Zi Yang Jiang

Intracochlear schwannomas confined to the otic capsule.

Objective: To determine the natural history and management for patients with intracochlear schwannomas. Study Design: Retrospective case series of intracochlear schwannomas confined to the otic capsule. Setting: Tertiary referral center. Patients: Ten patients were found to have schwannomas limited to the cochlea from 1998 to 2009. Interventions: All subjects underwent at least 1 magnetic resonance imaging (MRI) study and had at least 1 audiogram. Two patients underwent a transotic excision for intractable symptoms. Main Outcome Measures: Presenting symptoms, initial and follow-up MRI findings, audiometric testing results, and need for surgical intervention were recorded for each subject. Results: Hearing loss was present in all 10 patients at their initial presentation. Tinnitus was present in 50% of patients, and vertigo was present in 30% of patients. No patient presented with aural fullness or facial weakness. The pattern of hearing loss seemed to correlate with the location of the lesion within the cochlea. Of the 9 patients that had follow-up MRIs, 3 patients showed tumor growth. Two of the 10 patients underwent surgical excision for intractable vertigo that resulted in resolution of symptoms. Conclusion: Hearing loss is the most common finding in patients with intracochlear schwannomas, followed by tinnitus and vertigo. If the patient does not have symptoms of intractable vertigo, observation with serial MRI scans is indicated. Surgical excision should be reserved for patients with intractable vertigo or with significant tumor growth.

Inferior turbinate surgery in children: a survey of practice patterns.

A variety of techniques for inferior turbinate reduction have been used in children, but to date practice patterns have not been studied. The purpose of this survey was to study the practice of inferior turbinate surgery among pediatric otolaryngologists.

Medicolegal Concerns Among Neurotologists in Ordering Mris for Idiopathic Sensorineural Hearing Loss and Asymmetric Sensorineural Hearing Loss

Objective: To determine if neurotologists order magnetic resonance imaging (MRI) in cases of idiopathic sudden sensorineural hearing loss (sudden deafness) and of asymmetric sensorineural hearing loss (ASNHL) for medicolegal reasons. Study Design: Survey of 480 American neurotologists. Main Outcome Measures: 1) The frequency with which neurotologists/otologists in the United States order MRI in sudden deafness and ASNHL, 2) the frequency of medicolegal issues as motivations for ordering MRIs, 3) the frequency of abnormal MRIs, and 4) the prevalence of auditory brainstem reflex (ABR) and acoustic reflex testing as screening tools before ordering an MRI. Results: Approximately 146 responses (30.4%) were received. Ninety-five percent and 94% ordered MRIs in their patients with ASNHL and sudden deafness respectively. Forty percent of the respondents said medicolegal concerns factored into their decision to order a scan. Seventy-seven percent and 82% reported finding vestibular schwannomas in less than 1% to 4% of MRIs for ASNHL and sudden deafness, respectively. Approximately one-third of the respondents still use ABR and acoustic reflex testing as screening tools. Conclusion: MRIs are the gold standard for determining retrocochlear pathology in the setting of sudden deafness and ASNHL but are expensive. Approximately one-third of the respondents still use ABR and acoustic reflex testing as screening tools before ordering MRI. MRI typically have a low yield in finding an abnormality (usually <1%-4%). Neurotologists in our survey seem to recognize this quandary: they usually order an MRI, although they know it will usually be negative, and 40% of them cite medicolegal concerns as one of the motivations for their decision. This suggests that routine use of MRI partially reflects the practice of defensive medicine rather than medicine based on evidence. Perhaps MRIs are rarely indicated as the initial screening tool in ASNHL and sudden deafness, given their high cost and low yield of abnormal findings, and their routine use should and could be reduced to contain medical costs.

Clinical Impact of Early CT Scans after Lateral Skull-Base Surgery

Objective To determine the frequency and clinical significance of abnormalities on postoperative computerized tomography (CT) scans performed within 24 hours after lateral skull base surgery. Study Design Case series with chart review. Setting Inpatient tertiary care hospital. Methods Adult patients undergoing lateral skull base surgery were identified using CPT code search from January 2010 to January 2013. Patient demographics, type of skull base lesion, surgical approach, length of operation, time between end of the surgery and CT scan, CT scan findings, and patients’ postsurgical neurologic status were collected. Results One hundred and seventy-two patients were identified who had a postoperative CT scan after lateral skull base surgery. Diagnoses included schwannoma (95), cerebrospinal fluid fistula (29), middle fossa encephaloceles (9), meningioma (13), superior semicircular canal dehiscence (12), and other disease processes (14). The approaches were middle fossa (64), translabyrinthine (70), suboccipital (17), infratemporal (8), and combined/other (13). Mild pneumocephalus was almost always found, along with mild extra-axial blood. Twenty-four patients had significant mass effect found on CT scan, but this was present preoperatively. Three patients had a mild subdural without neurological decline. No patient suffered any clinically significant neurological decline, although 5 patients reported finger numbness that resolved spontaneously and 2 patients had confusion in the immediate postoperative period. Conclusion Clinically significant abnormalities on immediate postoperative CT scans were rare, as were cases of neurological decline. Further prospective studies could determine a more cost-effective algorithm for routine use of postoperative imaging.

