Mark A. Vecchiotti

An Experimental Model of Sudden Death Due to Low-Energy Chest-Wall Impact (Commotio Cordis)

BACKGROUND The syndrome of sudden death due to low-energy trauma to the chest wall (commotio cordis) has been described in young sports participants, but the mechanism is unknown. METHODS We developed a swine model of commotio cordis in which a low-energy impact to the chest wall was produced by a wooden object the size and weight of a regulation baseball. This projectile was thrust at a velocity of 30 miles per hour and was timed to the cardiac cycle. RESULTS We first studied 18 young pigs, 6 subjected to multiple chest impacts and 12 to single impacts. Of the 10 impacts occurring within the window from 30 to 15 msec before the peak of the T wave on the electrocardiogram, 9 produced ventricular fibrillation. Ventricular fibrillation was not produced by impacts at any other time during the cardiac cycle. Of the 10 impacts sustained during the QRS complex, 4 resulted in transient complete heart block. We also studied whether the use of safety baseballs, which are softer than standard ones, would reduce the risk of arrhythmia. A total of 48 additional animals sustained up to three impacts during the T-wave window of vulnerability to ventricular fibrillation with a regulation baseball and safety baseballs of three degrees of hardness. We found that the likelihood of ventricular fibrillation was proportional to the hardness of the ball, with the softest balls associated with the lowest risk (two instances of ventricular fibrillation after 26 impacts, as compared with eight instances after 23 impacts with regulation baseballs). CONCLUSIONS This experimental model of commotio cordis closely resembles the clinical profile of this catastrophic event. Whether ventricular fibrillation occurred depended on the precise timing of the impact. Safety baseballs, as compared with regulation balls, may reduce the risk of commotio cordis.

Otologic outcomes after blast injury: the Boston Marathon experience

Objective Otologic trauma was the most common physical injury sustained after the April 15, 2013, Boston Marathon bombings. The goal of this study is to describe the resultant otologic morbidity and to report on early outcomes. Study Design Multi-institutional prospective cohort study. Methods Children and adults seen for otologic complaints related to the Boston Marathon bombings comprised the study population. Participants completed symptom assessments, quality-of-life questionnaires, and audiograms at initial and 6-month visits. Otologic evaluation and treatment, including tympanoplasty results, were reviewed. Results More than 100 patients from eight medical campuses have been evaluated for blast-related otologic injuries; 94 have enrolled. Only 7% had any otologic symptoms before the blasts. Ninety percent of hospitalized patients sustained tympanic membrane perforation. Proximity to blast (RR = 2.7, p < 0.01) and significant nonotologic injury (RR = 2.7, p < 0.01) were positive predictors of perforation. Spontaneous healing occurred in 38% of patients, and tympanoplasty success was 86%. After oral steroid therapy in eight patients, improvement in hearing at 2 and 4 kHz was seen, although changes did not reach statistical significance. Hearing loss, tinnitus, hyperacusis, and difficulty hearing in noise remain persistent and, in some cases, progressive complaints for patients. Otologic-specific quality of life was impaired in this population. Conclusion Blast-related otologic injuries constitute a major source of ongoing morbidity after the Boston Marathon bombings. Continued follow-up and care of this patient population are warranted.

Photodynamic therapy of cottontail rabbit papillomavirus-induced papillomas in a severe combined immunodeficient mouse xenograft system

To evaluate the efficacy of photodynamic therapy (PDT) with the phthalocyanine photosensitizer Pc 4 for treating an animal model of recurrent respiratory papillomatosis (RRP).

Endolymphatic duct violation during retrosigmoid dissection of the internal auditory canal: a human temporal bone radiographic study.

Objective/Hypothesis: Successful hearing preservation after acoustic neuroma resection is sometimes complicated by delayed hearing deterioration. The goal of this study was to investigate the hypothesis that internal auditory canal (IAC) drilling during retrosigmoid acoustic neuroma removal may result in endolymphatic duct (ELD) injury, a potential cause of delayed hearing loss (HL) after hearing preservation surgery.

Sedation after airway reconstruction in children: A protocol to reduce withdrawal and length of stay.

