Todd M. Brickman

Effectiveness of Amitriptyline Versus Cough Suppressants in the Treatment of Chronic Cough Resulting From Postviral Vagal Neuropathy

Objective: The objective of this prospective, randomized, controlled study (N = 28) was to evaluate the effectiveness of amitriptyline versus cough suppressants in the treatment of chronic cough resulting from postviral vagal neuropathy.

Choanal Atresia: Embryologic Analysis and Evolution of Treatment, a 30-Year Experience†‡

Objectives: Choanal atresia (CA) is a congenital obstruction of the posterior nasal apertures. Multiple surgical techniques have been proposed to repair the atresia. The purpose of this study is to review the basic science and embryology of CA with emphasis on the senior authors extensive experience, and refinement of the treatment of CA. In addition, we will review the outcomes after surgical correction of pediatric patients with CA.

Nonsteroidal Anti-inflammatory Drugs and Postoperative Bleeding Following Adenotonsillectomy in Pediatric Patients

OBJECTIVE To assess the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on bleeding for pediatric adenotonsillectomy in a retrospective study, based on the common practices at 2 different tertiary care facilities. DESIGN A retrospective study. SETTING Two different tertiary care facilities. PATIENTS Children up to 16 years of age, who underwent elective adenotonsillectomy or tonsillectomy, were included in the study. All indications for adenotonsillectomy, and all surgical techniques were included. Children with a bleeding tendency, and those with contraindications to the use of NSAIDs (eg, because of allergy), were excluded from the study. INTERVENTIONS Nonsteroidal anti-inflammatory drugs. MAIN OUTCOME MEASURE Postoperative bleeding in patients. RESULTS A total of 1160 patients were selected who met the criteria: 673 patients underwent an adenotonsillectomy or tonsillectomy and did not receive any preoperative and postoperative ibuprofen, and 487 patients underwent routine adenotonsillectomy or tonsillectomy and were given postoperative ibuprofen. We noted a 0.7% postoperative bleeding rate in patients who were not allowed to take ibuprofen perioperatively. There was a 1.0% postoperative bleeding rate in patients who were allowed to take ibuprofen perioperatively (P = .75). CONCLUSION Ibuprofen is not a contraindication to adenotonsillectomy or tonsillectomy and should be used in the control of postoperative pain if it is indicated in the patient.

The prevalence and clinical course of patients with ‘incidental’ acoustic neuromas

Conclusions. This study suggests that among patients diagnosed with ‘incidental’ acoustic neuromas (ANs), a substantial portion are discovered incidentally. Small and medium-sized ANs that are found incidentally may have a more benign nature, and may be less likely to require interventions. Objective. To estimate the prevalence of ANs, and to compare the prognosis and progression of the disease between those diagnosed incidentally verse symptomatically with an AN. Patients and methods. This was a retrospective evidence-based case series of patients with AN treated at a tertiary medical center between November 1999 and January 2005. An MRI with gadolinium was performed on all patients to establish the diagnosis of AN. A medical chart review of these patients was searched for sex distribution, age, presenting symptoms, hearing loss, speech discrimination scores, tumor characteristics by imaging, intervention performed, and time between diagnosis and intervention. The studied population was divided into those patients with pre-imaging audiovestibular symptoms provoking a clinical suspicion of AN (symptomatic group) and those without a pre-imaging suspicion of AN (incidental group). Results. The charts of 120patients with ANs were analyzed and categorized as either incidentally or symptomatically discovered. Incidentally discovered ANs accounted for 12% of patients with the diagnosis of AN in our population. The average age at diagnosis was 55.7 and 52.8years (p=0.50) in the symptomatic and incidental groups, respectively. The gender distribution was not different between the groups (p=0.08). Audiometry revealed a speech discrimination score asymmetry greater in the symptomatic group (p<0.0001). Tumor size by imaging performed at diagnosis in the incidental population was 1.09cm on average, compared with 1.5cm in the symptomatic patients (p=0.08). A greater proportion of patients with symptomatically discovered AN underwent intervention by surgical resection, stereotactic radiosurgery, or radiation compared with patients with incidentally discovered AN (76% versus 47%, p=0.02).

3D Printed Pediatric Temporal Bone: A Novel Training Model.

Objective Temporal bone dissection is a fundamental element of otologic training. Cadaveric temporal bones (CTB) are the gold standard surgical training model; however, many institutions do not have ready access to them and their cost can be significant:

Round window insertion of precurved electrodes is traumatic.

