Faculty Bibliography

OBJECTIVE:Cochlear implant (CI) technology and techniques have advanced over the years. There has not been the same degree of change in programming and there remains a lack of standardization techniques. The purpose of this study is to compare performance in cochlear implant subjects using experienced clinician (EC) standard programming methods versus an Artificial Intelligence, FOX based algorithm for programming. STUDY DESIGN/METHODS:Prospective, nonrandomized, multicenter study using within-subject experimental design SETTING:: Tertiary referral centers. PATIENTS/METHODS:Fifty-five adult patients with ≥ 3 months experience with a Nucleus 5, 6, Kanso, or 7 series sound processor. INTERVENTION/METHODS:Therapeutic Main Outcome Measures: CNC words and AzBio sentences in noise (+10 dB SNR) tests were administered in a soundproof booth followed by a direct connect psychoacoustic battery using the EC program. Tests were repeated 1 month later using the optimized FOX program. Subjective measures of patient satisfaction were also measured. RESULTS:Performance for the EC program was compared to the FOX program for both measures. Group mean results revealed equivalent performance (Kruskal-Wallis ANOVA p = 0.934) with both programming methods. While some patients had better performance with the FOX method and some performed more poorly, the majority had equivalent performance and preferred the FOX system. CONCLUSION/CONCLUSIONS:The study demonstrated that on average, FOX outcomes are equivalent to those using traditional programming techniques. In addition, the FOX programming method can effect standardization across centers and increase access for many individuals who could benefit.

Extracardiac rhabdomyoma is an uncommon benign striated muscle tumor with a predilection for the head and neck region. However, it is extremely rare for extracardiac rhabdomyoma to present as a thyroid nodule. We report a case of rhabdomyoma diagnosed by thyroid fine-needle aspiration (FNA) in a patient with Birt-Hogg-Dubé (BHD) syndrome. A 60-year-old man with BHD syndrome presented for recurrent pneumothorax. Chest CT incidentally identified a thyroid nodule. Subsequent sonography confirmed a 4.44 × 2.28 × 2.82 cm solid, hypoechoic nodule with smooth margins in the right upper pole. Ultrasound-guided FNA revealed many clusters and scattered isolated large polygonal cells with abundant granular cytoplasm and small peripherally located nuclei. Vague striations in the cytoplasm were focally identified. No follicular cells or colloid was present. Immunocytochemistry on one direct smear slide demonstrated diffuse positivity for desmin, supporting muscular differentiation. Subsequent surgery identified an adult rhabdomyoma originating from the inferior constrictor muscle of the neck and anteriorly displacing the thyroid. Because the mass was intimately associated with the thyroid gland, it was initially mistaken for a thyroid nodule on ultrasound. Diagnosis of rhabdomyoma on FNA is challenging, especially when rhabdomyoma mimics a thyroid nodule on imaging. The differential diagnosis includes Hurthle cell neoplasm, granular cell tumor, colloid nodule, and normal striated skeletal muscle. Adequate radiologic data and familiarity with the cytologic features of rhabdomyoma are critical for an accurate diagnosis.

Importance/UNASSIGNED:Esophageal perforations are difficult to diagnose and have a high mortality rate. Cervical esophageal perforations (CEPs) are the second most common anatomic type of esophageal perforations and are most often due to iatrogenic injury. They are often managed more conservatively than thoracic perforations. The current literature on CEPs is mostly observational, with a paucity of prospective controlled studies. In addition, there is scarce literature focusing specifically on iatrogenic CEPs (iCEPs) as an entity of their own. Observations/UNASSIGNED:The existing studies on esophageal perforations address treatment by anatomic location and by cause, but few focus specifically on iCEPs. The cricopharynx is the most common site for injury in diagnostic endoscopy. The standard treatment is generally conservative management with drainage unless the perforation is greater than 2 cm, the diagnosis is delayed, or the patient shows signs of sepsis, which would prompt surgical intervention, most commonly in the form of primary repair via open or endoscopic approach. An open approach has been the mainstay of therapy; however, use of endoscopic clips, stents, and suturing is increasingly on the rise. Guideline recommendations on the optimal therapeutic approach for iCEPs are lacking. The most consistent recommendation in the literature is immediate and individualized treatment. Conclusions and Relevance/UNASSIGNED:The management of iCEPs is controversial. There is a need for additional prospective studies comparing treatment options for iCEPs to establish a gold standard treatment and to assess for the expanding role of endoscopic interventions.

OBJECTIVE:We describe our experience using the extracorporeal video microscope, the "exoscope" for repair of a temporal bone encephalocele. METHOD/METHODS:The patient is a 69-year-old male with a right temporal lobe encephalocele herniating through a tegmen defect. He underwent definitive tegmen defect repair and bipolar cauterization of the encephalocele. The authors elected for a combined transmastoid and transtemporal approach in order to isolate the tegmen defect and provide watertight repair. The Synaptive robotic BrightMatter (Toronto, ON) drive video exoscope monitor system was used for the entirety of the case including both the transmastoid approach and transtemporal craniotomy. RESULTS:No intraoperative complications were encountered during either the transmastoid (mastoidectomy) or transtemporal craniotomy. The authors were able to complete the entire case without abandonment of the exoscope in favor of the traditional binocular microscope. Advantages of this technology in clinical practice includes high-resolution three-dimensional visualization, increased degrees of freedom for exoscope adjustment, and reduced surgeon fatigue in a fixed, unnatural posture. Limitations include decreased depth perception and increased operative time. CONCLUSION/CONCLUSIONS:The exoscope system is a safe and effective alternative or adjunct to the existing binocular operating microscope for lateral skull based procedures. The exoscope provides the surgeon with a comfortable, high-resolution visualization without compromising surgical exposure and patient safety.SDC video link: http://links.lww.com/MAO/A837.

