Thomas Q. Gallagher

Analyzing Factors Associated with Major Complications after Adenotonsillectomy in 4776 Patients: Comparing Three Tonsillectomy Techniques

Objective: To compare the rates of major complications (postoperative hemorrhage requiring return to the operating room or cauterization in the emergency department and dehydration requiring intravenous fluids or readmission) in a large cohort of children undergoing adenotonsillectomy by three different techniques. Study Design: Case series with chart review, case-controlled study. Setting: Regional childrens hospital. Subjects and Methods: Subjects comprised patients aged 1 to 18 years undergoing adenoidectomy, tonsillectomy, or adenotonsillectomy by microdebrider, coblator, or Bovie over a 36-month period. Major complications identified were compared to two case-matched controls to try to identify patients at risk for major postoperative complications. Results: The overall complication rate was 80 of 4776 (1.7 ± 0.4% [percent ± 95% confidence interval]). Of the 3362 patients who received either an adenotonsillectomy or tonsillectomy alone, 80 had a complication (2.3 ± 0.5%). Major complication rates differed among tonsil removal techniques: 34 of 1235 (2.8 ± 0.9%) coblation; 40 of 1289 (3.1 ± 0.9%) electrocautery; six of 824 (0.7 ± 0.7%) microdebrider (P < 0.001). Postoperative hemorrhage occurred in older children (8.5 vs 5.5 years; P < 0.001), while age did not influence postsurgical dehydration (5.33 vs 5.49 years). The case-control portion of the study did not find any reliable way to identify patients at risk for complications during adenotonsillectomy. Identity of the surgeon was not a confounding independent variable, nor was participation by resident surgeons. Conclusion: In this “real life” teaching hospital surgical setting in which three different techniques of tonsillectomy are routinely performed by a variety of resident and attending surgeons, microdebrider intracapsular tonsillectomy is associated with lower rates of post-tonsillectomy hemorrhage and dehydration when compared to coblation and electrocautery complete tonsillectomy technique.

Recurrent respiratory papillomatosis: update 2008.

Purpose of reviewRecurrent respiratory papillomatosis (RRP) is the most common benign neoplasm of the larynx in children. Over the past several years some exciting new therapeutic options as well as some relevant research into the disease process has emerged that may offer new insight and methods in managing this frustrating disease. Recent findingsRecent investigations have resulted in the following findings: more accurate prevalence estimates of human papilloma virus in women in the United States; correlation of socioeconomic status and disease severity; the malignant potential of human papilloma virus in head and neck cancer; the role of the host immune system in RRP; the efficacy of a vaccine preventing human papilloma virus; the emergence of pulsed dye laser and potassium-titanyl-phosphate laser as a therapy for RRP; the efficacy of cidofovir as an adjunctive therapy for RRP; and the role of cyclooxygenase-2 in the molecular biology of RRP. SummaryThe management of RRP is ever evolving. Despite several new therapies discussed in this study, it is still a disease with the potential for high morbidity. As the focus of therapy shifts from treatment to prevention, it will take many years to determine whether prevention strategies are effective in limiting the spread of this disease. In the mean time, further research is needed to gain better control of this disease process.

Pharmacotherapy of recurrent respiratory papillomatosis: an expert opinion

Background: Recurrent respiratory papillomatosis is caused by the human papillomavirus types (HPV) 6 and 11. It affects both children and adults. In a small number of cases, the disease can be very aggressive causing significant morbidity and possibly death. Surgical therapy is the primary treatment but in patients with aggressive disease, adjunctive therapy is initiated. The majority of these adjuncts center on immunomodulation, disruption of molecular signaling cascades or interruption of viral replication to help decrease the severity of the disease. Recently, a preventative vaccine has become available but data on its effectiveness will be at least a decade away. In the mean time, researchers are examining other vaccination strategies in the fight against HPV disease. Objective: We will review the following pharmacotherapies used in the adjunct treatment of RRP: interferon, acyclovir, ribivirin, cidofovir, COX-2 inhibitors, retinoids, anti-reflux medications, zinc, indole-3-carbinol, therapeutic/preventative vaccines. Methods: This is a review paper. Utilizing Medline and Pubmed from 1966 to present, the key words as well as the above listed adjunct treatments were searched for relevant papers. Conclusion: The evidence supporting each of these adjuncts varies with a majority having only case reports or cases-series to support their use. However, there is hope on the horizon with regard to the HPV vaccine and its potential to prevent future transmission of this disease.

Thyroglossal Duct Cyst Excision

Thyroglossal duct cysts (TGDCs) are the most common congenital anomaly of the neck. The most common presentation of TGDCs is a firm, midline mass. The Sistrunk procedure is the recommended treatment for TGDCs. Based on anatomic and embryologic study, Dr. Sistrunk recommended removal of not only the cyst and central portion of the hyoid bone, but also a central core of deep tongue musculature. By doing so, the rate of recurrence is decreased from approximately 50 to 3-5%. In this chapter, the authors will describe the Sistrunk procedure step by step including surgical pearls for success.

