Congenital cytomegalovirus (CMV) for the pediatric otolaryngologist.

Cytomegalovirus (CMV) is a double-stranded DNA virus and a member of the herpesvirus family. It is the most common congenital viral infection. For symptomatic infections, symptoms can vary widely but tends to have a predilection for the central nervous system and for the reticuloendothelial system. Sensorineural hearing loss (SNHL) is by far the most common sequelae of congenital CMV infection. For this reason, it is imperative to understand the screening, diagnosis, and possible treatment options for congenital CMV induced SNHL. This literature review explores the association of CMV with hearing loss, screening for congenital CMV infections, possible treatments options, and the development of a possible vaccine.

Experimental testing of hypotheses for temperature- and pH-based niche specialization of ammonia oxidizing archaea and bacteria.

Investigation of niche specialization in microbial communities is important in assessing consequences of environmental change for ecosystem processes. Ammonia oxidizing bacteria (AOB) and archaea (AOA) present a convenient model for studying niche specialization. They coexist in most soils and effects of soil characteristics on their relative abundances have been studied extensively. This study integrated published information on the influence of temperature and pH on AOB and AOA into several hypotheses, generating predictions that were tested in soil microcosms. The influence of perturbations in temperature was determined in pH 4.5, 6 and 7.5 soils and perturbations in pH were investigated at 15°C, 25°C and 35°C. AO activities were determined by analysing changes in amoA gene and transcript abundances, stable isotope probing and nitrate production. Experimental data supported major predictions of the effects of temperature and pH, but with several significant discrepancies, some of which may have resulted from experimental limitations. The study also provided evidence for unpredicted activity of AOB in pH 4.5 soil. Other discrepancies highlighted important deficiencies in current knowledge, particularly lack of consideration of niche overlap and the need to consider combinations of factors when assessing the influence of environmental change on microbial communities and their activities.

Polysomnographic outcomes following lingual tonsillectomy for persistent obstructive sleep apnea in down syndrome.

OBJECTIVES/HYPOTHESIS: Lingual tonsil hypertrophy is a common cause of persistent airway obstruction in patients with Down syndrome (DS) following adenotonsillectomy (T&A); however, little is known about the effect of lingual tonsillectomy (LT) on polysomnographic outcomes in these patients. Our objective was to describe changes in sleep-related respiratory outcomes following LT in children with DS and persistent obstructive sleep apnea (OSA) following T&A. STUDY DESIGN: Retrospective case series. METHODS: We included all children with DS who underwent polysomnography before and after LT at a tertiary care center from 2003 to 2013. Nonparametric analysis of variables was performed. RESULTS: Forty patients with DS underwent LT; 21 met inclusion criteria. The mean age at surgery was 9.3 ± 4.3 years and 47.6% were female. The median apnea-hypopnea index (AHI) was 9.1 events/hour (range, 3.8 to 43.8 events/hour) before surgery and 3.7 events/hour (range, 0.5 to 24.4 events/hour) after surgery. The median improvement in overall AHI and the obstructive AHI (oAHI) were 5.1 events/hour (range, -2.9 to 41) and 5.3 events/hour (range, -2.9 to 41), respectively (P <.0001). The mean oxygen saturation nadir improved from 84% to 89% (P =.004). The mean time with CO2 > 50 mm Hg, central index, and percentage of rapid eye movement sleep were not significantly different. After surgery, the oAHI was <5 events/hour in 61.9% and ≤1 in 19% of patients. CONCLUSIONS: In children with DS, persistent OSA after T&A and lingual tonsil hypertrophy, LT significantly improved AHI, oAHI, and O2 saturation nadir. We recommend that children with DS should be evaluated for lingual tonsil hypertrophy if found to have persistent OSA following T&A. LEVEL OF EVIDENCE: 4 Laryngoscope, 2016 127:520-524, 2017.

Branchial cleft anomalies and thymic cysts.

Branchial cleft anomalies are a common cause of congenital neck masses and can present as a cyst, sinus, or fistula. A comprehensive understanding of the embryologic basis of these anomalies aids in diagnosis and surgical excision. Fistulas tend to present at an earlier age than sinuses or cysts, with most lesions presenting as either a neck mass, draining sinus, or recurrent infections. The eventual management of each is complete surgical excision, which is curative. A history of recurrent preoperative infections leads to a higher rate of recurrence.