Laryngoscope, 125:2216–2219, 2015

Lower island trapezius myocutaneous flap reconstruction of a large neck defect in an infant

Free tissues transfer has been well-described in infants but there is limited data on techniques for reconstruction of large neck defects with regional myocutaneous flaps in this population. We report on the use of a lower island trapezius myocutaneous flap to reconstruct a large posterior neck and occiput wound in an 18-month-old child. The use of a regional myocutaneous flap allowed for reliable transfer of a relatively large volume of skin and soft tissue, providing coverage of the internal jugular vein and spinal accessory nerve as well as limiting the likelihood of debilitating scar contracture.

A rare case of pediatric Nontraumatic Myositis Ossificans in the posterior triangle

BACKGROUND Myositis Ossificans Cicumscripta is a rare condition characterized by aberrant bone formation in paramuscular soft tissue of the extremities usually associated with trauma or a genetic mutation. Very few cases involve the head or neck and it is rarely found in the pediatric population. OBJECTIVES We present a case of a 5-month old with a rapidly growing posterior neck mass suspicious for neoplasia, which was treated with surgical resection and found to be a non-traumatic, non-genetic form of Myositis Ossificans. The workup, treatment, and findings of the patient are outlined and a review of the literature on this disease is discussed. CONCLUSION Myositis Ossificans is characterized by aberrant bone formation typically occurring after trauma but may be secondary to an underlying genetic abnormality. The case presented in the absence of trauma or an underlying genetic abnormality and is therefore an exceedingly rare instance of the sporadic form that presented spontaneously in the head and neck of a pediatric patient.

Predicting Surgical Intervention in Micrognathic Infants

Objective: To determine which factors in the early neonatal period may predict subsequent need for surgical intervention in infants with micrognathia. Method: A retrospective case series of 123 infants from 2 tertiary pediatric referral centers over a 10-year period. Results: Forty-eight (39%) of micrognathic children required definitive airway intervention during infancy in this series. These interventions came in the form of tracheostomy (n = 12), mandibular distraction osteogenesis (MDO) (n = 33), or prolonged intubation prior to withdrawal of care (n = 3). Factors associated with a need for definitive airway intervention included a history of intubation or tracheotomy in the first 24 hours of life (OR: 8.22; CI: 3.14-21.54), a history of intrauterine growth restriction (OR: 4.1; CI: 1.00-16.71), neurologic impairment (OR: 3.83; CI: 1.33-11.06), and prematurity (<37 weeks gestational age) (OR: 2.38; CI: 1.02-5.56). Those with isolated micrognathia without cleft palate were less likely to require intervention (OR: 0.2; CI: 0.05-0.71). Conclusion: While it is understood that the need for MDO or tracheostomy should be determined on a case-by-case basis, this study identifies a number of factors, which may predict which neonates with micrognathia are at increased risk for requiring early surgical intervention for respiratory and feeding problems.

Rehabilitation of Microglossia with Mandibular Distraction

Objective: Describe an approach to surgical rehabilitation of feeding, speech, and upper airway obstruction in an infant with microglossia and micrognathia. Method: Case report and literature review. Results: We describe a 17-month-old child with micrognathia, microglossia, and submucus cleft palate who was initially fed via g-tube and did not require early airway interventions. As the child was attaining normal developmental milestones, the decision was made to perform bilateral mandibular distraction osteogenesis as a means of improving feeding, speech, and clinical symptoms of obstructive sleep apnea. In this report, relevant literature is also reviewed as it pertains to the rehabilitation and reconstruction of this rare craniofacial anomaly. Conclusion: Mandibular distraction osteogenesis improved glossoptosis and created a more favorable position of the tongue within the oral cavity. This in turn allowed for an overall improvement in oral motor function culminating in removal of the feeding tube.

Regional Flap Reconstruction of a Neck Defect in an Infant

Objective: 1) Describe the use of a lower island trapezius myocutaneous flap to reconstruct a large posterior neck and occiput wound in an 18-month-old child. 2) Review prior uses of regional myocutanous flaps for soft tissue reconstruction in infants and small children. Method: Case report and literature review. Results: While there is an increasing body of literature documenting the safe and effective use of free tissue transfer in the pediatric age group, there is little published on the use of regional myocutaneous flaps for reconstruction of larger ablative defects. We report on the use of a lower island trapezius myocutaneous flap to reconstruct a large posterior neck and occiput wound in an 18-month-old child. The case is described in detail and the literature reviewed. Conclusion: Techniques for regional reconstruction of large neck defects in infants have not been widely described. The lower island trapezius myocutaneous flap allowed for transfer of a large volume of skin and soft tissue, improving functional outcome and limiting development of scar contracture.