Tracheostomy Incidence and Complications: A National Database Analysis.

OBJECTIVE: To describe the incidence of tracheostomy-related complications and identify prognostic risk factors. STUDY DESIGN: Administrative database analysis. SETTING: Outpatient and inpatient insurance claims records obtained from a national database. METHODS: PearlDiver, a private analytics database of insurance claims from Medicare, Medicaid, and commercial insurance companies, was used to identify patients who underwent tracheostomies and associated complications between January 2010 and October 2021 by CPT and ICD-9/ICD-10 codes. RESULTS: A total of 198,143 tracheostomies were identified from PearlDiver, and at least 1 tracheostomy-related complication occurred within 90 days of the procedure in 22,802 (10.3%) of these cases. The proportion of tracheostomy-related complications was 2.3 times higher in 2019 compared to 2010 (95% confidence interval [CI]: 2.18-2.52). The risk of developing tracheostomy-complications was associated with the hospital region (highest in the Midwest as compared to the West [odds ratio [OR] = 1.32; 95% CI: 1.25-1.39]), provider specialty (highest for otolaryngologists as compared to nonsurgical physicians [OR = 2.22; 95% CI: 2.10-2.34]), insurance plan type (lowest for cash payment compared to Medicaid [OR = 0.70, 95% CI: 0.50-0.94]), and Elixhauser Comorbidity Index (ECI) (highest in patients with ECI of 7+ compared to 0-1 [OR = 2.96; 95% CI: 2.17-3.24]), but was not significantly associated with patient age (OR = 0.99; 95% CI: 0.99-0.99), or gender (OR = 1.04; 95% CI: 1.01-1.07). CONCLUSIONS: Complications after tracheostomy are common and sicker patients are at higher risk for complications. Identifying factors associated with increased risk for complications could help to improve patient and family counseling, guide quality improvement initiatives, and inform future studies on tracheostomy outcomes.

Human Leukocyte Antigen Genotyping of Idiopathic Subglottic Stenosis.

OBJECTIVE: Despite recent scientific inquiry, idiopathic subglottic stenosis (iSGS) remains an enigmatic disease. The consistent demographics of the affected population suggest genetic factors may contribute to disease susceptibility. Given the inflammation observed in the affected proximal airway mucosa, we interrogated disease association with human leukocyte antigen (HLA) polymorphisms. Polymorphisms in the HLA locus have previously been shown to influence individuals' susceptibility to distinct inflammatory diseases. METHODS: High-resolution HLA typing of 37 iSGS patients was compared with 1,242,890 healthy Caucasian controls of European ancestry from the USA National Marrow Donor Program and 281 patients with granulomatosis with polyangiitis (GPA). RESULTS: Complete HLA genotyping of an iSGS population showed no significant associations when compared to a North American Caucasian control population. Unlike GPA patients, iSGS was not associated with allele DPB1*04:01 nor did allele homozygosity correlate with disease severity. CONCLUSIONS: There was not a detectable HLA association observed in iSGS. These results support the concept that iSGS possesses a distinct genetic architecture from GPA. If genetic susceptibility exists in iSGS, it likely lies outside the HLA locus. LEVEL OF EVIDENCE: NA, basic science Laryngoscope, 133:2533-2539, 2023.

Historical Review and Modern Case of Spontaneous Laryngeal Abscess.