Infant botulism due to C. butyricum type E toxin: a novel environmental association with pet terrapins.

We describe two cases of infant botulism due to Clostridium butyricum producing botulinum type E neurotoxin (BoNT/E) and a previously unreported environmental source. The infants presented at age 11 days with poor feeding and lethargy, hypotonia, dilated pupils and absent reflexes. Faecal samples were positive for C. butyricum BoNT/E. The infants recovered after treatment including botulism immune globulin intravenous (BIG-IV). C. butyricum BoNT/E was isolated from water from tanks housing pet 'yellow-bellied' terrapins (Trachemys scripta scripta): in case A the terrapins were in the infant's home; in case B a relative fed the terrapin prior to holding and feeding the infant when both visited another relative. C. butyricum isolates from the infants and the respective terrapin tank waters were indistinguishable by molecular typing. Review of a case of C. butyricum BoNT/E botulism in the UK found that there was a pet terrapin where the infant was living. It is concluded that the C. butyricum-producing BoNT type E in these cases of infant botulism most likely originated from pet terrapins. These findings reinforce public health advice that reptiles, including terrapins, are not suitable pets for children aged <5 years, and highlight the importance of hand washing after handling these pets.

Thyroid ala perichondrial flaps for subglottic reconstruction.

OBJECTIVES/HYPOTHESIS: Techniques available for reconstruction of the cricotracheal region in adults are currently suboptimal. We sought to 1) understand the anatomic basis for the thyroid ala perichondrial flap, 2) describe the technique of harvesting and intraluminal placement, and 3) learn the limitations of defects for which it can be used. STUDY DESIGN: Cadaveric anatomical study. METHODS: In fresh cadaveric specimens, the perichondrium of the outer layer of the thyroid cartilage was elevated by tracing the superior, medial, and lateral borders of each thyroid cartilage ala. The inferiorly based flap was then placed into the airway through the cricothyroid membrane. The extent of coverage was measured. RESULTS: A total of 10 flaps were performed (6 male and 4 female). The average length of thyroid perichondrial flaps obtained was 1.67 cm. All flaps were able to completely cover the cricoid cartilage and extended to but did not cover the first tracheal ring. Once placed intraluminally, the flaps extended 2.4 cm below the vocal cords. Using both flaps enabled coverage of the entire anterior 180 degrees of the airway lumen in all specimens. There were no significant differences in male/female or right-sided/left-sided flaps. CONCLUSIONS: The thyroid ala perichondrial flap is technically feasible and can provide coverage of anterior airway defects up to approximately 2.4 cm below the true vocal cords. This flap could enable transfer of vascularized tissue to aid in cricotracheal reconstruction.

Endoscopic endonasal transpterygoid approaches: anatomical landmarks for planning the surgical corridor.

OBJECTIVES/HYPOTHESIS: Endoscopic endonasal transpterygoid approaches (EETA) use the pneumatization of the sinonasal corridor to control lesions of the middle and posterior skull base. These surgical areas are complex and the required surgical corridors are difficult to predict. AIM: Define anatomical landmarks for the preoperative planning of EETAs. STUDY DESIGN: Anatomical study. METHODS: We reviewed images from high-resolution maxillofacial CT scans with (0.6-mm axial slice acquisition). Cephalometric measurements were obtained using Kodak Carestream Image Software (Rochester, NY). RESULTS: Average distance from midline to the vidian canal was 12.78 mm (range 9.4-15.8 mm). Average horizontal distance from the vidian canal to the foramen rotundum was 5.6 mm (range 2.8-11.5 mm). Average vertical distance from the vidian canal to the foramen rotundum was 6.22 mm (range 4.3-9.3 mm). These landmarks are consequential during the preoperative planning of the surgical corridor. To facilitate communication, we classified EETAs as: A) Partial removal of the pterygoid plates (transposition of temporo-parietal fascia); B) removal of anteromedial aspect of the pterygoid process (lesions involving the lateral recess of the sphenoid sinus); C) involves dissecting the vidian nerve to control the petrous ICA and removing the pterygoid plates base to reach the petrous apex, Meckel's cave, or cavernous sinus; D) variable removal of the pterygoid plates to access the infratemporal fossa; and E) removal of pterygoid process and medial third of the Eustachian tube to expose the nasopharynx. CONCLUSIONS: Our novel classification and landmarks system helps to understand the anatomy of this complex area and to accurately plan the EETA.

