Matthew Shew

Migrated esophageal foreign body presents as acute onset dysphagia years later: A case report §

Ingested esophageal foreign bodies are commonly seen in the pediatric population. Rarely do they perforate and migrate through neck fascial planes asymptomatically. We present a case of an otherwise healthy 11 year old with sudden onset dysphagia that based on MRI and CT findings was most consistent with an esophageal duplication cyst. However upon surgical exploration, a circular disk like foreign body was identified adjacent to the esophagus. Given the patients age and no reports of purposeful ingestion, it is most likely the patient had ingested this disk foreign body in early childhood, leaving her asymptomatic for 8 years prior to presentation.

Epidemiology of Dizzy Patient Population in a Neurotology Clinic and Predictors of Peripheral Etiology

OBJECTIVE To compare the proportion of peripheral versus nonperipheral dizziness etiologies among all patients, inclusive of those presenting primarily or as referrals, to rank diagnoses in order of frequency, to determine whether or not age and sex predict diagnosis, and to determine which subgroups tended to undergo formal vestibular testing. STUDY DESIGN Retrospective cohort. SETTING Academic neurotology clinic. PATIENTS Age greater than 18 neurotology clinic patients with the chief complaint of dizziness. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Age, sex, diagnosis, record of vestibular testing. RESULTS Two thousand seventy-nine patients were assigned 2,468 diagnoses, of which 57.7 and 42.3% were of peripheral and nonperipheral etiologies, respectively. The most common diagnoses were Ménières (23.0%), vestibular migraine (19.3%), benign paroxysmal positional vertigo (BPPV) (19.1%), and central origin, nonmigraine (16.4%). Peripheral diagnoses are more likely to be found in men than in women (odds ratio [OR] 1.59). Peripheral diagnoses were most likely to be found in the 60 to 69 age group (OR 3.82). There was not a significant difference in rate of vestibular testing between women and men. Among patients with two diagnoses, the most common combinations were vestibular migraine and BPPV then vestibular migraine and Ménières. CONCLUSIONS A large proportion of patients seen for the chief complaint of dizziness in the neurotology clinic were found not to have a peripheral etiology of their symptoms. These data challenge a prevalent dogma that the most common causes of dizziness are peripheral: BPPV, vestibular neuritis, and Ménières disease. Age and sex are statistically significant predictors of peripheral etiology of dizziness.

Surgical Treatment of Orbital Blowout Fractures: Complications and Postoperative Care Patterns

Orbital fractures are a common result of facial trauma. Sequelae and indications for repair include enophthalmos and/or diplopia from extraocular muscle entrapment. Alloplastic implant placement with careful release of periorbital fat and extraocular muscles can effectively restore extraocular movements, orbital integrity, and anatomic volume. However, rare but devastating complications such as retrobulbar hematoma (RBH) can occur after repair, which pose a risk of permanent vision loss if not addressed emergently. For this reason, some surgeons take the precaution of admitting patients for 24-hour postoperative vision checks, while others do not. The incidence of postoperative RBH has not been previously reported and existing data are limited to case reports. Our aim was to examine national trends in postoperative management and to report the incidence of immediate postoperative complications at our institution following orbital repair. A retrospective assessment of orbital blowout fractures was undertaken to assess immediate postoperative complications including RBH. Only patients treated by a senior surgeon in the Department of Otolaryngology were included in the review. In addition, we surveyed AO North America (AONA) Craniomaxillofacial faculty to assess current trends in postoperative management. There were 80 patients treated surgically for orbital blowout fractures over a 9.5-year period. Nearly all patients were observed overnight (74%) or longer (25%) due to other trauma. Average length of stay was 17 hours for those observed overnight. There was one (1.3%) patient with RBH, who was treated and recovered without sequelae. Results of the survey indicated that a majority (64%) of responders observe postoperative patients overnight. Twenty-nine percent of responders indicated that they send patients home the same day of surgery. Performance of more than 20 orbital repairs annually significantly increased the likelihood that faculty would manage patients on an outpatient basis postoperatively (p = 0.04). For orbital blowout fractures, the number of immediate postoperative complications at our institution is low. In addition, North American trends in postoperative management of orbital blowout fractures may suggest that selected patients can be managed on an outpatient basis, which would have a positive effect on conservation of diminishing healthcare resources.

