Applications of Preoperative and Intraoperative Technologies for Complex Primary and Secondary Facial Trauma Reconstruction.

This article provides a review of the current technologies available in the preoperative and intraoperative management of complex and secondary maxillofacial trauma reconstruction. These patients present a unique challenge for which the advancement of imaging technologies, patient-specific modeling and implants, and intraoperative imaging and navigation can play an important role to improve their post-treatment outcomes.

International Medical Graduates in Otolaryngology Education: The Overlooked Path to Diversity and Inclusivity.

"International Medical Graduates" (IMGs) make up a large percentage of "underrepresented in medicine" physicians and comprise 25% of the US physician workforce. The American Academy of Otolaryngology-Head and Neck Surgery, in its "Statement on Diversity," has expressed its enduring commitment to inclusion and diversity in all its forms. However, unlike various other specialties, a discussion about integration of IMGs in Otolaryngology has not been raised in our community. This commentary reviews the data on the recruitment of IMGs in Otolaryngology residency programs and highlights the need for a strategic effort to increase their participation in the US residency programs. Strong benefits may be derived from this effort such as promoting inclusivity and diversity of the workforce and increasing the support of the nation's underserved communities.

Combined endoscopic endonasal & transoral approach to transpatial lesion involving the infratemporal fossa and masticator space: A case study and literature review / Abordaje endoscópico combinado endonasal y transoral a una lesión transespacial involucrando la fosa infratemporal y el espacio masticador: Reporte de caso y revisión de la literatura

Transpatial skull base lesions involving the infratemporal fossa (ITF) are challenging due to the complex neurovascular structures of the region. Open approaches have traditionally been utilized to access these spaces. We present a 55-year-old woman presented with a mesenchymal mass involving the left ITF and masticator space. A combined endoscopic endonasal transpterygoid approach was performed followed by an endoscopic transoral-transmandibular corridor to access and resect the tumor. The post-operative course was unremarkable with no recurrence during her follow-up. Combined endoscopic approaches for transpatial tumor resection offered sufficient exposure to access safely each space (AU)

Las lesiones de la base craneal con una distribución transespacial e involucrando la fosa infratemporal (ITF) representan un desafío debido a las complejas estructuras neurovasculares de dicha región. Los abordajes abiertos han sido empleados tradicionalmente para acceder a estas regiones. Presentamos el caso de una mujer de 55 años que consultó por una lesión mesenquimal localizada en la ITF izquierda y en el espacio masticatorio. Se realizó un abordaje combinado endoscópico transpterigoideo endonasal seguido de un abordaje endoscópico transoral-transmandibular para acceder y resecar el tumor. El curso postoperatorio fue anodino, y no ha presentado recidiva con 21 meses de seguimiento. Los abordajes endoscópicos combinados para la resección de lesiones tumorales, con una distribución transespacial involucrando la ITF, ofrecen una exposición suficiente para acceder de forma segura a cada espacio (AU)

Combined endoscopic endonasal & transoral approach to transpatial lesion involving the infratemporal fossa and masticator space: A case study and literature review.

Transpatial skull base lesions involving the infratemporal fossa (ITF) are challenging due to the complex neurovascular structures of the region. Open approaches have traditionally been utilized to access these spaces. We present a 55-year-old woman presented with a mesenchymal mass involving the left ITF and masticator space. A combined endoscopic endonasal transpterygoid approach was performed followed by an endoscopic transoral-transmandibular corridor to access and resect the tumor. The post-operative course was unremarkable with no recurrence during her follow-up. Combined endoscopic approaches for transpatial tumor resection offered sufficient exposure to access safely each space.

A Cost-Effective and Reproducible Cadaveric Training Model for Internal Carotid Artery Injury Management During Endoscopic Endonasal Surgery: The Submersible Peristaltic Pump.

BACKGROUND: Internal carotid artery injury (ICAI) represents one of the most challenging complications in endoscopic endonasal neurosurgery and its rarity results in limited opportunities for trainees and surgeons to achieve proficiency in its management. Currently, available models for ICAI have employed costly systems that prevent their widespread use. The objective of this study is to validate an affordable submersible peristaltic pump (SPP)-based model as a reproducible and realistic paradigm for ICAI management training. METHODS: A laceration of the left parasellar internal carotid artery was purposely carried out in 2 human cadaveric heads. A blood substitute was perfused to ensure a perfusion flow of 1 L/min using an affordable SPP. A cohort of 20 neurosurgery and otolaryngology residents, fellows, and attendings were enrolled to evaluate the realism and content validity of the model using a validated 5-grade questionnaire. RESULTS: The model proved to mimic a real intraoperative scenario of ICAI with an expected output flow of 1 L/min. Questionnaire responses reported a realistic experience and the impact of this model on improving trainee surgical coordination and capability to rehearse the most accepted repair technique. The use of a fixed noninjected head allowed the reproducibility of the training session without the additional cost of new fresh-frozen heads. The affordable SPP allowed an impactful reduction of ICAI model training expenses maintaining high realism. CONCLUSIONS: The SPP-based ICAI model with noninjected cadaveric specimens is an affordable and cost-effective system that allows reproducibility and realism. These qualities favor greater adoption in neurosurgery and otolaryngology training curricula.

