Faculty Bibliography

This study aims to document the historical conceptualization of the inner ear as the anatomical location for the appreciation of sound at a continuum of frequencies and to examine the evolution of concepts of tonotopic organization to our current understanding. Primary sources used are from the sixth century BCE through the twentieth century CE. Each work/reference was analyzed from two points of view: to understand the conception of hearing and the role of the inner ear and to define the main evidential method. The dependence on theory alone in the ancient world led to inaccurate conceptualization of the mechanism of hearing. In the sixteenth century, Galileo described the physical and mathematical basis of resonance. The first theory of tonotopic organization, advanced in the seventeenth century, was that high-frequency sound is mediated at the apex of the cochlea and low-frequency at the base of the cochlea. In the eighteenth and nineteenth centuries, more accurate anatomical information was developed which led to what we now know is the accurate view of tonotopic organization: the high-frequency sound is mediated at the base and low-frequency sound at the apex. The electrical responses of the ear discovered in 1930 allowed for physiological studies that were consistent with the concept of a high to low tone sensitivity continuum from base to apex. In the mid-twentieth century, physical observations of models and anatomical specimens confirmed the findings of greater sensitivity to high tones at the base and low tones at the apex and, further, demonstrated that for high-intensity sound, there was a spread of effect through the entire cochlea, more so for low-frequency tones than for high tones. Animal and human behavioral studies provided empirical proof that sound is mediated at a continuum of frequencies from high tones at the base through low tones at the apex of the cochlea. Current understanding of the tonotopic organization of the inner ear with regard to pure tones is the result of the acquisition over time of knowledge of acoustics and the anatomy, physical properties, and physiology of the inner ear, with the ultimate verification being behavioral studies. Examination of this complex evolution leads to understanding of the way each approach and evidential method through time draws upon previously developed knowledge, with behavioral studies providing empirical verification.

The transsphenoidal corridor for pituitary adenoma surgery was established as early as 1906 by Schloffer and was subsequently refined by Cushing throughout the early 20thcentury [1]. The use of intraoperative magnetic resonance imaging (iMRI) in endoscopic endonasal transsphenoidal resections, however, is a relatively contemporary addition to the surgical treatment of pituitary tumors. The morbidity of these cases has decreased over the years in light of advances in intraoperative navigation as well as improvements in endoscope dynamics and surgical instruments. Despite such improvements, a substantial number of patients require repeat surgeries or subsequent radiotherapy for residual and/or recurrent disease. This can be largely attributed to cavernous sinus invasion or suprasellar extension, which pose technical challenges to achieving gross total resections (GTRs). The rate of GTR for pituitary tumors cited in the literature varies from 59-88%.[2-3] The advantage of iMRI is that it provides the surgeon with immediate feedback regarding their progress and ability to safely achieve GTR which, in pituitary surgery, is critical for long term cure. Additionally, although there is concern for increased risk of postoperative endocrine dysfunction, Zhibin et al prove that this is not necessarily the case. In their series, 133 patients who underwent iMRI had higher rates of GTR and did not have a significant difference in postoperative hypopituitarism. [4] This study includes a combined retrospective and prospective comparative analysis of 238 patients who underwent transsphenoidal resection of a pituitary tumor from January 2013 until May 2019. All patients were operated on by one of four experienced neurosurgeons and one of three experienced otolaryngologists. There were 203 patients who did not undergo iMRI and 25 patients who did. A 3 tesla MRI magnet was used in all cases. All intraoperative images were read and interpreted by a senior neuroradiologist at our institution. Amongst the two groups, there was no statistically significant difference in patient age (p = 0.488), tumor size (microadenoma versus macroadenoma, p = 0.878), and primary versus recurrent tumor (p = 0.837). The use of iMRI did not yield a decrease in the length of stay (4.84 days in the no iMRI group and 5 in the iMRI group, p = 0.777). There were zero cases of a return to the OR for residual tumor in the intraoperative MRI group versus the non-MRI group. However, this did not reach statistical significance. This study did not yield a statistically significant difference in GTR (p = 0.75), near total resection (NTR, p = 0.167), or subtotal resection (p = 0.083). This is likely secondary to a low sample size and therefore power in the iMRI group. Finally, there was no significant difference in the number of patients requiring postoperative DDAVP (p = 0.099) or hydrocortisone (p = 0.873) after discharge. Preliminary results reveal a potential benefit of iMRI use to assess for residual disease which can be addressed immediately during the initial operation, thus decreasing the need for re-operations. Furthermore, the ability to correlate intraoperative findings with an intraoperative structure may lead to more precise identification and preservation of normal gland, which can possibly decrease the incidence of postoperative endocrine dysfunction

An ideal nasal osteotomy should deliver precise, predictable, and reproducible cosmetic and functional results while minimizing soft-tissue trauma and postoperative complications. In addition to closing an open roof deformity after hump reduction, other common indications for osteotomies include the crooked nose and a wide bony vault. The literature has reported numerous and diverse osteotomy techniques as well as differences in timing of osteotomies. Each has its own merits and indications, and its proponents. In this article, we review the anatomy and nomenclature relating to osteotomies. We review the locations and paths of the osteotomies-lateral, intermediate, medial, and superior/transverse. We consider the percutaneous and endonasal approaches, as well as timing of osteotomies and other considerations. We also discuss technical considerations in the selection of instrumentation for osteotomies.

