Joseph D. Brunworth

Impact of Duty Hour Restrictions on Otolaryngology Training: Divergent Resident and Faculty Perspectives†

Objectives: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) passed a controversial mandate limiting resident work hours. We sought to examine the impact of these restrictions on otolaryngology programs and to explore faculty and resident perspectives.

Head and Neck Manifestations and Quality of Life of Patients with Ectodermal Dysplasia

OBJECTIVES: Ectodermal dysplasias (EDs) are a group of genetic disorders characterized by deficient ectodermal and mesodermal development. Studies examining resultant otolaryngologic issues are few. The objectives of this study were to delineate the head and neck manifestations and quality of life in EDs. STUDY DESIGN AND SETTING: For 75 individuals, comprehensive histories were taken and otolaryngologic examinations were performed, and subjects rated their otolaryngologic symptom severity. A validated quality of life instrument (SF-8) was administered. RESULTS: The majority of subjects had a diagnosis of hypohidrotic ED (72%). Otolaryngologic conditions included otitis media (28%), cerumen impaction (48%), nasal obstruction/crusting (51%), heat intolerance (76%), and eczema (39%). Physical findings included peg teeth/hypodontia (76%), alopecia (41%), nasal crusting (41%), and saddle nose deformity (44%). Quality of life scores were generally high. Overall, health was rated “good to excellent” by 87 percent. CONCLUSION: Patients with ED frequently experience significant otolaryngologic symptoms, although most patients report a good quality of life. SIGNIFICANCE: A greater understanding of the otolaryngologic issues in ED should help facilitate diagnosis and improve management.

Rhinologic Manifestations of Ectodermal Dysplasia

Background The Ectodermal Dysplasias (ED) are a group of uncommon genetic disorders characterized by deficient development of tissues derived from ectoderm and mesoderm. Abnormalities of the respiratory epithelium prevent normal mucociliary function. We explored the prevalence and severity of sinonasal features in affected individuals. Methods Thirty-four subjects with ED were evaluated. A focused history and thorough nasal examination including flexible nasopharyngoscopy were performed. Patients and caregivers rated the severity of rhinologic symptoms with a standard scale. Standardized smell tests were also performed. Results The study included 21 males and 13 females whose mean age was 18.8 years (range, 4 months to 85 years). The majority (79%) had Hypohydrotic ED. Nearly half of the individuals evaluated reported moderate to severe nasal obstruction. Allergic symptoms were present in 44% of individuals whereas 41% had a history of sinusitis. Nasal concretions were significantly more troublesome in those aged 15 and under (p = 0.028). Eighteen percent had undergone sinonasal surgery. On examination, normal intranasal structures were identifiable in all patients. However, dry mucosae, prominent crusts, and concretions were found in most (79%). A deviated nasal septum was present in 23% of individuals and a saddle nose deformity in 18. Smell tests were normal for age in all subjects. Conclusion Rhinologic issues are prevalent and problematic in individuals with ED. Management should focus on humidification, nasal debridement, and tailored therapy for allergic rhinitis and sinusitis. Increased awareness of the sinonasal concerns in ED will facilitate diagnosis and improve the care of these patients.

Update on endoscopic endonasal resection of skull base meningiomas

The objective of this work was to report success rates as well as potential obstacles in transnasal endoscopic resection of anterior skull base meningiomas.

Avascular necrosis after oral corticosteroids in otolaryngology: Case report and review of the literature.

Objective In this report, we present a rare case of avascular necrosis (AVN) in an otherwise healthy 42-year-old male patient treated with low dose oral corticosteroids for his bronchitis. A systematic review of the literature related to AVN and corticosteroids was performed. Case Report Forty-two-year-old male with no underlying conditions predisposing him to AVN who had been treated four years before for chronic bronchitis with two courses of oral prednisone therapy presented with bilateral AVN of the hips. Methods An OVID database search of the terms “low total dose,” “corticosteroids,” and “avascular necrosis” was performed. Two PubMed searches of various permutations of “low-dose,” “corticosteroids,” “avascular necrosis,” and “osteonecrosis” were also performed. Results were then narrowed to relevant articles. Results Median total dose of oral corticosteroids in patients with AVN in reviewed articles was 981 mg, with lowest reported association at 105 mg. Median duration of therapy was 16 days with shortest course of six days. Conclusion There is emerging data linking AVN with corticosteroid doses previously thought to be safe. After reviewing the relevant literature, it is our consensus to inform all patients regarding AVN before oral corticosteroid use.