Utility of MRIs in adult cochlear implant evaluations

Objectives To determine the prevalence of MRI abnormalities in adults undergoing cochlear implantation and to correlate abnormalities to audiology data. Study Design Case series. Setting Academic medical center. Methods Adult patients (>18 yr old) undergoing cochlear implant evaluation from January 2008 to December 2012 were identified based on CPT code search. Demographics, preoperative MRI findings, operative findings, and audiometric data were collected. Results The study included 188 patients. Seventeen (9%) patients had significant otic capsule or vestibulocochlear nerve pathologies: 5 vestibular schwannomas, 4 enlarged vestibular aqueducts, 2 hypoplastic cochlear nerves, 2 labyrinthitis ossificans, 1 cochlear aplasia, 1 posterior semicircular canal malformation, 1 calcified meningioma, and 1 cholesterol granuloma. MRI results were normal (65%) or with findings not directly related to hearing loss (incidental findings, 25%) in the remaining patients. Mean pure tone average (PTA) differences (between the implanted and contralateral ear) did not significantly vary between normal-incidental and abnormal MRI scans (-6.6 dB versus -6.7 dB, p = 0.99) nor did speech discrimination scores (SDS) scores (8.5% versus 8.4%, p = 0.99). No significant difference was found in HINT scores for patients with a normal versus an abnormal MRI (19% versus 16,%, p = 0.62). Conclusion Although the majority of precochlear implantation MRIs were normal or demonstrated incidental findings, such as white matter changes, significant MRI findings affecting implantation site and patient counseling were found in almost 10% of patients. Audiogram findings did not correlate with abnormal findings on MRIs. Routine use of MRI in adult cochlear implant candidates may be warranted.

Endoscopic culture-directed antibiotic therapy: Impact on patient symptoms in chronic rhinosinusitis

BACKGROUND Endoscopically guided cultures are frequently employed to guide antimicrobial therapy in refractory chronic rhinosinusitis (CRS) patients. The objective of this study was to determine the impact of culture-directed antibiotics on patient symptoms. METHODS Retrospective review was conducted of 105 adult CRS patients undergoing evaluation in the ambulatory clinic of tertiary care academic medical center. RESULTS The most common microbes were Staphylococcus aureus (29.5%), Pseudomonas aeruginosa (23.8%) and methicillin-resistant S. aureus (11.4%). Normal respiratory flora or no growth was found in 19% of patients. Culture results changed antibiotic choices in 77% of patients. Statistically significant change in total SNOT-20 scores and all 4 subdomains was noted, with improvement being clinically meaningful in the rhinologic subdomain (-1.10, p<0.0001). Repeat purulence was only noted in 5 cases (4.8%). Multivariate regression analysis demonstrated that concurrent use of oral steroids was independently associated with improvement in the rhinologic subdomain (p=0.0041). The mean length of follow-up was 37 days. Length of follow-up (14-30, 31-60, 61-90 days) did not statistically impact SNOT-20 scores. CONCLUSION Endoscopic-derived sinus cultures are associated with clinically meaningful change in the rhinologic subdomain of SNOT-20 scores, and repeat purulence was infrequently noted at follow-up. Further prospective studies are needed to better delineate the role of cultures in CRS management. LEVEL OF EVIDENCE 4.

Airway evaluation in children with single ventricle cardiac physiology

OBJECTIVE Children with single ventricle cardiac physiology (SVC) often require airway procedures as an adjunct to their care. Descriptive analysis with a focus on outcomes of airway procedures in SVC patients have not been fully described in the literature. METHODS Retrospective, single-center cohort review of 270 patients born between Aug-2007 and Jan-2017. Patients were identified by cardiac database for single ventricle pathophysiology. A subset of these patients were identified to have been evaluated by otolaryngology with airway evaluations and/or interventions. RESULTS 88/270 patients (32.6%) required investigation or intervention for airway pathology. The most frequent procedure was flexible fiberoptic laryngoscopy (58/88 patients); it was the only procedure performed in 40 patients. Seventeen patients required tracheostomies with an associated increased length of stay (p < 0.001). Patients with cardiac procedures involving dissection around the aortic arch were considered higher airway risk due to the threat of recurrent laryngeal nerve injury, and were more likely to have vocal cord paralysis (58%) compared to patients with lower risk procedures (21%; p < 0.001). However, on multivariate logistic regression, vocal cord paralysis did not statistically impact the odds for tracheostomy placement, although the presence of subglottic stenosis increased the odds ratio of tracheostomy by 14.7 (p = 0.02). CONCLUSIONS Children with SVC often require airway evaluation and intervention. Patients with high risk cardiac procedures had a higher risk of recurrent laryngeal nerve injury but the presence of subglottic stenosis was the best predictor for a tracheostomy. This study represents one of the largest series of SVC children evaluated for airway pathology.

