Steven David Schaefer

Consequence of Dysphagia in the Hospitalized Patient: Impact on Prognosis and Hospital Resources

OBJECTIVE To determine if comorbid dysphagia in all hospitalized patients has the potential to prolong hospital stay and increase morbidity. Dysphagia is increasingly prevalent with age and comorbid medical conditions. Our research group has previously shown that dysphagia is a bad prognostic indicator in patients with stroke. DESIGN Analysis of national database. MAIN OUTCOME MEASURES The National Hospital Discharge Survey (NHDS), 2005-2006, was evaluated for presence of dysphagia and the most common comorbid medical conditions. Patient demographics, associated disease, length of hospital stay, morbidity and mortality were also evaluated. RESULTS There were over 77 million estimated hospital admissions in the period evaluated, of which 271,983 were associated with dysphagia. Dysphagia was most commonly associated with fluid or electrolyte disorder, esophageal disease, stroke, aspiration pneumonia, urinary tract infection, and congestive heart failure. The median number of hospitalization days for all patients with dysphagia was 4.04 compared with 2.40 days for those patients without dysphagia. Mortality increased substantially in patients with dysphagia associated with rehabilitation, intervertebral disk disorders, and heart diseases. CONCLUSIONS Dysphagia has a significant impact on hospital length of stay and is a bad prognostic indicator. Early recognition of dysphagia and intervention in the hospitalized patient is advised to reduce morbidity and length of hospital stay.

Endoscopic paranasal sinus surgery: Indications and considerations

Recently, American otolaryngologists have become increasingly interested in endoscopic paranasal sinus surgery. This trend has been beneficial, because it has enhanced the understanding of the anatomy and pathophysiology of the sinuses. However, as with the introduction of any new surgical technique, it takes both time and experience to acquire the skills necessary to perform this procedure. To evaluate the state of endoscopic sinus surgery, we analyzed the experience of one of the authors with 100 consecutive patients undergoing therapeutic endoscopic sinus surgery over 23 months. With an average follow‐up of 5 months (range: less than 1 month to 20 months), 14 patients had minor complications. The most common complication was synechia between the middle turbinate and the lateral nasal wall (six patients), resulting in revision surgery in four patients. Eighty‐three patients were judged as having significantly improved after surgery, while ten were improved but had one episode of sinusitis postoperatively. The results of this series suggest that endoscopic paranasal sinus surgery is an efficacious advance in the treatment of sinusitis, given the limitations discussed in this report.

Evidence of ige-mediated hypersensitivity in allergic fungal sinusitis†

Despite documentation of specific immunologic hypersensitivity in a few case reports, controversy continues as to the role of allergy versus true infection in the clinical entity of allergic fungal sinusitis (AFS). Using a modified radioallergosorbent test (RAST) to multiple fungal antigens, 16 patients meeting the histologic criteria of AFS and with positive fungal cultures were compared to 5 control patients with similar preoperative clinical findings but without histologic or culture evidence of AFS. All patients were immunocompetent and none demonstrated histologic evidence of tissue invasion. All AFS patients were RAST-positive to at least one fungal antigen in the family of their cultured organism with positive defined as class 2 or greater. No control patient was RAST-positive to either dematiaceous or Aspergillus fungal antigens. Thus, modified RAST testing can aid in the routine clinical diagnosis of AFS, and it provides further serologic evidence for a type I hypersensitivity in the pathogenesis of AFS.

Endoscopic management of frontal sinus disease

Depending on the pathologic process, the treatment of frontal sinus disease has consisted of obliteration or ablation of the sinus, or restoration of drainage into the nose. Intranasal endoscopic enlargement of the frontal recess and ostium, and removal of disease from the medial aspect of the frontal sinus offers a minimally invasive alternative to previous operations in selected patients. To better understand the indications, limitations, and potential problems with this operation, our experience with endoscopic frontal sinusotomy in 36 patients over a 30‐month period is reported. During the follow‐up period, 21 patients had complete resolution of all symptoms, 11 patients were improved but had at least one episode of sinusitis or headache post‐operatively, and 3 patients were worse, 2 of whom required frontal sinus obliteration for control of disease. Although endoscopic frontal sinusotomy appears to be a useful alternative to traditional frontal sinus procedures in selected patients, the reader is cautioned that such surgery is technically difficult and has not yet stood the test of time required of any frontal sinus operation.