Observation of Retropharyngeal Fluid Collection in 2 COVID-19 Positive Patients.

Our understanding of the novel coronavirus, COVID-19, is growing; yet, there remains much we do not understand, and unique presentations are abundant. One potential presentation is retropharyngeal edema, defined as fluid in the retropharyngeal space. Multiplanar imaging with computed tomography or magnetic resonance imaging is ideal for characterizing and diagnosing these fluid collections rapidly as possible life-threatening complications may develop (eg, airway obstruction and mediastinitis). Here, we discuss the presentation, imaging identification, treatment, and recovery of retropharyngeal fluid collection in 2 COVID-19 cases. The significance of this article is to suggest conservative management as a viable treatment option for retropharyngeal fluid collection, as opposed to incision and drainage, in the setting of COVID-19.

Implementation and Evaluation of a Virtual Elective in Otolaryngology in the Time of COVID-19.

OBJECTIVE: To develop and evaluate a virtual otolaryngology medical student elective created during the COVID-19 crisis with the intention of teaching the basic tenets of otolaryngology and increasing exposure to the specialty. STUDY DESIGN: Cross-sectional survey. SETTING: Emory University School of Medicine. METHODS: A 1-week virtual otolaryngology curriculum was offered to third- and fourth-year medical students that centered on the American Academy of Otolaryngology-Head and Neck Surgery Foundation's handbook Primary Care in Otolaryngology (fourth edition). The course covered a variety of topics and was conducted remotely via online video conferencing software. We applied multiple teaching modalities and surveyed students regarding the effectiveness of the course. Mixed methods analysis was employed to analyze the course data. RESULTS: Twelve students participated; 67% reported their baseline precourse understanding of otolaryngology in the "poor-fair" range. After the course, 92% of students reported increased understanding, with 42% and 58% reporting "good" and "very good" understanding, respectively. Following completion of the course, posttest scores on summative assessments were significantly higher than pretest scores (P < .001). Ninety-two percent of students reported either "increased" or "greatly increased" interest in otolaryngology postcourse. Qualitative survey results revealed students' appreciation of course organization, formative assessments, and case-based learning. CONCLUSIONS: An otolaryngology elective administered through a virtual format can be effective at providing an educational experience and garnering interest in the field. Positive exposure to otolaryngology can increase medical students' interest in pursuing the specialty and expand their general knowledge of consultation, diagnosis, and management in otolaryngology.

Review of Orbital Fractures in an Urban Level I Trauma Center.

OBJECTIVE: To perform a comprehensive review and analysis of surgically treated orbital fractures. STUDY DESIGN: Retrospective cohort chart review study for surgically treated orbital fractures during 5 years. RESULTS: A total of 173 patients (average age 41.6 years) were diagnosed with orbital fractures. Most were male with a ratio of 3.3:1. Most fractures were caused by assault (39.3%); 22.5% of the cases were bilateral. The left orbit (40.5%) was fractured more than the right. The orbital floor (97.1%) was the most common anatomic location and the maxilla (65.3%) was the most commonly involved bone. The average time from trauma to surgical intervention was 8.7 ± 14.6 days and the average time from surgical intervention to discharge was 5.1 ± 9.0 days. The transconjunctival incision (63%) was the most commonly used incision, and nonresorbable implant (92.7%) was the most commonly used implant. Finally, the length of stay for the repair of a simple orbital fracture was less than for complex orbital fracture (1.5 days and 5.9 days, respectively). CONCLUSION: Understanding the patterns and mechanisms of injury associated with orbital fractures can assist in developing standardized treatment protocols across all surgical specialties. This would ultimately allow for a uniform high quality of surgical care for patients with maxillofacial fractures.

Craniomaxillofacial Trauma Experience in Otolaryngology Residency: A National Survey of Program Directors.