OBJECTIVE:We report a case of recurrent eosinophilic otitis media (EOM) successfully treated with the novel monoclonal IL-5 inhibitor benralizumab. We also review literature relevant to EOM diagnosis and potential for biologic treatment. PATIENT/METHODS:A 24-year-old woman with bilateral otitis media with effusion unresponsive to standard treatment. INTERVENTION(S)/METHODS:Multidisciplinary treatment using subcutaneous benralizumab after diagnosis of EOM. MAIN OUTCOME MEASURE(S)/METHODS:Behavioral audiometry, peripheral serology, otomicroscopy, and eosinophilic otitis media symptom severity. RESULTS:Recalcitrant otitis media with effusion (OME) in the setting of nasal polyposis and asthma prompted clinical suspicion for EOM, which was confirmed by pathologic examination of middle ear effusion and soft tissue biopsy. Treatment with benralizumab was initiated by pulmonology and well-tolerated. Within 2 months of treatment onset there was a cessation of EOM symptoms, a reduction of peripheral eosinophil levels, and an improvement in conductive hearing loss. CONCLUSIONS:Monoclonal antibodies such as benralizumab may be an effective treatment option for EOM. A high level of clinical suspicion in patients with bronchial asthma, nasal polyposis, and recalcitrant OME may allow early diagnosis of EOM. Awareness of emerging biologic treatment options is important in the management of this challenging entity and may prevent long-term sequelae.

OBJECTIVES/OBJECTIVE:Development of novel vocal fold (VF) therapeutics is limited by a lack of standardized, meaningful outcomes. We hypothesize that automated microindentation-based VF biomechanical property mapping matched to histology permits quantitative assessment. STUDY DESIGN/METHODS:Ex vivo. METHODS:Twelve anesthetized New Zealand white rabbits underwent endoscopic right VF injury. Larynges were harvested/bisected day 7, 30, or 60 (n = 4/group), with four uninjured controls. Biomechanical measurements (normal force, structural stiffness, and displacement at 1.96 mN) were calculated using automated microindentation mapping (0.3 mm depth, 1.2 mm/s, 2 mm spherical indenter) with a grid overlay (>50 locations weighted toward VF edge, separated into 14 zones). Specimens were marked/fixed/sectioned, and slides matched to measurement points. RESULTS:In the injury zone, normal force/structural stiffness (mean, standard deviation [SD]/mean, SD) increased from uninjured (2.2 mN, 0.64/7.4 mN/mm, 2.14) and day 7 (2.7 mN, 0.75/9.0 mN/mm, 2.49) to day 30 (4.3 mN, 2.11/14.2 mN/mm, 7.05) and decreased at 60 days (2.7 mN, 0.77/9.1 mN/mm, 2.58). VF displacement decreased from control (0.28 mm, 0.05) and day 7 (0.26 mm, 0.05) to day 30 (0.20 mm, 0.05), increasing at day 60 (0.25 mm, 0.06). A one-way ANOVA was significant; Tukey's post hoc test confirmed day-30 samples differed from other groups (P < 0.05), consistent across adjacent zones. Zones far from injury remained similar across groups (P = 0.143 to 0.551). These measurements matched qualitative histologic variations. CONCLUSION/CONCLUSIONS:Quantifiable VF biomechanical properties can be linked to histology. This technological approach is the first to simultaneously correlate functional biomechanics with histology and is ideal for future preclinical studies. LEVEL OF EVIDENCE/METHODS:NA Laryngoscope, 2019.

BACKGROUND/UNASSIGNED:The Alexis retractor is a device that provides simultaneous radial retraction and wound protection during surgical procedures. Although typically used in abdominal and pelvic surgeries, there has been increased development of novel operative techniques utilizing the Alexis retractors in head and neck surgeries. METHODS/UNASSIGNED:We describe 2 cases of utilizing the Alexis retractor to attain transoral exposure in the setting of free flap reconstruction of intraoral defects. RESULTS/UNASSIGNED:In both cases, the Alexis retractor provided improved retraction, decreasing the number of instruments required for adequate exposure. Additionally, the polyurethane sheath component acted as a protective membrane over the lips and mucosa. CONCLUSIONS/UNASSIGNED:The Alexis retractor can be a powerful retraction tool for certain surgical procedures involving the head and neck regions.