Mirabelle Sajisevi

Modeling alterations in sinonasal physiology after skull base surgery.

Background Endonasal endoscopic skull base surgery (EESBS) often requires significant alterations in intranasal anatomy. For example, posterior septectomy (PS) with middle turbinate resection (MTR) is frequently performed to provide access to large sellar and clival tumors. However, little is known about the alterations that occur in sinonasal physiology. This study was designed to assess changes in sinonasal physiology after virtually performed endoscopic skull base surgery. Methods Three-dimensional models of the sinonasal passage were created from computed tomography scans in three subjects with varying anatomy: no SD (SD), right anterior SD, and left anterior SD, respectively. Four additional surgery types were performed virtually on each model: endoscopic transsphenoidal approach (ETSA) with small (1 cm) PS (smPS), ETSA with complete (2 cm) PS, ETSA with smPS and right MTR, and ETSA with complete PS and right MTR. Computational fluid dynamics (CFD) simulations were performed on the 3 presurgery and 12 virtual surgery models to assess changes from surgery types. Results Increased nasal airflow corresponded to amount of tissue removed. Effects of MTR on unilateral airflow allocation were unchanged in subject with no SD, worsened in leftward SD, and reversed in rightward SD. Severity of airflow and mucosal wall interactions trended with amount of tissue removed. MTR hindered flow interactions with the olfactory mucosa in subjects with SD. Conclusion CFD simulations on virtual surgery models are able to reasonably detect changes in airflow patterns in the computer-generated nasal models. In addition, each patients unique anatomy influences the magnitude and direction of these changes after virtual EESBS. Once future studies can reliably correlate CFD parameters with patient symptoms, CFD will be a useful clinical tool in surgical planning and maximizing patient outcomes.

What is the role of imaging in tinnitus

BACKGROUND Tinnitus is the perception of an auditory sensation in the absence of external stimuli. It affects up to 10% of the population and often brings patients to the attention of otolaryngologists. There are many benign causes of tinnitus, and serious underlying causes must be ruled out.Tinnitus can be categorized as subjective versus objective and pulsatile versus nonpulsatile. These distinctions, along with a detailed clinical history and neurotologic examination, help guide selection of further studies. Imaging is performed for patients believed to have a high probability of detecting a radiologic abnormality or a potential for a serious underlying condition. The ideal imaging modality should be one that is able to evaluate for the greatest number of etiologies with the lowest cost. In this Best Practice review, we examine the role of the various imaging modalities in the diagnosis of pulsatile and nonpulsatile tinnitus.

Nonadherence to Guideline Recommendations for Tympanostomy Tube Insertion in Children Based on Mega-database Claims Analysis

Objective To estimate the nonadherence rate of pressure equalization (tympanostomy) tube (PET) placement in the preceding 3-year period before release of the 2013 American Academy of Otolaryngology—Head and Neck Surgery Foundation clinical practice guideline (CPG). Study Design Analysis of the Truven Health MarketScan Research Databases (2010-2012). Subjects and Methods Medical claims data from 2010 to 2012 were analyzed. Children aged ≤12 years with otitis media (OM)–related diagnoses were identified. Adherence and nonadherence rates for OM and PET placement were analyzed through administrative codes extrapolated from the key action statements (KASs) of the CPG. KASs were aggregated to estimate the overall nonadherence and determine areas for quality improvement. Results A total of 9,726,411 visits with OM-associated codes among 3,710,730 children were identified: 2.9% (80,451 of 3,239,700) were considered nonadherent to KAS 1 because a code for PET placement occurred with a first episode of OM with effusion <3 months; 52.1% (14,534 of 27,913) underwent PET placement for OM with effusion of >3 months and had a concurrent hearing loss code. For those without hearing loss who underwent PET placement, 48.3% (52,921 of 109,583) had a diagnosis code indicating risk for speech, language, or learning problems. For each KAS, we found heterogeneity of computed nonadherence rates by region, age, and season. Conclusion Before guideline dissemination, we found low to moderate rates of nonadherence to guideline recommendation. Deeper analysis of mega-databases could provide better insights for measurement of guideline adherence. The expansion of administrative and clinical databases provides a unique opportunity to investigate the impact of CPGs.

The Role of Professional Identity Formation in Balancing Residency Service Versus Educational Needs.

