Incidence of Neoplasm in Patients Referred for Epistaxis.

Objectives: The primary objective was to identify the incidence of neoplastic disease in patients referred for epistaxis. Secondary objectives included identification of any mass lesion, and the need for further workup with imaging and/or biopsy as well as risk factors associated with identification of a mass lesion. Study Design: Retrospective cohort study. Methods: Medical records of adult patients who presented to Tufts Medical Center over an 11 year period (2010-2021) with a chief complaint of epistaxis were reviewed. The primary outcome was identification of a nasal or nasopharyngeal mass. Patient characteristics including age, sex, race, smoking status, anticoagulation, comorbidities (hypertension, allergic rhinitis, vasculitis), and treatment of epistaxis (used as surrogate for severity of epistaxis) were also examined. Results: A total of 1164 patients met inclusion and exclusion criteria. Thirty-six nasal masses were found among patients presenting with epistaxis (3.09%, P < .001), comprised primarily of benign etiology (2.66%) including nasal polyposis and thornwaldt cyst. Asian race correlated with finding of mass lesion (75%, P = .007). Five malignancies were found (0.43%) including nasopharyngeal carcinoma (2 patients), extranodal natural killer T-cell lymphoma (2 patients), and nasal adenocarcinoma (1 patient). Conclusions: Epistaxis is a common cause for referral to otolaryngology. Although the incidence of neoplasm in our patient population was low, nasal mass lesions warranting further workup were identified in 36 patients. Findings of neoplasm were more common in patients of Asian ethnicity, which may reflect the increased prevalence of nasopharyngeal carcinoma in this population. Otolaryngologic evaluation and nasal endoscopy should be considered in all cases of epistaxis.

Rare Complications in Chondrolaryngoplasty: Preparation for Safe Outcomes.

Chondrolaryngoplasty ("tracheal shave") is a common procedure requested by transgender women as well as cisgender men and women. Management of intraoperative complications is crucial given the risk of damage to the vocal cords and loss of the airway in patients who are not intubated. We present two rare complications of chondrolaryngoplasty and their management.

Unusual complication after augmentation genioplasty: Odontogenic infection requiring implant removal.

Augmentation genioplasty is a common surgical procedure with extremely low infection rates. We present the case of a healthy middle-aged woman who experienced years of chronic infection after chin implantation due to an exposed mandibular canine root, which is exceedingly rare. Awareness of this potential complication may reduce patient morbidity.

Pharyngeal wall and soft palate motion after two common speech surgeries.

PURPOSE: To assess how pharyngeal wall and soft palate motion are affected after two common interventions for velopharyngeal insufficiency. MATERIALS AND METHODS: A retrospective observational study was performed. A database of patients who had undergone Furlow palatoplasty or pharyngeal flap surgery between 2011 and 2019 and had video-archived preoperative and postoperative nasopharyngoscopy recordings was created. Recordings were deidentified and randomized, with 5 randomly-selected videos duplicated to determine intra-rater reliability. The videos were scored by 3 experienced raters using a modified Golding-Kushner scale. Pre- and postoperative scores were compared using paired t-test. Inter- and intra-rater reliability were estimated using intra-class correlation (ICC). RESULTS: There were 17 patients who met inclusion criteria. The mean age was 6.9 years (range 3-22 years, 59% male). In the Furlow palatoplasty group (n = 9), an increase in left soft palate motion was noted postoperatively (t(8) = 2.71, p = 0.02). In the pharyngeal flap group (n = 8), increases in lateral pharyngeal wall motion (left: t(7) = 3.58, p = 0.008, right: t(7) = 3.84, p = 0.006) and right soft palate motion (t(6) = 2.49, p = 0.04) were identified. Intra-rater reliability and inter-rater agreement were lower than prior studies utilizing the Golding Kushner scale. CONCLUSIONS: Our results provide objective evidence that Furlow palatoplasty and pharyngeal flap surgeries achieve velopharyngeal closure by increasing movement at different anatomical sites. Palatal and pharyngeal wall motion observed during preoperative nasopharyngoscopy may influence a surgeon's choice of intervention.