OBJECTIVES/UNASSIGNED:To evaluate volume changes within the tongue post chemoradiation therapy (CRT). STUDY DESIGN/UNASSIGNED:Retrospective review. SETTING/UNASSIGNED:Academic Medical Center. SUBJECTS AND METHODS/UNASSIGNED:Subjects included 19 patients that received CRT as the primary treatment for tonsillar or hypopharynx squamous cell carcinoma. Tongue volumes were calculated by three raters from thin slice computed tomography images collected before treatment and up to 29 months post-CRT. Body mass index (BMI) was also collected at each time point. RESULTS/UNASSIGNED: < .001) decreased by 0.11 units (SEM = 0.02) per month post radiation. CONCLUSION/UNASSIGNED:Tongue dysfunction and decreased tongue strength are significant contributors to the dysphagia that patients experience after receiving CRT. In this study, both tongue volume and BMI decreased post-CRT; therefore, BMI could potentially be used as a predictor of tongue volume post-CRT.

A lack of reliable laryngeal thermal injury models precludes laryngeal burn wound healing studies and investigation of novel therapeutics. We hypothesize that a swine laryngeal burn model can allow for laryngeal burn evaluation over time. Twelve Yorkshire crossbreed swine underwent tracheostomy and endoscopically directed laryngeal burns using heated air (150-160°C). Swine larynges were evaluated and sectioned/stained at 12 hours, 1, 3, 7, 14, and 21 days. A board-certified veterinary pathologist assessed anatomic regions (left and right: epiglottis, true/false vocal folds, and subglottis) using a nine criteria histological injury scoring scale. Six swine were euthanized at scheduled endpoints, three prematurely (airway concerns), and three succumbed to airway complications after 16 to 36 hours. Endoscopic and gross examination from scheduled endpoints revealed massive supraglottic edema and tissue damage, particularly around the arytenoids, extending transglottically. Swine from premature endpoints had comparatively increased edema throughout. Microscopic evaluation documented an inverse relationship between injury severity score and time from injury. Inflammation severity decreased over time, nearly resolving by 14 days. Neutrophils predominated early with histiocytes appearing at 3 days. Granulation tissue appeared at 3 days, and early epiglottic and/or subglottic fibrosis appeared by 7 days and matured by 14 days. Edema, abundant initially, decreased by day 3 and resolved by day 7. This approach is the first to provide longitudinal analysis of laryngeal thermal injuries, reflecting some of the first temporal wound healing characteristic data in laryngeal thermal injuries and providing a platform for future therapeutic studies.

BACKGROUND:The modified Blair incision is the standard facial incision for the vast majority of parotid gland lesions. We utilize three types of incisions: "classic mini-Blair" for parotid body tumors, "cervical mini-Blair" for parotid tail tumors, and "vertical mini-Blair" for anterior parotid tumors. In this study, we describe the surgical and esthetic outcomes of these individually tailored incisions. METHODS:Patients undergoing parotidectomy between 2011 and 2013 were included. The surgical outcomes and patients' satisfaction were assessed. RESULTS:Of 122 patients, 89 were included. All patients completed a questionnaire assessing the postoperative course and patients' satisfaction regarding the surgery in general and the scar in particular. Among these patients, 78 (87%) had a benign pathology and 11 (13%) had malignant tumors. The tumors were located at the parotid body in 57 patients (64%), at the parotid tail in 19 (21%), at the deep lobe in 8 (9%), and at the anterior parotid gland in 5 (6%). All tumors were removed successfully with negative margins on pathology. No inadvertent permanent facial nerve paralysis occurred. The median operation time was 72 min (23-211). The average patient scores of satisfaction with the surgical scar and with the surgery were 9.54 and 9.72, respectively. CONCLUSIONS:Individualized mini-Blair incision is feasible for benign as well as selected malignant parotid tumors.

Mucous membrane plasmacytosis (MMP) is an uncommon variant of mucositis represented by a polyclonal plasma cell infiltration of mucosal tissue. Various clinical presentations in the upper airway have been reported ranging from erythematous mucosa to fungating masses. Histologic features include mucosal epithelial hyperplasia or psoriasiform changes with a dense submucosal infiltrate of polytypic plasma cells. Molecular studies for immunoglobulin gene rearrangement should be performed in all cases of MMP to rule out clonal neoplastic expansion of plasma cells. We present a case of MMP with over 15 years of clinical follow-up, emphasizing the relatively benign clinical course of this disorder.

OBJECTIVE:To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND:Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS:The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS:These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS:Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.