Faculty Bibliography

OBJECTIVES/OBJECTIVE:The medial sural artery perforator (MSAP) free flap is an uncommonly utilized soft tissue flap in head and neck reconstruction. It is a thin, pliable, fasciocutaneous flap that provides significant pedicle length. The donor site can be closed primarily, and its location is more aesthetically pleasing to patients. We aim to describe the MSAP flap and compare it to other commonly used free flaps in the head and neck. STUDY DESIGN/METHODS:Retrospective case series. METHODS:A retrospective review of all MSAP cases performed at New York University Langone Health was performed from July 2016 to November 2017. We examined the patients' age, diagnosis, history of prior radiation therapy, and comorbidities, as well as flap-specific information and recipient site. RESULTS:(15 cm × 8 cm). The flaps ranged from 5 to 12 mm in thickness. Venous coupler size ranged from 2.0 to 3.5 mm. Primary closure of the donor site was achieved in 18 of 21 flaps. Twenty of 21 flaps were transferred successfully. CONCLUSION/CONCLUSIONS:The MSAP flap is a highly versatile and reliable option for a thin, pliable soft tissue flap with a donor site that may be preferable over the radial forearm free flap and anterolateral thigh flap in complex head and neck reconstruction. LEVEL OF EVIDENCE/METHODS:4. Laryngoscope, 2018.

Purpose: Non-tuberculous mycobacteria (NTM) can cause clinically significant lung disease and frequent pneumonias. It is unknown whether impaired swallowing contributes to the pathophysiology of NTM. Patients with NTM may exhibit decreased airway protection. Our aim is to determine airway protection and bolus clearance in patients with NTM. Method(s): Videofluoroscopy (VF) was prospectively collected from 98 patients with NTM (67 female; ages 33-88). Two boluses of 3,5,10 ml thin liquid, two 5 cc puree Varibar, cracker were analyzed per subject (N = 980 swallows).Outcome measures included Penetration/Aspiration Scale (PAS) and ordinal ratings of residue in the valleculae and pyriform sinuses. Worst PAS scores categorized subject as unsafe (C 3) or safe (B 2). The correlation between clinical information and the present of penetration/aspiration and pharyngeal residue structures was analyzed. Result(s): Inter-and intra-rater reliability of PAS ratings were assessed using two-way mixed intraclass correlation coefficients (ICC) on 20% of the data with excellent results (intra-rater: ICC 0.98, 95% CI 0.95-0.98 and inter-rater: ICC 0.85, 95% CI 0.69-0.92). The proportion of impaired swallows in the whole dataset was 12.9% (127/980 swallows with PAS scores C 3). There was no correlation between presence of penetration/aspiration and pharyngeal residue with productive cough, pneumonia, smoking history and presence of acid reflux. Conclusions (Including Clinical Relevance): Patients with NTM appear to have impaired swallow function as represented by impaired airway protection. Future work should explore swallowing physiology compared to a control group

OBJECTIVES:The purpose of this study was to obtain an electrophysiological analog of masking release using speech-evoked cortical potentials in steady and modulated maskers and to relate this masking release to behavioral measures for the same stimuli. The hypothesis was that the evoked potentials can be tracked to a lower stimulus level in a modulated masker than in a steady masker and that the magnitude of this electrophysiological masking release is of the same order as that of the behavioral masking release for the same stimuli. DESIGN:Cortical potentials evoked by an 80-ms /ba/ stimulus were measured in two steady maskers (30 and 65 dB SPL), and in a masker that modulated between these two levels at a rate of 25 Hz. In each masker, a level series was undertaken to determine electrophysiological threshold. Behavioral detection thresholds were determined in the same maskers using an adaptive tracking procedure. Masking release was defined as the difference between signal thresholds measured in the steady 65-dB SPL masker and the modulated masker. A total of 23 normal-hearing adults participated. RESULTS:Electrophysiological thresholds were uniformly elevated relative to behavioral thresholds by about 6.5 dB. However, the magnitude of masking release was about 13.5 dB for both measurement domains. CONCLUSIONS:Electrophysiological measures of masking release using speech-evoked cortical auditory evoked potentials correspond closely to behavioral estimates for the same stimuli. This suggests that objective measures based on electrophysiological techniques can be used to reliably gauge aspects of temporal processing ability.