OBJECTIVE: Laryngeal abscesses are rare in the modern antibiotic era. Historically, they were associated with systemic infections including typhoid fever, measles, gonorrhea, syphilis, and tuberculosis. More recent authors have described cases resulting from iatrogenic injury and immunosuppression. This report presents a novel case of laryngeal abscess in the setting of uncontrolled diabetes and a detailed review of modern, reported cases of spontaneous laryngeal abscess. METHODS: Report of a single case. Also, PubMed was queried for cases of laryngeal abscess since 1985. CASE REPORT: A 58-year-old male with poorly controlled diabetes presented with odynophagia, dysphagia, and dyspnea. He had biphasic stridor, and flexible laryngoscopy showed reduced mobility of bilateral vocal folds and narrowed glottic airway. He was taken urgently for awake tracheostomy and microdirect laryngoscopy. Laryngoscopy demonstrated fullness and fluctuance of the right hemilarynx. The abscess cavity was entered endoscopically via paraglottic incision extending into the subglottis. The patient was treated with an 8-week course of ampicillin-sulbactam with resolution of infection. RESULTS: Seven additional cases of spontaneous laryngeal abscesses published after 1985 were identified. In total, 6 of 8 had some form of immunodeficiency (75%). The most common presenting symptoms were dysphonia (8/8, 100%), odynophagia (5/8, 62.5%), and dyspnea/stridor (4/8, 50%). All cases were treated with surgical incision and drainage. CONCLUSIONS: Laryngeal abscesses are rare in the era of modern antibiotics. This review confirms that the majority of recent episodes occurred in the setting of immunodeficiency and are caused by non-tubercular bacteria. These infections are commonly associated with impaired vocal fold mobility which may contribute to dyspnea, stridor, and airway compromise. Surgical intervention is necessary for treatment and culture-directed antimicrobial therapy. Poorly controlled diabetes is a newly described context for development of spontaneous laryngeal abscess.

Interpreter Use and Patient Satisfaction in the Otolaryngology Outpatient Clinic.

Background Communication between providers and patients is essential to patient care and to the patient-physician relationship. It plays a significant role in both measurable and perceived quality of care. This study explores the satisfaction of English-speaking and limited English proficiency (LEP) patients with English-speaking providers, focusing on the correlation between patients' primary language and the use of interpreter services on patients' visit satisfaction. Methodology This study was designed to have a sample size sufficient to detect a 10% difference in the primary outcome, overall visit satisfaction, between language-concordant patients and LEP patients in the interpreter and no interpreter groups, assuming a two-tailed alpha of 0.05 and power of 80%. All collected data were analyzed using the Statistical Package for the Social Sciences software, version 25 (IBM Corp, Armonk, NY, USA), and significance was determined if p <0.05. Results Of the total 209 patients, 65 utilized professional interpreter services, nine used an ad-hoc interpreter, and 135 did not require an interpreter. Patients who used an interpreter demonstrated lower visit satisfaction compared with patients who did not (p < 0.001). Patients expressed significantly greater preference for in-person interpreter (mean = 9.73) or a family member (mean = 9.44) compared to telephone services (mean = 8.50) (p = 0.002). The overall satisfaction scores did not significantly differ between different interpreter types (p = 0.157). Conclusions LEP patients experienced lower visit satisfaction compared to language-concordant patients. The data suggest that perceived quality of communication was a factor in these lower satisfaction reports. While LEP patients did prefer in-person interpreters, there was no significant difference in overall visit satisfaction between different types of interpreters.

Delayed onset of tooth decay in a routine pediatric adenotonsillectomy.

Adenotonsillectomy is a common pediatric surgical procedure with a well-defined safety profile. Major complications from this procedure include bleeding/hemorrhage, infection, pain leading to dehydration, and airway obstruction or edema. Though rare, oral endotracheal intubation and oral retractor placement may result in injuries to the teeth and the surrounding soft tissue. We describe a rare case of delayed tooth decay in a 3-year-old female following an otherwise routine adenotonsillectomy.

Online Reputations: Comparing Hospital- and Patient-Generated Ratings in Academic Otolaryngology.

OBJECTIVES: This study compares hospital-generated online ratings to patient-generated online ratings in academic otolaryngology and evaluates physician factors influencing these results. METHODS: Websites of academic otolaryngologists were assessed for inclusion of hospital-generated Press Ganey surveys. Corresponding scores on Healthgrades and Vitals.com were identified via internet search. Hospital ratings were compared with patient-generated ratings, including score, demographics, and number of ratings. All data was collected between July 15th 2019 and August 22nd 2019. RESULTS: 742 academic otolaryngologists with hospital-generated ratings were identified. Mean hospital-generated rating was significantly higher ((4.70, 95% CI 4.69-4.72) than patient-generated rating (Vitals:4.26, 95% CI 4.18-4.34, and Healthgrades:4.02, 95% CI 3.87-4.18; P < .001). In patient-generated rating, an increased number of rating scores (>20) was associated with male gender, professor ranking, and >30 years in practice (P < .005). Physician demographics did not impact number of ratings in hospital-generated setting. With patient-generated, lower aggregate score was associated with professor ranking (P = .001). In hospital-generated, lower score was associated with >30+ years in practice (P = .023). Across all platforms, comprehensive otolaryngologists and neurotologists/otologists were rated lower in comparison to other specialties (PGS:P < .001,Vitals:P = .027,Healthgrades:P = .016). CONCLUSION: Hospital-generated ratings yield higher mean scores than patient-generated platforms. Between sources, Healthgrades.com scores were lower than those of Vitals.com. Professors with >30 years of practice generated more reviews in patient-generated ratings, and these physicians were generally rated lower. Access to patient-generated ratings is universal and physicians should be aware of variability between online rating platforms as scores may affect referrals and practice patterns.