Fulminant and Diffuse Cerebral Toxoplasmosis as the First Manifestation of HIV Infection: A Case Presentation and Review of the Literature.

BACKGROUND One of the most common causes of central nervous system (CNS) opportunistic infections in immunocompromised patients is toxoplasmosis. It can cause focal or disseminated brain lesions leading to neurological deficit, coma, and death. Prompt management with optimal antibiotics is vital. However, the diagnosis of cerebral toxoplasmosis is challenging in infected individuals with human immunodeficiency virus (HIV). The possible diagnosis is based on clinical presentation, imaging, and specific serologic investigations. The diagnosis can be confirmed by histopathological examination and/or by finding nucleic material in the spinal cerebrospinal fluid (CSF) examination. CASE REPORT We present a review of the literature with a rare illustrative case of diffuse CNS toxoplasmosis as the first manifestation of HIV infection in a young patient. Brain MRI showed diffuse, ring-enhancing lesions, and significant midline shift. Decompressive hemicraniectomy for control of intracranial pressure and anti-infectious therapy were performed. CONCLUSIONS This should raise awareness that cerebral toxoplasmosis can occur in pediatric patients with HIV infection, and, more importantly, as the first manifestation of AIDS. Although the prognosis is often poor, early diagnosis and immediate treatment of this life-threatening opportunistic infection can improve outcomes.

Falxuplication, a Novel Method for Wrap-Clipping a Fusiform Aneurysm: Technical Note.

BACKGROUND: Various techniques have been used for wrap-clipping a ruptured, fusiform intracranial aneurysm; however, there is no available literature on use of the falx cerebri for wrap-clipping. We present a review of the literature, with an illustrative case, of a ruptured fusiform pericallosal artery aneurysm firmly attached to the lower edge of the falx cerebri and not amenable to endovascular intervention. METHODS: Although the firm attachment between the inferior falx and the fusiform aneurysm was maintained, a section of the lower thinner part of the falx cerebri firmly attached to the aneurysm was dissected and wrapped around the fusiform aneurysm, and then stabilized with a fenestrated clip. We chose a segment slightly longer than the length of the fusiform aneurysm to avoid pre- and post-wrap-clipping stenosis. RESULTS: Postprocedure, except for a small area of numbness on the left distal anterolateral left leg, the patient was neurologically intact and remained neurologically intact at a 12-month follow-up. CONCLUSIONS: An inferior thin segment of the falx cerebri can be used for wrap-clipping of ruptured fusiform anterior cerebral artery aneurysms. Furthermore, the inferior falx can be wrapped around the attached fusiform anterior cerebral artery aneurysm without compromising flow, offering a safe solution in these unusually complex cases.

Cranial Osteomyelitis: A Comprehensive Review of Modern Therapies.

BACKGROUND: Cranial osteomyelitis is a rare but potentially life-threatening condition that requires early diagnosis with prompt and appropriate management by neurosurgeons to prevent further central nervous system complications. METHODS: The literature in the Medline database was comprehensively reviewed with the keywords "cranial osteomyelitis," "skull base osteomyelitis (SBO)," "central skull base osteomyelitis," and "temporal bone osteomyelitis." Items in the reference list of each article relevant to the objective of this study were reviewed. RESULTS: This review produced 183 articles: 13 book chapters, 24 case reports, 17 case series, 98 original articles, 30 review articles, and 1 meta-analysis. We classified cranial osteomyelitis as sinorhino-otogenic, including anterior, middle, and posterior skull base osteomyelitis; and non-sinorhino-otogenic, including iatrogenic, posttraumatic, hematologic, and osteomyelitis with other causes. CONCLUSIONS: New diagnostic modalities, the introduction of broad-spectrum antibiotics, and recent advances in neurosurgical procedures have led to a decrease in the rate of treatment failure in cranial osteomyelitis. Early recognition of initial nonspecific symptoms is key to diagnosing and managing this treatable but life-threatening condition. Early identification of the causative pathogen, appropriate broad-spectrum antibiotic therapy over a period of 8-20 weeks, and aggressive surgical debridement are essential for managing cranial osteomyelitis. On the other hand, inadequate treatment is responsible for refractory cases and poses a great diagnostic challenge. A new classification dividing cranial osteomyelitis into sinorhino-otogenic versus nonsinorhino-otogenic groups could prove valuable for clinical communication and treatment.

