Faculty Bibliography

OBJECTIVES/HYPOTHESIS: Widespread universal newborn hearing screening has led to increased identification of infant hearing loss. Supported by improved diagnostic tools allowing more definitive diagnosis of profound sensorineural hearing loss in young children, cochlear implantation in children <12 months of age is now common. Literature supports short-term safety and improved auditory outcomes in these young children, however long-term data is lacking. The study examines issues of long-term safety and efficacy in cochlear implant patients implanted <1 year of age. STUDY DESIGN: Retrospective chart review. METHODS: Fifty children who received cochlear implants before 1 year of age were followed for up to 7 years. Age at implantation ranged from 5 to 11 months with a mean of 9.1 months. Three patients had simultaneous bilateral implantation at 8 to 9 months of age. Medical records were reviewed for complications incurred during length of device usage, including time of complication, management, and resolution. Auditory assessment included both the Infant-Toddler Meaningful Auditory Integration Scale and tests of speech perception. RESULTS: All 50 patients had full insertions of the electrode array. There were a total of eight complications (16%) in seven patients, three major (6%) and five minor (10%), which occurred at or before 10 months postoperatively. There were no perioperative anesthetic complications. CONCLUSIONS: Cochlear implantation in children <12 months of age is safe and efficacious over an extended period of time. Rates and nature of both major and minor complications are comparable to studies in adults and older children and support continued monitoring of these patients over the long-term

PURPOSE: To systematically review the literature examining the effects of neuromuscular electrical stimulation (NMES) on swallowing and neural activation. The review was conducted as part of a series examining the effects of oral motor exercises (OMEs) on speech, swallowing, and neural activation. METHOD: A systematic search was conducted to identify relevant studies published in peer-reviewed journals from 1960 to 2007. All studies meeting the exclusion/inclusion criteria were appraised for quality and categorized as efficacy or exploratory research based on predetermined criteria. RESULTS: Out of 899 citations initially identified for the broad review of OMEs, 14 articles relating to NMES qualified for inclusion. Most of the studies (10/14) were considered exploratory research, and many had significant methodological limitations. CONCLUSIONS: This systematic review reveals that surface NMES to the neck has been most extensively studied with promising findings, yet high-quality controlled trials are needed to provide evidence of efficacy. Surface NMES to the palate, faucial pillars, and pharynx has been explored in Phase I research, but no evidence of efficacy is currently available. Intramuscular NMES has been investigated in a single Phase I exploratory study. Additional research is needed to document the effects of such protocols on swallowing performance.

OBJECTIVE:To assess the utility of the pectoralis major muscle flap (PMMF) in patients undergoing salvage total laryngectomy. DESIGN/METHODS:Retrospective cohort analysis. SETTING/METHODS:Tertiary care cancer center. PATIENTS/METHODS:The study included 461 patients who underwent laryngectomy. Eighty of them underwent salvage surgery with primary pharyngeal closure. INTERVENTIONS/METHODS:Of the 80 patients, 69 (86%) underwent primary pharyngeal closure alone and 11 (14%) underwent a PMMF, which was used to buttress the pharyngeal suture line. MAIN OUTCOME MEASURE/METHODS:Two hundred thirty-six variables were recorded for each patient. Complications related to pharyngeal closure were measured. RESULTS:Sixty-four percent of the patients who underwent PMMF also underwent chemoradiation therapy as the initial definitive treatment compared with 25% in the non-PMMF group (P = .03). On multivariate analysis, chemoradiation therapy was the only independent predictor of pharyngocutaneous fistula formation (relative risk, 1.82; P = .02). Nevertheless, the pharyngocutaneous fistula rate was similar in the PMMF (27%) and the non-PMMF (24%) groups. Furthermore, similar durations of tube feeding, days to oral feeding, and hospitalization period were recorded in both groups. CONCLUSION/CONCLUSIONS:The PMMF should be used judiciously as a surgical adjunct in high-risk patients, with the goal of minimizing the risk for the development of a pharyngocutaneous fistula.