Magnetic Laryngeal Reanimation as a Novel Treatment of Vocal Fold Immobility.

OBJECTIVE: Vocal fold paralysis may result from surgical complications, trauma, tumor, or unknown causes. When both cords are affected, paramedian fixation can lead to life-threatening obstruction. Current treatments, including tracheostomy, cordotomy, and arytenoidectomy, compromise speech and swallow function to maintain a safe airway. To preserve all three critical laryngeal functions, Otolaryngologists need a solution for bilateral vocal fold paralysis that restores motion. This study uses implantable electromagnet technology to create dynamic vocal fold movement in a proof-of-concept, preliminary model. METHODS: A prototype was constructed from a neodymium disk magnet and cylindrical solenoid electromagnet coupled to a battery and 3-way switch. The disk magnet was implanted in an ex vivo porcine larynx model lateral to the arytenoid, affixed with suture. The electromagnet was seated in a window cut in the thyroid cartilage. RESULTS: By driving current in two directions through the electromagnet, the vocal fold was successfully moved towards and away from the electromagnet. The neutral vocal fold opening was 5.8 mm, and the maximal opening was 7.7 mm, representing a 31.4% increase in the cross-sectional area of the glottis. CONCLUSION: This model demonstrated proof of concept of a magnetic laryngeal reanimation device. The full device will include a respiratory effort sensor and implantable processor to time the action of the magnets with respirations. There is currently no effective treatment to re-establish vocal fold motion in patients with vocal fold paralysis. This system has the potential to give patients with bilateral vocal fold paralysis a surgical option to restore vocal fold motion.

Hey Siri: How Effective are Common Voice Recognition Systems at Recognizing Dysphonic Voices?

OBJECTIVES/HYPOTHESIS: Interaction with voice recognition systems, such as Siri™ and Alexa™, is an increasingly important part of everyday life. Patients with voice disorders may have difficulty with this technology, leading to frustration and reduction in quality of life. This study evaluates the ability of common voice recognition systems to transcribe dysphonic voices. STUDY DESIGN: Retrospective evaluation of "Rainbow Passage" voice samples from patients with and without voice disorders. METHODS: Participants with (n = 30) and without (n = 23) voice disorders were recorded reading the "Rainbow Passage". Recordings were played at standardized intensity and distance-to-dictation programs on Apple iPhone 6S™, Apple iPhone 11 Pro™, and Google Voice™. Word recognition scores were calculated as the proportion of correctly transcribed words. Word recognition scores were compared to auditory-perceptual and acoustic measures. RESULTS: Mean word recognition scores for participants with and without voice disorders were, respectively, 68.6% and 91.9% for Apple iPhone 6S™ (P < .001), 71.2% and 93.7% for Apple iPhone 11 Pro™ (P < .001), and 68.7% and 93.8% for Google Voice™ (P < .001). There were strong, approximately linear associations between CAPE-V ratings of overall severity of dysphonia and word recognition score, with correlation coefficients (R2 ) of 0.609 (iPhone 6S™), 0.670 (iPhone 11 Pro™), and 0.619 (Google Voice™). These relationships persisted when controlling for diagnosis, age, gender, fundamental frequency, and speech rate (P < .001 for all systems). CONCLUSION: Common voice recognition systems function well with nondysphonic voices but are poor at accurately transcribing dysphonic voices. There was a strong negative correlation with word recognition scores and perceptual voice evaluation. As our society increasingly interfaces with automated voice recognition technology, the needs of patients with voice disorders should be considered. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1599-1607, 2021.

