Faculty Bibliography

BACKGROUND: Inferior turbinate (IT) hypertrophy and adenoid hypertrophy are both causes of pediatric nasal obstruction. OBJECTIVE: The purpose of this survey was to study nasal obstruction evaluation and management among pediatric otolaryngologists with respect to IT and adenoid hypertrophy. METHODS: A questionnaire with embedded clinical videos was sent electronically to American Society of Pediatric Otolaryngology members. RESULTS: A total of 435 questionnaires were sent, and 75 were completed. Respondents were presented with scenarios that involved a 7-year-old child with nasal obstruction unresponsive to medical therapy, and the respondents were asked to choose a surgical plan, either IT reduction, adenoidectomy, or combined IT reduction and adenoidectomy. Three questions described the extent of IT and adenoid obstruction in text form, although three questions included a video of the child's nasal endoscopy. In questions with perceived or stated IT hypertrophy, the respondents chose to perform IT reduction significantly more frequently when the perceived or stated adenoid hypertrophy was less severe (p < 0.0001 for video and p = 0.039 for written questions). CONCLUSION: The decision to perform IT reduction in children is inversely related to the extent of adenoid hypertrophy. Future studies on pediatric IT surgery should include objective descriptions of the IT and adenoid in study subjects.

Oral mucositis (OM) is among the most common, painful, and debilitating toxicities of cancer regimen-related treatment, resulting in the formation of ulcers, which are susceptible to increased colonization of microorganisms. Novel discoveries in OM have focused on understanding the host-microbial interactions, because current pathways have shown that major virulence factors from microorganisms have the potential to contribute to the development of OM and may even prolong the existence of already established ulcerations, affecting tissue healing. Additional comprehensive and disciplined clinical investigation is needed to carefully characterize the relationship between the clinical trajectory of OM, the local levels of inflammatory changes (both clinical and molecular), and the ebb and flow of the oral microbiota. Answering such questions will increase our knowledge of the mechanisms engaged by the oral immune system in response to mucositis, facilitating their translation into novel therapeutic approaches. In doing so, directed clinical strategies can be developed that specifically target those times and tissues that are most susceptible to intervention.

OBJECTIVE: To perform a systematic review of the pathogenesis of medication-induced salivary gland dysfunction (MISGD). MATERIALS AND METHODS: Review of the identified papers was based on the standards regarding the methodology for systematic reviews set forth by the World Workshop on Oral Medicine IV and the PRISMA statement. Eligible papers were assessed for both the degree and strength of relevance to the pathogenesis of MISGD as well as on the appropriateness of the study design and sample size. A total of 99 papers was retained for the final analysis. RESULTS: MISGD in human studies was generally reported as xerostomia (the sensation of oral dryness) without measurements of salivary secretion rate. Medications may act on the central nervous system (CNS) and/or at the neuroglandular junction on muscarinic, alpha-and beta-adrenergic receptors and certain peptidergic receptors. The types of medications that were most commonly implicated for inducing salivary gland dysfunction were those acting on the nervous, cardiovascular, genitourinary, musculo-skeletal, respiratory, and alimentary systems. CONCLUSIONS: Although many medications may affect the salivary flow rate and composition, most of the studies considered only xerostomia. Thus, further human studies are necessary to improve our understanding of the association between MISGD and the underlying pathophysiology

OBJECTIVES/HYPOTHESIS:To evaluate the increase in access to the maxillary sinus (MS) with transnasal endoscopic medial maxillary sinus wall transposition (TEMMT), while preserving major structures of the nasal cavity. STUDY DESIGN:The study was divided into three parts: anatomical, radiographic, and case series. METHODS:Three cadaveric dissections (total of six sides) confirmed the feasibility of the TEMMT approach. Radiographic measurements using maxillofacial computed tomography scans were taken to assess the maximal antrostomy. The TEMMT approach was performed on six consecutive patients with benign MS disease. RESULTS:The cadaveric measurements were consistent with the radiographic measurements, which confirmed the maximum access to the MS. The radiographic measurements ranged from 14.4 to 39.1 mm in the anteroposterior dimension, 8.2 to 23.7 mm in the superior-inferior dimension, and 36° to 98° in the angle between the medial and anterior wall of the MS. In the patient series, five patients presented with an odontogenic cyst, and one patient had an antrochoanal polyp in the MS. The TEMMT approach provided excellent access and adequate resection, as well as preservation of the nasolacrimal duct and inferior turbinate. Finally, the mucosal flap was sufficient to cover the inferior meatal antrostomy. CONCLUSIONS:TEMMT provides excellent access into the MS, especially the floor and anterior wall, without the morbidities of the Caldwell-Luc or medial maxillectomy approach. In addition, the transposition of the inferior turbinate and the mucosal flap provides coverage of the medial wall with preservation of the inferior meatus, inferior turbinate, and nasolacrimal duct for patients with benign MS disease. LEVEL OF EVIDENCE:NA Laryngoscope, 126:1504-1509, 2016.