This article aimed to assess the depth and volume of craniomaxillofacial (CMF) trauma exposure and education in otolaryngology residency training in the United States. This is a cross-sectional survey. A 15-question web-based survey was distributed to program directors of 106 Accreditation Council for Graduate Medical Education (ACGME)-approved otolaryngology residency programs to inquire about program size and demographics, trauma coverage, case volume, and education. Responses were collected anonymously. A total of 77 responses were received, representing 73% of residency programs. Seventy-five programs (97%) reported that their residents rotated at a level 1 trauma center, and 72 (94%) covered CMF trauma. Sixty-one programs (79%) included pediatric CMF trauma. The majority of programs (76%) allocated less than 10% of residency-dedicated didactic lecture time to CMF trauma. Residents in all programs typically logged at least 11 to 20 cases before graduation with 24% of programs averaging more than 50 cases per resident. Ninety percent of respondents described the training as "somewhat" to "very adequate." CMF coverage by the otolaryngology department, number of cases, and dedicated didactic lecture time to CMF trauma were significant factors on the perception of adequate training. The majority of program directors felt that the training in CMF trauma was adequate. Reasons for this may include that most residents rotate at level 1 trauma centers, have exposure to pediatric trauma, encounter an adequate volume of cases, and have dedicated didactic time to CMF education.

Upper Nasopharyngeal Corridor for Transnasal Endoscopic Drainage of Petroclival Cholesterol Granulomas: Alternative Access in Conchal Sphenoid Patients.

Background Cholesterol granulomas arising at the petrous apex can be treated via traditional open surgical, endoscopic, and endoscopic-assisted approaches. Endoscopic approaches require access to the sphenoid sinus, which is technically challenging in patients with conchal sphenoidal anatomy. Clinical Presentation A 55-year-old woman presented with intermittent headaches and tinnitus. Formal audiometry demonstrated moderately severe bilateral hearing loss. CT of the temporal bones and sella revealed a well-demarcated expansile lytic mass. MRI of the face, orbit, and neck showed a right petrous apex mass measuring 22 × 18 × 19 mm that was hyperintense on T1- and T2-weighted images without enhancement, consistent with a cholesterol granuloma. The patient had a conchal sphenoidal anatomy. Operative Technique Herein, we present an illustrative case of a low-lying petroclival cholesterol granuloma in a patient with conchal sphenoidal anatomy to describe an alternative high nasopharyngeal corridor for endoscopic transnasal transclival access. Postoperative Course Postoperatively, the patient's symptoms recovered and no complications occurred. Follow-up imaging demonstrated a patent drainage tract without evidence of recurrence. Conclusion In patients with a conchal sphenoid sinus, endoscopic transnasal transclival access can be gained using a high nasopharyngeal approach. This corridor facilitates safe access to these lesions and others in this location.

Prognosis for sixth nerve palsy arising from paranasal sinus disease.

BACKGROUND: The abducens nerve, cranial nerve VI (CNVI), is the medial-most nerve in the cavernous sinus. Its close proximity to the sphenoid sinus makes it susceptible to injury, invasion, or compression from a sphenoid pathology leading to horizontal gaze diplopia. A wide range of literature describes myriad causes for CNVI palsy, but there is a lack of references that point to paranasal sinus pathology as an etiology, as well as the prognosis and timeline for resolution. Here, we describe a series of patients that presented with CNVI palsy, their management, and prognosis for recovery. This study was designed to evaluate and understand prognostic factors predicting disease course and likelihood of resolution in patients with abducens nerve palsy. METHODS: A multi-institutional retrospective review was performed of all patients presenting with CNVI palsy between 2009 and 2012. The demographic data, radiological features, treatment regimens, and disease courses were analyzed. RESULTS: Fifteen patients at four institutions were identified. Seven patients had neoplasms originating from the paranasal sinuses, three suffered from allergic fungal sinusitis, three patients had invasive fungal sinusitis, one patient had fibrous skull base dysplasia, and one had chronic bacterial sinusitis. The average follow-up time from presentation was 9 months (range, 1-16 months). Thirteen patients underwent surgery, three received chemotherapy, and four had radiation therapy. CNVI palsy resolved in 50% of the cases, with an average time to resolution of 6 weeks (range, 2-12 weeks). CONCLUSION: Paranasal sinus pathology is a rare cause of CNVI palsy. A number of factors may help to predict prognosis in these patients. Masses compressing, but not destroying or invading, the cavernous sinus had optimal posttreatment outcomes with full resolution occurring as early as 2 weeks. Destructive lesions that invaded CNVI and its vasculature, i.e., invasive fungus, were negative indicators for recovery. Knowledge of factors that affect recovery can help clinicians predict disease course and prognosis for resolution of the defect.

Cytokine correlation between sinus tissue and nasal secretions among chronic rhinosinusitis and controls.