Residency is a unique time in one’s medical career. It is a time of intense learning and mentorship, as well as work and service. The aspects of service and education in residency have often been regarded as being on the opposite ends of a spectrum. As an example, consider the scenario of a resident who has decided, midresidency, to move into another specialty. In order to provide the best preparation for this new career choice, one might assume that freeing up time to participate in research projects and prepare for application into the newly chosen specialty would be the best course of action. After all, once the decision has been made to change specialties, what educational value remains in being part of a specialty that one will never practice? Certainly, various logistical and professional concerns may exist regarding completing clinical duties to minimize disruptions of colleagues’ schedules resulting from a resident leaving a program midyear. However, the completion of such obligations would seem to fall squarely in the ‘‘service’’ category, with little to no educational utility. This underscores the fact that service and education in residency are often considered opposing, and mutually exclusive, considerations. There is a resident survey given by the Accreditation Council for Graduate Medical Education (ACGME), which is conducted to monitor compliance with the accreditation standards, and residents are asked how often their clinical education is comprised of excessive service obligations. 1 The ACGME highlights the emphasis on learning activities and supports the principle that the balance of education and service should be weighted on the side of education. The ACGME’s expectation that education should receive a higher priority than service likely is rooted in the exploitation of residents dating back to the 1920s and 1930s, when interns were relegated to paperwork and inserting intravenous lines, while having limited opportunities for didactics or clinical rounds. 2 The ACGME standards emphasize the educational aspects of residency training. However, who really determines what constitutes ‘‘excessive service obligations’’? Currently, the arbiter is on the trainee, and this has led to some challenges. 3,4 In addition, neither ‘‘education’’ nor ‘‘service’’ is defined by the ACGME, and trainees responding to the survey may not be aware of the experiential learning that occurs during service provision. As those who have entered or completed medical training are aware, there are essential tasks residents must perform that fall under the heading of ‘‘work’’ or ‘‘service,’’ such as administrative duties or scheduling. The work required of the residents and their attending teams to effectively care for patients on an inpatient service and manage busy clinic schedules can be significant. While the educational experience may be the primary factor focused on during residency training, this focus may present a false dichotomy in how service aspects are ‘‘balanced,’’ particularly as education and service aspects often are intertwined. In contrast to viewing the relationship of education and service as a ‘‘balance’’ between the 2 dimensions, the educational experience can be understood as a dynamic process. In some instances, the emphasis will be on education, and in other instances, on service.

Image-Guided Placement of Osseointegrated Implants for Challenging Auricular, Orbital, and Rhinectomy Defects

Objectives: Prosthetic reconstruction can restore the preoperative form and function after surgery for head and neck malignancies. We demonstrate the use of preoperative planning and intraoperative image guidance for placement of osseointegrated implants to restore craniofacial defects. Methods: A retrospective review of patients with craniofacial defects treated with image-guided placement of osseointegrated prosthetic implants was performed. Results: Case 1: 55-year-old male who underwent total auriculectomy with anterolateral thigh reconstruction. Case 2: 64-year-old male who required orbital exenteration and total auriculectomy with latissimus dorsi reconstruction. Case 3: 74-year-old male presented after a total rhinectomy. Cases 1 and 3 received adjuvant radiation prior to implantation. Case 2 underwent simultaneous placement of osseointegrated hearing and prosthetic implants. Computed tomography scans were used to perform preoperative planning to determine the optimal implant trajectories and sites. Complications included tissue overgrowth, delayed nonunion of implant, wound infection, and dehiscence. Conclusions: Defects following oncologic resection of head and neck malignancies can be difficult to achieve with native tissue alone. Osseointegrated implants offer an excellent means for reconstruction but can be challenging due to limited bone stock and anatomic landmarks. This can be overcome using intraoperative image guidance techniques for prosthetic reconstruction.

Incidence of Retrocochlear Pathology Found on MRI in Patients With Non-Pulsatile Tinnitus.

