Robert J. Yawn

Eosinophilic Laryngitis in Children with Aerodigestive Dysfunction

Objective To describe the presence of laryngeal eosinophils and associated symptomatology in patients with aerodigestive dysfunction. Study Design Case series with chart review. Setting Single tertiary pediatric referral center. Subjects Eighty-one consecutive pediatric patients referred to a multidisciplinary aerodigestive clinic with upper airway concerns. Methods Microlaryngoscopy and posterior arytenoid biopsy, flexible bronchoscopy, esophagogastroduodenoscopy and esophageal biopsy, and impedance probe testing were performed as indicated by clinical symptoms. Positive versus negative posterior arytenoid biopsy for eosinophils and the presence or absence of concomitant histopathological laryngitis and/or esophagitis were measured. Results Nine of 81 (11%) patients had positive laryngeal biopsy for eosinophils (range, 1-29 eosinophils/high-powered field [HPF]). Three of these 9 patients also had concurrent biopsy-proven eosinophilic esophagitis, while 8 of 81 total patients had biopsy-proven eosinophilic esophagitis. The frequency of biopsy-proven eosinophilic esophagitis was higher in patients with posterior arytenoid eosinophils versus patients without laryngeal eosinophils (33% versus 6.9%, P = .0408). Conclusions Eosinophilic inflammation in the larynx has not been described in children with complex aerodigestive complaints. Posterior arytenoid eosinophils may serve as a marker of chronic laryngeal inflammation in children with aerodigestive dysfunction, although their exact role in this inflammation remains unclear. In our population, >15 eosinophils/HPF within posterior arytenoid biopsies was associated with concomitant eosinophilic esophagitis.

Cochlear implantation: a biomechanical prosthesis for hearing loss.

Cochlear implants are a medical prosthesis used to treat sensorineural deafness, and one of the greatest advances in modern medicine. The following article is an overview of cochlear implant technology. The history of cochlear implantation and the development of modern implant technology will be discussed, as well as current surgical techniques. Research regarding expansion of candidacy, hearing preservation cochlear implantation, and implantation for unilateral deafness are described. Lastly, innovative technology is discussed, including the hybrid cochlear implant and the totally implantable cochlear implant.

Novel application of the Sonopet for endoscopic posterior split and cartilage graft laryngoplasty

INTRODUCTION Posterior glottic stenosis (PGS) presents a challenge to the airway surgeon. A variety of techniques, ranging from endoscopic laser arytenoidectomy and partial cordotomy to open laryngotracheoplasty with anterior and posterior costal cartilage grafting, have been described with variable results in addressing this problem in adults. Endoscopic posterior cricoid split and rib graft (EPCS/RG) was first described in 2003 by Inglis et al. in 10 pediatric patients with PGS and subglottic stenosis as an alternative to open procedures. Adult patients present additional challenges to the airway surgeon. Increased incidence of cervical spine disease can make adequate exposure difficult in adult patients, and increased rates of ossification in the adult airway cartilages and mature scar tissue can make endoscopically splitting the cricoid difficult. The authors present a series of adult patients with PGS and tracheotomy dependence who were managed with EPCS/RG, although one patient was unable to complete the operation in a fully endoscopic fashion due to cricoid ossification. Challenges in intraoperative management will be discussed in presenting EPCS/RG as a feasible option for select adult patients. We herein present an algorithm that posits an ultrasonic aspirator as a solution to the problem of splitting an ossified cricoid seen more commonly in this population. MATERIALS AND METHODS

Facial nerve repair after operative injury: Impact of timing on hypoglossal-facial nerve graft outcomes

PURPOSE Reanimation of facial paralysis is a complex problem with multiple treatment options. One option is hypoglossal-facial nerve grafting, which can be performed in the immediate postoperative period after nerve transection, or in a delayed setting after skull base surgery when the nerve is anatomically intact but function is poor. The purpose of this study is to investigate the effect of timing of hypoglossal-facial grafting on functional outcome. MATERIALS AND METHODS A retrospective case series from a single tertiary otologic referral center was performed identifying 60 patients with facial nerve injury following cerebellopontine angle tumor extirpation. Patients underwent hypoglossal-facial nerve anastomosis following facial nerve injury. Facial nerve function was measured using the House-Brackmann facial nerve grading system at a median follow-up interval of 18months. Multivariate logistic regression analysis was used determine how time to hypoglossal-facial nerve grafting affected odds of achieving House-Brackmann grade of ≤3. RESULTS Patients who underwent acute hypoglossal-facial anastomotic repair (0-14days from injury) were more likely to achieve House-Brackmann grade ≤3 compared to those that had delayed repair (OR 4.97, 95% CI 1.5-16.9, p=0.01). CONCLUSIONS Early hypoglossal-facial anastomotic repair after acute facial nerve injury is associated with better long-term facial function outcomes and should be considered in the management algorithm.

