Sami P. Moubayed

Vertebrobasilar insufficiency presenting as isolated positional vertigo or dizziness: A double-blind retrospective cohort study

Vertebral artery (VA) stenosis caused mainly by atherosclerosis accounts for up to 20% of posterior circulation strokes. Isolated positional vertigo or dizziness can be the initial presentation symptom. The objective is to compare the presence of isolated positional vertigo or dizziness in patients with evaluation of VA morphology, thrombotic stroke risk factors, and evolution of symptoms with time.

An unusual finding of corneal edema complicating selective laser trabeculoplasty

CAN J OPHTHALMOL—VOL. 44, NO. 3, 2009 337 been using topical prednisolone acetate drops once daily at presentation. Corneal scraping revealed gram-negative bacilli on smears. Corneal scraping was inoculated in blood agar, chocolate agar, thioglycolate broth, and brain–heart infusion broth. The patient was started on moxifloxacin (0.5%) drops. The bacterial culture yielded a moderate growth of gramnegative bacilli from all inoculated media. The isolate was a lactose nonfermenter and was oxidase negative. Further identification of the isolate was made using the mini-API (Analytical Profile Index; BioMerieux SA, Craponne, France). An ID-23GN strip was inoculated with pure culture of the isolate and incubated as per standard protocol. The API score was 99% for the identification of A. xylosoxidans. The organism was sensitive to gentamicin, amikacin, and ceftazidime, and resistant to chloramphenicol, ciprofloxacin, ofloxacin, gatifloxacin, and moxifloxacin. Thus, moxifloxacin was discontinued and fortified gentamicin, 15 mg/mL (1.5%), was started every half hour for 3 days, followed by every hour for 7 days, and thereafter 6 times a day for 1 month. Topical medication was continued for 10 weeks. The infection resolved with scarring and conjunctivalization. Alcaligenes xylosoxidans is a gram-negative, oxidasenegative, nonlactose-fermenting bacillus. It is closely related to the Bordetella genus and frequently confused with Pseudomonas. Previous reports of A. xylosoxidans keratitis have demonstrated association with prior use of steroid and compromised or traumatized cornea. It has also been reported after use of contact lens. Majekodunmi reported a patient with bacterial keratitis who had Clostridium welchii and Achromobacter growing simultaneously. As in previous cases, our patient had a compromised cornea. Prior use of topical steroid might be another risk factor. A review of the sensitivity pattern of A. xylosoxidans shows it is consistently sensitive to carbenicillin and trimethoprim-sulfamethoxazole. It is resistant to firstgeneration cephalosporins and to all aminoglycosides. It has variable sensitivity to piperacillin, ceftazidime, ciprofloxacin, and chloramphenicol. Contrary to previous reports, the strain of the organism seen in our patient was sensitive to gentamicin. However, it was resistant to fourth-generation fluoroquinolones such as gatifloxacin and moxifloxacin. Alcaligenes xylosoxidans, although rare, should be considered a potential pathogen causing keratitis in eyes with a compromised ocular surface where steroids have been used.

Predictors of length of stay, reoperation, and readmission following total laryngectomy

To identify relevant patient and surgical risk factors associated with prolonged length of stay, return to the operating room, and readmission within 30 days following total laryngectomy using the American College of Surgeons National Quality Improvement Program (ACS‐NSQIP)

North-American survey on HPV-DNA and p16 testing for head and neck squamous cell carcinoma.

OBJECTIVES Human papillomavirus (HPV)-positive head and neck squamous cell carcinomas (HNSCC) have been shown to have a significantly better prognosis and response to current treatment modalities. Current guidelines recommend systematic HPV-DNA and/or p16 testing on HNSCCs, although treatment approach should not be directed by test results. The objectives of this study were to (1) assess whether HPV-DNA and/or p16 status are systematically evaluated across North American otolaryngologists-head and neck surgeons and (2) whether the status is used to direct treatment approach. MATERIALS AND METHODS A 15-question online survey was sent to three associations: the Association of Oto-rhino-laryngology-Head and Neck Surgery of Quebec, the Canadian Society of Otolaryngology-Head and Neck Surgery, and the American Head and Neck Society. RESULTS Sixty-seven percent of respondents systematically test for HPV-DNA and/or p16 on HNSCC sites, while 58.3% report using test results to direct treatment for oropharyngeal cancers. A lack of official guidelines was the primary reason (81.8%) physicians did not use test results to direct treatment. Academic centre physicians (83.3%) and physicians with ⩾50% oncologic practice (87.6%) were more likely to test for HPV-DNA and/or p16 in HNSCC compared to non-academic centre physicians (39.7%) and physicians with <50% oncologic practices (51.4%) (p<0.001). Cost of the tests (69.2%), lack of relevance (46.1%) and time constraints (30.8%) were the primary reasons HPV-DNA and/or p16 were not tested. CONCLUSION The majority of North American respondents in this survey systematically test for HPV-DNA and/or p16 in HNSCC sites, and most indicate that test results influence their treatment approach for oropharyngeal cancers.