Prevalence and natural history of obstructive sleep apnea in pediatric patients with laryngomalacia.

OBJECTIVE: Laryngomalacia is the most common cause of infant stridor, and obstructive sleep apnea (OSA) is sometimes found concurrently in patients with laryngomalacia. OSA has been shown to improve after surgical treatment of laryngomalacia, but the majority of laryngomalacia patients have spontaneous resolution of symptoms. It is unknown whether their comorbid OSA also resolves. This study seeks to define the incidence of OSA in laryngomalacia and assess for resolution of OSA with polysomnography data. METHODS: Retrospective cohort study at a tertiary care academic medical center. All pediatric patients with diagnoses of laryngomalacia or stridor were reviewed, and patients with laryngomalacia confirmed by Otolaryngologist exam were included. All patients with laryngomalacia were recommended to undergo polysomnography. RESULTS: A total of 108 patients had laryngomalacia confirmed by an Otolaryngologist. Of those patients, 56 completed a polysomnogram, and 44 (79%) were diagnosed with OSA. Among the OSA patients, 34 had no surgery, 5 underwent supraglottoplasty, and 5 underwent adenoidectomy or adenotonsillectomy. Follow-up polysomnograms were performed for 9 non-surgical patients, 4 supraglottoplasty patients, and 4 adenoidectomy or adenotonsillectomy patients. Mean change in AHI was -2.81 without surgery, -8.18 after supraglottoplasty, and -2.94 after adenoidectomy or adenotonsillectomy. CONCLUSION: OSA is often present in patients who have laryngomalacia, and the proportion in this population was higher than previous reports. The only significant predictor for obstructive sleep apnea was race, specifically Black/African American. Among patients with follow-up polysomnograms, the largest OSA improvement was in supraglottoplasty patients, but all patients improved.

An ex vivo porcine model of the anterior glottoplasty for voice feminization surgery.

OBJECTIVE: Perceived gender identity is correctly assigned when a combination of physical and vocal attributes become congruent. Several voice feminization procedures have gained popularity, but current evidence of their impact on vocal feminization is limited to case series. This study establishes an ex vivo porcine phonatory model to evaluate the ideal extent of anterior glottic web formation in relation to frequency elevation and airway patency. METHODS: Six fresh porcine larynges were obtained and fitted with arytenoid adduction sutures. Compressed air was passed through the larynges, and the vocal folds were adducted to induce phonation. Vocal fold length, posterior glottic width, fundamental frequency, and sound pressure intensity were measured as the vocal folds were progressively shortened as per the anterior glottic web surgical technique. RESULTS: The average fundamental frequency prior to web formation was 109.7 Hz. The maximum frequency achieved after web formation was 403.7 Hz, and the web proportions varied from 11.8% to 61.0% of the length of the membranous vocal folds. The glottic cross-sectional area showed an expected inverse linear relationship to the length of the glottic web. Creation of an anterior glottic web caused consistent elevation of pitch, but there was a gradual plateau of effect with increased length of the web. CONCLUSION: The ex vivo porcine larynx is demonstrated as an effective, available, and low-cost model for further study of vocal pitch elevation surgical techniques. We demonstrate that in addition to progressively reducing the cross-sectional area of the airway, additional benefit from increased web length is limited. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E206-E212, 2020.

Clinical scribes and their association with patient experience in the otolaryngology clinic.

OBJECTIVES/HYPOTHESIS: Electronic health records have brought many advantages but also placed a documentation burden on the provider during and after the clinic visit. Some otolaryngologists have countered this challenge by employing clinical scribes. This project aimed to better understand the influence of scribes on patient experience in the otolaryngology clinic. STUDY DESIGN: Retrospective cohort survey study. METHODS: Patients presenting to the otolaryngology clinic for new and follow-up appointments were recruited to complete surveys about their experience. RESULTS: A total of 153 patients completed the survey, and 96 of those patients (62.7%) interacted with a scribe. Patient satisfaction was not significantly associated with participation of the scribe (P = .668). Similarly, patient rating of their physician on a scale of 1 to 10 was not associated with scribe involvement (P = .851). The patients who did interact with a scribe responded that the scribe positively impacted the visit 77.1% of the time. Participation of a resident, primary language other than English, and use of interpreter were associated with lower satisfaction (P = .004, P < .001, and P < .001, respectively). CONCLUSIONS: There are no published data on the effect of scribes on patient experience in the otolaryngology clinic. In other specialties, scribes have been demonstrated as having a positive effect on provider satisfaction, clinical productivity, and patient perception. These data demonstrate that patient satisfaction was neither impaired nor improved by the presence of the scribe in this clinic. In light of benefits demonstrated by prior studies, these findings support the conclusion that scribes are a useful adjunct in providing high-level otolaryngology care. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E134-E139, 2020.