The Natural History of Petroclival Meningiomas: A Volumetric Study

OBJECTIVES This study characterizes primary petroclival meningioma growth rates, before intervention, using volumetric analysis. In addition, predictors of growth are analyzed. METHODS Patients with previously untreated petroclival meningiomas were retrospectively reviewed (1999-2015). Image analysis software was used to perform volumetric analyses of tumor size and growth. Three-dimensional segmentation volumetric analyses were compared with volumes estimated utilizing three orthogonal dimensions. Tumor growth was defined as a 15% increase in volume. RESULTS Thirty-four patients who underwent at least two magnetic resonance imaging (MRI) studies before intervention were included. The mean age was 55.2 years, and 65.7% were women. The mean tumor volume at presentation was 5.6 cm (range, 0.1-25.8 cm) as determined from segmentation volumetric analysis. At a mean follow-up of 44.5 months (range, 3.7-125.1 mo), 88.2% of tumors grew. The mean annual volumetric growth rate was 2.38 cm/yr (-0.63 to 25.9 cm/yr). Tumor volume, T2 hyperintensity within the tumor, peritumoral edema, and ataxia and/or cerebellar symptoms at presentation were all significantly associated with greater rates of tumor growth. Ultimately, 10 (29.4%) patients underwent treatment during the follow-up period. CONCLUSION Our experience demonstrates that the vast majority (88%) of untreated petroclival meningiomas grow; the mean volumetric growth rate was noted to be 2.38 cm/yr. We found a significant association between increased growth rate and larger tumor size at diagnosis, T2 hyperintensity within the tumor, peritumoral edema, and the presence of ataxia and/or cerebellar symptoms.

Audiometric Outcomes Following Endoscopic Ossicular Chain Reconstruction

OBJECTIVE To evaluate the audiometric outcomes following endoscopic ossicular chain reconstruction (OCR). STUDY DESIGN Retrospective case series. SETTING Two tertiary referral centers. PATIENTS Sixty two ears with ossicular discontinuity. INTERVENTION(S) Endoscopic and microscopic OCR in patients with ossicular discontinuity. MAIN OUTCOME MEASURES Bone and air pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). RESULTS Sixty two ears were included for analysis. Patients that underwent ossiculoplasty were subdivided based on prosthesis type (total ossicular replacement prosthesis [TORP] and partial ossicular replacement prosthesis [PORP], primary and staged ossiculoplasties, and surgical approach [microscopic and total endoscopic]). Forty two ears required PORP reconstructions, while 20 ears required TORP reconstructions. The microscope was used to reconstruct the ossicular chain in 31 cases, while an exclusive endoscopic approach was used in the remaining 31 patients. Controlling for the prosthesis, there were no significant postoperative differences in bone PTA, air PTA, and ABG between primary and staged ossiculoplasties, or surgical approach. CONCLUSIONS Controlling for the type of prosthesis, there were no significant differences in hearing outcomes with respect to staged ossicular chain reconstruction or whether the endoscope or microscope was used for visualization. Thus, in this series, endoscopic OCR yields similar audiometric outcomes when compared with microscopic OCR.

Primary Epidermoid Tumors of the Cerebellopontine Angle: A Review of 47 Cases

Objective: To analyze disease presentation, treatment, and clinical course of a consecutive series of patients with primary cerebellopontine angle (CPA) epidermoids. Patients: Forty-seven consecutive patients with previously untreated CPA epidermoids. Intervention(s): Observation and microsurgery. Main Outcome Measures: Disease- and treatment-associated morbidity, recurrence. Results: Forty-seven patients (mean age 39 years; 53% women) were analyzed and the average duration of follow-up was 42 months. The most common presenting symptom was headache (27; 57%); 13 (28%) exhibited preoperative asymmetric sensorineural hearing loss, 3 (6%) facial nerve paresis, and 3 (6%) hemifacial spasm. Thirteen patients (28%) were initially observed over a mean interval of 56 months; however, five experienced disease progression requiring operation. Thirty-nine patients (83%) underwent surgical resection; 18 (46%) received gross total, 5 (13%) near total, and 16 (41%) aggressive subtotal resection. Three patients (8%) recurred at a median of 53 months; two after subtotal and one after gross total resection. Ninety-three percent of patients with useful hearing maintained serviceable hearing following treatment and one patient (3%) experienced mild long-term postoperative facial nerve paresis (HB II/VI). All patients with preoperative facial nerve paresis recovered normal function postoperatively. There were no episodes of stroke or death. Conclusions: Surgical intervention is effective in alleviating symptoms of cranial neuropathy and brainstem compression from CPA epidermoids. Gross total resection is preferred; however, aggressive subtotal removal should be considered with adherent or extensive disease as reoperation rates are low, even in the setting of aggressive subtotal resection. Conservative observation with serial imaging is a viable initial strategy in asymptomatic or minimally symptomatic patients.

Lateral-to-malleus underlay tympanoplasty: surgical technique and outcomes.

