Faculty Bibliography
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Department/Unit:Otolaryngology
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7803
Expert Witness Testimony Guidelines: Identifying Areas for Improvement
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.
PMID: 25389319
ISSN: 0194-5998
CID: 1348992
Pectoralis Major Myocutaneous Flap versus Free Fasciocutaneous Flap for Reconstruction of Partial Hypopharyngeal Defects: What Should We Be Doing?
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.
PMID: 25388998
ISSN: 1098-8947
CID: 1348952
Osteoradionecrosis of the Sub-axial Cervical Spine Following Treatment for Head and Neck Carcinomas
Objectives: To study the MRI and PET/CT imaging of osteoradionecrosis of the sub-axial cervical spine, a serious long-term complication of radiation therapy for head and neck cancers that can lead to pain, vertebral instability, myelopathy, and cord compression. Methods and Materials: This is a single-institution retrospective review of patients diagnosed and treated for osteoradionecrosis of the sub-axial cervical spine following surgery and radiation for head and neck cancer. Results: We report PET/CT and MRI imaging for four patients, each with extensive treatment for recurrent head and neck cancer. Osteomyelitis and discitis are the end stage manifestations of osteoradionecrosis of sub-axial spine. Conclusions: Osteoradionecrosis of the sub-axial spine has variable imaging appearance and needs to be differentiated from recurrent or metastatic disease. Surgical violation of the posterior pharyngeal wall on top of compromised vasculature in patients treated heavily with radiation therapy may predispose the sub-axial cervical vertebrae to osteoradionecrosis, with possible resultant osteomyelitis and discitis. MRI and PET/CT imaging are complimentary in this setting. PET/CT images may be misinterpreted in view of history of head and neck cancer. MRI should be utilized for definitive diagnosis of osteomyelitis and discitis in view of its imaging specificity. Advances in Knowledge: We identify the end-stage manifestation of osteoradionecrosis in the sub-axial spine on PET/CT and MRI to facilitate its correct diagnosis.
PMCID:4277380
PMID: 25375626
ISSN: 0007-1285
CID: 1341352
Geographic and temporal trends in frontal sinus surgery
BACKGROUND: The purpose of this study was to evaluate geographic and temporal trends in frontal sinus surgery procedures. METHODS: Medicare Part B data files from 2000 to 2011 were examined for temporal trends in various frontal sinus procedures, and the most recent year containing geographic information (2010) was evaluated for Current Procedural Terminology (CPT) code use. Additionally, nationwide charges per procedure were recorded. Regional populations of individuals >/=65 years old were obtained from the 2010 U.S. Census, and surgical society websites were used to determine the number of practicing rhinologists and otolaryngologists in each region. RESULTS: The use of open approaches declined by one third, while endoscopic procedures went from 6463 to 19262 annually, with the most marked increases occurring from 2006 through 2011. Geographic variation was noted, with practitioners in the South Atlantic states performing the greatest number of endoscopic procedures in 2010, whereas the East South Central states had the greatest number when controlling for population. There was an inverse relationship between endoscopic procedures performed and number of fellowship-trained rhinologists (controlling for regional populations) (R2 = 0.66). The first year frontal sinus ballooning had a unique CPT code illustrated decreased reimbursements for non-balloon endoscopic surgery ($609) relative to balloon approaches ($2635). CONCLUSION: Declines in open frontal sinus surgery and marked increases in endoscopic approaches have potential implications for residency training. Potential reasons for marked increases in endoscopic approaches include the rising popularity of balloon technologies, although this is speculative. Geographic variation exists in frontal sinus surgery patterns, including an inverse relationship between endoscopic approaches and the number of fellowship-trained rhinologists.