The body as a living bioreactor: a feasibility study of pedicle flaps for tracheal transplantation.

Reconstruction of long-segment tracheal stenosis remains problematic. Ex vivo transplantation of stem cell-derived tracheas has been established in humans using external tissue bioreactors. These bioreactors, however, are not widely accessible. Thus, we are developing a rotational flap-based "internal bioreactor" to allow in vivo stem cell engraftment in a pre-vascularized recipient bed. This muscle will also then serve as a carrier for the transplanted trachea during rotation into position for airway reconstruction. Herein, we present a study investigating the feasibility of two pedicle muscle flaps for implantation and subsequent tracheal transplantation. Trapezius and latissimus flaps were raised using established surgical techniques. The length and width of each flap, along with the distance from the pedicle takeoff to the trachea, were measured. The overall ability of the flaps to reach the trachea was assessed. Twelve flaps were raised in 5 fresh adult human cadavers. For the trapezius flap, averages were: flap length of 16.4 cm, flap width of 5.95 cm at the tip, and distance from the pedicle takeoff to the trachea of 11.1 cm. For the latissimus dorsi flap, averages were: flap length of 35.4 cm, flap width of 7.25 cm at the tip, and distance from the pedicle takeoff to the trachea of 27.3 cm. All flaps showed sufficient durability and rotational ability. Our results show that both trapezius and latissimus dorsi flaps can be transposed into the neck to allow tension-free closure of tracheal defects. For cervical tracheal transplantation, both flaps are equally adequate. We believe that trapezius and latissimus dorsi muscle flaps are potential tracheal implantation beds in terms of vascular supply, durability, and rotational ability.

Trans-oral robotic submandibular gland removal.

Submandibular gland excision is traditionally performed via a trans-cervical approach. While generally regarded as a relatively simple surgical procedure, several complications are possible, including injury to the marginal mandibular branch of the facial nerve, lingual nerve, hypoglossal nerve, facial artery and a visible unsightly neck scar or keloid. The trans-oral route has the ability to eliminate a cervical scar and decrease risk of injury to several structures. Coincident with the development of the trans-oral approach, robotic surgery has been gaining popularity in the operative management of early oral cavity, tonsil, and tongue base malignancies. A 51-year-old female presented to our institution with a 15-year history of recurrent left submandibular gland sialoadenitis. She previously underwent a rhytidectomy with cervicoplasty and was interested in a trans-oral approach to avoid a neck incision. Here we present a novel application of the da Vinci Surgical Robot for trans-oral removal of the submandibular gland.

Expanded endoscopic endonasal approaches to skull base meningiomas.

Anterior cranial base meningiomas have traditionally been addressed via frontal or frontolateral approaches. However, with the advances in endoscopic endonasal treatment of pituitary lesions, the transphenoidal approach is being expanded to address lesions of the petrous ridge, anterior clinoid, clivus, sella, parasellar region, tuberculum, planum, olfactory groove, and crista galli regions. The expanded endoscopic endonasal approach (EEEA) has the advantage of limiting brain retraction and resultant brain edema, as well as minimizing manipulation of neural structures. Herein, we describe the techniques of transclival, transphenoidal, transplanum, and transcribiform resections of anterior skull base meningiomas. Selected cases are presented.

Traumatic cerebrospinal fluid leaks.

This article discusses the epidemiology, diagnosis, and management of traumatic cerebrospinal fluid (CSF) leaks. An overview of traumatic CSF leaks is presented, and both conservative and operative therapies are reviewed. Management decisions are discussed based on the current literature. Controversial clinical topics are addressed, including the use of prophylactic antibiotics and the timing of surgical repair.

Quantitative analysis of endoscopic endonasal approaches to the infratemporal fossa.