Vitamin D deficiency and its relationship to cancer stage in patients who underwent thyroidectomy for papillary thyroid carcinoma.

PURPOSE: As imaging technology improves and more thyroid nodules and malignancies are identified, it is important to recognize factors associated with malignancy and poor prognosis. Vitamin D has proven useful as a prognostic tool for other cancers and may be similarly useful in thyroid cancer. This study explores the relationship of Vitamin D to papillary thyroid carcinoma stage while accounting for socioeconomic covariates. MATERIALS AND METHODS: The medical records of all patients who underwent thyroidectomy at one institution between 2000 and 2015 were reviewed. Subjects with non-papillary thyroid cancer pathology, prior malignancy, and without Vitamin D levels were excluded. The remaining 334 patient records were examined for cancer stage, Vitamin D levels, Vitamin D deficiency listed in history, and demographic and comorbid factors. RESULTS: Vitamin D laboratory values showed no significant relationship to cancer stage (p = 0.871), but patients with Vitamin D deficiency documented in the medical record were more likely to have advanced disease (28.6% versus 14.7%; p = 0.028). The patients with documented Vitamin D deficiency also had lower 25-hydroxyvitamin D nadirs (21.5 ng/mL versus 26.5 ng/mL, p = 0.008) and were more likely to be on Vitamin D supplementation (92.6% versus 41.8%, p < 0.001). CONCLUSIONS: The results suggest that Vitamin D deficiency may have value as a negative prognostic indicator in papillary thyroid cancer and that pre-operative laboratory evaluation may be less useful. This is important because Vitamin D deficiency is modifiable. While different racial subgroups had different rates of Vitamin D deficiency, neither race nor socioeconomic status showed correlation with cancer stage.

Carotid body tumor with hidden internal carotid artery aneurysm.

BACKGROUND: The most common head and neck paraganglioma is the carotid body paraganglioma. Treatment of carotid body tumors is primarily surgical, and uncontrolled growth leads to cranial nerve deficits and more morbid resection. METHODS: A 60-year-old man was referred for evaluation of carotid body tumor, and workup revealed an internal carotid artery (ICA) aneurysm within the known mass. RESULTS: Interventional Radiology performed angiogram and stenting across aneurysm with interval dramatic reduction in size of mass, and surgery was avoided altogether. CONCLUSIONS: Surgical resection is indicated for carotid body paragangliomas when the patient can tolerate the surgery and when the tumor was not very advanced. This patient had a small tumor that initially appeared easily resectable. Failure to detect the ICA aneurysm before resection may have resulted in devastating vascular injury and possible stroke or death. Identification of underlying vascular pathology is essential for safe treatment and should be prioritized, especially considering this case.

Bilateral congenital cholesteatoma: A case report and review of the literature.

OBJECTIVES: Congenital cholesteatoma (CC) occurs less commonly than acquired cholesteatoma (AC), and bilateral CC (BCC) is even more rare with only 38 such cases having been reported in the past 42 years. Because of the rarity of this condition, providers confronted with cases of BCC may find it difficult to treat while balancing complete removal of disease, optimal hearing outcomes, and minimized surgical burden in the pediatric patient. This review alerts physicians that BCC occurs, highlights past presentations and management strategies, describes the considerations in treatment and offers an algorithm helpful in the management of BCC. METHODS: Review of a single case with extensive review of published reports from 1975 to 2017 pertaining to management of BCC. RESULTS: A five-year-old boy presented with bilateral congenital cholesteatoma. Tympanomastoidectomy was performed to remove cholesteatoma in the left ear then in the right ear months later. Ossicular chain reconstruction was deferred in both cases. Second look procedures revealed persistent cholesteatoma in both ears. In the descriptions of the 38 published BCC cases, the extent and location of the CC varied widely as did the approach to management. In the 18 cases that had descriptions of surgical management, four had second look procedures. In the 16 reports that described extent of cholesteatoma, 12 had the first of two or more operations on the ear with more extensive cholesteatoma. CONCLUSIONS: Risks are increased for recidivism/recurrence and hearing impairment in children with BCC compared to children with unilateral CC. We present a novel algorithm for management of BCC that recommends surgery for cholesteatoma removal first in the more severely affected ear and delayed OCR for both ears. Simultaneous surgery may be considered in certain cases.

