Philip D. Littlefield

Radiofrequency excision versus monopolar electrosurgical excision for tonsillectomy.

OBJECTIVE: We previously compared radiofrequency (Evac) tonsillotomy with monopolar electrosurgical (Bovie) tonsillectomy and showed significantly less pain with the Evac. Tonsillotomy leaves a cuff of tonsil behind, the significance of which is unknown. We hypothesize that Evac tonsillectomy also is less painful than Bovie tonsillectomy. STUDY DESIGN AND SETTING: We compared Evac (ENTec Evac 70; ArthroCare, Sunnyvale, CA) and Bovie tonsillectomy in a prospective, blinded fashion. Each participant had 1 tonsil removed by each device. We recorded, by side, the surgical time, blood loss, operative difficulty, pain (postoperative days 1, 3, 5, 7, 10, and 14), and the side that each patient preferred. RESULTS: Data were analyzed for 17 patients. They reported significantly less pain with the Evac (P < 0.036, F = 5.87). The Evac was preferred by 12 of 14 patients. CONCLUSION: Evac tonsillectomy is significantly less painful than Bovie tonsillectomy. Patients blinded to treatment preferred the Evac technique. SIGNIFICANCE: The Evac device decreases postoperative pain.

Lessons learned in otologic surgery: 30 years of malpractice cases in the United States.

Objective To analyze malpractice litigation trends to better understand the causes and outcomes of suits involving otologic surgeries to prevent future litigation and improve physician awareness. Methods Court records of legal trials from 1983 to 2012 were obtained from 2 major computerized databases—WESTLAW and LexisNexis. Data were compiled on the demographics of the defendant, plaintiff, use of otolaryngologists/otologists as expert witnesses, nature of injury, type of surgery, legal allegations, verdicts, and judgments. Results Fifty-eight unique cases met inclusion criteria and were selected for review. The most common surgeries that went to trial were mastoidectomy (48%), ossiculoplasty (21%), and tympanoplasty (16%). Eleven (19%) of the cases were resolved through a settlement before a verdict was reached. Verdicts in favor of the plaintiffs (31%) were awarded an average of

Tympanoplasty Outcomes for Blast-Induced Perforations from Iraq and Afghanistan 2007-2012

1,131,189. The most common alleged injuries were hearing loss (45%) and facial nerve injury (38%). Of the cases found in favor of the plaintiff, the most common reasons cited were improper performance of the surgery (50%), failure to properly diagnose and treat (33%), and inadequate informed consent and delay in diagnosis (22% each). Case outcomes involving pediatric patients were not significantly different than those of adults (p = 0.34); however, adults received higher financial awards on average (

Late presentation of subcutaneous emphysema and pneumomediastinum following elective tonsillectomy

1 million versus

Adverse Events Following Vestibular Schwannoma Surgery: A Comparison of Surgical Approach

232,000; p < 0.0003). Conclusion Obtaining an appropriate diagnosis, thoroughly discussing all options and potential risks, presenting realistic expectations, and executing the surgery correctly are crucial to patient care. Understanding the reasons surgeons go to trial may assist in mitigating risk for potential lawsuits.

Ceruminous adenocarcinoma: An analysis of the Surveillance Epidemiology and End Results (SEER) database

Objective To describe characteristics of blast-induced tympanic membrane perforations that do not spontaneously heal, evaluate the outcomes of tympanoplasty techniques, and understand the factors associated with surgical success. Setting Two tertiary military health care institutions. Study Design Case series with chart review. Subjects and Methods This study reviewed the practice of 1 military neurotologist and included all tympanoplasties for combat blast-induced perforations from 2007 to 2012, which comprised a total of 55 patients. Surgical outcomes and associated perioperative factors were examined to include size, location, bilateral involvement, timing of surgery, and surgical technique. Results Fifty-five patients (68 ears) met inclusion criteria. Thirty-six (53%) were total or near-total perforations, and 51% of patients had bilateral perforations. The overall success rate was 77%. It was 82% for lateral grafts and 70% for medial grafts, but the difference between these was not statistically significant. Age was a significant factor, with a success rate of 56% for ages 25 to 34 years, compared with 90% for 20 to 24 and >34 years. Patients who had bilateral sequential tympanoplasties also had lower success rates than those who had only unilateral surgery (62% vs 87%, P = .002). Ossicular disruptions were found in 5 ears, and cholesteatoma was discovered in 8. Surgical timing did not predict success, as the average time until repair was 153 days in successful cases and 151 days in failures. The mean conductive hearing improvement was 13.6 dB, and there were no major complications. Conclusion Tympanoplasty can be challenging in this population. Age and bilateral surgery were the only independent variables that showed significance.