Endoscopically Assisted Drilling, Exposure of the Fundus through a Presigmoid Retrolabyrinthine Approach: A Cadaveric Feasibility Study:

The presigmoid retrolabyrinthine approach to the cerebellopontine angle is traditionally described to not provide access to the internal auditory canal (IAC). We aimed to evaluate the extent of the IAC that could be exposed with endoscopically assisted drilling and to measure the percentage of the IAC that could be visualized with the microscope and various endoscopes after drilling had been completed. Presigmoid retrolabyrinthine approaches were performed bilaterally on 4 fresh cadaveric heads. We performed endoscopically assisted drilling to expose the fundus of the IAC, which resulted in exposure of the entire IAC in 8 of 8 temporal bone specimens. The microscope afforded a mean view of 83% (n = 8) of the IAC. The 0°, 30°, 45°, and 70° endoscope each afforded a view of 100% of the IAC in 8 of 8 temporal bone specimens. In conclusion, endoscopic drilling of the IAC of can provide an extradural means of exposing the entire length of the IAC while preserving the labyrinth.

Magnetic Resonance Imaging in a Neurofibromatosis Type 2 Patient with a Novel MRI-Compatible Auditory Brainstem Implant

Auditory brainstem implantation has become a key technique for the rehabilitation of hearing in patients with neurofibromatosis type 2. The nature of this devastating genetic disease requires ongoing MRI for the patients lifespan. Today, most auditory brainstem implants require removal of the magnet that connects the internal device to the external speech processor to undergo imaging as their disease progresses. Patients have the option of having a short procedure to have the magnet taken out and replaced each time, or alternately using a headband to secure the processor over the receiver coil of the internal device. Novel magnet technology has led to the development of a freely rotating magnet that can be used inside the magnetic field of an MRI scanner without losing magnet strength and without being displaced from the body of the device. We report one of the first patients implanted with a Med-El Synchrony ABI in the United States who subsequently underwent successful imaging with MRI 1.5 tesla to follow for other existing schwannomas.

Impact of Resident Participation on Operative Time and Outcomes in Otologic Surgery

Objectives To describe the impact of resident involvement in tympanoplasty on operative time and surgical complication rates. Study Design Case series with chart review. Setting Tertiary medical center. Subjects and Methods Current Procedural Terminology codes were used to identify patients in the 2011-2014 public use files of the American College of Surgeons National Surgical Quality Improvement Program who underwent a tympanoplasty or tympanomastoidectomy. Cases were included if the database indicated whether the operating room was staffed with an attending alone or an attending with residents. Categorical and continuous variables were compared with chi-square, Fisher’s exact, and Mann-Whitney U tests. Generalized linear models with a log-link and gamma distribution were used to examine the factors affecting operative time. Results Overall, 1045 cases met our study criteria (tympanoplasty, n = 797; tympanomastoidectomy, n = 248). Resident involvement increased mean operative time for tympanoplasties by 46% (107 vs 73 minutes, P < .001) and tympanomastoidectomies by 49% (175 vs 117 minutes, P < .001). While controlling for confounding factors, the variable with the largest impact on operative time was resident involvement. There were no significant differences observed in the rate of surgical complications between attending-alone and attending-resident cases. Conclusion Resident involvement in tympanoplasty and tympanomastoidectomy did not affect the surgical complication rate. Resident involvement increased operative time for tympanoplasties and tympanomastoidectomies; however, the specific reasons for the increase are not explained by the available data.

Juxtafacial Lipoma within the Mastoid Bone

L ipoma or other fat-containing neoplasms of the head and neck are relatively common, occurring in about 13% to 25% of masses in this region. Most of these lesions present subcutaneously, with occasional deeper involvement in the neck. Lipomatous involvement of the temporal bone is very rare and typically involves the internal auditory canal if present. We present a unique case of an adipocytic lesion of the mastoid bone near the stylomastoid foramen causing facial nerve weakness.