INTRODUCTION: Although rare, complications in cochlear implantation may result from surgical or technical mishaps, reaction to the foreign body, infection, or mechanical device failure. Delayed cerebrospinal fluid (CSF) leak is a rarely reported condition that may present with asymptomatic swelling over the receiver-stimulator (RS). In our practice, meticulous drilling of a bony well is important in preventing device migration and maintaining a low device profile but there is the potential for immediate or delayed complication from this technique. OBJECTIVE: We report two cases of the diagnosis and management of delayed extradural CSF collection of the RS bony well and describe its successful management. PATIENTS: Two pediatric cochlear implant patients, 10 and 17 months of age with devices from different manufacturers. INTERVENTION(S): Operative exploration and repair without device removal. MAIN OUTCOME AND RESULTS: Although the initial postoperative course was uncomplicated with both patients receiving benefit from their device, both presented at varying intervals month(s) later with swelling over the RS. There were no signs of infection but the swelling prevented use of the device. Extradural CSF collection was suspected, confirmed operatively, and repaired with complete resolution without the need for reimplantation. CONCLUSION: Delayed CSF leak may present as an asymptomatic swelling over the RS after cochlear implantation. Sterile fluid aspiration may confirm the diagnosis and management can proceed conservatively or with operative exploration and repair. Future device designs with lower profiles may facilitate device fixation while allowing for a more shallow well, further reducing the risk of this rare complication.

Moderate-to-severe fatigue occurs in up to 94% of oncology patients undergoing active treatment. Current interventions for fatigue are not efficacious. A major impediment to the development of effective treatments is a lack of understanding of the fundamental mechanisms underlying fatigue. In the current study, differences in phenotypic characteristics and gene expression profiles were evaluated in a sample of breast cancer patients undergoing chemotherapy (CTX) who reported low (n = 19) and high (n = 25) levels of evening fatigue. Compared to the low group, patients in the high evening fatigue group reported lower functional status scores, higher comorbidity scores, and fewer prior cancer treatments. One gene was identified as upregulated and 11 as downregulated in the high evening fatigue group. Gene set analysis found 24 downregulated and 94 simultaneously up- and downregulated pathways between the two fatigue groups. Transcript origin analysis found that differential expression (DE) originated primarily from monocytes and dendritic cell types. Query of public data sources found 18 gene expression experiments with similar DE profiles. Our analyses revealed that inflammation, neurotransmitter regulation, and energy metabolism are likely mechanisms associated with evening fatigue severity; that CTX may contribute to fatigue seen in oncology patients; and that the patterns of gene expression may be shared with other models of fatigue (e.g., physical exercise and pathogen-induced sickness behavior). These results suggest that the mechanisms that underlie fatigue in oncology patients are multifactorial.

Submandibular gland ptosis is a common impediment to obtaining superior surgical aesthetic results in neck lift surgery. Techniques for suspending the submandibular gland have been proposed, but these procedures have the drawbacks of disturbing the floor of the mouth mucosa and periosteum. We present an approach of submandibular gland suspension for the treatment of gland ptosis by employing a platysma and hyoid bone fascia cradle. Our technique was performed on cadaveric models. The platysma muscle and hyoid bone cradle for submandibular gland ptosis was created on the left side of the neck in two cadavers. A submental incision with sharp dissection was performed to raise a supraplatysmal flap. A subplatysmal plane was developed until the submandibular gland was identified. Sutures were used to pexy the platysma to the hyoid bone periosteum and deep cervical fascia, tightening the overlying muscle and in turn elevating the submandibular gland. Submandibular gland ptosis must be corrected in order to achieve exemplary aesthetic results. Our approach of creating a cradle with the platysma and hyoid bone avoids the potential complications of previously described sling procedures, while still maintaining the integrity of the gland and surrounding tissues.

OBJECTIVE: To describe this institution's experience with and the long-term outcomes of early type 1 thyroplasty for unilateral vocal fold paralysis (UVFP) following surgery on the aortic arch. STUDY DESIGN: Retrospective chart review with telephone questionnaire. SETTING: Academic tertiary care center. SUBJECTS AND METHODS: Three hundred forty-eight patients with UVFP following surgery on the aortic arch since 1999 were identified; 40 were available for follow-up. The number of revision procedures following initial thyroplasty was ascertained, and the Voice Handicap Index (VHI) was administered by telephone. The hypothesis that early thyroplasty produced voice outcomes and revision rates comparable to injection laryngoplasty was established prior to the initiation of data collection. RESULTS: Six out of the 40 patients (15%) required revision thyroplasty following their initial procedure. Mean VHI of all patients was 36.0 (SD, 27.2). Mean VHI was significantly different in the 18 to 39 age group (13.1) when compared to the 40 to 59 (51.8) and 60+ (37.7) age groups (P = .013). Mean follow-up since initial thyroplasty was 46.5 months (SD, 42.2). CONCLUSIONS: In the setting of aortic arch surgery with injury to the recurrent laryngeal nerve, early thyroplasty produces voice outcomes comparable to those achieved in the literature with repeated injection and delayed thyroplasty and can be considered in select populations.