Head and neck manifestations of gastroesophageal reflux

Gastroesophageal reflux (GER) is a common condition with many manifestations which are of interest to the otolaryngologist. Factors predisposing to GER include anatomic abnormalities of the esophagus and pharynx, neurogenic disease and diet induced decreased lower esophageal sphincter pressure. Three interesting cases are reported, including subglottic stenosis which has not previously been thought to be a complication of GER. A literature review of otolaryngologic symptoms, the problems of diagnosis, and a suggested treatment plan are presented.

Comparison of two methods of tonsillectomy

No consensus exists regarding the best method of tonsillectomy. This report concerns two popular methods: 1. electrocautery excision and 2. dissection/snare followed by point coagulation of bleeding sites. To compare these methods, a prospective, randomized, single-blinded study was conducted in which 28 patients had one tonsil removed by dissection/snare and selective cautery of bleeders and the other removed by the electrocautery. Operative time and blood loss were compared. Patients rated the severity of their pain and blood loss postoperatively. Intraoperative bleeding was significantly less on the side of cautery excision, although the operative time was longer. At follow-up, pain was rated worse on the side of cautery excision.

A prospective randomized trial of methotrexate versus cisplatin in the treatment of recurrent squamous cell carcinoma of the head and neck

A prospective randomized study was conducted to determine the relative effectiveness, toxicity and tolerance of methotrexate (MTX) versus cisplatin (DDP) in patients with recurrent head and neck squamous cell carcinoma. Forty‐four patients were randomized to receive either MTX, 40 mg escalated to 60 mg/m2 IV push weekly, or DDP, 50 mg/m2 6 hour infusion days 1 and 8 every 4 weeks. All patients had objectively measurable disease and a performance status greater than 60% (Karnofsky scale). All had been treated with surgery and/or radiotherapy. No patients had prior chemotherapy. Prior treatment, performance status, and site of primary disease were comparable in both groups. Complete and partial objective responses were achieved in 23.5% of the MTX group and 28.6% of the DDP group (P = 0.51). Median duration of response was 84 days in the MTX group and 92 days in the DDP group. Median survival of patients was 6.1 months with MTX and 6.3 months with DDP. Mucositis was noted in 38% of patients in the MTX group (P = 0.001) compared to none in the DDP group. Vomiting occurred in 87% of patients in the DDP group (P < .0001) compared to 10% of patients in the MTX group. This study demonstrates that in the treatment of recurrent head and neck squamous cell carcinoma, MTX and DDP are equally effective, although MTX appears to be better tolerated. Cancer 52:206‐210, 1983.

Inner ear histopathology in patients treated with Cis-Platinum.†‡

Temporal bone histopathology was studied in five patients (aged 51–67) who received cis‐diamminedichloroplatinum (DDP) chemotherapy for head and neck squamous cell carcinoma. In each case, a sensorineural hearing loss occurred during the course of treatment and temporal bones were acquired 3–5 hours postmortem for anatomical study.

Computed Tomography in the Assessment of Mandibular Invasion by Intraoral Carcinoma

A critical factor in the pretreatment evaluation of patients with carcinoma of the oral cavity or oropharynx is the presence or absence of bone invasion. A prospective study was performed to compare the sensitivity and specificity of plain radiographs and computed tomography in detecting mandibular invasion by cancer arising in these sites. Forty-three consecutive patients with previously untreated oral cavity or oropharyngeal carcinoma were evaluated preoperatively by intraoral radiographs (dental occlusal views and panoramic radiographs) and CT, and the results were compared with postoperative pathologic findings. Of the 11 cases in which pathologic examination confirmed bone invasion, conventional x-ray films were positive in seven (63.6%). Computed tomography confirmed bone invasion in all 11 (100%) of these patients. In addition, the CT scan was more specific than conventional x-ray films in detecting bone invasion. Based on the findings in this study, we strongly recommend CT as the only radiographic study necessary to evaluate intraoral carcinoma prior to treatment.

Acute Management of Laryngeal Trauma Update

The management of 120 laryngeal injury patients at a major trauma center over 23 years is presented in the form of two patient populations. The first population consists of 52 previously analyzed and reported laryngeal trauma patients who served as the basis for the subsequent refinement of treatment of a second population of 68 patients. Collectively, these patients form a series unique in that 1) it comprises the largest number of such injuries treated at one institution, 2) the management principles remained the same throughout the entire 23 years, and 3) the majority of the patients were managed by one physician. The experience gained from these patients is examined in the hope of resolving prevailing controversies about the treatment of the acutely injured larynx.