Phantom vestibular perception: Unfeasible or unnoticed?

Subcutaneous emphysema and pneumomediastinum are rare complications following elective tonsillectomy. Although the mechanism of injury is unclear, air is thought to enter through either the buccopharyngeal mucosa during surgery or via alveolar rupture during positive pressure ventilation. Patients typically present immediately after surgery or upon anesthesia emergence. We describe a case of delayed pneumomediastinum in a 30year-old female who presented 4days after surgery. With only one other case described, we review the literature and remind the reader to be cognizant of this late complication.

Asymmetric Hearing Loss Prompting MRI Referral in a Military Population: Redefining Audiometric Criteria:

OBJECTIVE Compare complications of vestibular schwannoma (VS) resection by surgical approach. STUDY DESIGN Retrospective cohort. SETTING The 2008 to 2013 American College of Surgeons-National Surgical Quality Improvement Program. PATIENTS Adult patients with VS resection by an otolaryngologist. INTERVENTIONS VS resection via transtemporal (TT), retrosigmoid (RS), or middle cranial fossa (MCF) approaches. MAIN OUTCOME MEASURES Hearing preservation approaches were compared with hearing sacrificing approaches. Demographics and intraoperative factors were analyzed to identify predictors of medical and surgical complications, return to the operating room, and death. The effect of trainee presence was evaluated with respect to complications, operative length, and hospital length of stay. RESULTS One hundred eleven VS resections were identified. Patients were predominantly women (57%) and older than 50 years (69%). The TT approach accounted for 50% of the cases, while RS (36%) and MCF (14%) were less common. The risk of any postoperative complication was 17%. There were no patient deaths. There was no difference in the overall complication rate among surgical approaches, nor in the overall, surgical, or medical complication rates between hearing preservation and hearing sacrificing approaches. Trainee presence did not change operation length, hospital length of stay, or complication rates. CONCLUSIONS Complication rates of VS resection are no different when comparing TT, RS, or MCF approaches. Trainee involvement did not significantly affect complications. This study is limited by the inability to evaluate procedure-specific variables (e.g., facial nerve weakness and hearing preservation rates), but offers a unique survey of global 30-day complication rates reported to a large, multi-institutional, publically available database.

Updates in medical malpractice: an otology perspective.

OBJECTIVES Ceruminous adenocarcinoma is a rare malignancy. However, due to the paucity of cases, this has been difficult to study. Using a population-based national database, patient demographics and survival trends were analyzed to further elucidate the management of this malignancy. METHODS The SEER database was queried for patients diagnosed with ceruminous adenocarcinoma between 1973 and 2010. RESULTS Twenty-two patients were identified in the database. The average age of diagnosis was between 60 and 64 years. All of the patients underwent surgical resection of the primary malignancy. Eight patients (36%) also had postoperative radiation. CONCLUSIONS Ceruminous adenocarcinoma is uncommon but may not have as poor a prognosis as previously thought. Surgical resection alone appears to be a reasonable treatment option. Larger prospective studies are needed, but database analysis like this may provide clarity on the management of uncommon diseases.

Dizziness, malpractice, and the otolaryngologist

Abstract Objective: Phantom percepts frequently accompany the loss or damage of body parts or sensation, and have been described for virtually everything except for the vestibular system. Is it possible that phantom vestibular percepts exist and explain some cases of chronic dizziness, or is there something unique to the vestibular system that forbids this? Study design: This review surveyed the literature for any references to phantom vestibular perceptions. This was followed by a broader survey of phantom phenomena. Areas of focus were hearing, the limbs, and vision, and these were theoretically related to the vestibular system. Results: There apparently are no references to vestibular phantoms. There is robust research on tinnitus, phantom limb syndrome, and phantom eye syndrome. There are similar features and proposed aetiological models among these syndromes. Conclusion: It is within reason that vestibular phantom percepts exist, but to date have gone unnoticed due to the subjective nature of vestibular symptoms. However, the vestibular system is unique in several ways that may make phantom percepts far less likely than with other sensory systems. In particular, the cerebral cortex does not have any areas with exclusively vestibular input. In addition, the brainstem processes bilateral vestibular inputs in a unique push-pull mechanism, and synaptic plasticity in the vestibular nucleus facilitates compensation from vestibular injuries. In addition, unlike other senses, there is no conscious perception of vestibular laterality (i.e. which side is injured). This intriguing concept is challenging to prove.