OBJECTIVES/HYPOTHESIS: Compare cytokine levels in sinus tissue to sinus secretions from controls and chronic rhinosinusitis patients. STUDY DESIGN: In vitro. METHODS: Polyurethane foam sponges were placed into middle meati of patients with chronic rhinosinusitis without nasal polyps (CRSsNP), with polyps (CRSwNP), and controls. Sinus biopsies were then taken from the same location. Protein levels of tumor necrosis factor-alpha (TNF-α), interferon-γ (IFN-γ), and interleukins (IL) 2, 4, 6, 8, 10, and 17A were measured via cytometric bead assay for each sample. Protein values from sinus tissue and secretions were compared with Pearson's correlation between samples as well as one-way ANOVA with posthoc t test between groups. RESULTS: Samples from 43 patients in total were examined. Mucus was measured from 10 controls, 11 CRSsNP and 10 CRSwNP, and sinus tissue was measured from 10 controls, 15 CRSsNP and 10 CRSwNP. IL-8 and IFN-γ levels were outside of the detectable range of the assay. Levels of secreted IL-2, 4, 6, 10, and 17A correlated with tissue levels (P < 0.05 for all, r > 0.49) while TNF-α did not (P = 0.71). CRSsNP had elevated mucus levels of IL-2, 4, 6, 10, and 17A compared to controls. CRSwNP had elevated mucus levels of IL-4, 6, 10, 17A, and TNF-α compared to controls. CONCLUSIONS: Cytokine levels in sinus secretions correlate with levels in sinus tissue and are elevated in CRS versus control based on Th1/Th2 skewing.

Impact of synechiae after endoscopic sinus surgery on long-term outcomes in chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: Synechiae are one of the most common unwanted outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). However, there has been scant investigation into the true significance of synechiae formation after ESS. The aim of this study was to evaluate the impact of synechiae formation on health-related quality of life (HRQoL) outcomes after ESS in patients with CRS. STUDY DESIGN: Prospective, multi-institutional cohort. METHODS: Rhinosinusitis Disability Index (RSDI) and Chronic Sinusitis Survey (CSS) scores were measured in adult patients before and after undergoing ESS for CRS. Differences in HRQoL were evaluated between those who developed sinonasal synechiae and those who did not, controlling for demographic factors, medical comorbidities, and measures of disease severity at baseline. RESULTS: A total of 286 patients underwent ESS, with 55 (19.2%) developing synechiae in the follow-up period. Patients developing synechiae reported significantly less improvement on the RSDI total scores (13.5 vs. 21.4, P = 0.008), RSDI physical subscores (5.3 vs. 8.3, P = 0.007), RSDI emotional subscores (2.9 vs. 5.8, P = 0.008), CSS total scores (14.5 vs. 21.2, P = 0.093), and CSS symptom subscores (19.9 vs 30.3, P = 0.069) compared to those who did not develop synechiae postoperatively. These differences persisted even after controlling for baseline differences in disease severity. CONCLUSIONS: Synechiae of the sinonasal cavity commonly occurs following ESS, particularly in those undergoing revision surgeries. Although both groups improve, the degree of HRQoL improvement appears to be less in those who form postoperative synechiae after surgery compared to those who do not.

House dust mite allergen Der p 1 effects on sinonasal epithelial tight junctions.

BACKGROUND: Epithelial permeability is highly dependent upon the integrity of tight junctions, which are cell-cell adhesion complexes located at the apical aspect of the lateral membrane of polarized epithelial cells. We hypothesize that sinonasal epithelial exposure to Der p 1 house dust mite antigen decreases expression of tight junction proteins (TJPs), representing a potential mechanism for increased permeability and presentation of antigens across the sinonasal epithelial layer. METHODS: Confluent cultured primary human sinonasal epithelial cells were exposed to recombinant Der p 1 antigen vs control, and transepithelial resistance measurements were performed over 24 hours. Antibody staining for a panel of TJPs was examined with immunofluorescence/confocal microscopy and Western blotting. Tissue for these experiments was obtained from 4 patients total. RESULTS: Der p 1 exposed sinonasal cells showed a marked decrease in transepithelial resistance when compared to control cells. In addition, results of Western immunoblot and immunofluorescent labeling demonstrated decreased expression of TJPs claudin-1 and junction adhesion molecule-A (JAM-A) in Der p 1-exposed cultured sinonasal cells vs controls. CONCLUSION: Der p 1 antigen exposure decreases sinonasal epithelium TJP expression, most notably seen in JAM-A and claudin-1 in these preliminary experiments. This decreased TJP expression likely contributes to increased epithelial permeability and represents a potential mechanism for transepithelial antigen exposure in allergic rhinitis.