Tracheal Resection and Reanastomosis

Isolated short segment tracheal stenosis occurs in a relatively rare subpopulation of patients with laryngotracheal stenosis. Etiologies include both acquired and congenital, the most common being the acquired type. Management options include observation, endoscopic balloon dilation with or without CO(2) laser, stent placement and open airway surgery. In this chapter, we will discuss tracheal resection and reanastomosis with emphasis on surgical pearls for success.

Percutaneous transtracheal needle insufflation: A useful emergency airway adjunct simply constructed from common items found on your anesthesia cart

Using material already available in the operating room, we describe the construction and application of a percutaneous transtracheal needle insufflation device to be used in pediatric airway emergencies. Our technique of percutaneous needle insufflation using common materials found in the operating room can be a helpful adjunct in a time of need. Quickly constructed and at a minimal cost, the device can be just one of the many useful tools found in the otolaryngologists airway armamentarium.

Direct Laryngoscopy and Rigid Bronchoscopy

Laryngoscopy and rigid bronchoscopy represent a necessary tool in the otolaryngologists arsenal. The advancement in designing smaller and more versatile laryngeal equipment and fiber-optic telescopes as well as the increasingly higher resolution of still and video imagery have allowed otolaryngologists to better diagnose and treat many airway lesions. This chapter describes the basic equipment necessary as well step-by-step description of the technique to perform rigid airway endoscopy.

Use of a Novel Airway Kit and Simulation in Resident Training on Emergent Pediatric Airways

Objective Development of a novel pediatric airway kit and implementation with simulation to improve resident response to emergencies with the goal of improving patient safety. Methods Prospective study with 9 otolaryngology residents (postgraduate years 1-5) from our tertiary care institution. Nine simulated pediatric emergency airway drills were carried out with the existing system and a novel portable airway kit. Response times and time to successful airway control were noted with both the extant airway system and the new handheld kit. Results were analyzed to ensure parametric data and compared with t tests. A Bonferroni adjustment indicated that an alpha of 0.025 was needed for significance. Results Use of the airway kit significantly reduced the mean time of resident arrival by 47% (P = .013) and mean time of successful intubation by 50% (P = .007). Survey data indicated 100% improved resident comfort with emergent airway scenarios with use of the kit. Discussion Times to response and meaningful intervention were significantly reduced with implementation of the handheld airway kit. Use of simulation training to implement the new kit improved residents’ comfort and airway skills. This study describes an affordable novel mobile airway kit and demonstrates its ability to improve response times. Implications for Practice The low cost of this airway kit makes it a tenable option even for smaller hospitals. Simulation provides a safe and effective way to familiarize oneself with novel equipment, and, when possible, realistic emergent airway simulations should be used to improve provider performance.

Military Otolaryngology Resident Case Numbers and Board Passing Rates during the Afghanistan and Iraq Wars

Objective During the wars in Iraq and Afghanistan, the US military has continued to train medical residents despite concern that postgraduate medical education at military training facilities has suffered. This study compares the experience of otolaryngology residents at military programs with the experience of their civilian counterparts. Study Design Retrospective review. Setting Academic military medical centers. Subjects and Methods Resident caseload data and board examination passing rates were requested from each of the 6 Department of Defense otolaryngology residency programs for 2001 to 2010. The American Board of Otolaryngology and the Accreditation Council for Graduate Medical Education provided the national averages for resident caseload. National board passing rates from 2004 to 2010 were also obtained. Two-sample t tests were used to compare the pooled caseloads from the military programs with the national averages. Board passing rates were compared with a test of proportions. Results Data were available for all but one military program. Regarding total cases, only 2001 and 2003 showed a significant difference (P < .05), with military residents completing more cases in those years. For individual case categories, the military averages were higher in Otology (299.6 vs 261.2, P = .033) and Plastics/Reconstruction (248.1 vs 149.2, P = .003). Only the Head & Neck category significantly favored the national average over the military (278.3 and 226.0, P = .039). The first-time board passing rates were identical between the groups (93%). Conclusion Our results suggest that the military otolaryngology residency programs are equal in terms of caseload and board passing rates compared with civilian programs over this time period.

The otolaryngologic manifestations of Sotos syndrome

OBJECTIVE Sotos syndrome is a genetic disorder caused by mutations in the NSD1 gene. It is characterized by excessive growth in early life. It features craniofacial abnormalities, developmental delay, hypotonia and advanced bone age. A review of the current literature reveals only chronic otitis media and conductive hearing loss as otolaryngologic manifestations of Sotos syndrome. Our objective was to determine if there are additional manifestations relevant to the otolaryngologist. METHODS We performed a retrospective case series in which the Department of Defense electronic medical record was searched for ICD 9 code 253.0 (acromegaly/gigantism). Records were reviewed for genetic testing indicative of Sotos syndrome. These records were further analyzed for evidence of otolaryngologic problems. RESULTS Seventeen patients were identified with five having confirmed NSD1 mutations consistent with Sotos syndrome. Of these, 4/5 had otolaryngologic problems such as conductive hearing loss, aspiration, laryngomalacia, obstructive sleep apnea and sensorineural hearing loss. CONCLUSIONS Currently there is no description in the literature of these additional manifestations of Sotos syndrome. We present this case series to support the idea that an otolaryngologist should be involved in the multidisciplinary care required for these patients.