The Eating Assessment Tool-10 (EAT-10) is a 10-item patient-reported outcome measure (PROM) for dysphagia patients. The objective of this study was to translate and validate the EAT-10_Heb and to test for a correlation between its score and residue, penetration and aspiration on Fiberoptic Endoscopic Examination of Swallowing (FEES). 136 patients visiting two specialized dysphagia clinics and undergoing FEES between April 2015 and August 2017, filled the EAT-10_Heb. 23 patients refilled the EAT-10_Heb during a 2-week period following their first visit. FEES were scored for residue (1 point per consistency, maximum 3 points) and penetration and aspiration (1 point for penetration, 2 points for aspiration per consistency, maximum 6 points). 51 healthy volunteers also filled the EAT-10_Heb. Internal consistency and test-retest reproducibility were examined for reliability testing. Validity was established by comparing EAT-10_Heb scores of dysphagia patients to healthy controls. The EAT-10_Heb score was then correlated with the FEES score. Internal consistency of the EAT-10_Heb was high (Cronbach's alpha = 0.925) as was the test-retest reproducibility (Spearman's correlation coefficient = 0.82, p < 0.0001). The median EAT-10_Heb score was significantly higher in the dysphagia group compared to healthy controls (13, IQR 7-22 points for dysphagia patients compared to 0, IQR 0-0 points for healthy controls, p < 0.0001). A weak correlation was found between the EAT-10_Heb scores and the FEES score (Pearson's correlation coefficient = 0.376, p < 0.0001). While the EAT-10_Heb was found to be a reliable and valid PROM, it only weakly correlates with the pathological findings on FEES examination.

OBJECTIVES/UNASSIGNED:To examine the frequency in which angled endoscopes are necessary to visualize the true maxillary ostium (TMO) following uncinectomy and prior to maxillary antrostomy. Additionally, to identify preoperative computed tomography (CT) measures that predict need for an angled endoscope to visualize the TMO. STUDY DESIGN/UNASSIGNED:Retrospective study. SETTING/UNASSIGNED:Tertiary academic hospital. PATIENTS AND METHODS/UNASSIGNED:Patients who underwent endoscopic sinus surgery (ESS) between December of 2017 and August of 2018 were retrospectively identified. Cases were reviewed if they were primary ESS cases for chronic rhinosinusitis without polyposis and if they were at least 18 years of age. RESULTS/UNASSIGNED:Sixty-three maxillary antrostomies were reviewed (82.5% were from bilateral cases). Thirty-five cases (55.6%) required an angled endoscope in order to visualize the TMO. Of the preoperative CT measures examined, a smaller sphenoid keel-caudal septum-nasolacrimal duct (SK-CS-NL) angle was significantly associated with need for an angled endoscope intraoperatively to visualize the TMO (17.1° SD ± 3.2 vs 15.0° SD ± 2.9; P = .010). CONCLUSION/UNASSIGNED:Angled endoscopes are likely required in the majority of maxillary antrostomies to visualize the TMO. This is important to recognize in order to prevent iatrogenic recirculation. The SK-CS-NL angle may help to identify cases preoperatively which require an angled endoscope to identify the TMO during surgery.

Wind is a major navigational cue for insects, but how wind direction is decoded by central neurons in the insect brain is unknown. Here we find that walking flies combine signals from both antennae to orient to wind during olfactory search behavior. Movements of single antennae are ambiguous with respect to wind direction, but the difference between left and right antennal displacements yields a linear code for wind direction in azimuth. Second-order mechanosensory neurons share the ambiguous responses of a single antenna and receive input primarily from the ipsilateral antenna. Finally, we identify novel "wedge projection neurons" that integrate signals across the two antennae and receive input from at least three classes of second-order neurons to produce a more linear representation of wind direction. This study establishes how a feature of the sensory environment-wind direction-is decoded by neurons that compare information across two sensors.

