Marisa A. Ryan

FoxP3 and indoleamine 2,3-dioxygenase immunoreactivity in sentinel nodes from melanoma patients

OBJECTIVE 1) Assess FoxP3/indoleamine 2,3-dioxygenase immunoreactivity in head and neck melanoma sentinel lymph nodes and 2) correlate FoxP3/indoleamine 2,3-dioxygenase with sentinel lymph node metastasis and clinical recurrence. STUDY DESIGN Retrospective cohort study. METHODS Patients with sentinel lymph node biopsy for head and neck melanoma between 2004 and 2011 were identified. FoxP3/indoleamine 2,3-dioxygenase prevalence and intensity were determined from the nodes. Poor outcome was defined as local, regional or distant recurrence. The overall immunoreactivity score was correlated with clinical recurrence and sentinel lymph node metastasis using the chi-square test for trend. RESULTS Fifty-six sentinel lymph nodes were reviewed, with 47 negative and 9 positive for melanoma. Patients with poor outcomes had a statistically significant trend for higher immunoreactivity scores (p=0.03). Positive nodes compared to negative nodes also had a statistically significant trend for higher immunoreactivity scores (p=0.03). Among the negative nodes, there was a statistically significant trend for a poor outcome with higher immunoreactivity scores (p=0.02). CONCLUSION FoxP3/indoleamine 2,3-dioxygenase immunoreactivity correlates with sentinel lymph node positivity and poor outcome. Even in negative nodes, higher immunoreactivity correlated with poor outcome. Therefore higher immunoreactivity may portend a worse prognosis even without metastasis in the sentinel lymph node. This could identify a subset of patients that may benefit from future trials and treatment for melanoma through Treg and IDO suppression.

Practice patterns in supraglottoplasty and perioperative care

OBJECTIVES Supraglottoplasty is the first-line surgical treatment for severe laryngomalacia. The purpose of this study is to determine the current trends of practice patterns in managing children who require supraglottoplasty. METHODS A 25-question survey regarding supraglottoplasty techniques and perioperative management was sent by e-mail to 274 physician members of the Society for Ear, Nose and Throat Advances in Children (SENTAC). RESULTS 101 surgeons responded and 72% of respondents were in academic practice (p < 0.0001). All four United States regions, Canada and the United Kingdom were represented. The most commonly reported age of patients undergoing supraglottoplasty was 1-3 months (62% of respondents). Indications include worsening airway symptoms (43%), failure to thrive (41%) and worsening feeding (10%). The majority of respondents (89%) treat these patients for reflux with 54% prescribing PPIs and 41% prescribing H2 blockers. Cold steel is the most popular surgical technique (73%) followed by laser (14%), microdebrider (10%) and coblator (3%) (p < 0.0001). Most respondents (92%) administer intraoperative steroids with the majority of them choosing dexamethasone (99%). Perioperative antibiotics are administered by 23% of respondents. Almost all respondents admit their patients for post-operative observation (99%) and 53% of these admit to PICU rather than step-down or floor status. The level of care is associated with the number of supraglottoplasties performed per year (p = 0.009) and with the geographic region (p = 0.02). Surgeons who perform fewer supraglottoplasties tend to admit to a higher level of care. Those in the South and Northeast regions tend to admit more to floor status. Only 13% routinely keep patients intubated post-operatively. CONCLUSIONS This provider survey study highlights some significant variations and trends in practice patterns of otolaryngologists who perform supraglottoplasty. The majority utilizes anti-reflux pharmacotherapy; however, there is no consensus in which type. The method for supraglottoplasty also varies with cold steel being the most popular, although no single method has been shown to be superior. There is variation in post-operative care with trends for keeping patients extubated and admitting them to an intensive care. With the importance of safe, effective, and also cost-conscious care, further studies are needed to understand the optimal management of those who undergo supraglottoplasty.

Is Gadolinium contrast enhancement necessary in screening MRI for asymmetric sensorineural hearing loss

BACKGROUND Gadolinium contrast enhanced T1 weighted magnetic resonance imaging (GdT1W MRI) is the most widely accepted evaluation for asymmetric sensorineural hearing loss (ASNHL). It has replaced auditory brainstem response (ABR) and computed tomography to detect anatomical abnormalities such as acoustic neuromas (ANs) as the initial screening test after obtaining the history, physical, and audiogram. The cost of a complete brain GdT1W MRI is not insignificant. Gadolinium has a risk of nephrogenic systemic fibrosis and must be used cautiously with renal dysfunction. Alternatively, noncontrasted fast spin-echo T2-weighted (FSE T2W) MRIs focused on the internal auditory canal (IAC) and cerebellopontine angle (CPA) can be performed in only 10 minutes. The sensitivity of these protocols for screening, particularly for smaller lesions, has been questioned. Disagreement exists regarding the cost-effectiveness and necessity of an initial GdT1W MRI, which is relevant in an era needing cost-containment.