Facial artery musculomucosal flap for reconstruction of skull base defects: A cadaveric study

Failure in skull base defects reconstruction following tumor resection can have serious consequences such as ascending meningitis and pneumocephaly. The nasoseptal flap showed a very low incidence of cerebrospinal fluid leak but is not always available. The superiorly pedicled facial artery musculomucosal (FAMM) flap has been successfully used for reconstruction of head and neck defects. Our objective is to show that the FAMM flap can be used as a new alternative in skull base reconstruction.

Predicting Depression and Quality of Life among Long-term Head and Neck Cancer Survivors

Objective The aim of this study is to identify clinical factors that are predictive of depression and quality of life (QOL) among long-term survivors of head and neck squamous cell carcinoma and to develop predictive scores using these factors. Study Design Cohort study Setting Tertiary referral center. Subjects and Methods A total of 209 posttreatment (median follow-up, 38.7 months) head and neck cancer patients were prospectively evaluated using the Hospital Anxiety Depression Scale (HADS), the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30, and the EORTC Quality of Life Questionnaire Head and Neck 35, and pretreatment patient-related, tumor-related, and treatment-related predictors were identified using chart review. Bivariate (χ2 and t test) and multivariate (linear regression) analyses were used to construct predictive models. Results Significant pretreatment predictors of depression were identified on multivariate analysis as smoking at diagnosis, >14 alcoholic drinks per week, T3 or T4 status, and >3 medications (P < .001). Two or more of these factors yielded an 82.3% sensitivity in detecting significant depressive symptoms (defined as a HADS cutoff score of 5). Significant predictors of fatigue, global health/QOL, social contact, speech, pain, swallowing, and xerostomia were also identified. Conclusion Pretreatment predictors of long-term depression and QOL have been defined using multivariate models, and an easily applicable predictive score of long-term depression is proposed. Potential eventual clinical applications include prophylactic intervention in at-risk patients.

Systematic review and meta-analysis of venous thromboembolism in otolaryngology-head and neck surgery.

The purpose of this study was to present our systematic review and meta‐analysis of the data on venous thromboembolism (VTE; deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) in otolaryngology–head and neck surgery (OHNS).

The 10-Item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for Functional and Cosmetic Rhinoplasty

Importance Rhinoplasty is a common operation in which shape and function are intimately related, whether the procedure is cosmetic, functional, or combined in nature. There is currently no properly developed and validated patient-reported outcome measure (PROM) to evaluate both functional and cosmetic components of rhinoplasty. Objective To develop, validate, and field test the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) to evaluate both functional and cosmetic outcomes of rhinoplasty. Design, Setting, and Participants Survey development study between October 2016 and April 2017 in a tertiary referral facial plastic and reconstructive surgery clinic. Preoperative and postoperative adult patients undergoing rhinoplasty, whether cosmetic or reconstructive, were included. A fifth group of adult nonrhinoplasty patients (facial cosmetic or reconstructive) were also included for the field test. Main Outcomes and Measures Generated and reduced items, psychometric validation measures of the SCHNOS, and differences on scales between groups. Results For survey development, a total of 18 patients and 5 experts were interviewed. Of these patients, 5 were male, and 13 were female. Their mean (SD) age was 38 (14.8) years (range, 20-64 years). Field testing included 191 patients (67% were women and the mean [SD] age was 41.5 [15.8] years). A total of 10 items were included after generation, cognitive interviews, and item reduction. The 10 items represent 2 domains: nasal obstruction (first 4 items) and nasal cosmesis (last 6 items). For both domains, Cronbach &agr; was excellent: 0.94 (95% CI, 0.92-0.95) for obstruction and 0.94 (95% CI, 0.93-0.95) for cosmesis. Exploratory factor analysis using scree plots for each domain showed that the domains are unidimensional in nature with each domain evaluating what it is intended to assess (nasal obstruction and cosmesis). The factor loading estimates were high for all the items, varying from 0.74 to 0.92. Kruskal-Wallis testing showed a significance level of P < .001 when evaluating the difference between groups (preoperative cosmetic, postoperative cosmetic, preoperative functional, postoperative functional, and nonrhinoplasty) for all individual questions, composite scores, and Nasal Obstruction Symptom Evaluation (NOSE) score. Correlations between the obstruction composite score and the NOSE scores were r = 0.943 (P < .001), which is very strong. The obstruction and cosmesis composite scores were only weakly correlated (r = 0.388; P < .001). Conclusions and Relevance We have developed and validated a new PROM to evaluate both functional and cosmetic rhinoplasty patients. The domains of obstruction and cosmesis were found to be internally consistent and unidimensional. The SCHNOS provides a short, validated questionnaire that we recommend for use in all functional or cosmetic rhinoplasty patients. Level of Evidence N/A.