300 to

Does electrocautery damage cochlear implants

500. Furthermore, pediatric cadaveric temporal bones are not readily available. Our objective is to develop a pediatric temporal bone model. Study Design Temporal bone model. Setting Tertiary Children’s Hospital. Subjects Pediatric patient model. Methods We describe the novel use of a 3D printer for the generation of a plaster training model from a pediatric high- resolution CT temporal bone scan of a normal pediatric temporal bone. Results Three models were produced and were evaluated. The models utilized multiple colors (white for bone, yellow for the facial nerve) and were of high quality. Two models were drilled as a proof of concept and found to be an acceptable facsimile of the patient’s anatomy, rendering all necessary surgical landmarks accurately. The only negative comments pertaining to the 3D printed temporal bone as a training model were the lack of variation in hardness between cortical and cancellous bone, noting a tactile variation from cadaveric temporal bones. Conclusion Our novel pediatric 3D temporal bone training model is a viable, low-cost training option for previously inaccessible pediatric temporal bone training. Our hope is that, as 3D printers become commonplace, these models could be rapidly reproduced, allowing for trainees to print models of patients before performing surgery on the living patient.

Exploratory tympanotomy revealing incus discontinuity and stapedial otosclerosis as a cause of conductive hearing loss.

Objective Assess endocochlear trauma by adjusting: 1) location of cochleostomy or round window insertion, and 2) size of precontoured electrode array. Study Design Cadaveric temporal bone study. Methods Locations of electrode placement into the cochlea were as follows: 1) round window, 2) anterior inferior to the round window, 3) anterior inferior to the round window niche, 4) superior to the round window niche. Two types of electrode arrays were used: a larger precontoured electrode and thinner precurved research electrode. Histologic sections were made by a blinded third party. Results Fourteen bones were included in the study. Six (42.8%) of the bones were right ears. Seven bones had no endocochlear trauma. Seven bones have intracochlear trauma. Round window insertions had a high incidence of intracochlear trauma with precontoured electrodes (3/4 bones). Superior cochleostomies with electrode placement had significant intracochlear trauma (2/2 bones). Insertions made anterior inferior to the round window annulus had a 50% incidence of intracochlear trauma (2/4 bones). No endocochlear trauma observed for insertions through traditional cochleostomies (4/4 bones). Less endocochlear trauma was observed with the thinner electrode: 57% versus 42% in the larger electrode array. A higher incidence of tip fold-over was observed with the thinner electrode array (2/7 electrodes). No tip fold-over was noted in the larger electrode. Conclusion The traditional cochleostomy had the least incidence of endocochlear trauma. The smaller electrode array did not significantly affect the incidence of endocochlear trauma, but the thinner array had a higher incidence of tip fold-over, which caused trauma distally. Level of Evidence 2C.

Acute and Delayed Management of Maxillofacial Trauma

Objectives 1) Evaluate the effects of monopolar cautery on cochlear implant devices. 2) Determine whether voltage fluctuations within the cochlear implant adversely affect the cochlear implant devices Study Design Two Med-El cochlear implants modified to record voltage difference from the apical and proximal electrodes were implanted into an unembalmed, fresh cadaver. Cautery was applied to the ipsilateral pectoralis major muscle and ipsilateral temporalis muscle at bipolar, monopolar coagulation, and monopolar cut settings of 50 W. The intensity in each modality setting was increased by increments of 10 W to a maximum of 100 W. Integrity testing was performed before, during, and after each cautery setting. Voltage fluctuations were measured during cautery, and maximal voltage changes for each setting were noted. After explantation, devices were returned to the manufacturer for in-depth failure analysis to evaluate for any damage to the devices. Setting Tertiary medical center. Subjects Cadaveric study. Methods Basic science laboratory. Results No change in impedance or integrity testing occurred at any cautery setting when applied to either to pectoralis major or temporalis. The maximum voltage change was 22 V. Comprehensive device analysis showed no evidence of device damage from the study. Conclusions The cochlear implant devices had no evidence of electrical damage by monopolar cautery, even up to levels of 100 W in the temporalis muscle. The maximum voltage change was 22 V, likely resulting from protecting diodes within the implant. Additional study is necessary, but more flexible recommendations regarding electrosurgery in cochlear implant recipients should be considered.

Transoral Endoscopic Assisted ORIF of Orbital Rim Fractures

Objective: To describe a unilateral progressive conductive hearing loss caused by incus discontinuity (without erosion of the long process of the incus), and otosclerosis with fixation of the stapedial footplate. Study Design: Case report. Setting: Department of Otolaryngology, Head and Neck Surgery of the University of Rochester Medical Center, which is a regional tertiary referral center. Patient: A 54-year-old woman with multiple otologic complaints including tympanic membrane perforations, otalgia, tinnitus, and hearing loss. Audiography demonstrated 100% speech discrimination bilaterally and a significant conductive right-sided hearing loss. Intervention: The patient underwent a stapedectomy, during which a discontinuity between the long process of the incus and the stapes with no bony erosion was identified. The stapedectomy was completed and an ossicular piston prosthesis was inserted to reestablish ossicular continuity with the tympanic membrane. Main Outcome Measure: Improved subjective hearing confirmed objectively by audiography. Conclusion: This is the third reported case of an unusual combination of otosclerosis and ossicular discontinuity, and the first such case report in a patient without head trauma. In addition, it adds a unique item to the differential diagnosis of the pathologic features implicated in an ear with a conductive deficit and normal tympanogram.