Long-term follow-up of amitriptyline treatment for idiopathic cough.

To evaluate short‐ and long‐term treatment outcomes of amitriptyline for idiopathic cough.

CO2 laser myringoplasty: a minimally invasive technique for treating tympanic membrane atelectasis.

Objective 1) To describe a cost-effective, minimally invasive technique for treating tympanic membrane atelectasis, and 2) to present data on hearing improvement in patients receiving this as the basis for a future prospective study. Study Design Report of hearing and clinical outcome over a 4-year period. Setting Tertiary center. Patients Patients with tympanic membrane atelectasis and hearing loss. Intervention Valsalva, hydrodissection, or manual dissection reinflated the atelectatic segment under mask anesthesia. A CO2 laser hand-held fiber contracted the tympanic membrane. Then, myringotomy and pressure equalizing tube placement was performed. Main Outcome Measures Status of the tympanic membrane, patency of the tubes, and pure tone average air-bone gap on preoperative, postoperative, and most recent audiograms. Results Laser myringoplasty was performed on 60 ears of 43 patients. The average preoperative air-bone gap was 15 dB, and this significantly improved to 7dB (p < 0.001) postoperatively. Hearing improvement remained significant in the 17 patients with greater than 2 years’ follow-up (7 dB, p = 0.007). Patients with effusion had worse preoperative air-bone gap (19dB) compared with dry ears (12.5 dB, p = 0.02). However, postoperative and long-term air-bone gaps were not significantly different in the 2 groups (p = 0.3). Patients with myringostapediopexy that required or failed mechanical elevation did not have significant hearing improvement. Conclusion Laser myringoplasty for treatment of tympanic membrane atelectasis using a hand-held flexible fiber CO2 laser is feasible and may improve hearing immediately and long term. It is not useful in severe adherent atelectasis. More studies are indicated to confirm its overall cost-effectiveness and competitiveness with traditional methods of managing atelectasis.

Adherence to Clinical Practice Guidelines

Clinical practice guidelines are designed to synthesize and disseminate the best available evidence to guide clinical practice. The goal is to increase high-quality care and reduce inappropriate interventions. Clinical practice guidelines that systematically review evidence and synthesize it into recommendations are important because the available scientific evidence is normally neither rapidly nor broadly incorporated into practice. It is important to understand and improve the impact of our American Academy of Otolaryngology—Head and Neck Surgery Foundation clinical practice guidelines on this uptake of scientific knowledge. Considering the barriers to guideline adherence is a central part of this. This understanding can guide clinicians, future guideline authors, and researchers when using guidelines, writing them, and planning clinically relevant research.

Coblation of suprastomal granulomas in tracheostomy-dependent children

OBJECTIVE Suprastomal granulomas pose a persistent challenge for tracheostomy-dependent children. They can limit phonation, cause difficulty with tracheostomy tube changes and prevent decannulation. We describe the use of the coblator for radiofrequency plasma ablation of suprastomal granulomas in five consecutive children from September 2012 to January 2016. METHOD Retrospective case series at a tertiary medical center. RESULTS The suprastomal granuloma could be removed with the coblator in all 5 cases. Three were removed entirely endoscopically and 2 required additional external approach through the tracheal stoma for complete removal. There were no intraoperative or postoperative complications. One patient was subsequently decannulated and 2 patients have improved tolerance of their speaking valves. Two patients remain ventilator dependent, but their bleeding and difficulty with tracheostomy tube changes resolved. Three of the patients have had subsequent re-evaluation with bronchoscopy, demonstrating resolution or markedly decreased size of the granuloma. This technique is time efficient, simple and minimizes risks associated with other techniques. The relatively low temperature and use of continuous saline irrigation with the coblator device minimizes the risk of airway fires. Additionally, the risk of hypoxia from keeping a low fractional inspiratory oxygen level (FIO2) to prevent fire is avoided. The concurrent suction in the device decreases blood and tissue displacement into the distal airway. CONCLUSION Coblation can be used safely and effectively with an endoscopic or external approach to remove suprastomal granulomas in tracheostomy-dependent children. More studies that are larger and have longer follow-up are needed to evaluate the use of this technique.