OBJECTIVES/HYPOTHESIS: The operative management of infratemporal skull base lesions is challenging. Expanded endonasal approaches to this area can decrease surgical morbidity. Access lateral to the natural nasal corridor can be achieved via a middle meatal antrostomy, medial maxillectomy complemented by a septotomy, or anteromedial maxillotomy (i.e., Denker's approach). We sought to compare the access to the infratemporal fossa offered by these endoscopic endonasal approaches. STUDY DESIGN: Software-enabled CT scan measurements. METHODS: Axial CT scans obtained with submillimeter cuts through the skull base were examined. All calculations were performed on axial images obtained at the level of the sphenoid floor using Kodak Carestream Image Software (Rochester, NY) measuring tools. RESULTS: Fifty sides were examined. A medial maxillectomy increased the exposure on average by 18.5 degrees (SD = 4.28), when compared to maxillary antrostomy. When we augmented the access with an ipsilateral Denker's approach, an additional 33.5 degrees (SD = 4.81) of exposure were obtained (P < .0001). The addition of a 1-cm anteromedial maxillotomy accessed the entire posterior maxillary wall in 54% of cases. Equivalent access was obtained via a contralateral approach with a septotomy at 1.56 cm from the columella. To access the entire posterior maxillary wall the average anterior maxillotomy should be 1.1 cm (SD = 0.42). In contrast, to access the entire posterior maxillary wall using a contralateral approach the average septotomy position should be 1.52 cm (SD = 0.39) from the columella. CONCLUSIONS: This radioanatomic study provides objective support for the use of an ipsilateral Denker's approach to augment an endoscopic endonasal approach to the infratemporal fossa.

Stretching to prevent musculoskeletal injuries. An approach to workplace wellness.

A pre-shift stretching protocol to reduce employee injuries was initiated at a beverage company and a tin mill in the northeastern United States. The primary goal of this study was to determine the effects of a pre-shift stretching program on work-related musculoskeletal injuries. A secondary goal was to evaluate daily participation compliance during the 90-day program. Data on employee injuries during the stretching program were collected and compared to injury events during the same time period 1 year earlier. Comparison to injury events of the total eligible population during the study time frame was also included. Results of this pilot program in terms of injury rate reduction and participant compliance are promising. Study results may be useful for employers considering implementing similar programs and also suggest the need for further study in this area.

Mobility and survival of Salmonella Typhimurium and human adenovirus from spiked sewage sludge applied to soil columns.

AIMS: This study investigated the survival and transport of sewage sludge-borne pathogenic organisms in soils. METHODS AND RESULTS: Undisturbed soil cores were treated with Salmonella enterica ssp. enterica serovar Typhimurium-lux (STM-lux) and human adenovirus (HAdV)-spiked sewage sludge. Following an artificial rainfall event, these pathogens were analysed in the leachate and soil sampled from different depths (0-5 cm, 5-10 cm and 10-20 cm) after 24 h, 1 and 2 months. Significantly more STM-lux and HAdV leached through the soil cores when sewage sludge was present. Significantly more STM-lux were found at all soil depths, at all time periods in the sewage sludge treatments, compared to the controls. The rate of decline of STM-lux in the controls was more rapid than in the sewage sludge treatments. Survival and transport of HAdV were minimal. CONCLUSIONS: The presence of sewage sludge can significantly influence the transport and survival of bacterial pathogens in soils, probably because of the presence of organic matter. Environmental contamination by virus is unlikely because of strong soil adsorption. SIGNIFICANCE AND IMPACT OF THE STUDY: This study suggests that groundwater contamination from vertical movement of pathogens is a potential risk and that it highlights the importance of the treatment requirements for biosolids prior to their application to land.

Adverse effects associated with arginine alpha-ketoglutarate containing supplements.

The athletic performance supplement industry is a multibillion-dollar business and one popular category claims to increase nitric oxide (NO) production. We report three patients presenting to the emergency department with adverse effects. A 33-year-old man presented with palpitations, dizziness, vomiting, and syncope, after the use of NO(2) platinum. His examination and electrocardiogram (ECG) were normal. The dizziness persisted, requiring admission overnight. A 21-year-old man with palpitations and near syncope had used a "nitric oxide" supplement. He was tachycardic to 115 bpm with otherwise normal examination. Laboratory values including methemoglobin, and ECG were unremarkable. He was treated with 1 L of saline with no change in heart rate. He was admitted for observation. A 24-year-old man presented after taking NO-Xplode with palpitations and a headache. His examination, laboratory values, and ECG were normal. He was discharged. The purported active ingredient in these products is arginine alpha-ketoglutarate (AAKG), which is claimed to increase NO production by supplying the precursor L-arginine. The symptoms could be due to vasodilation from increased levels of NO, though other etiologies cannot be excluded. AAKG containing supplements may be associated with adverse effects requiring hospital admission.

The effects of smoking on short-term quality of life outcomes in sinus surgery.