Objective: To identify the incidence of retrocochlear pathology on MRI in patients with non-pulsatile tinnitus. Study Design: Retrospective review. Setting: Tertiary referral center. Patients: Adults with MRIs performed between March 1, 2008 and February 1, 2014 for non-pulsatile tinnitus with or without hearing loss. Intervention: MRI. Main Outcome Measure: Incidence of retrocochlear pathology. Results: Of the 218 patients who met inclusion criteria, 198 (91.3%) had unremarkable MRIs. Six patients (2.7%) had MRI findings that accounted for their tinnitus. Of these patients, five had unilateral tinnitus with asymmetric hearing loss because of acoustic neuroma found on MRI. One patient presented with bilateral tinnitus with asymmetric hearing loss and was found to have a right acoustic neuroma. Twenty (9.2%) patients had bilateral or unilateral tinnitus without hearing loss, all with unremarkable MRIs. Fourteen patients (6.4%) had incidental findings including two acoustic neuromas that were identified contralateral to the side of presenting tinnitus. Conclusions: Imaging should be used judiciously in the evaluation of tinnitus. Patients with unilateral tinnitus and asymmetric hearing loss were most likely to have abnormal findings. The majority of MRIs performed for tinnitus were normal in our study. Given the low incidence of MRI findings in the workup of tinnitus, every effort should be made to optimize screening protocols. Noncontrasted fast spin-echo T2-weighted MRI should be used to assess patients with tinnitus when there is low suspicion for retrocochlear pathology. Patients with unilateral non-pulsatile tinnitus with symmetric hearing may be observed, but clinical judgement should determine the need for further imaging.

Pediatrician approach to dysphonia.

OBJECTIVE The prevalence of voice disorders reaches up to 23.4% in the pediatric population and has a negative impact on quality of life. The objective of this study is to examine how pediatricians assess and manage patients with voice disorders and barriers they face when evaluating patients with dysphonia. SUBJECTS AND METHODS The study was designed as a cross-sectional survey. Pediatricians who are members of the North Carolina Pediatric Society or Duke University affiliated physicians were selected to participate in the study. They were emailed a description of the study with a link to a questionnaire regarding comfort level in recognizing an abnormal voice, how often they assess for dysphonia, barriers to evaluation of voice problems, reasons for referral, and common treatments employed. RESULTS A total of 1125 physicians were sent a questionnaire and 72 replied for a response rate of 6.4%. Of those who responded, only 16.7% routinely assess patients for voice problems. The most common reasons for not assessing patients for dysphonia include patients not complaining of voice problems or parents not concerned, and being unsure of the best method or available treatment options. Referrals were most commonly made when speech could not be understood or when the voice problem coincided with other neurological symptoms. Allergy and reflux medications were often trialed prior to referral. The majority of responders felt that voice problems impacted quality of life and 84.7% were interested in more information regarding pediatric voice problems. CONCLUSION Pediatricians encounter barriers in the assessment of voice problems in their patients. There is evidence from our study that they have interest in learning more about dysphonia. Otolaryngologists must continue to provide outreach to pediatricians to enhance the screening and management of patients with voice disorders.

Nasopharyngeal Masses Arising from Embryologic Remnants of the Clivus: A Case Series.

Objectives This study aims to (1) discuss rare nasopharyngeal masses originating from embryologic remnants of the clivus, and (2) discuss the embryology of the clivus and understand its importance in the diagnosis and treatment of these masses. Design and Participants This is a case series of three patients. We discuss the clinical and imaging characteristics of infrasellar craniopharyngioma, intranasal extraosseous chordoma, and canalis basilaris medianus. Results Case 1: A 16-year-old male patient with a history of craniopharyngioma resection, who presented with nasal obstruction. A nasopharyngeal cystic mass was noted to be communicating with a patent craniopharyngeal canal. Histology revealed adamantinomatous craniopharyngioma. Case 2: A 43-year-old male patient who presented with nasal obstruction and headache. Computed tomography (CT) and magnetic resonance imaging revealed an enhancing polypoid mass in the posterior nasal cavity abutting the clivus. Histopathology revealed chondroid chordoma. Case 3: A 4-year-old female patient with a recurrent nasopharyngeal polyp. CT cisternogram showed that this mass may have risen from a bony defect of the middle clivus suggestive of canalis basilaris medianus. Conclusions Understanding the embryology of the clivus is crucial when considering the differential diagnosis of a nasopharyngeal mass. Identification of characteristic findings on imaging is critical in the diagnosis and treatment of these lesions.

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.

A Case of Dysphonia and Cough Caused by Spontaneous Intracranial Hypotension.

A Case of Dysphonia and Cough Caused by Spontaneous Intracranial Hypotension Otolaryngology– Head and Neck Surgery 2014, Vol. 151(2) 367–368 American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814529913 http://otojournal.org Mirabelle Sajisevi, MD, Gina Vess, MA, CCC-SLP, and David L. Witsell, MD, MHS