Effect of changing postoperative pain management on bleeding rates in tonsillectomy patients

PURPOSE To review rates of post-tonsillectomy hemorrhage (PTH) at a quaternary medical center, including the impact of narcotic versus nonsteroidal anti-inflammatory drug (NSAID) postoperative pain management. MATERIALS AND METHODS A retrospective review was performed of tonsillectomies conducted at a single institution between 1/1/2013 and 1/1/2017. The rates of PTH and subsequent intervention were calculated. These were categorized into patients having surgery pre- and post-July 1, 2015, the former group receiving narcotics and the latter ibuprofen with acetaminophen. RESULTS Of 1351 total tonsillectomies, 3.04% had PTH requiring return to the hospital. 0.74% required no further surgical intervention, whereas 2.30% required secondary surgical control. The bleed rate prior to July 2015 was 3.15%, with 1.05% non-surgical bleeds and 2.10% requiring surgery. Post-July 2015, the bleed rate was 2.92%, with 0.44% non-surgical bleeds and 2.49% requiring surgery. There were no statistically significant differences between the two groups with respect to overall, non-surgical, and surgical hemorrhage rates (p > 0.05). Of the total bleeds, the need for secondary surgery in the narcotic group was 66.7% and 85% in the NSAID group (p = 0.18). During the study period, 36 patients with PTH had their initial tonsillectomy performed at outside institutions; 53% required surgical intervention. CONCLUSIONS Secondary hemorrhage remains a significant cause of morbidity in post-tonsillectomy patients, often requiring surgical intervention. This review found no increased bleeding risk associated with use of ibuprofen and acetaminophen as opposed to narcotic pain relief. LEVEL OF EVIDENCE III.

Surgical Outcomes and Postoperative Management in Spontaneous Cerebrospinal Fluid Rhinorrhea

Background The etiology of spontaneous cerebrospinal fluid (CSF) rhinorrhea remains unknown, though emerging evidence suggests that this likely represents a variant of idiopathic intracranial hypertension. Long‐term success rates for repair and postoperative management strategies remain variable. Methods Retrospective review of patients undergoing surgical management of spontaneous CSF rhinorrhea was conducted over a 5‐year period. Analysis was performed to correlate recurrence with demographics and perioperative variables. Lumbar puncture usage and neuro‐ophthalmological examinations in clinical management were also assessed. Results Forty‐eight patients were included in the study. The mean age was 51.4 years with 94% females. Leaks were most commonly located in the sphenoid (43.8%) and cribriform region (33.3%). The most common findings on magnetic resonance imaging were empty sella (48%) and Meckels cave diverticula (24%). Nine patients (18.8%) had recurrent CSF leaks. Six occurred >1 month postoperatively. Three had repeat endoscopic repairs, two received ventriculoperitoneal shunts, and one was managed with a lumbar drain, with overall success rate of 93.8%. Acetazolamide was utilized in 19 cases (39.6%) postoperatively. Overall, 59% of patients had elevated opening pressures on postoperative lumbar puncture (n = 32). Neuro‐ophthalmology evaluated 28 patients; 25% had visual field deficits, and 7.1% had papilledema. Conclusions Management of spontaneous CSF leaks remains a significant challenge. Endoscopic repair is successful in most patients with little morbidity; however, postoperative management remains inconsistent, and further studies are warranted to establish consensus on post‐surgical care. The association with elevated intracranial pressure and visual field deficits/papilledema suggests opening pressures, and neuro‐ophthalmologic evaluation should be considered in the treatment algorithm.

Evading Detection and Antibiotics: Internalization Rates of Different Strains of Group A Streptococcus

Objectives: (1) Determine the internalization rates of different strains of Group A Streptococcus (GAS). (2) Determine whether statistically different internalization rates occur in patients who receive a tonsillectomy for sleep-disordered breathing/sleep apnea versus chronic/recurrent tonsillitis. (3) Facilitate the development of GAS vaccine Methods: In vitro microbiology/tissue culture study at an academic tertiary referral center. All tonsillectomy specimens (performed for sleep disordered breathing spectrum and recurrent/chronic tonsillitis spectrum) were collected at the authors’ institution from September 2013 to November 2013. Each specimen was swabbed and bacteria cultured and emm typed. Only specimens with GAS were included in the study. The strains were grown in brain heart infusion (BHI) media to an optic density at 600 nm of 0.5. HeLa and nasopharyngeal carcinoma Detroit 562 cells were grown in tissue culture and subsequently infected with individual strains of GAS at a multiplicity of infection (MOI) of 1:10 for 2 hours. Cells were then washed with Dulbecco’s Modified Eagle Media (DMEM) and reincubated with DMEM plus gentamycin. The cells were then lysed, serial dilutions performed, and the lysate plated. Bacteria were counted and percent internalizations were calculated. This was repeated in triplicate for each strain. Results: Out of 396 eligible patients, 66 strains of GAS have been isolated. Both the Detroit and HeLa cells have been successfully grown in BHI. The bacterial strains have been subcultured. The authors plan on infecting the cells in March 2014 and will have have conclusive results by April 2014. Conclusions: None provided.