Insurance status as a predictor of mortality in patients undergoing head and neck cancer surgery.

OBJECTIVE: Explore relationship between insurance status and survival, determine outcomes that vary based on insurance status, and identify potential areas of intervention. STUDY DESIGN: Retrospective cohort analysis of patients who underwent resection of an upper aerodigestive tract malignancy at a single tertiary care hospital during a 5-year period. METHODS: Patients were categorized into four groups by insurance status: Medicaid or uninsured, Medicare and under 65 years of age, Medicare and 65 years or older, and private insurance. Data were collected from the medical record and analyzed with respect to survival and other outcomes. RESULTS: The final cohort consisted of 860 patients. Survival analysis demonstrated a hazard ratio of 2.1 (95% confidence interval [CI], 1.5-3.0) for the Medicaid/uninsured group when compared to the private insurance group. When adjusted for other variables, mortality was still different across insurance groups (P = 0.002). The following also were different across insurance groups: tumor stage (P < 0.001), American Society of Anesthesiologists score (P < 0.001), length of stay (P < 0.001), and complications (P = 0.021). The Medicaid/uninsured group was most likely to have a complication (odds ratio [OR] = 2.10, 95% CI 1.24-3.56, P = 0.006). CONCLUSION: Medicaid/uninsured patients present with more advanced tumors and have poorer survival than privately insured patients. Insurance status is predictive of tumor stage, comorbidity burden, length of stay, and complications. Specifically, the Medicaid/uninsured group had high rates of tobacco use and alcohol abuse, advanced stage tumors, and postoperative complications. Because alcohol abuse and advanced stage also were predictors of poor survival, they may contribute to the survival disparity for socially disadvantaged patients. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2784-2789, 2017.

Investigation of Postoperative Oral Fluid Intake as a Predictor of Postoperative Emergency Department Visits After Pediatric Tonsillectomy.

IMPORTANCE: This study contributes novel data on the association between oral fluid intake before discharge and adverse outcomes following tonsillectomy in pediatric patients. These data contribute to evidence-based, safe, and cost-effective decision making regarding discharge. OBJECTIVE: To determine whether the quantity of oral fluid intake before discharge is associated with adverse outcomes following tonsillectomy in pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort analysis was conducted using the electronic medical records of 1183 pediatric patients undergoing tonsillectomy between September 24, 2012, and June 5, 2015, at a tertiary care academic medical center. Exclusion criteria included age 18 years or older, overnight admission, and missing data on fluid intake. The final cohort comprised 473 patients. Data analysis was conducted from July 8 to August 23, 2015. EXPOSURES: All patients underwent tonsillectomy by 1 of 7 attending surgeons at our institution. All patients were given intravenous fluids and analgesia in the postanesthesia care unit before being admitted to the pediatric inpatient floor for monitoring before discharge. MAIN OUTCOMES AND MEASURES: The primary outcome measured was presentation to the emergency department within 2 weeks after tonsillectomy with a related complication. We also recorded hospital readmissions and returns to the operating room for related complications. The primary diagnosis was noted for each complication. RESULTS: Among 473 patients (235 male; mean [SD] age, 7.2 [3.5] years), oral fluid intake after tonsillectomy ranged from 0.7 to 66.7 mL/kg, with a mean (SD) intake of 18.2 (10.8) mL/kg. Mean (SD) time to discharge was 6.96 (1.91) hours (range, 1.68-14.25 hours). Overall, 31 patients (6.6%) presented to the emergency department for a related complication after tonsillectomy. No correlation was found between oral fluid intake after tonsillectomy and presentation to the emergency department (odds ratio, 1.03; 95% CI, 0.98-1.08; P = .29). CONCLUSIONS AND RELEVANCE: This study suggests that oral fluid intake before discharge is not predictive of presentation to the emergency department after tonsillectomy within the ranges studied and at this institution. Therefore, discharge criteria based strictly on thresholds for oral fluid intake may be unnecessary. Further study at multiple institutions using a wider range of fluid intake volumes or a large-scale randomized clinical trial is needed before conclusions can be generalized.

