Faculty Bibliography

BACKGROUND: Patients present to physicians across multiple disciplines with the complaint of sinus headache. This lay term is widely accepted in the media, yet has been repeatedly questioned in the medical literature, and experts in the fields of otolaryngology, neurology, and allergy have agreed that it is an overused and often incorrect diagnosis in the majority of patients. There have been review articles and consensus panels established regarding this issue, but thus far no guidelines based purely on a review of the level of evidence provided by the literature. METHODS: A systematic review of the literature was performed and the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE) instrument recommendations were followed. Study inclusion criteria were: adult population >18 years old, self-diagnosed or physician-diagnosed "sinus headache," clearly defined diagnostic criteria in diagnostic studies, and clearly defined primary clinical end-point in therapeutic studies. RESULTS: We identified and evaluated the literature on diagnosing and treating patients with a primary complaint of sinus headache. The literature was reviewed for both quality of research design as well as benefit and harm of the proposed interventions. CONCLUSION: If a thorough neurologic and otolaryngologic evaluation is performed, the majority of patients presenting with sinus headache in the absence of significant acute inflammatory findings will be diagnosed with migraine. In this situation, the appropriate treatment for the majority of patients presenting with sinus headache is migraine directed therapy. In a highly select group of patients, directed nasal surgery addressing endonasal contact points may be an option.

OBJECTIVES/HYPOTHESIS: This pilot study details the use of a software tool that uses continuous impedance measurement during electrode insertion, with the eventual potential to assess and optimize electrode position and reduce insertional trauma. STUDY DESIGN: Software development and experimental study with human cadaveric cochleae and two live surgeries. METHODS: A prototype program to measure intracochlear electrode impedance and display it graphically in real time has been developed. The software was evaluated in human cadaveric temporal bones while simultaneously making real-time fluoroscopic recordings and in two live surgeries during intracochlear electrode insertion. RESULTS: Impedance changes were observed with various scalar positions, and values were consistent with those obtained using clinically available software. Using Contour Advance electrodes, impedance values increased after stylet removal, particularly when using the monopolar mode. CONCLUSIONS: Impedance values seem systematically affected by electrode position, with higher values being associated with proximity to the cochlear wall. The new software is capable of acquiring impedance measurements during electrode insertion, and these data may be useful to guide surgeons to achieve optimal and atraumatic electrode insertion, to guide robotic electrode insertion, and to provide insights about electrode position in the cochlea.

Pilocytic astrocytoma (PA) is a World Health Organization grade I glioma that occurs most commonly in children and young adults. Specific genetic alterations have been described in PA, but the pathogenesis remains poorly understood. We studied microRNA (miRNA) alterations in a large cohort of patients with PA. A total of 43 PA, including 35 sporadic grade I PA, 4 neurofibromatosis-1 (NF1)-associated PA, and 4 PA with pilomyxoid features, as well as 5 nonneoplastic brain controls were examined. BRAF fusion status was assessed in most cases. RNA was examined using the Agilent Human miRNA Microarray V3 platform. Expression of miRNA subsets was validated using quantitative real-time PCR (qRT-PCR) with Taqman probes. Validation of predicted protein targets was performed on tissue microarrays with the use of immunohistochemistry. We identified a subset of miRNAs that were differentially expressed in pediatric PAs versus normal brain tissue: 13 miRNAs were underexpressed, and 20 miRNAs were overexpressed in tumors. Differences were validated by qRT-PCR in a subset, with mean fold change in tumor versus brain of -17 (miR-124), -15 (miR-129), and 19.8 (miR-21). Searching for predicted protein targets in Targetscan, we identified a number of known and putative oncogenes that were predicted targets of miRNA sets relatively underexpressed in PA. Predicted targets with increased expression at the mRNA and/or protein level in PA included PBX3, METAP2, and NFIB. A unique miRNA profile exists in PA, compared with brain tissue. These miRNAs and their targets may play a role in the pathogenesis of PA.

Introduction: We describe a novel, clinically applicable conduction study of the laryngeal nerves. Methods: Seventeen normal volunteer subjects were included. Activation of the sensory territory of the superior laryngeal nerve was performed by administration of low level brief electrical stimuli. The laryngeal closure reflex (LCR) evoked by this stimulus was recorded by needle electrodes. Mean minimal latencies were calculated for each response, and proposed values for the upper limit of normal were determined. Results: Uniform, consistent early ipsilateral responses and late bilateral responses, which exhibit greater variation in latency and morphology, were recorded. Significant side-to-side differences in latencies were observed, consistent with the length discrepancy between right and left recurrent laryngeal nerves. Conclusions: This technique yields clear, quantifiable data regarding neurologic integrity of laryngeal function, heretofore unobtainable in the clinical setting. This study may yield clinically relevant information regarding severity and prognosis in patients with laryngeal neuropathic injury. Muscle Nerve 47:432-436, 2013.