OBJECTIVE: The purpose of this study was to prospectively compare the short-term benefit of endoscopic sinus surgery for smokers and nonsmokers using a disease specific, clinically validated, quality of life outcomes measure, the Sinonasal Outcomes Test-20 (SNOT-20). STUDY DESIGN: Prospective clinical trial. METHODS: A total of 235 patients were prospectively enrolled at a single tertiary academic center. Preoperative SNOT-20 scores and comprehensive demographic data were obtained. All patients underwent endoscopic sinus surgery under the supervision of the senior author. Preoperative SNOT-20 scores were compared to short-term postoperative SNOT-20 scores. RESULTS: Short-term postoperative results were available for 221 patients for comparison. Preoperative SNOT-20 scores in 49 smokers (mean: 27.8) and 172 nonsmokers (mean: 26.2) were statistically similar. Both smokers and nonsmokers achieved a highly significant reduction in SNOT-20 scores at short-term follow-up evaluations. (P < .0005) Smokers achieved a greater reduction in SNOT-20 scores (mean difference: 22.1) at short-term follow-up compared to nonsmokers (mean difference: 16.1). This result was statistically significant (P < .044). CONCLUSIONS: This study confirms that smokers and nonsmokers achieve a highly significant short-term benefit from endoscopic sinus surgery using a clinically-validated symptom severity scale in a prospective study. Interestingly, smokers achieved a greater short-term benefit than nonsmokers did. This study calls into question the notion that current smokers are poorer candidates for endoscopic sinus surgery. Further prospective studies to confirm these results and provide long-term analysis should be performed.

Genetic and metabolic predictors of chemosensitivity in oligodendroglial neoplasms.

The -1p/-19q genotype predicts chemosensitivity in oligodendroglial neoplasms, but some with intact 1p/19q also respond and not all with 1p/19q loss derive durable benefit from chemotherapy. We have evaluated the predictive and prognostic significance of pretherapy (201)Tl and (18)F-FDG SPECT and genotype in 38 primary and 10 recurrent oligodendroglial neoplasms following PCV chemotherapy. 1p/19q loss was seen in 8/15 OII, 6/15 OAII, 7/7 OIII, 3/11 OAIII and was associated with response (Fisher-Exact: P=0.000) and prolonged progression-free (log-rank: P=0.002) and overall survival (OS) (log-rank: P=0.0048). Response was unrelated to metabolism, with tumours with high or low metabolism showing response. Increased (18)F-FDG or (201)Tl uptake predicted shorter progression-free survival (PFS) in the series (log-rank: (201)Tl P=0.0097, (18)F-FDG P=0.0170) and in cases with or without the -1p/-19q genotype. Elevated metabolism was associated with shorter OS in cases with intact 1p/19q (log-rank: (18)F-FDG P=0.0077; (201)Tl P=0.0004) and shorter PFS in responders (log-rank: (18)F-FDG P=0.005; (201)Tl P=0.0132). (201)Tl uptake and 1p/19q loss were independent predictors of survival in multivariate analysis. In this initial study, (201)Tl and (18)F-FDG uptake did not predict response to PCV, but may be associated with poor survival following therapy irrespective of genotype. This may be clinically useful warranting further study.

Archaea predominate among ammonia-oxidizing prokaryotes in soils.

Ammonia oxidation is the first step in nitrification, a key process in the global nitrogen cycle that results in the formation of nitrate through microbial activity. The increase in nitrate availability in soils is important for plant nutrition, but it also has considerable impact on groundwater pollution owing to leaching. Here we show that archaeal ammonia oxidizers are more abundant in soils than their well-known bacterial counterparts. We investigated the abundance of the gene encoding a subunit of the key enzyme ammonia monooxygenase (amoA) in 12 pristine and agricultural soils of three climatic zones. amoA gene copies of Crenarchaeota (Archaea) were up to 3,000-fold more abundant than bacterial amoA genes. High amounts of crenarchaeota-specific lipids, including crenarchaeol, correlated with the abundance of archaeal amoA gene copies. Furthermore, reverse transcription quantitative PCR studies and complementary DNA analysis using novel cloning-independent pyrosequencing technology demonstrated the activity of the archaea in situ and supported the numerical dominance of archaeal over bacterial ammonia oxidizers. Our results indicate that crenarchaeota may be the most abundant ammonia-oxidizing organisms in soil ecosystems on Earth.