OBJECTIVES/HYPOTHESIS: The potassium titanyl phosphate (KTP) laser is emerging as a potentially effective treatment for various vocal fold pathologies. To date, the precise mechanism(s) of action of this wavelength on the layered microarchitecture of the vocal fold remains unknown. The purpose of this study is to develop an in vivo model for the use of the KTP laser in the rat vocal fold and to characterize the potential of this model for future studies. STUDY DESIGN: In vivo survival surgery. METHODS: A model for videoendoscopic visualization and injury to the rat vocal fold was established using a microlaryngoscope and rigid telescope. Unilateral vocal fold injury was induced with the KTP laser at 10 Watts (W) 20 milliseconds (ms) pulse width. Animals were euthanized at 1 day post-treatment. Larynges were subjected to gross visual analysis and histological analyses via hematoxylin and eosin and trichrome staining. RESULTS: Consistent endoscopic visualization and injury was obtained without significant operative morbidity or mortality. The KTP laser caused superficial blanching and minor edema in the vocal fold, which resolved grossly by 24 hours postinjury. A modest inflammatory cell infiltrate was observed 1 day following injury. However, no remarkable alterations to the vocal fold microarchitecture were observed in the acute period. CONCLUSIONS: We propose that this novel model simulates the clinical scenario of laser use for the vocal folds. Use of this model will allow us to further characterize effects, mechanisms, and therapeutic efficacy of this wavelength

OBJECTIVES: We sought to assess the quantity of intraoperative bleeding from microdebrider intracapsular tonsillectomy (IT) relative to electrocautery tonsillectomy (ET). METHODS: Intraoperative tonsil bleeding was measured prospectively for all children younger than 19 years of age who underwent primary tonsillectomy for recurrent tonsillitis or adenotonsillar hypertrophy at a tertiary care academic children's hospital. We performed IT in 57 patients (33 male, 24 female; mean age, 64.3 months) and ET in 51 patients (20 male, 31 female; mean age, 92.4 months). RESULTS: Microdebrider IT resulted in more intraoperative bleeding than ET (27.9 versus 8.7 mL, p = 0.003; and 1.2 versus 0.2 mL/kg, p <0.001). The median and maximum blood losses, respectively, were 0.6 and 9.5 mL/kg for IT and 0 and 2.0 mL/kg for ET. Blood loss for ET was not related to whether a resident versus an attending physician was the operating surgeon (p = 0.11). A linear regression model did not demonstrate greater bleeding with recurrent tonsillitis (IT, p = 0.39; ET, p = 0.89) or with increased patient age (IT, p = 0.08; ET, p = 0.62). CONCLUSIONS: Microdebrider IT produces more intraoperative bleeding than ET. The difference in blood loss is statistically but not clinically significant. Microdebrider IT causes bleeding within acceptable limits, and thus patients and physicians should not be discouraged from choosing this procedure solely on the basis of the amount of intraoperative blood loss.

OBJECTIVE: To determine whether a 3-day course of postoperative antibiotics is as effective as a 7-day course in reducing pain and reducing time to resumption of a normal diet and level of activity following pediatric tonsillectomy. DESIGN: A prospective, randomized, placebo-controlled trial. SETTING: Academic medical center. PATIENTS: Forty-nine patients were enrolled in the study. Preoperative demographic information was obtained. INTERVENTIONS: Tonsillectomy with or without adenoidectomy was performed by the senior author (J.J.) using electrocautery. Patients were randomized to receive either a 3- or 7-day course of amoxicillin. MAIN OUTCOME MEASURES: Parents were asked to record the following information: analgesic use for the first 7 postoperative days, postoperative days the child initiated his or her usual diet and level of activity, and medical treatment for oral hemorrhage or dehydration. RESULTS: Of the 49 patients, 26 were randomized to receive 7 days of postoperative antibiotics (group A) and 23 to receive 3 days of antibiotics, followed by 4 days of placebo (group B). Results were obtained for 47 of the enrolled patients (96%). No statistically significant difference was noted between the 2 groups with regard to postoperative pain or time to resumption of a normal diet and level of activity. CONCLUSION: A 3-day course of antibiotics following pediatric tonsillectomy is as effective as a 7-day course with regard to postoperative analgesic use and resumption of normal diet and level of activity. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00662987