OBJECTIVE/UNASSIGNED:To evaluate rates of epiphora after transection and marsupialization of the nasolacrimal duct (NLD) during endoscopic sinus and skull base surgery. INTRODUCTION/UNASSIGNED:The nasolacrimal canal forms part of the medial wall of the maxillary sinus. Transecting the NLD is sometimes necessary for tumor resection or surgical access to maxillary sinus and infratemporal fossa pathology. There is no consensus for the endoscopic management of the NLD when only the duct is transected without involving the nasolacrimal sac. METHODS/UNASSIGNED:Medical records of 29 patients from 2 academic institutions who underwent endoscopic sinus and skull base surgery with transection of the NLD were retrospectively reviewed. Whether the duct was marsupialized or simply transected was recorded, and the postoperative rate of epiphora was calculated. RESULTS/UNASSIGNED:Mean age was 59 years (range, 14-86 years). Mean follow-up was 10.5 months (range, 1-33 months). The NLD was marsupialized in 16 (55%) and simply transected in 13 (45%) patients. Six patients underwent postoperative radiation. No patients in the marsupialization group had epiphora postoperatively, all with Munk score of 0. One patient in the transection group developed postoperative epiphora with Munk score of 1. Pathology included inverted papilloma (8), acute on chronic inflammation (6), B-cell lymphoma (3), juvenile nasopharyngeal angiofibroma (2), squamous cell carcinoma (2), Schneiderian papilloma (2), metastatic melanoma (1), HPV-related carcinoma (1), adenocarcinoma (1), benign epithelial cyst (1), adenoid cystic carcinoma (1), and erosive chronic sinusitis without nasal polyposis (1). CONCLUSION/UNASSIGNED:Management after transection of the NLD varies widely. The duct may be simply transected or marsupialized, or a formal dacryocystorhinostomy can be performed. The surgeon must also choose whether to place a stent. Based on our small series and review of the literature, marsupialization or simple transection of the NLD results in a low rate of postoperative epiphora in the setting of endoscopic sinus and skull base surgery.

Performance on cognitive tasks during learning is used to measure knowledge, yet it remains controversial since such testing is susceptible to contextual factors. To what extent does performance during learning depend on the testing context, rather than underlying knowledge? We trained mice, rats and ferrets on a range of tasks to examine how testing context impacts the acquisition of knowledge versus its expression. We interleaved reinforced trials with probe trials in which we omitted reinforcement. Across tasks, each animal species performed remarkably better in probe trials during learning and inter-animal variability was strikingly reduced. Reinforcement feedback is thus critical for learning-related behavioral improvements but, paradoxically masks the expression of underlying knowledge. We capture these results with a network model in which learning occurs during reinforced trials while context modulates only the read-out parameters. Probing learning by omitting reinforcement thus uncovers latent knowledge and identifies context- not "smartness"- as the major source of individual variability.

OBJECTIVE:To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of young infants who present with signs or symptoms of choanal atresia. METHODS:A two-iterative delphi method questionnaire was used to establish expert recommendations by the members of the International Otolaryngology Group (IPOG), on the diagnostic, intra-operative, post-operative and revision surgery considerations. RESULTS:Twenty-eight members completed the survey, in 22 tertiary-care center departments representing 8 countries. The main consensual recommendations were: nasal endoscopy or fiberscopy and CT imaging are recommended for diagnosis; unilateral choanal atresia repair should be delayed after at least age 6 months whenever possible; transnasal endoscopic repair is the preferred technique; long term follow-up is recommended (minimum one year) using nasal nasofiberscopy or rigid endoscopy, without systematic imaging. CONCLUSION/CONCLUSIONS:Choanal atresia care consensus recommendations are aimed at improving patient-centered care in neonates, infants and children with choanal atresia.