Karthik Rajasekaran

The utility of intrathecal fluorescein in cerebrospinal fluid leak repair

OBJECTIVE To evaluate the utility of intrathecal fluorescein (IF) for intraoperative localization and successful repair of cerebrospinal fluid (CSF) leaks. STUDY DESIGN Case series with chart review. SETTING Tertiary-care medical center. SUBJECTS AND METHODS Subjects included those undergoing endoscopic CSF leak repair with or without the use of IF. Informed consent was obtained from all patients undergoing the administration of IF (total dose 10 mg). RESULTS A total of 103 patients underwent CSF leak repair, and in 47 cases (45.6%), IF was used. Patients who were administered IF were more likely to have spontaneous CSF leak etiology (61.7% vs 16.1%; P < 0.001). Of the 47 cases with IF use, fluorescein was visualized at the skull base in 31 cases (66.0%), 11 (23.4%) had visible CSF leak without fluorescein coloration, and five (10.6%) had neither clear nor fluorescein-colored CSF visualized. Sensitivity and specificity for fluorescein detection was 73.8 percent (95% confidence interval [CI] 57.7%-85.6%) and 100 percent (95% CI 46.3%-100%), respectively. The false-negative rate was 26.2 percent (95% CI 15.8%-43.5%). Localization of the leak site was greater when fluorescein-colored CSF was visualized (100% vs 81.3%; P = 0.035). When fluorescein-colored CSF was not visualized intraoperatively, recurrence rates were 31.3 percent versus 9.7 percent when fluorescein coloration was seen, although this finding was not statistically significant (P = 0.10). CONCLUSION The use of IF facilitates the accurate localization of CSF leaks and may assist the surgeon in confirming a watertight closure. The lack of intraoperative fluorescein visualization should not rule out the presence of CSF leak, as evidenced by a false-negative rate of 26.2 percent.

Spontaneous CSF leaks: factors predictive of additional interventions.

Spontaneous cerebrospinal fluid (CSF) leaks represent a significant challenge due to frequent association with elevated intracranial pressure (ICP) and higher risk of surgical failure. The study objective was to review management strategy and identify factors associated with need for acetazolamide and/or ventriculoperitoneal shunt (VPS) placement.

Patient reported outcomes in endoscopic and open transcervical treatment for Zenker's diverticulum

To compare long‐term symptomatic outcomes between external transcervical (ET) and endoscopic stapling diverticulotomy (ESD) surgeries for Zenkers diverticulum.

Enlarged Neck Lymph Nodes in Children

Pediatric cervical lymphadenopathy is a challenging medical condition for the patient, family, and physician. There are a wide variety of causes for cervical lymphadenopathy and an understanding of these causes is paramount in determining the most appropriate workup and management. A thorough history and physical examination are important in narrowing the differential diagnosis. Diagnostic studies and imaging studies play an important role as well. This article reviews the common causes of lymphadenopathy, and presents a methodical approach to a patient with cervical lymphadenopathy.

Development of a Quality Care Plan to Reduce Otolaryngologic Readmissions Early Lessons from the Cleveland Clinic

Objectives Hospital readmissions are an important focus of national quality and cost containment efforts. With increased emphasis on the impact of unplanned readmissions, it is critical to evaluate factors contributing to readmission rates and optimize strategies aimed at reducing these rates. The objectives of this study were to discuss quality interventions implemented at our institution and to evaluate their impact on reducing readmissions. Study Design Case series with chart review. Setting Academic tertiary care medical center. Methods Medical records of patients who were admitted to an otolaryngology inpatient service and readmitted within 30 days of discharge between January 2010 and December 2012 were reviewed. A quality care plan (QCP) was developed, and various interventions were implemented during this time to affect these rates. Results There were 769, 816, and 798 admissions during the years 2010, 2011, and 2012, respectively. The number of readmissions during this time were 50 (6.5%), 51 (6.3%), and 28 (3.5%), respectively. There were no statistically significant differences in case mix index, demographics, and subsequent length of stay for those patients requiring readmission. The reduction in number of readmissions in 2012, after the institution of our QCP, was statistically significant (P < .05). Conclusion Readmission within 30 days in a large otolaryngology practice can be multifactorial. To reduce rates of readmission, it is essential to understand the diagnoses, postoperative complications, and comorbidities contributing to readmission. Implementation of a QCP composed of comprehensive discharge planning and close postdischarge follow-up can lead to a reduction in readmissions.