OBJECTIVES/HYPOTHESIS: Life-support training emphasizes the primacy of airway management. Acquiring these skills requires practice and exposure to events. Otolaryngology residents lack standardized training in advanced airway skills. This project aimed to create such a program by using simulation-based methodology evaluated using specific educationally based tools. STUDY DESIGN: Prospective cohort study. METHODS: The program consisted of lectures and simulation-based training sessions designed to impart competency in a set of defined airway skills to otolaryngology residents. Only participating residents who completed the course (n = 12) were evaluated both before and after the course for their fund of knowledge through multiple-choice examinations and for clinical reasoning and technical skills as assessed by a panel of otolaryngologists in simulated difficult airway situations. Self-assessment tools were also incorporated. RESULTS: The average multiple choice score was 12 of 27 (44%) before the course and 15 of 27 (55%) after the completion of the course (P = .001). Faculty assessment yielded a cumulative score of 80% and 91% pre- and postcourse, respectively (P = .002). Although all residents reported prior experience in a critical emergency airway situation, only one reported prior training in advanced airway skills. A significant increase in participants' self-perceived ability to carry out critical airway-related skills was observed. All respondents felt the course was effective. CONCLUSIONS: Simulation-based airway training courses can be effectively incorporated into existing educational curricula for otolaryngology residents, and their success can be measured using educationally based tools. With such a course, residents can be expected to demonstrate measurable improvement in clinical knowledge base, technical skills, and self-perceived ability to handle difficult airway situations. Laryngoscope, 2013.

OBJECTIVE: To analyze the effects of residual hearing on postoperative speech performance in traditional cochlear implant (CI) patients implanted with a conventional electrode. STUDY DESIGN: Retrospective review. SETTING: Academic tertiary referral center. PATIENTS: A total of 129 adults implanted by a single surgeon at a tertiary care facility between June 2005 and November 2010 with measurable preoperative pure tone thresholds at any frequency were included. INTERVENTION: Cochlear implantation with a conventional electrode via an anterior inferior cochleostomy. MAIN OUTCOME MEASURE: Speech perception using monosyllabic word scores in quiet and sentences in quiet and noise in the electric (CI-only) condition of the implanted ear. Preservation of hearing was defined as complete for postoperative thresholds within 10 dB of preimplant values and partial if greater than 11 dB. Pure tone audiometry and speech perception testing were performed preoperatively and at regular intervals postoperatively, with the 1-year evaluation being the final outcome period. RESULTS: Preservation at any frequency or level was not a factor in speech perception outcome, although preservation was more common in low frequencies. Hearing preservation was correlated with younger age at implantation, but was not related to length of hearing loss, cause of deafness, device type, sex, preoperative speech performance, or low-frequency pure-tone average. CONCLUSION: Hearing can be preserved in traditional CI patients implanted with a conventional electrode. Although preservation of hearing may have implications for future technology, it is not currently correlated with speech performance in the CI-only condition.

Kikuchi-Fujimoto lymphadenitis is a self-limited disorder that typically presents in young females as painless cervical lymphadenopathy with fever, anemia, and leukopenia. The clinical manifestations and pathologic findings suggest a viral etiology, yet specific etiologic agents remain unknown. Although there are studies reporting positive associations between Kikuchi-Fujimoto lymphadenitis and parvovirus B19 and herpesviruses, other studies have failed to find an association with these viruses. To our knowledge, this current study is the largest study of Kikuchi-Fujimoto lymphadenitis in Western patients that used polymerase chain reaction testing for 4 different common viral pathogens often implicated as etiologic agents in Kikuchi-Fujimoto lymphadenitis. Archival material from 3 institutions was included, following confirmation of the diagnosis of Kikuchi-Fujimoto lymphadenitis by 2 independent pathologists. Polymerase chain reaction from the paraffin-embedded tissue sections for parvovirus B19, Epstein-Barr virus, human herpesvirus 6, and human herpesvirus 8 was performed. Eighteen cases of Kikuchi-Fujimoto lymphadenitis were analyzed, 12 of which (60%) were cervical lymph nodes. All the cases showed typical geographic necrosis with abundant apoptotic debris, although the degree of necrosis was variable. Polymerase chain reaction revealed a high prevalence of parvovirus B19 in the controls (44%); there were fewer positive cases seen in the Kikuchi-Fujimoto lymphadenitis cases (11%), but this did not reach statistical significance (P = .25).There were no significant differences between cases and controls in the prevalence of Epstein-Barr virus, human herpesvirus 6, and human herpesvirus 8 (P = .50 for all 3). Polymerase chain reaction failed to reveal a positive association between Kikuchi-Fujimoto lymphadenitis and 4 common suspected viral agents. These findings do not support a role for Epstein-Barr virus, human herpesvirus 6, human herpesvirus 8, or parvovirus B19 in the pathogenesis of Kikuchi-Fujimoto lymphadenitis.

