Faculty Bibliography

Background Partial hypopharyngeal defects are most commonly reconstructed with the pectoralis major myocutaneous flap (PMMF) or free fasciocutaneous (FFC) flap. The purpose of this study is to determine the ideal method for reconstruction of partial hypopharyngeal defects by reviewing our institutional experience and the literature. Methods A retrospective review of partial hypopharyngeal reconstructions since 2009 was performed. A National Library of Medicine search of studies on partial hypopharyngeal reconstruction since 1988 was performed. Data on complications, diet, and speech were extracted and pooled. Results A total of 18 patients were studied-9 had PMMF reconstruction and 9 had FFC reconstruction. Operative time (8.75 vs. 13.0 hours, p = 0.0003) was shorter in the PMMF group. Pharyngocutaneous fistula developed in one PMMF patient (11.1%) and two FFC patients (22.2%). Late strictures occurred in three PMMF patients. Six patients in each group (66.7%) progressed to a regular diet. Three patients in each group produced tracheoesophageal speech after TEP. Literature review identified 36 relevant studies, with 301 patients reconstructed with PMMF and 605 patients with FFC. Pooled-data analysis revealed that PMMF had higher reported rates of fistula (24.7 vs. 8.9%, p < 0.0001) and requirement for second surgery (11.3 vs. 5.5%, p = 0.04). There was no difference in stricture rates or progression to regular diet. Fewer PMMF patients produced tracheoesophageal speech (17.5 vs. 52.1%, p < 0.0001). Conclusions PMMF and FFC flaps are valid approaches to reconstructing partial hypopharyngeal defects, though rates in the literature of fistula, need for revisional surgery, and tracheoesophageal speech after laryngectomy are more favorable after free flap reconstruction.

OBJECTIVES/OBJECTIVE:Pitch plasticity has been observed in Hybrid cochlear implant (CI) users. Does pitch plasticity also occur in bimodal CI users with traditional long-electrode CIs, and is pitch adaptation pattern associated with electrode discrimination or speech recognition performance? The goals of this study were to characterize pitch adaptation patterns in long-electrode CI users, to correlate these patterns with electrode discrimination and speech perception outcomes, and to analyze which subject factors are associated with the different patterns. DESIGN/METHODS:Electric-to-acoustic pitch matches were obtained in 19 subjects over time from CI activation to at least 12 months after activation, and in a separate group of 18 subjects in a single visit after at least 24 months of CI experience. Audiometric thresholds, electrode discrimination performance, and speech perception scores were also measured. RESULTS:Subjects measured over time had pitch adaptation patterns that fit one of the following categories: (1) "Pitch-adapting," that is, the mismatch between perceived electrode pitch and the corresponding frequency-to-electrode allocations decreased; (2) "Pitch-dropping," that is, the pitches of multiple electrodes dropped and converged to a similar low-pitch; and (3) "Pitch-unchanging," that is, the electrode pitches did not change. Subjects measured after CI experience had a parallel set of adaptation patterns: (1) "Matched-pitch," that is, the electrode pitch was matched to the frequency allocation; (2) "Low-pitch," that is, the pitches of multiple electrodes were all around the lowest frequency allocation; and (3) "Nonmatched-pitch," that is, the pitch patterns were compressed relative to the frequency allocations and did not fit either the matched-pitch or low-pitch categories. Unlike Hybrid CI users which were mostly in the pitch-adapting or matched-pitch category, the majority of bimodal CI users were in the latter two categories, pitch-dropping/low-pitch or pitch-unchanging/nonmatched-pitch. Subjects with pitch-adapting or matched-pitch patterns tended to have better low-frequency thresholds than subjects in the latter categories. Changes in electrode discrimination over time were not associated with changes in pitch differences between electrodes. Reductions in speech perception scores over time showed a weak but nonsignificant association with dropping-pitch patterns. CONCLUSIONS:Bimodal CI users with more residual hearing may have somewhat greater similarity to Hybrid CI users and be more likely to adapt pitch perception to reduce mismatch with the frequencies allocated to the electrodes and the acoustic hearing. In contrast, bimodal CI users with less residual hearing exhibit either no adaptation, or surprisingly, a third pattern in which the pitches of the basal electrodes drop to match the frequency range allocated to the most apical electrode. The lack of association of electrode discrimination changes with pitch changes suggests that electrode discrimination does not depend on perceived pitch differences between electrodes, but rather on some other characteristics such as timbre. In contrast, speech perception may depend more on pitch perception and the ability to distinguish pitch between electrodes, especially since during multielectrode stimulation, cues such as timbre may be less useful for discrimination.