Endoscopic sinus surgery in adults with cystic fibrosis: effect on lung function, intravenous antibiotic use, and hospitalization.

OBJECTIVE: To ascertain the effect of endoscopic sinus surgery (ESS) on lung function, intravenous (IV) antibiotic use, and hospitalization in adults with cystic fibrosis (CF). DESIGN: Retrospective analysis. SETTINGS: Tertiary care center. PATIENTS: Fifteen adults with a diagnosis of CF undergoing ESS between March 1, 2006, and June 31, 2008. MAIN OUTCOME MEASURES: Twelve-month preoperative and 12-month postoperative pulmonary function testing (forced vital capacity [FVC] and forced expired volume in 1 second [FEV1]), number of IV antibiotic courses, total number of days of intravenous antibiotic use, and number of inpatient hospital days (IHDs) were assessed. RESULTS: Twenty-two adults with CF underwent ESS; 15 patients had adequate data for evaluation. No significant differences were found between mean preoperative and postoperative FEV1 (61.3% vs 59.5%; P = .41) or FVC (76.4% vs 76.1%; P = .97) or between best preoperative and postoperative FEV1 (67.4% vs 67.0%; P = .95) or FVC (84.2% vs 83.0%; P = .86) (paired samples t test). The number of IV antibiotic courses and the total number of days of IV antibiotic use did not differ between the preoperative and postoperative periods (Wilcoxon signed rank test P = .61 and P = .10, respectively). However, the number of IHDs was significantly lower in the 1-year postoperative period (36.7 days) vs the 1-year preoperative period (59.1 days) (Wilcoxon signed rank test, z = -2.20, P = .03). CONCLUSIONS: This preliminary study of ESS in adult CF patients indicates significant reduction in the number of IHDs in the postoperative period. However, there is no evidence that ESS improved lung function or the need for IV antibiotics.

Slow-release nanoparticle-encapsulated delivery system for laryngeal injection.

OBJECTIVES/HYPOTHESIS: There is a need for a slow-release system for local delivery of therapeutics to the larynx. Most therapeutic substances, such as steroids or chemotherapeutic agents that are injected into the larynx are cleared rapidly. Repeated laryngeal injection of these substances at short intervals is impractical. Injectable encapsulated poly(lactide-co-glycolide) (PLGA) nanoparticles offer a potential slow-release delivery system for biologically active substances in the larynx. STUDY DESIGN: Controlled animal study. METHODS: PLGA nanoparticles were fabricated using a double emulsion method and were loaded with Texas Red-dextran (NPTR), hepatocyte growth factor (NPHGF), and bovine serum albumin (NPBSA). In vitro release of NPTR, NPBSA, and NPHGF was determined over approximately 2 weeks to assess potential duration of PLGA nanoparticle delivery. In vivo release of NPTR was assessed in a murine vocal fold injection model. The transcriptional effect of NPHGF on procollagen was measured in vitro to assess whether released growth factor retained functionality. RESULTS: In vitro release kinetics demonstrated slow release of NPTR, NPBSA, and NPHGF over 12 to 14 days. In vitro NPTR release correlated with in vivo results. In vivo presence of NPTR occurred up to 7 days compared to 1 day for Texas Red control. In addition, NPHGF ameliorated transforming growth factor-beta induced procollagen in vitro in 3T3 fibroblast cells. CONCLUSIONS: The results demonstrate the potential utility of nanoparticle encapsulation as an effective method for long-term delivery of specific drugs and biologically active substances to the larynx.

Age-related changes in the murine larynx: initial validation of a mouse model.

OBJECTIVES: Changes in voice are commonly associated with aging (presbyphonia). Age-related voice change significantly impairs elderly individuals' ability to communicate meaningfully with others and affects their quality of life. With changing age demographics in our society and increasing emphasis on quality of life, treatment of presbylaryngis is becoming more paramount. METHODS: We used 9 aged and 9 young mice to validate a mouse model for the aging larynx. We stained the larynges with Alcian blue to determine the hyaluronic acid content, trichrome stain to determine the collagen content, and immunohistochemical stain for alpha smooth muscle actin to determine the myofibroblast content. Morphometric measurements were performed for muscle area, muscle thickness, and muscle fiber diameter. RESULTS: Statistically significant differences in the density measurements of hyaluronic acid and collagen reflected decreased hyaluronic acid and increased collagen content in the aging larynx. We found alpha smooth muscle actin-labeled myofibroblasts only in the aged larynges. No statistically significant differences were found in the morphometric measurements. CONCLUSIONS: Aged mice may make a practical model for the age-related changes in the vocal folds that can be used further in studies aiming to correct these changes.