To describe a 15-year single-institution experience of 41 cases of acute invasive fungal sinusitis (AIFRS), identify clinical indicators predictive of AIFRS, and discuss our approach to these high-acuity patients. Study Design Case series with chart review. Setting Tertiary referral center; The Pennsylvania State University Hershey Medical Center. Subjects and Methods A retrospective review was performed for AIFRS consultations between September 1999 and March 2014. Variables reviewed included underlying condition, presenting symptoms, absolute neutrophil count, disease extent on examination, radiographic findings, medical treatment, biopsy results, surgical treatment, and outcomes. Univariate analysis was performed to determine variables significantly associated with AIFRS. Outcome measures were assessed and patient assessment algorithm developed. Results Of 131 patients evaluated, 41 were diagnosed with AIFRS; 92.7% had an underlying hematologic malignancy. Disease predictive variables included absolute neutrophil count <500/μL (P < .0001; sensitivity = 78%), mucosal abnormalities of middle turbinate (P < .0001; specificity = 88%) and septum (P < .0001; specificity = 97%), and specifically, necrosis of the middle turbinate (P < .0001; specificity = 97%). Twenty-five AIFRS patients (61%) survived until discharge; 25% (n = 10) expired secondary to AIFRS infection explicitly. Conclusion This series represents one of the largest single-institution experiences of AIFRS published to date. Timely diagnosis is necessary to improve patient outcomes and limit morbidity. Maintaining a high index of suspicion in at-risk patient populations, followed by prompt evaluation and management, is crucial in suspected AIFRS. The presence or absence of certain findings appear to correlate with biopsy results and may aid in appropriately gauging clinical suspicion for the presence of AIFRS.

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.

Prevention of Complications in Revision Endocrine Surgery of the Head & Neck

Revision cervical endocrine surgery increases risks for injury to important adjacent structures, possibly resulting in hoarseness and postoperative hypocalcemia. With anatomic knowledge and appropriate use of meticulous dissection techniques, the surgeon strives to minimize morbidity. Technologic advances have provided tools to aid in these difficult cases and maintain the thoroughness of resection while reducing morbidity. The judicious use of preoperative imaging can assist the surgeon in identifying the precise location of disease, thus reducing unnecessary dissection and risk to surrounding structures, while still performing complete resections.

Case-Logging Practices in Otolaryngology Residency Training: National Survey of Residents and Program Directors

Objective (1) Evaluate the consistency and manner in which otolaryngology residents log surgical cases. (2) Assess the extent of instruction and guidance provided by program directors on case-logging practices. Study Design Cross-sectional national survey. Setting Accreditation Council for Graduate Medical Education otolaryngology residency programs in the United States. Subjects and Methods US otolaryngology residents, postgraduate year 2 through graduating chiefs as of July 2016, were recruited to respond to an anonymous questionnaire designed to characterize surgical case-logging practices. Program directors of US otolaryngology residency programs were recruited to respond to an anonymous questionnaire to elucidate how residents are instructed to log cases. Results A total of 272 residents and 53 program directors completed the survey, yielding response rates of 40.6% and 49.5%, respectively. Perceived accuracy of case logs is low among residents and program directors. Nearly 40% of residents purposely choose not to log certain cases, and 65.1% of residents underreport cases performed. More than 80% of program directors advise residents to log procedures performed outside the operating room, yet only 16% of residents consistently log such cases. Conclusion Variability in surgical case-logging behaviors and differences in provided instruction highlight the need for methods to improve consistency of logging practices. It is imperative to standardize practices across otolaryngology residency programs for case logs to serve as an accurate measure of surgical competency. This study provides a foundation for reform efforts within residency programs and for the Resident Case Log System.

Frozen Section as a Rapid and Accurate Method for Diagnosing Acute Invasive Fungal Rhinosinusitis

Objective Identify methods to improve the frozen-section diagnosis of acute invasive fungal rhinosinusitis. Study Design Biopsies with frozen section for suspected acute invasive fungal rhinosinusitis were reviewed to identify causes for missed diagnoses and evaluate methods for potential improvement. Setting All aspects of the study were performed at the Penn State Milton S. Hershey Medical Center. Subjects and Methods All frozen sections performed for suspected acute invasive fungal rhinosinusitis between 2006 through 2017 were reviewed with their diagnoses compared to the final diagnoses. Sensitivity and specificity were determined for each biopsy specimen to evaluate the diagnostic method and for each patient for its effectiveness on outcome. Causes for frozen-section failures in diagnosis were identified. A periodic acid–Schiff stain for fungus (PASF) was modified for use on frozen tissue (PASF-fs) and applied both retrospectively and prospectively to frozen sections to determine its ability to identify undetected fungus and improve diagnostic sensitivity. Results Of 63 biopsies positive for acute invasive fungal rhinosinusitis, 51 were diagnosed on frozen section, while 61 were identified by including the novel PASF-fs stain, reducing the failure rate from 19% to 3%. Of 41 cases that were positive, 34 were diagnosed on frozen section. Of the 7 that were not, 5 were identified by including the PASF-fs, reducing the failure rate from 17% to 5%. Conclusions Frozen section interpretation of biopsies for suspected acute invasive fungal rhinosinusitis using a PASF-fs stain should enable a rapid and accurate diagnosis with improved outcomes by shortening the time to surgery.

Acoustic Analysis of Upper Airway Obstruction in the Excised Human Larynx

Upper airway obstruction is an emergency that requires quick and decisive intervention. Stridor is the sound created by airflow through a partially obstructed airway, and has been described to vary with the site and degree of obstruction. This study sought to determine the sound characteristics of stridor in the excised human larynx. Five fresh cadaver human larynges were harvested and subjected to obstructions at supraglottic, glottic, and subglottic subsites. Subglottic pressure, airflow, and audio signal were recorded. Data were analyzed on the basis of laryngeal obstruction subsite and the degree of laryngeal resistance. Visual inspection demonstrated certain trends in peak spectral energy depending on the site and, more significantly, the amount of obstruction. Statistical analysis of spectral waveforms showed better correlation with the amount of obstruction than with the site of obstruction. In summary, the frequency distribution of stridor produced in an excised human larynx was influenced by the amount of laryngeal resistance, but not by the site of airway obstruction.