Objective The lateral-to-malleus underlay tympanoplasty (LMUT) involves dissection of the tympanic membrane remnant from the malleus with subsequent graft placement medial to the annulus but lateral to the malleus. The objective of the current study is to describe the clinical outcomes using the LMUT technique. Patients One hundred forty-one ears undergoing LMUT. To isolate the effects of tympanoplasty on audiometric outcome, only cases with an intact and mobile ossicular chain were evaluated; ears with ossicular discontinuity, fixation, and/or ossicular chain reconstruction were excluded. Intervention Lateral-to-malleus underlay tympanoplasty. Main Outcome Measures 1) Change in air-bone gap and bone conduction thresholds; 2) tympanic membrane lateralization; and 3) primary and delayed graft failure. Results One hundred forty-one tympanoplasties were analyzed. In the early postoperative period, 140 (99%) of 141 grafts were intact and, at a mean of 32.1 months, 121 (85.8%) remained without significant retraction or reperforation. There were no cases of early or delayed graft lateralization. The mean preoperative and most recent postoperative air-bone gaps were 23.7 dB and 14.1 dB, respectively (p < 0.001). Surgery was not associated with a transient or long-term bone conduction threshold shift. Conclusion The LMUT technique offers improved exposure of the tympanic space and a low rate of graft failure. The risks of sensorineural hearing loss with ossicular chain manipulation and tympanic membrane lateralization from graft placement lateral to the malleus are very low.

Tracheocutaneous fistula repair with autologous auricular cartilage cap graft.

INTRODUCTION As one of the oldest recorded surgical procedures, tracheotomy remains a frequently performed procedure today, with over 110,000 U.S. cases in 2006. Complications such as tracheocutaneous fistula (TCF) formation are relatively infrequent, making single-institution studies difficult to design. Reported rates of TCF are usually less than 1% in adult patients, many of who had required long-term ventilation. In pediatric populations, the rate has been estimated to be between 6% to 30%. Risk factors for persistent fistula are length of time with tracheostomy, age, radiation, history of previous tracheotomy, and obesity. If spontaneous closure does not occur, fibrosis of the surrounding tissue may result in a persistent TCF and iatrogenic laryngotracheal stenosis, the so-called A-frame deformity. Additionally, in cases when large areas cartilaginous support have been lost or deranged by scar, simple closure without restoring structure can also lead to Aframe or Lambdoid deformity. The large fistulae may require additional tissue, which has been described in previous studies utilizing combinations of skin and muscle flaps and rib cartilage grafts. Additionally, Riedel et al. describe a small case series using conchal cartilage grafts in conjunction with deltopectoral flaps in irradiated head and neck cancer patients. Although this may be necessary for some patients with very large skin defects and radiation comorbidities, others may benefit from a more conservative approach. Herein we describe a novel, stent-supported, single-staged auricular cartilage cap graft for TCF repair with fistulae greater than 1 cm by 1 cm to prevent subsequent A-frame deformity by restoring tracheal architecture.

The utility of bronchoalveolar lavage findings in the diagnosis of eosinophilic esophagitis in children

INTRODUCTION Bronchoalveolar lavage (BAL)-nucleated cell counts and the lipid-laden alveolar macrophage index (LLMI) have been investigated in predicting chronic aspiration as well as reflux esophagitis with variable results. To date, BAL neutrophil percentages and the LLMI have not been described in patients with eosinophilic esophagitis (EoE). OBJECTIVES To evaluate BAL neutrophil percentages and LLMI levels in patients with EoE and compare these levels in patients with aerodigestive concerns without biopsy-proven EoE. METHODS Retrospective review of patients referred to an aerodigestive evaluation team for overlapping aerodigestive complaints (dysphagia, stridor, subglottic stenosis, feeding intolerance, and chronic aspiration). Patients underwent microlaryngoscopy, esophagogastroduodenoscopy with biopsy, and bronchoscopy and BAL were indicated by symptoms. BAL neutrophil percentages, LLMI levels, esophageal biopsy results, and esophageal dual-probe pH/impedance were recorded and compared. RESULTS Fifty-one patients were included in the study that underwent comprehensive workup for aerodigestive complaints. Patients were subdivided into two groups: (1) negative esophageal biopsy (for EoE) and (2) positive esophageal biopsy. There were no significant differences between the groups in percentage neutrophils (p=0.55, unpaired t-test) or LLMI levels (p=0.14, unpaired t-test). DISCUSSION BAL neutrophil percentages and the LLMI are unreliable in identifying patients with silent aspiration and gastroesophageal reflux. To date, there is no report of the utility of BAL neutrophil percentages and the LLMI in diagnosing patients with EoE. Our series indicates no correlation in neutrophil percentages or LLMI in patients with EoE versus patients without EoE that are referred to tertiary centers with aerodigestive concerns. CONCLUSION BAL neutrophil percentages and LLMI levels are not a reliable predictor of eosinophilic esophagitis in children with complex aerodigestive concerns. Esophageal biopsy remains the gold standard for diagnosis of EoE and the challenge remains to find other markers that raise suspicion for EoE for the non-gastroenterologist or that stage the extent of disease beyond the esophagus.