OBJECTIVE/HYPOTHESIS: Oxidative damage mediates the lower airway response to cigarette smoke (CS). In the vocal folds, the tissue phenotype is both distinct and largely uncharacterized. We sought to investigate the effects of CS on the oxidative status and fibroblast phenotype in the vocal folds. Specifically, we hypothesized that CS would induce a hypermetabolic fibroblast phenotype and altered oxidative metabolism potentially providing insight into the relationship among CS, Reinke's edema (RE), and malignancy. STUDY DESIGN: In vivo/in vitro. METHODS: Heme oxygenase (HO)-1 gene expression was examined in human tissue. In vitro, the effects of cigarette smoke condensate (CSC) on HO-1 gene expression and secretion was assayed. In addition, CS-mediated intracellular reactive oxygen species synthesis was quantified, and compared to the response in pulmonary fibroblasts (HFL). We then examined the effects of CSC on migration and proliferation in human vocal fold fibroblasts (HVOX). RESULTS:: HO-1 expression was approximately 4-fold higher in RE samples versus vocal fold polyps. CSC induced HO-1 gene expression and secretion in a time- and dose-dependent fashion in vitro. CSC also increased intracellular ROS in both HVOX and HFL. CSC decreased HVOX proliferation and migration in a dose-dependent manner. CONCLUSIONS: These data suggest that the fibroblast phenotype is influenced by smoke. Our data suggest that the antioxidant response in the vocal fold tissue may be one mechanism of chemoprotection, a putative explanation for the observation that RE rarely transforms to malignancy. In addition, CSC does not appear to induce a hypermetabolic fibroblast phenotype as expected

PURPOSE OF REVIEW: Cochlear implantation is a well tolerated and effective procedure in the rehabilitation of profoundly and severely hearing-impaired individuals. Cochlear reimplantation may be necessary for a variety of reasons. The recent literature regarding the indications, surgical considerations, and outcomes in revision cochlear implant (RCI) surgery is reviewed here. RECENT FINDINGS: A small but significant percentage (3-8%) of all cochlear implant procedures requires RCI surgery. The most common indication for RCI is hard failure (40-80%), but other common indications include soft failures, wound complications, infection, improper initial placement, and electrode extrusions. There is a high rate of surgical success in RCI with preservation or improvement of preoperative performance in the majority of patients, in addition to the alleviation of prereimplantation symptoms. Both children and adults benefit from RCI when indicated and experience similar auditory successes following RCI. SUMMARY: The need for RCI is uncommon, but the potential for restoration or improvement in speech perception and alleviation of symptoms exists. Regardless of indication, RCI surgery is well tolerated, and, with thoughtful preparation, individualized patient counseling, and proper surgical technique, most patients can expect successful outcomes

OBJECTIVE: JAK2V617F occurs in approximately 93% of patients with polycythemia vera and approximately 50% of patients with either primary myelofibrosis or essential thrombocythemia. Chromosomal abnormalities are detected in 50% of patients with primary myelofibrosis, 29% with polycythemia vera, and 8% to 10% with essential thrombocythemia. The relationship between the presence of such chromosomal abnormalities and the JAK2V617 allele burden, and the role that each of these genetic events play in the origins and progression of the myeloproliferative neoplasms (MPNs), remain unclear. MATERIALS AND METHODS: Individual hematopoietic colonies were assayed in vitro from the CD34(+) cells of six JAK2V617F-positive MPN patients with marker chromosomal abnormalities. Colonies were simultaneously analyzed for JAK2 genotype and chromosomal abnormalities. RESULTS: Among the 248 colonies assayed from cultures containing 500 CD34(+) cells, chromosomal abnormalities were detected in 5% of colonies with wild-type JAK2, 32% of JAK2V617F heterozygous colonies and 56% of JAK2V617F homozygous colonies. Overall, 92% of chromosomally abnormal colonies were also JAK2V617F homozygous. Although 54 colonies contained wild-type JAK2 exclusively, 4 of these colonies were characterized by chromosomal abnormalities. CONCLUSION: This study indicates that MPN hematopoietic progenitor cells do not necessarily always acquire genetic events in the same sequence. (Chromosomally abnormal progenitor cells are closely associated with JAK2V617F homozygosity; p=0.0001.). Chromosomal abnormalities such as +8, +9 can occasionally precede acquisition of JAK2V617F. These findings support the existence of earlier genetic events that precede JAK2V617F or cytogenetic abnormalities in MPN hematopoietic progenitor cells