Faculty Bibliography

BACKGROUND: Spontaneous cerebrospinal fluid (CSF) leaks are caused by intracranial hypertension. Given this underlying etiology, patients may be at risk for developing multiple skull base defects. OBJECTIVE: The purpose of our study is to present the prevalence of multiple simultaneous skull base defects in patients with spontaneous CSF rhinorrhea. METHODS: We performed a retrospective chart review in a tertiary care practice of 44 consecutive patients with spontaneous CSF rhinorrhea who underwent endoscopic repair by the senior author (R.R.C.) to determine the prevalence of having multiple simultaneous skull base defects identified at the time of surgery. We defined this as two or more bony defects identified endoscopically with intact intervening bone with or without soft tissue prolapse into the nasal cavity or paranasal sinus cavity. RESULTS: Eight of 44 patients (18.2%) were found to have multiple simultaneous skull base defects. The average body mass index (BMI) of the study population was 34.5 (range, 22.7-59). CONCLUSION: A significant number of patients with spontaneous CSF rhinorrhea may have more than one skull base defect present at the time of presentation. The clinical significance of this finding in surgical and medical decision making is not clear at this time.

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.

Importance: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) in children describes neuropsychiatric symptom exacerbations that relate temporally to streptococcal infections. Recent case reports suggest tonsillectomy may effectively reduce these symptoms; however, no consensus treatment guidelines exist. This study examines whether tonsillectomy improves neuropsychiatric symptoms in children with PANDAS who have incomplete response to antibiotic therapy. Observations: Ten patients met strict diagnostic criteria for PANDAS. Comparisons were made between parental reports of symptom severity at diagnosis, after antibiotic treatment (in 10 patients), and after tonsillectomy (in 9). From a baseline severity score of 10, antibiotics alone improved symptoms to a median (interquartile range [IQR]) score of 8 (6.5-10.0) (P = .03). Nine children who subsequently underwent tonsillectomy reported symptom improvement in comparison with treatment with antibiotics alone, including those with no response to antibiotics. Symptom severity improved at all periods after tonsillectomy compared with antibiotics alone. The median score [IQR] 3 months postoperatively was 3 (0.0-6.5) (P = .01); 6 months postoperatively, 3 (0.0-5.0) (P = .02); 1 year postoperatively, 3 (0.0-5.0) (P = .02); and 3 years postoperatively, 0.5 (0.0-2.3) (P = .03). Four of the 9 had complete resolution after tonsillectomy. Conclusions and Relevance: This PANDAS cohort whose neuropsychiatric symptoms did not respond sufficiently to antibiotics may have gained benefit from tonsillectomy.

OBJECTIVE: To determine whether sacrifice of the internal jugular vein (IJV) causes subsequent changes in the jugular bulb. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Patients were selected by CPT code for neck dissection and were included in the study if they had undergone unilateral neck dissection and had preoperative and postoperative computed tomographic scans through the temporal bone. INTERVENTIONS: The jugular bulb was measured in the axial plane for anteroposterior and mediolateral diameters. MAIN OUTCOME MEASURES: Cross-sectional area of the jugular bulb was calculated, and comparison was made between preoperative and postoperative studies in patients with or without ligation of the IJV. RESULTS: After unilateral neck dissection, the mean change in the size of the jugular bulb ipsilateral to surgery with sacrifice of the IJV was found to be -10.4 mm (95% confidence interval [95% CI], +/-8.54 mm); ipsilateral to surgery without sacrifice of the internal jugular, -0.2 mm (95% CI, +/-3.24 mm); contralateral to surgery with sacrifice of the IJV, +1.9 mm (95% CI, +/-11.12 mm); and contralateral to surgery without sacrifice of the IJVa, +1.0 mm (95% CI, +/-2.66 mm). Analysis of variance demonstrated a significant difference for changes in the jugular bulb area ipsilateral to surgery with sacrifice of the IJV (p = 0.03) when compared with contralateral to surgery without sacrifice of the IJV. CONCLUSION: Changes in size of the jugular bulb occur with surgical manipulation of the jugular vein. This study demonstrates a decrease in the size of the jugular bulb with ipsilateral IJV sacrifice.