OBJECT Physicians are often solicited by patients or colleagues for clinical recommendations they would make for themselves if faced by a clinical situation. The act of making a recommendation can alter the clinical course being taken. The authors sought to understand this dynamic across different neurosurgical scenarios by examining how neurosurgeons value the procedures that they offer. METHODS The authors conducted an online survey using the Congress of Neurological Surgeons listserv in May 2013. Respondents were randomized to answer either as the surgeon or as the patient. Questions encompassed an array of distinct neurosurgical scenarios. Data on practice parameters and experience levels were also collected. RESULTS Of the 534 survey responses, 279 responded as the "neurosurgeon" and 255 as the "patient." For both vestibular schwannoma and arteriovenous malformation management, more respondents chose resection for their patient but radiosurgery for themselves (p = 0.002 and p = 0.001, respectively). Aneurysm coiling was chosen more often than clipping, but those whose practice was >/= 30% open cerebrovascular neurosurgery were less likely to choose coiling. Overall, neurosurgeons who focus predominantly on tumors were more aggressive in managing the glioma, vestibular schwannoma, arteriovenous malformation, and trauma. Neurosurgeons more than 10 years out of residency were less likely to recommend surgery for management of spinal pain, aneurysm, arteriovenous malformation, and trauma scenarios. CONCLUSIONS In the majority of cases, altering the role of the surgeon did not change the decision to pursue treatment. In certain clinical scenarios, however, neurosurgeons chose treatment options for themselves that were different from what they would have chosen for (or recommended to) their patients. For the management of vestibular schwannomas, arteriovenous malformations, intracranial aneurysms, and hypertensive hemorrhages, responses favored less invasive interventions when the surgeon was the patient. These findings are likely a result of cognitive biases, previous training, experience, areas of expertise, and personal values.

BACKGROUND: Several recent analyses of indeterminate thyroid nodules classified as Bethesda III (follicular lesion of undetermined significance) have reported considerably greater rates of malignancy than those initially reported by the Bethesda System for Reporting Cytopathology (BSRTC). These values, however, may be overestimates owing to several sources of bias, such as referral, selection, and publication biases. Our aim was to analyze the prevalence of malignancy in Bethesda III and IV thyroid nodules in a comprehensive health system less prone to institutional referral bias, excluding incidental carcinomas, and we examine the literature for publication bias. METHODS: We performed a retrospective analysis with pathologic re-review of 119 patients with Bethesda III/IV cytology undergoing surgery in a comprehensive health system by examining patient and nodule characteristics. A review of the literature was performed and analyzed for publication bias. RESULTS: The malignancy rate in resected thyroid nodules was 13% (6/48) for Bethesda III and 28% (20/71) for Bethesda IV. There were 9 of 119 patients (8%) with incidental microcarcinomas. Age <30 years was associated with an increased risk of malignancy (odds ratio, 25.8; P = .005). Sex, nodule size, and ultrasonographic features were not associated with risk of malignancy. Analysis of the literature was indicative of publication bias for Bethesda III cohorts, with reported rates positively skewed (P = .039). CONCLUSION: In a comprehensive health system, the rate of malignancy in Bethesda III nodules was similar to the range reported by the BSRTC. Recent reports of greater rates of malignancy may be attributable to institutional referral patterns, operative selection, inclusion of incidental microcarcinomas, and publication bias.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:Head and neck squamous cell carcinoma (HNSCC) cells are resistant to cell death induced by tumor necrosis factor ligands such as tumor necrosis factor α (TNFα) or TNF-related apoptosis-inducing ligand (TRAIL) and cytotoxic chemotherapies. Recently, genetic alterations in cell death pathways, including inhibitor of apoptosis proteins, have been demonstrated in HNSCC. We investigated the effects of birinapant, a novel, second mitochondria-derived activator of caspases (SMAC)-mimetic that targets inhibitor of apoptosis proteins, alone and in combination with TNFα, TRAIL, or chemotherapy docetaxel. STUDY DESIGN/METHODS:Experimental study using human HNSCC cell lines in vitro and xenograft mouse model in vivo. METHODS:A panel of HNSCC cell lines with varying genetic alterations in cell death pathway components were treated with birinapant ± TNFα, TRAIL, and docetaxel and were assessed for effects on cell density, cell cycle, and death. Synergism was determined at varying concentrations of treatments using the Chou-Talalay method. Combination studies using birinapant ± docetaxel were performed in a xenograft mouse model. RESULTS:Birinapant, alone or in combination with TNFα or TRAIL, decreased cell density in cell lines, with IC50 s ranging from 0.5 nM to > 1 µM. Birinapant alone or with TNF significantly increased subG0 cell death in different lines. Docetaxel showed synergism with birinapant ± TNFα in vitro. Birinapant monotherapy-inhibited growth in a tumor xenograft model resistant to docetaxel, and combination treatment further delayed growth. CONCLUSIONS:Birinapant alone or in combination with TNFα or TRAIL and docetaxel decreased cell density, increased cell death, and displayed antitumor activity in a preclinical HNSCC xenograft exhibiting aberrations in cell death pathway components and docetaxel resistance.