PMID: 25367305
ISSN: 2042-6984
CID: 1341062
Long-term Outcomes and Patterns of Failure in Orbital Lymphoma Treated with Primary Radiotherapy
ABSTRACT The purpose of this study was to evaluate the long-term outcome and patterns of failure in patients treated with primary radiotherapy (RT) for orbital lymphoma (OL). Seventy-nine patients diagnosed with Stage IE OL between 1995 and 2012 were included. Fifty-nine patients (75%) had mucosa-associated lymphoid tissue and 20 patients (25%) were of follicular lymphoma subtype. The median follow-up was 49.7 months. Major tumor sites were conjunctivas (29%), orbit (47%), and lacrimal glands (24%). After treatment to a median dose of 30.6Gy, there were a total of 0 local, 1 contralateral orbital, 2 regional, and 2 distant recurrences - all outside of the treatment fields. The 10-year local relapse-free, distant metastasis-free and overall rates were 100%, 94.2%, and 98.2%, respectively. Definitive RT to 30Gy was shown to be highly effective for indolent OL and this study represents one of the largest single institution studies using primary RT for Stage IE OL.
PMID: 25356924
ISSN: 1042-8194
CID: 1322882
Facial nerve paralysis after pre-operative embolization of a paraganglioma
Vascular tumors pose a challenging problem in treatment, as surgical planning can be extensive. Often times, pre-operative embolization is required to minimize blood loss during surgery. With the advent of new biochemical compounds, embolization modalities have evolved over the past decade. Although rare, side effects and complications of embolic materials have been cited sporadically in the literature. We present an interesting case of a patient afflicted with facial paralysis and other cranial neuropathies following embolization of a paraganglioma, along with the appropriate imaging that confirms the etiology of her paralysis.
PMID: 25241031
ISSN: 0196-0709
CID: 1259102
Subscapular system of flaps: An 8-year experience with 105 patients
BACKGROUND: Review patient and defect factors in which this donor site is an optimal choice for reconstruction and to discuss strategies to overcome the perceived drawbacks of this system of flaps. METHODS: A retrospective medical chart review was conducted on all patients who underwent the subscapular system of free flaps for head and neck reconstruction. RESULTS: Ninety-eight reconstructions were performed for mandibular defects, 4 for maxillary defects alone and 3 for combined mandible-maxilla defects. The overall success rate was 98%. CONCLUSION: The subscapular system of free flaps is an excellent option in patients for whom the alternative donor sites are either not usable or lack the associated soft tissue elements required for a successful reconstruction. This flap should also be considered as a first choice for patients with complex/extensive surgical defects requiring multiple, independently mobile, soft tissue components; in patients who will benefit from a large muscle flap placed over the vital structures in the neck; patients of advanced age; and patients in whom early mobilization is critical. (c) 2014 Wiley Periodicals, Inc. Head Neck, 2014.
PMID: 24800735
ISSN: 1043-3074
CID: 1261392
Cross-Disorder Genome-Wide Analyses Suggest a Complex Genetic Relationship Between Tourette's Syndrome and OCD
Objective: Obsessive-compulsive disorder (OCD) and Tourette's syndrome are highly heritable neurodevelopmental disorders that are thought to share genetic risk factors. However, the identification of definitive susceptibility genes for these etiologically complex disorders remains elusive. The authors report a combined genome-wide association study (GWAS) of Tourette's syndrome and OCD. Method: The authors conducted a GWAS in 2,723 cases (1,310 with OCD, 834 with Tourette's syndrome, 579 with OCD plus Tourette's syndrome/chronic tics), 5,667 ancestry-matched controls, and 290 OCD parent-child trios. GWAS summary statistics were examined for enrichment of functional variants associated with gene expression levels in brain regions. Polygenic score analyses were conducted to investigate the genetic architecture within and across the two disorders. Results: Although no individual single-nucleotide polymorphisms (SNPs) achieved genome-wide significance, the GWAS signals were enriched for SNPs strongly associated with variations in brain gene expression levels (expression quantitative loci, or eQTLs), suggesting the presence of true functional variants that contribute to risk of these disorders. Polygenic score analyses identified a significant polygenic component for OCD (p=2x10-4), predicting 3.2% of the phenotypic variance in an independent data set. In contrast, Tourette's syndrome had a smaller, nonsignificant polygenic component, predicting only 0.6% of the phenotypic variance (p=0.06). No significant polygenic signal was detected across the two disorders, although the sample is likely underpowered to detect a modest shared signal. Furthermore, the OCD polygenic signal was significantly attenuated when cases with both OCD and co-occurring Tourette's syndrome/chronic tics were included in the analysis (p=0.01). Conclusions: Previous work has shown that Tourette's syndrome and OCD have some degree of shared genetic variation. However, the data from this study suggest that there are also distinct components to the genetic architectures of these two disorders. Furthermore, OCD with co-occurring Tourette's syndrome/chronic tics may have different underlying genetic susceptibility compared with OCD alone.