Prevalence of metabolic bone disease among chronic rhinosinusitis patients treated with oral glucocorticoids

Background The treatment of chronic rhinosinusitis (CRS) often requires chronic or intermittent oral steroid therapy, which has the potential for adverse skeletal effects, including osteoporosis and increased risk of fragility fractures. The purpose of this study was to determine the prevalence of osteopenia/osteoporosis (OP) or low bone density (LBD) in patients with CRS with/without polyposis treated with oral glucocorticoids. Methods Retrospective chart analysis was performed at a tertiary-care rhinology practice. Patients with CRS with/without polyposis evaluated between September 2003 and July 2008 were included if they had (1) previous history of oral steroid usage (≥5 mg daily for at least 3 months) and (2) previous bone mineral density evaluation. Results A total of 197 patients were included with a mean age of 51.1 years (range, 15–79 years). The primary presenting diagnoses included CRS with polyposis in 176 cases (89.3%) and CRS without polyposis in 21 cases (10.7%). Concomitant asthma was present in 161 patients (81.7%). Overall, the prevalence of low bone mass was 38.6%. Among men >50 years of age and postmenopausal women, the prevalence of osteopenia/OP or LBD was 62.5 and 62.2%, respectively. Comparing men >50 years of age and postmenopausal women to their respective younger populations, both had a statistically higher presence of low bone mass (p < 0.0001), with an odds ratio of 10.6 (3.9–28.7) and 34.6 (7.4–161.5), respectively. There was no statistical difference in the presence of bone loss when comparing groups by gender. A multivariable analysis of common comorbidities revealed age to be the only factor associated with increased risk for OP/osteopenia or LBD. Conclusion Patients with CRS with/without polyposis treated with oral steroids who underwent bone density testing were found to have a high prevalence of LBD. High index of suspicion is required to identify at-risk patients and to initiate careful evaluation and treatment to prevent additional bone-related complications.

Upper airway manifestations of granulomatosis with polyangiitis.

Upper airway manifestations, particularly sinonasal manifestations, are encountered frequently in granulomatosis with polyangiitis (GPA). Nasal endoscopy often reveals crusting, friable erythematous mucosa, and granulation. Up to 25% of patients may have a “saddle-nose” deformity as cartilage destruction worsens. Treatment is often complicated by loss of mucociliary function and necrosis, leading to refractory symptoms. Culture-directed antibiotics, topical antibiotic and saline irrigations, and occasional debridement of adherent crusts can reduce the frequency of sinonasal exacerbations and improve obstructive symptoms. Surgery should be reserved for patients unresponsive to maximal medical therapy. Saddle-nose reconstruction is possible in highly selected patients and can improve nasal breathing and resolve anosmia. Up to 20% of patients with GPA have subglottic stenosis; patients with respiratory symptoms should undergo laryngoscopy to assess the presence of subglottic narrowing. Although systemic manifestations of GPA are managed by immunosuppressive therapy, most patients with subglottic stenosis of GPA require surgical management (ie, endoscopic dilation, endoscopic or laser excision, surgical resection followed by reconstruction).

Facial Nerve Neurorrhaphy and the Effects of Glucocorticoids in a Rat Model

Objective After nerve injury, an exaggerated neuroinflammatory process may hinder neuron regeneration and recovery. Immunomodulation using glucocorticoids may therefore improve facial nerve injury outcomes. This study aims to examine the effect of both local and systemic dexamethasone administration on facial nerve functional recovery after axotomy in a rat model. Study Design Randomized, placebo-controlled, blinded animal study. Setting Animal laboratory. Subjects and Methods Seventy-four Wistar rats underwent facial nerve axotomy with immediate neurorrhaphy. Rats were randomly assigned a postoperative group: control (no therapy); systemic dexamethasone 0.5, 1, 5, or 10 mg/kg for 3 administrations; or topically applied dexamethasone at 2 or 4 mg/mL. Blinded, standardized facial assessments and nerve conduction studies (NCS) were performed. Gross facial motion assessments were corroborated with vibrissae frequency video analysis. Results At 8 weeks, rats receiving systemic dexamethasone at 5 mg/kg attained greater eye blink closure (P = .004) and vibrissae motion (P = .012) compared with controls. Systemic dexamethasone at 0.5, 1, and 10 mg/kg and intraoperative topical application of dexamethasone at 2 or 4 mg/mL did not produce a significant improvement in facial motion compared with controls. Nerve conduction studies show a trend of increased return of compound muscle action potential amplitude levels compared with baseline among rats that received systemic dexamethasone 5 mg/kg but do not achieve statistical significance. Conclusion In a rat facial nerve axotomy model, high-dose systemic dexamethasone therapy may improve functional recovery when administered in the immediate period following neurorrhaphy.