Autoimmune-Related Nasal Septum Perforation: A Case Report and Systematic Review

Background Inflammatory injury of nasal respiratory mucosa is a common feature of multisystem autoimmune disease. Certain autoimmune disorders are associated with nasal septum perforation (NSP). We performed a systematic review of the literature to better understand the association of NSP with specific autoimmune disorders. This is a case report of a 29-year-old woman with a history of arthralgia, autoreactive antibody titers, platelet dysfunction, and NSP. The constellation of symptoms and potential familial involvement indicated that the NSP in this patient was an early sign of an autoimmune disorder, an unknown autoimmune disorder, or a known disease with incomplete penetrance. Methods A systematic review of the literature was performed by two independent reviewers. Relevant articles were reviewed, and data that pertained to autoimmune-related NSP were extracted and analyzed. Results Overall, 140 cases of autoimmune-associated NSPs were reported. Granulomatosis with polyangiitis (48%), relapsing polychondritis (26%), and cocaine-induced midline lesions (15%) constituted 89.3% of the reported cases. Conclusion NSP is a potential sign of systemic disease. The identification of an NSP, especially in the context of other unexplained symptoms or workup suggestive of an autoimmune disorder, should prompt clinical evaluation for multisystem autoimmune disease with consideration of granulomatosis with polyangiitis, relapsing polychondritis, or cocaine-induced midline lesions.

Adjunctive Endonasal Procedures with Dacryocystorhinostomy

Considering the wide breadth of nasal disorders commonly encountered in the general population, it is not surprising to find overlap with patients presenting with lacrimal ailments. In fact, within the subset of patients in whom surgical intervention is deemed prudent, it is occasionally necessary to perform simultaneous endonasal procedures at the time of dacryocystorhinostomy. In addition to septal deviation requiring septoplasty for access to the lacrimal system, one must also assess for various other nasal diseases including turbinate hypertrophy, nasal polyposis, rhinosinusitis, and multiple other neighboring disease processes. Emphasis must be placed on proper preoperative evaluation of concurrent disease to ensure the surgical candidate is properly consented prior to the day of surgery.

Diagnostic dilemmas of mechanical restriction of the medial rectus: A case report

Background Due to the proximity of the maxillary sinus and ethmoid sinuses to the orbit, inflammatory processes that originate in the sinonasal region have the potential to extend into the orbit. Objective We presented a case of ptosis and restrictive strabismus of the medial rectus muscle. Methods A case report with a literature review of possible diagnoses. Results Biopsy, imaging, and laboratory evaluation by otolaryngology, ophthalmology, and rheumatology services were unable to identify the cause of the fibrosis after 22 months of follow-up. A response to oral steroids indicated an inflammatory process. Conclusion Unilateral mechanical restriction of the medial rectus muscle is a rare complication of nasal disease. Inflammatory processes and iatrogenic injury are known to cause fibrosis of surrounding tissue. We presented a unique case of medial rectus fibrosis that did not meet the diagnostic criteria of recognized etiologies.

Heroin-induced nasal necrosis and septal perforation

Abstract We present the case of a 44-year-old woman with a 28-year history of intranasal heroin use who developed severe necrosis of the nasal mucosa and septal perforation. She denied any prior insufflation of cocaine or other substances. Necrosis of the septum was recurrent and persistent despite repeated debridement. Necrosis and perforation of the nose and palate are well-described consequences of intranasal cocaine abuse, often attributed to cocaine’s vasoconstrictive properties. However, there have been few reports of similar effects associated with heroin. This case and other recent reports of non-vasoconstrictive substances causing nasal and palatal necrosis suggest that vasoconstriction alone may be an incomplete explanation for the pathogenesis of cocaine induced midline destructive lesions (CIMDL). Cocaine and other recreational drugs, including heroin, may cause midline destruction through a common non-vasoconstrictive mechanism, possibly mediated by antineutrophil cytoplasmic antibodies.

Isolated craniopharyngioma in the nasal cavity

Abstract We describe the occurrence of a papillary squamous infrasellar craniopharyngioma isolated to the nasal cavity and maxillary sinus in a 48-year-old male presenting with epistaxis and nasal obstruction. Diagnosis was made by histological analysis of incisional biopsy in clinic. Computed tomography and magnetic resonance imaging were performed to evaluate the extent of tumor involvement. The tumor was excised by endoscopic surgery in the operating room with intraoperative frozen section analysis to confirm clear margins. The patient had an uncomplicated post-operative course and no evidence of tumor recurrence at eight months follow-up. This represents the third confirmed case of infrasellar craniopharyngioma isolated to the nasal cavity.