Synapses and receptive fields of the cerebral cortex are plastic. However, changes to specific inputs must be coordinated within neural networks to ensure that excitability and feature selectivity are appropriately configured for perception of the sensory environment. We induced long-lasting enhancements and decrements to excitatory synaptic strength in rat primary auditory cortex by pairing acoustic stimuli with activation of the nucleus basalis neuromodulatory system. Here we report that these synaptic modifications were approximately balanced across individual receptive fields, conserving mean excitation while reducing overall response variability. Decreased response variability should increase detection and recognition of near-threshold or previously imperceptible stimuli. We confirmed both of these hypotheses in behaving animals. Thus, modification of cortical inputs leads to wide-scale synaptic changes, which are related to improved sensory perception and enhanced behavioral performance.

OBJECTIVES/HYPOTHESIS: Deficient health literacy remains a widespread public issue. As such, the National Institutes of Health (NIH) recommends that all patient resources should be written around a sixth-grade level. The authors evaluate healthcare-oriented resources specified for patient use on the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) Web site in order to identify potential areas of improvement and highlight those sections that may serve as paradigms for future revisions. STUDY DESIGN: Descriptive and correlational design. METHODS: Seventeen healthcare-oriented resources specifically for patients were downloaded in February 2012 from the American Academy of Facial Plastic and Reconstructive Surgery Web site. Readability assessments of each article were performed using Readability Studio Professional Edition Version 2012.1. These tests included the Flesch Reading Ease, Flesch-Kincaid Grade Level, SMOG Grading, Coleman-Liau Index, Gunning-Fog Index, the New Fog Count, the New Dale-Chall Readability Formula, FORCAST formula, Raygor Readability Estimate, and the Fry Graph. RESULTS: Patient health education material found on the AAFPRS Web site has been found to be written at an average grade level of 12th grade using 10 different readability scales. CONCLUSIONS: Modifications of the patient education section of the AAFPRS Web site can increase the readability of the literature, and allow greater comprehension among a wider audience. Laryngoscope, 2013.

OBJECTIVES/HYPOTHESIS: The h-index is an accurate and reliable indicator of scholarly productivity that takes into account relevance, significance, and influence of research contributions. As such, it is an effective, objective bibliometric that can be used to evaluate academic otolaryngologists for decisions regarding appointment and advancement. In this study, we evaluate the impact of NIH funding on scholarly productivity in otolaryngology. STUDY DESIGN: Analysis of bibliometric data of academic otolaryngologists. METHODS: Funding data for the 20 otolaryngology departments with the largest aggregate total of NIH grants for the fiscal years (FY) 2011 and 2012 was obtained using the National Institutes of Health Research Portfolio Online Reporting Tools Expenditures and Reports (RePORTER) Database. H-indices were calculated using the Scopus online database, and then compared to funding data at both the departmental and individual level. RESULTS: Faculty members in otolaryngology departments who received NIH funding had significantly greater research productivity and impact, as measured by the h-index, than their nonfunded peers. H-indices increased with greater NIH funding levels, and investigators with MD degrees tended to have higher mean NIH funding levels than those with PhDs. While there was no correlation between average h-index and NIH funding totals at the level of departments, there was greater correlation upon examination of NIH funding levels of individual investigators. CONCLUSIONS: The h-index has a strong relationship with, and may be predictive of, grant awards of NIH-funded faculty members in otolaryngology departments. This bibliometric may be useful in decisions regarding appointment and advancement of faculty members within academic otolaryngology departments. Laryngoscope, 2013.