The Ethical Implications of the Reclassification of Noninvasive Follicular Variant Papillary Thyroid Carcinoma

BACKGROUND Several studies have highlighted the lack of consensus in the diagnosis of follicular variant of papillary thyroid carcinoma (FVPTC). An international multidisciplinary panel to address the controversy was assembled at the annual meeting of the Endocrine Pathology Society in March of 2015, leading to the recent publication reclassifying encapsulated (or noninvasive) FVPTC (EFVPTC) as a benign neoplasm. Does this change in histologic taxonomy warrant a change in clinical practice, and how should it affect those who have been given this diagnosis in the past? We consider the financial and psychological impact of this reclassification and discuss the ethical, legal, and practical issues involved with sharing this information with the patients who are affected. SUMMARY The total direct and indirect cost of thyroid cancer surveillance in patients is significant. High levels of clinically relevant distress affect up to 43% of patients with papillary thyroid carcinoma, as estimated by the Distress Thermometer developed by the National Comprehensive Cancer Network for detecting distress in cancer patients. Although there are currently no legal opinions that establish a precedent for recontacting patients whose clinical status is altered by a change in nomenclature, the prudent course would be to attend to the requirements of medical ethics. CONCLUSION Informing patients with a previous diagnosis of EFVPTC that the disease has been reclassified as benign is expected to have a dramatic effect on their surveillance needs and to alleviate the psychological impact of living with a diagnosis of cancer. It is important to re-evaluate the pathologic slides of those patients at risk to ensure that the invasive nature of the tumor is comprehensively evaluated before notifying a patient of a change in diagnosis. The availability of the entire tumor for evaluation of the capsule may prove to be a challenge for a portion of the population at risk. We believe that it is the clinicians professional duty to make a sincere and reasonable effort to convey the information to the affected patients. We also believe that the cost savings with respect to the need for additional surgery, radioactive iodine, and rigorous surveillance associated with a misinterpretation of the biology of the diagnosis of EFVPTC in less experienced hands will likely more than offset the cost incurred in histologic review and patient notification.

Microvascular Reconstruction of Segmental Mandibular Defects without Tracheostomy

Objective To report our experience with mandibular resection and reconstruction using vascularized bone-containing free flaps without an elective tracheostomy. Study Design Case series with chart review. Setting Tertiary referral hospital center. Subjects and Methods Sixty-six patients undergoing mandibular reconstruction with vascularized bone-containing free flaps without an elective tracheostomy were identified between 1995 and 2013. We describe patient, tumor, and surgical factors and report perioperative outcomes in this population. Results Most patients underwent fibula free flap reconstruction (n = 61, 92.44%). The 4 most frequent indications for resection were osteoradionecrosis, parotid carcinoma, oral squamous cell carcinoma, and osteomyelitis. Bone defects ranging from 4.0 to 13.0 cm were reconstructed, and associated soft-tissue defects were reconstructed with skin paddle sizes ranging from 24.0 to 450.0 cm2. There was only 1 patient with a bilateral central mandibular defect, and there were no tongue/pharyngeal soft-tissue defects or bilateral neck dissections. One case required emergent tracheostomy on postoperative day 1, and 2 more patients developed respiratory complications. There were no cases of perioperative death or flap failure. Conclusion Mandibular free flap reconstruction is feasible without an elective tracheostomy in a subset of carefully selected patients without bilateral central mandibular defects, tongue/pharynx defects, or bilateral neck dissection.