PMCID:4282594
PMID: 25158072
ISSN: 0002-953x
CID: 1162352
Transient Hearing Loss Within a Critical Period Causes Persistent Changes to Cellular Properties in Adult Auditory Cortex
Sensory deprivation can induce profound changes to central processing during developmental critical periods (CPs), and the recovery of normal function is maximal if the sensory input is restored during these epochs. Therefore, we asked whether mild and transient hearing loss (HL) during discrete CPs could induce changes to cortical cellular physiology. Electrical and inhibitory synaptic properties were obtained from auditory cortex pyramidal neurons using whole-cell recordings after bilateral earplug insertion or following earplug removal. Varying the age of HL onset revealed brief CPs of vulnerability for membrane and firing properties, as well as, inhibitory synaptic currents. These CPs closed 1 week after ear canal opening on postnatal day (P) 18. To examine whether the cellular properties could recover from HL, earplugs were removed prior to (P17) or after (P23), the closure of these CPs. The earlier age of hearing restoration led to greater recovery of cellular function, but firing rate remained disrupted. When earplugs were removed after the closure of these CPs, several changes persisted into adulthood. Therefore, long-lasting cellular deficits that emerge from transient deprivation during a CP may contribute to delayed acquisition of auditory skills in children who experience temporary HL.
PMCID:4494023
PMID: 24554724
ISSN: 1047-3211
CID: 915882
Active idiotypic vaccination versus control immunotherapy for follicular lymphoma
PURPOSE/OBJECTIVE:Idiotypes (Ids), the unique portions of tumor immunoglobulins, can serve as targets for passive and active immunotherapies for lymphoma. We performed a multicenter, randomized trial comparing a specific vaccine (MyVax), comprising Id chemically coupled to keyhole limpet hemocyanin (KLH) plus granulocyte macrophage colony-stimulating factor (GM-CSF) to a control immunotherapy with KLH plus GM-CSF. PATIENTS AND METHODS/METHODS:Patients with previously untreated advanced-stage follicular lymphoma (FL) received eight cycles of chemotherapy with cyclophosphamide, vincristine, and prednisone. Those achieving sustained partial or complete remission (n=287 [44%]) were randomly assigned at a ratio of 2:1 to receive one injection per month for 7 months of MyVax or control immunotherapy. Anti-Id antibody responses (humoral immune responses [IRs]) were measured before each immunization. The primary end point was progression-free survival (PFS). Secondary end points included IR and time to subsequent antilymphoma therapy. RESULTS:At a median follow-up of 58 months, no significant difference was observed in either PFS or time to next therapy between the two arms. In the MyVax group (n=195), anti-Id IRs were observed in 41% of patients, with a median PFS of 40 months, significantly exceeding the median PFS observed in patients without such Id-induced IRs and in those receiving control immunotherapy. CONCLUSION/CONCLUSIONS:This trial failed to demonstrate clinical benefit of specific immunotherapy. The subset of vaccinated patients mounting specific anti-Id responses had superior outcomes. Whether this reflects a therapeutic benefit or is a marker for more favorable underlying prognosis requires further study.
PMID: 24799467
ISSN: 1527-7755
CID: 5971732