Osseointegrated implants for auricular prostheses: An alternative to autologous repair: Osseointegrated Implants vs. Autologous Repair

This study compares the hospital cost of osseointegrated implants for retention of an auricular prosthesis to autologous ear reconstruction.

Recurrent post-tonsillectomy bleeding due to an iatrogenic facial artery pseudoaneurysm

Abstract This is a report of an illustrative case of recurrent post-tonsillectomy bleeding that was caused by an iatrogenic facial artery pseudoaneurysm and controlled by endovascular embolization. A 37 year-old female who underwent bilateral tonsillectomy for chronic tonsillitis had recurrent secondary hemorrhage despite multiple operative interventions to control the bleeding. Because of the recurrent nature of the bleeding, an angiography of the external carotid artery was performed demonstrating a pseudoaneurysm of the left facial artery with active extravasation. This was successfully embolized with ethylene vinyl alcohol copolymer and the bleeding did not recur. Most post-operative bleeds can be managed with bedside or intraoperative interventions. However, pseudoaneurysms should be considered in the differential diagnosis of recurrent bleeds refractory to surgical control.

What is the optimal age to repair tympanic membrane perforations in pediatric patients

BACKGROUND Tympanic membrane perforation is a common pediatric otolaryngology diagnosis that most frequently occurs after myringotomy tube extrusion, complicated otitis media, or traumatic perforation. Repair is often necessary if it does not heal spontaneously. Untreated perforations can lead to conductive hearing loss, speech delays, chronic otorrhea, the need for precautions during water sports, and migration of squamous epithelium into the middle ear space where it can form cholesteatoma. Repair is typically performed with autologous fascia and/or cartilage grafts and can be described as a tympanoplasty or myringoplasty. The reported success of repair ranges from 35% to 94%, which is lower than in the adult population. This difference may be due to relatively more frequent upperrespiratory tract infections or persistent Eustachian tube dysfunction in children. The variability in criteria for surgical and audiologic success contributes to the wide range reported in the literature. Most studies on this topic do not exactly follow the American Academy of Otolaryngology– Head and Neck Surgery 1995 guidelines for the evaluation of treatment results of conductive hearing loss. Duration, size, and location of the perforation; status of the contralateral middle ear; Eustachian tube function; adenoid hypertrophy; and surgeon experience can all influence the outcome. Disagreement exists regarding the optimal age to repair tympanic membrane perforations and whether there is benefit to waiting until the child is past a certain age. Many different algorithms for timing repair have been proposed. The purpose of this study is to evaluate the literature to determine the optimal time to repair tympanic membrane perforations in the pediatric population. LITERATURE REVIEW Preceding studies that recommended delaying tympanic membrane repair to 7 to 11 years of age lacked longterm follow-up. In 2007, Yung et al. published results from a full year after primary repair of central perforations due to chronic otitis media. Previous studies may have missed late failures. Fifteen children aged 4 to 8 years were compared to 36 children aged 9 to 13 years, and success was defined as an “intact tympanic membrane, free from OME, atelectasis, ear discharge, and myringitis, and with no worsening of hearing.” Success was achieved 63% of the time. They found no difference in outcome between the older and younger age groups for either the full definition of success or for any of the components of the definition. The majority of publications evaluating pediatric age assessed repair with fascia grafts. After positive reports of perforation closure with cartilage grafts in adults, Friedman et al. compared type I cartilage tympanoplasty outcomes in a total of 119 patients in three age groups: age 4 to 7, 7 to 10, and 10 to 13 years. They found no difference in graft take or audiological outcomes between the three groups. Their overall success ranked high at 95% at an average of 1.5 years after surgery. Their clinical algorithm is to perform tympanoplasty after 4 years of age. If the contralateral middle ear is abnormal, they will treat the nose, consider adenoidectomy, and delay tympanoplasty until age 7. A prolonged delay of tympanic membrane repair may have negative long-term effects. An analysis by Knapik et al. of a cohort of 201 patients without dysmorphic syndromes who underwent tympanoplasty alone found no difference in anatomic outcomes between 0 to 11 years olds compared to 12 to 18 year olds. Anatomic failures were defined as ears with “perforations, middle ear cholesteatoma or tympanic membrane retractions higher than grade 1.” Although there was no difference in air–bone gaps between the two age strata, preoperative and postoperative bone conduction thresholds were significantly worse in the older cohort. Knapik et al postulated that this may be due to recurring infections in the setting of a chronic perforation that result in long-term irreversible inner ear damage. Complications can also occur as a result of the procedure itself. Ribeiro et al. divided 79 tympanoplasties From the Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center (M.A.R., D.K.), Durham, North Carolina, U.S.A.