Sternohyoid Flap for Facial Reanimation: A Comprehensive Preclinical Evaluation of a Novel Technique

IMPORTANCE Neuromuscular reanimation of the face provides the correct specific neural functional input and thereby prevents synkinesis. Unfortunately, this ideal situation is rarely encountered in the clinical setting. OBJECTIVES To assess the technical feasibility of and define the surgical procedure for harvesting the sternohyoid muscle as a novel free flap for use in facial reanimation indications. DESIGN, SETTING, AND PARTICIPANTS Fresh, postmortem, nonfixed cadavers were used to define the anatomy and perform the flap harvest procedures. Twenty-four flap harvests were performed. Angiography was performed on the pedicle of the harvested flaps to assess potential flap perfusion. Adenosine triphosphatase staining was performed on the muscle specimens to establish fiber type. MAIN OUTCOME MEASURES The harvest technique, pedicle (arterial or venous), nerve length, and flap geometry parameters were characterized. RESULTS The sternohyoid muscle was found to be reliably vascularized by the superior thyroid artery in all cases with an appropriate arterial and venous pedicle for vascular anastomosis. The mean arterial (5.5 cm) and venous (5.9 cm) pedicle lengths are comparable with gracilis flaps. The mean motor nerve length was 10.7 cm. The inclusion of the hyoid bone allows rigid fixation, and the muscle size, fiber type, and volume profiles all compare favorably to the gracilis flap for use in the indication of facial reanimation. Mock surgical procedures were performed to define inset parameters. This flap potentially allows single-stage cross-facial neurorrhaphies to be performed. CONCLUSIONS AND RELEVANCE This is the first article, to our knowledge, of the sternohyoid muscle as a potential donor site for free-tissue transfer. This muscle has a predictable vascular pedicle and neural innervation along with size and fiber type parameters that make it an ideal potential free flap for facial reanimation. LEVEL OF EVIDENCE NA.

Pathological Review of Turbinate Tissue from Functional Nasal Surgery: Incurring Costs without Adding Quality

Objective Inferior turbinate surgery for nasal obstruction can be performed in a variety of ways. Only a few of these methods produce tissue that can be sent for pathologic analysis. According to the College of American Pathologists, turbinate tissues are not exempt from requisite pathologic evaluation. Our objectives were to evaluate the clinical value and cost implications of routine pathological examination of turbinate specimens. Study Design Case series with chart review. Setting Academic tertiary care medical center. Subjects and Methods Charts of patients who underwent an inferior turbinate procedure for nasal obstruction between January 2008 and August 2011 were reviewed. Results Thirteen hundred consecutive cases from 17 surgeons were identified. Among these patients, 223 (17%) underwent an isolated turbinate reduction procedure and 779 (59%) underwent a reduction procedure in conjunction with a septoplasty. The remaining patients had a turbinate procedure in addition to another head and neck procedure. Only 591 (45%) turbinate reduction procedures were performed by methods that were tissue producing, and of these, 137 (23%) were sent for pathologic analysis. All submitted specimens received a gross examination and 123 (90%) also underwent histologic analysis. No abnormalities were reported. Conclusion At our institution, most surgeons did not submit turbinate tissues for pathologic examination even when a specimen was produced. Of the specimens sent, no abnormal pathologic results were identified. Our results suggest that routine pathologic evaluation of inferior turbinate specimens may not contribute to patient care and perhaps represents an unnecessary cost.