Subarachnoid Trabeculae: A Comprehensive Review of Their Embryology, Histology, Morphology, and Surgical Significance.

INTRODUCTION: Brain is suspended in cerebrospinal fluid (CSF)-filled subarachnoid space by subarachnoid trabeculae (SAT), which are collagen-reinforced columns stretching between the arachnoid and pia maters. Much neuroanatomic research has been focused on the subarachnoid cisterns and arachnoid matter but reported data on the SAT are limited. This study provides a comprehensive review of subarachnoid trabeculae, including their embryology, histology, morphologic variations, and surgical significance. METHODS: A literature search was conducted with no date restrictions in PubMed, Medline, EMBASE, Wiley Online Library, Cochrane, and Research Gate. Terms for the search included but were not limited to subarachnoid trabeculae, subarachnoid trabecular membrane, arachnoid mater, subarachnoid trabeculae embryology, subarachnoid trabeculae histology, and morphology. Articles with a high likelihood of bias, any study published in nonpopular journals (not indexed in PubMed or MEDLINE), and studies with conflicting data were excluded. RESULTS: A total of 1113 articles were retrieved. Of these, 110 articles including 19 book chapters, 58 original articles, 31 review articles, and 2 case reports met our inclusion criteria. CONCLUSIONS: SAT provide mechanical support to neurovascular structures through cell-to-cell interconnections and specific junctions between the pia and arachnoid maters. They vary widely in appearance and configuration among different parts of the brain. The complex network of SAT is inhomogeneous and mainly located in the vicinity of blood vessels. Microsurgical procedures should be performed with great care, and sharp rather than blunt trabecular dissection is recommended because of the close relationship to neurovascular structures. The significance of SAT for cerebrospinal fluid flow and hydrocephalus is to be determined.

The role of same-sex mentorship and organizational support in encouraging women to pursue surgery.

INTRODUCTION: While women represent approximately half of all medical students, only 38% of general surgery residents are women. The objective of this study is to explore how access to mentors and organizational support affects career choices. METHODS: In June of 2016, a survey was sent to medical students at a single institution (n = 472). Questions utilized a 5-point Likert scale. A two-sample t-test was used to evaluate data. RESULTS: A total of 160 students participated in the survey. Among MS1/MS2 students, women were more likely to rank same-sex role models as a positive influence (mean 3.1 vs. 2.4; p < 0.05). Similar results were seen among MS3/MS4 students (mean 3.6 vs. 2.5; p < 0.05). More women ranked the presence of organizations that support women in surgery as being important (mean 4.6 vs. 4.1; p < 0.05). CONCLUSION: Exposure to same-sex mentors was highly rated among female participants. These findings encourage the creation of national mentorship programs. Early involvement in organizations can positively influence career choice. Addressing gaps in mentorship opportunities and widening accessibility to national organizations are important in reducing barriers.

Gestational Exposure to Air Pollution Alters Cortical Volume, Microglial Morphology, and Microglia-Neuron Interactions in a Sex-Specific Manner.