Objectives Intraoperative vagus nerve monitoring during skull base surgery has been reported with the use of an oral nerve monitoring endotracheal tube. However, the intraoral presence of an endotracheal tube can limit exposure by its location in the operative field during transfacial approaches and by limiting superior mobilization of the mandible during transcervical approaches. We describe a transnasal vagus nerve monitoring technique. Design and Participants Ten patients underwent open skull base surgery. Surgical approaches included transcervical (five), transfacial/maxillary swing (three), and double mandibular osteotomy (two). The vagus nerve was identified, stimulated, and monitored in all cases. Main Outcome Measures Intraoperative nerve stimulation, pre- and postoperative vagus nerve function through the use of flexible laryngoscopy in conjunction with assessment of subjective symptoms of hoarseness, voice change, and swallowing difficulty. Results Three patients had extensive involvement of the nerve by tumor with complete postoperative nerve deficit, one patient had a transient deficit following dissection of tumor off of nerve with resolution, and the remaining patients had nerve preservation. One patient experienced minor epistaxis during monitor tube placement that was managed conservatively. Conclusions Transnasal vagal nerve monitoring is a simple method that allows for intraoperative monitoring during nerve preservation surgery without limiting surgical exposure.

Purpose: The Penumbra RubyTM Coil system (Ruby) is a new generation of larger (.020) platinum detachable coils designed for peripheral arterial and venous embolization. Recent literature has shown the importance of packing density on occlusion stability and recanalization rates.1 Reported herein are preliminary results from the multicenter Aneurysm Coiling Efficiency (ACE) registry on the packing density and resulting long term outcomes of patients with peripheral embolizations by Ruby. Materials and Methods: Between Mar 2012 and Sep 2014, data from 62 Ruby cases at 12 centers were collected: 11 splenic artery aneurysms, 9 renal artery aneurysms, 1 hepatic artery aneurysm, 2 mesenteric artery aneurysms, 7 AVMs, 6 fistulae, 3 varices, and 23 vessel sacrifices. Results: Mean Ruby placed per aneurysm was 9 with a mean packing density of 26% in the aneurysms/malformations cases (N=39). Aneurysm volumes at the splenic and renal arteries were 110 to 21,500 mm³ and neck width was from 4 to 16 mm. Mean fluoroscopy time was 29 min. Among the 21 aneurysm cases with post-treatment occlusion data, 100% achieved Raymond Scale Class I occlusion. Of the 10 patients with 6-month follow up data, 100% displayed complete Class I occlusion with 0% recanalization. The remaining 11 patients are expected to complete their 6-month follow up at time of presentation.Of the 23 peripheral vessel sacrifices, 100% had successful coil embolization. Mean number of Ruby placed was 4 with a mean fluoroscopy time of 22 min. Out of the 11 patients with 6-month follow up data, 100% displayed stable occlusion. No procedural SAEs were recorded in any of the 62 cases. Conclusion: Using Ruby in the peripheral vasculature resulted in a high packing density and complete occlusion which remained stable for 6 months. Consistent with the published literature that 24% packing density is optimal to prevent recanalization, these results confirmed an association between high packing density and low recurrence of recanalization.1 Upon further validation, the use of packing density as an index for stable long-term outcome in the treatment of peripheral malformations should be considered, perhaps even emphasized

Expert witnesses play an invaluable, if controversial, role by deciphering medical events for juries in cases of alleged negligence. We review expert witness guidelines among major surgical societies and identify gaps within these standards, as our hope is that this spurs discussion addressing areas for improvement. Of 8 surgical societies with accessible guidelines, none included specific compensation guidelines or limits, detailed reporting mechanisms regarding unethical behavior by legal professionals, or addressed the appropriateness of testifying frequently and exclusively for one side. Several processes possibly deterring grossly inaccurate testimony have been adopted by other surgical societies and should potentially be addressed by the American Academy of Otolaryngology-Head and Neck Surgery. These include offering an expert witness testimony certification path, strengthening the formalized grievance process, and encouraging members to sign an affirmation statement.

PURPOSE OF REVIEW: Over the past decade, substantial insight into the biological function of the tumor suppressors neurofibromin (NF1) and Merlin (NF2) has been gained. The purpose of this review is to highlight some of the major advances in our understanding of the biology of neurofibromatosis type 1 (NF1) and neurofibromatosis type 2 (NF2) as they relate to the development of novel therapies for these disorders. RECENT FINDINGS: The development of increasingly sophisticated preclinical models over the recent years has provided the platform from which to rationally develop molecular targeted therapies for both NF1 and NF2-related tumors, such as within the Department of Defense-sponsored Neurofibromatosis Clinical Trials Consortium. SUMMARY: Clinical trials with molecular-targeted therapies have become a reality for neurofibromatosis patients, and hold substantial promise for improving the morbidity and mortality of individuals affected with these disorders.