CONTEXT.: Approximately 30% of women report pain in the affected breast prior to breast cancer surgery. OBJECTIVES: The purpose of this secondary analysis of our prospective study was to determine how women who experienced both preoperative and persistent postsurgical breast pain (n=107) differed from women who did not report preoperative breast pain and did (n=158) or did not (n=122) experience persistent postsurgical breast pain. METHODS: Differences in demographic and clinical characteristics were evaluated. Linear mixed effects (LME) modeling was used to evaluate for group differences in symptom severity, function, sensation, and quality of life (QOL) over time. RESULTS: Between-group differences in demographic and clinical characteristics as well as trajectories of shoulder function and QOL were identified. Women with both preoperative and persistent postsurgical breast pain were younger; were more likely to report swelling, strange sensations, hardness, and numbness in the affected breast prior to surgery; and were more likely to have reconstruction at the time of surgery. Women with both preoperative and persistent postsurgical breast pain had more biopsies in the prior year, more lymph nodes removed, and reported more severe acute postsurgical pain than women without preoperative breast pain. LME modeling revealed significant group effects for the majority of outcomes evaluated. Over the six months of the study, women with both preoperative and persistent postsurgical pain had persistently poorer shoulder flexion and physical well-being than women without preoperative breast pain. CONCLUSION: Investigations of the etiology and molecular mechanisms of preoperative breast pain, as well as interventions for this high risk group, are needed.

Preclinical evidence of successful combinations of ionizing radiation with immunotherapy has inspired testing the translation of these results to the clinic. Interestingly, the preclinical work has consistently predicted the responses encountered in clinical trials. The first example came from a proof-of-principle trial started in 2001 that tested the concept that growth factors acting on antigen-presenting cells improve presentation of tumor antigens released by radiation and induce an abscopal effect. Granulocyte-macrophage colony-stimulating factor was administered during radiotherapy to a metastatic site in patients with metastatic solid tumors to translate evidence obtained in a murine model of syngeneic mammary carcinoma treated with cytokine FLT-3L and radiation. Subsequent clinical availability of vaccines and immune checkpoint inhibitors has triggered a wave of enthusiasm for testing them in combination with radiotherapy. Examples of ongoing clinical trials are described in this report. Importantly, most of these trials include careful immune monitoring of the patients enrolled and will generate important data about the proimmunogenic effects of radiation in combination with a variety of immune modulators, in different disease settings. Results of these studies are building a platform of evidence for radiotherapy as an adjuvant to immunotherapy and encourage the growth of this novel field of radiation oncology.

OBJECTIVE: To compare measures of dry mouth following extended use of an alcohol-based mouthrinse (LISTERINE Antiseptic [LA]) and a non-alcohol-based mouthrinse (Crest Pro-Health Rinse [CPH]) on healthy adults with "normal" salivary flow. METHODS: This single-site, randomized, observer-blinded, parallel study compared unstimulated whole salivary flow and perceived dryness following daily use at weeks 4 and 12 versus baseline. Noninferiority, between-treatment flow comparisons (0.15 mL/min margin), and between-treatment comparisons of the mean Bluestone Mouthfeel Questionnaire (BMQ) visual analog scale scores were made using analysis of covariance. RESULTS: Measures of dry mouth were comparable between mouthrinses, as demonstrated by both noninferiority of LA versus CPH flow (P < .001) and no significant differences between groups in the BMQ measures at 4 or 12 weeks. CONCLUSIONS: Extended use of an alcohol-based mouthrinse is no more likely to cause reduction in salivary flow or perceived dryness in individuals with normal salivary flow compared with a non-alcohol-based mouthrinse (CPH).

PURPOSE: Interest in a variety of neoplastic, functional, neurological, and age-related laryngeal disorders has contributed to the development of laryngology as an established subspecialty. Funding support plays a critical role in facilitating scholarship within the field. Our objectives were to evaluate who is receiving funding from the NIH for topics relevant to voice disorders, and further describe temporal trends in grants awarded. METHODS: The NIH RePORTER database was searched for grants relevant to voice disorders. Data were further organized by PI specialty, academic department, and funding totals. Furthermore, PI scholarly impact, as measured by the h-index, was calculated. RESULTS: A total of 830 funded fiscal years (for 232 unique projects) totaling $203 million have supported projects examining voice disorders. A plurality of projects (32.8%) was awarded to PIs in otolaryngology departments, followed by 17.2% to speech pathology/communication sciences departments. Although year-to-year variation was noted, otolaryngology departments received approximately 15% of funding annually. Funded otolaryngologists had similar scholarly impact values to individuals in other specialties. CONCLUSIONS: The study of voice disorders involves an interdisciplinary approach, as PIs in numerous specialties receive NIH funding support. As they receive a considerable proportion of this funding and had similar h-indices compared to other specialties involved, otolaryngologists have just as much scholarly impact despite being a smaller specialty. As speech and language pathologists also comprised a significant proportion of individuals in this analysis, enhanced cooperation and encouragement of interdisciplinary scholarly initiatives may be beneficial.

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.