Atypical location of the hypoglossal nerve and its implications: a case report.

INTRODUCTION: Successful surgery in the neck is dependent on reliable anatomical relationships between nerves, vessels, and muscles. These landmarks and planes are also essential to avoiding undue morbidity and mortality. Anatomic variants of the hypoglossal nerve are rare, and their incidences are unknown. METHODS: We describe a case of a hypoglossal nerve found coursing superficial to the internal jugular vein in a 52-year-old woman treated with bilateral selective neck dissection for metastatic thyroid malignancy. RESULTS: The vulnerable nerve was protected, and she maintained excellent speech and swallow function post-operatively. CONCLUSIONS: The variant course of the nerve may pose higher risk for injury in neck surgery. Surgeons should be aware of the possibility of aberrant anatomy in this region and exercise extra caution to avoid nerve injury.

A comparative study of solid carbon acid catalysts for the esterification of free fatty acids for biodiesel production. Evidence for the leaching of colloidal carbon.

The preparation of a variety of sulfonated carbons and their use in the esterification of oleic acid is reported. All sulfonated materials show some loss in activity associated with the leaching of active sites. Exhaustive leaching shows that a finite amount of activity is lost from the carbons in the form of colloids. Fully leached catalysts show no loss in activity upon recycling. The best catalysts; 1, 3, and 6; show initial TOFs of 0.07 s(-1), 0.05 s(-1), and 0.14 s(-1), respectively. These compare favorably with literature values. Significantly, the leachate solutions obtained from catalysts 1, 3, and 6, also show excellent esterification activity. The results of TEM and catalyst poisoning experiments on the leachate solutions associate the catalytic activity of these solutions with carbon colloids. This mechanism for leaching active sites from sulfonated carbons is previously unrecognized.

Replacement of a thiourea with an amidine group in a monofunctional platinum-acridine antitumor agent. Effect on DNA interactions, DNA adduct recognition and repair.

A combination of biophysical, biochemical, and computational techniques was used to delineate mechanistic differences between the platinum-acridine hybrid agent [PtCl(en)(L)](NO(3))(2) (complex 1, en = ethane-1,2-diamine, L = 1-[2-(acridin-9-ylamino)ethyl]-1,3-dimethylthiourea) and a considerably more potent second-generation analogue containing L' = N-[2-(acridin-9-ylamino)ethyl]-N-methylpropionamidine (complex 2). Calculations at the density functional theory level provide a rationale for the binding preference of both complexes for guanine-N7 and the relatively high level of adenine adducts observed for compound 1. A significant rate enhancement is observed for binding of the amidine-based complex 2 with DNA compared with the thiourea-based prototype 1. Studies conducted with chemical probes and on the bending and unwinding of model duplex DNA suggest that adducts of complex 2 perturb B-form DNA more severely than complex 1, however, without denaturing the double strand and significantly less than cisplatin. Circular and linear dichroism spectroscopies and viscosity measurements suggest that subtle differences exist between the intercalation modes and adduct geometries of the two complexes. The adducts formed by complex 2 most efficiently inhibit transcription of the damaged DNA by RNA polymerase II. Not only do complexes 1 and 2 cause less distortion to DNA than cisplatin, they also do not compromise the thermodynamic stability of the modified duplex. This leads to a decreased or negligible affinity of HMG domain proteins for the adducts formed by either Pt-acridine complex. In a DNA repair synthesis assay the lesions formed by complex 2 were repaired less efficiently than those formed by complex 1. These significant differences in DNA adduct formation, structure, and recognition between the two acridine complexes and cisplatin help to elucidate why compound 2 is highly active in cisplatin-resistant, repair proficient cancer cell lines.