Microglia are the resident immune cells of the brain, important for normal neural development in addition to host defense in response to inflammatory stimuli. Air pollution is one of the most pervasive and harmful environmental toxicants in the modern world, and several large scale epidemiological studies have recently linked prenatal air pollution exposure with an increased risk of neurodevelopmental disorders such as autism spectrum disorder (ASD). Diesel exhaust particles (DEP) are a primary toxic component of air pollution, and markedly activate microglia in vitro and in vivo in adult rodents. We have demonstrated that prenatal exposure to DEP in mice, i.e., to the pregnant dams throughout gestation, results in a persistent vulnerability to behavioral deficits in adult offspring, especially in males, which is intriguing given the greater incidence of ASD in males to females (∼4:1). Moreover, there is a striking upregulation of toll-like receptor (TLR) 4 gene expression within the brains of the same mice, and this expression is primarily in microglia. Here we explored the impact of gestational exposure to DEP or vehicle on microglial morphology in the developing brains of male and female mice. DEP exposure increased inflammatory cytokine protein and altered the morphology of microglia, consistent with activation or a delay in maturation, only within the embryonic brains of male mice; and these effects were dependent on TLR4. DEP exposure also increased cortical volume at embryonic day (E)18, which switched to decreased volume by post-natal day (P)30 in males, suggesting an impact on the developing neural stem cell niche. Consistent with this hypothesis, we found increased microglial-neuronal interactions in male offspring that received DEP compared to all other groups. Taken together, these data suggest a mechanism by which prenatal exposure to environmental toxins may affect microglial development and long-term function, and thereby contribute to the risk of neurodevelopmental disorders.

A second look at the utility of serial routine repeat computed tomographic scans in patients with traumatic brain injury.

BACKGROUND: The practice of a routine repeat head computed tomographic scans in patients with traumatic brain injury (TBI) is under question. The aim of our study was to evaluate the utility of a more than 1 repeat head computed tomography (M1CT) scans in patients with TBI. METHODS: We performed a 3-year analysis of a prospectively collected database of all TBI patients presenting to our level I trauma center. Patients who received M1CT scans were included. Findings and reason (without neurologic decline vs after neurologic decline) for M1CT were recorded. Primary outcome measure was neurosurgical intervention. RESULTS: A total of 296 patients that underwent M1CT were included. Of those, 291 patients (98.6%) had M1CT without a neurologic decline, and neurosurgical intervention was performed in 1 patient (.3%) who was inexaminable (Glasgow coma scale score = 6). The remaining (n = 5) had M1CT due to a neurologic decline; 4 patients (80%) of the 5 had worsening of ICH; and neurosurgical intervention was performed in 3 (75%) of the 4 patients. CONCLUSIONS: The practice of multiple repeat head computed tomographic scans should be limited to inexaminable patients or patients with neurological deterioration.

Iron sucrose impairs phagocytic function and promotes apoptosis in polymorphonuclear leukocytes.

BACKGROUND: With the recent implementation of bundling reimbursement policy, the use of intravenous (IV) iron preparations for the management of anemia in the end-stage renal disease (ESRD) population has dramatically increased. Iron overload increases the risk of infections in individuals with or without kidney disease. IV iron administration in ESRD patients impairs bacteriocidal capacity of polymorphonuclear leukocytes (PMNs) against Escherichia coli. These preparations consist of an elemental iron core and a carbohydrate shell. In addition to the iron core, the carbohydrate shell may affect PMNs. We therefore examined the effect of iron sucrose, a commonly used preparation, on phagocytic capacity of PMNs from a group of normal individuals against Gram-positive (Staphylococcus aureus) and Gram-negative (E. coli) bacteria. METHODS: Iron sucrose was added to heparinized blood samples at pharmacologically-relevant concentrations and incubated for 4 and 24 h at 37°C to simulate in vivo condition. Blood samples mixed with equal volume of saline solution served as controls. To isolate the effects of the carbohydrate shell, blood samples were co-treated with the iron chelator, desferrioxamine. RESULTS: Iron sucrose caused significant PMN apoptosis and dose-dependent suppression of phagocytic function against both Gram-positive and Gram-negative bacteria. These abnormalities were prevented by desferrioxamine which precluded contribution of the carbohydrate shell to the PMN dysfunction. CONCLUSIONS: At pharmacologically-relevant concentrations, iron sucrose promotes apoptosis and inhibits phagocytic activities of PMNs. The deleterious effect of iron sucrose is mediated by its elemental iron core, not its carbohydrate shell, and as such may be shared by other IV iron preparations.