Petrous Apex Pneumatization: Influence on Postoperative Cerebellopontine Angle Tumor Cerebrospinal Fluid Fistula

Objective: Multiple investigators have sought to identify risk factors for cerebrospinal fluid (CSF) leak following cerebellopontine angle (CPA) tumor resection. We evaluated whether pneumatization of the petrous apex (PA) is a risk factor for CSF fistula. Method: We conducted a retrospective chart review at 2 major tertiary academic institutions undergoing CPA tumor resection and analyzed their respective head or temporal computed tomography (CT) scans if available. Results: A total of 91 cases were identified; 51 (64%) demonstrated PA pneumatization, and a total of 17 CSF leaks were identified. We discovered higher rates of CSF leak (25.0% vs 13.7%; P = .273) and CSF rhinorrhea (15.0% vs 5.9%; P = .174) in patients with PA pneumatization compared to those without PA pneumatization. Conclusions: Isolated PA pneumatization may be a risk factor and communication pathway for CSF fistula. Further studies will need to be broadened across multiple institutions to draw any additional and stronger conclusions.

Tinnitus perception in patients after vagal nerve stimulator implantation for epilepsy

PURPOSE Vagal nerve stimulation in conjunction with sound therapy has been proposed as a treatment for subjective tinnitus. The purpose of this study is to retrospectively review the effect of VNS on perception of tinnitus in epilepsy patients. We explore the incidence of tinnitus and its perceived reduction in patients requiring implantation of VNS for medically refractory seizures. MATERIALS AND METHODS A phone survey was conducted in adult patients with prior VNS implantation. A questionnaire including the visual analog scale (VAS) of tinnitus loudness was used to determine the presence and severity of tinnitus. RESULTS Out of the 56 patients who had completed the phone survey, 20 (35%) reported the presence of pre-operative tinnitus. The tinnitus positive group was significantly older (p = 0.019). Of the 20 pre-operative tinnitus positive patients, all patients continued to have tinnitus post-operatively. Four (20%) noted no changes in VAS of tinnitus loudness while 16 (80%) had at least a one-point decrease. The mean difference between pre- and post-operative VAS of loudness was 2.05, with a standard deviation of 1.84 and this was statistically significant (p < 0.001). CONCLUSIONS In this study, we evaluate the potential of vagal nerve stimulation to alter the perception of tinnitus in patients with refractory epilepsy. Eighty percent of patients noted some level of subjective tinnitus improvement after VNS implantation. Given this finding, there may be a potential additional benefit to the use of VNS in patients with epilepsy.

Therapeutic Mastoidectomy Does Not Increase Postoperative Complications in the Management of the Chronic Ear

OBJECTIVE Tympanoplasty with or without concurrent therapeutic mastoidectomy is a controversial topic in the management of chronic ear disease. We sought to describe whether there is a significant difference in postoperative complications. STUDY DESIGN Retrospective cohort study. SETTING American College of Surgeons National Surgical Quality Improvement Program public files. PATIENTS Current procedural terminology codes were used to identify patients with chronic ear disease undergoing tympanoplasty ± concurrent mastoidectomy in the 2011 to 14 American College of Surgeons National Surgical Quality Improvement Program files. INTERVENTION Therapeutic. MAIN OUTCOME MEASURES Variables were compared with χ, Fischers exact, and Mann-Whitney U tests, as appropriate to analyze postoperative complications between tympanoplasty with or without concurrent mastoidectomy. To account for confounding factors, presence of a complication was analyzed in binary logistic regression. Analysis considered sex, hypertension, obesity, advanced age, diabetes, smoking status, American Society of Anesthesiologists Physical status, procedure. RESULTS There were 4,087 patients identified meeting criteria (tympanoplasty = 2,798, tympanomastoidectomy = 1,289). There was no statistical difference in postoperative complications (tympanoplasty n = 49 [1. 8%], tympanomastoidectomy n = 33 [2. 6%]; p = 0. 087) or return to the operating room (tympanoplasty = 4 [0. 1%], tympanomastoidectomy = 6 [0. 5%]; p = 0. 082). Binary logistic regression demonstrated smoking as a predictor of a postoperative complication (OR: 1. 758, 95% CI: 1. 084-2. 851; p = 0. 022), while concurrent mastoidectomy did not significantly increase the risk of complication (OR: 1. 440, 95% CI: 0. 915-2. 268; p = 0. 115). There was a significant difference in mean operative time between tympanoplasty and tympanomastoidectomy: 85.7 versus 154.23 min, p < 0. 001. CONCLUSION In the management of chronic ear disease, tympanoplasty with concurrent mastoidectomy increases time under anesthesia, but it is not associated with any increased postoperative complications compared with tympanoplasty alone.