The Impact of COVID-19 on Patient Interest in Facial Plastic Surgery.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to an unforeseen surge in demand for facial plastic surgery (FPS). The objective of this study was to survey patients who pursued cosmetic FPS during COVID-19 to better understand how changes in lifestyle, digital media usage, and their facial self-image influenced their decision to pursue surgery. METHODS: A web-based survey was sent to 150 patients who had undergone FPS at an outpatient clinic between May 1 and July 30, 2020. Questions included changes in patients' lifestyle habits, use of video conferencing and social media, Likert scale ratings of motivational factors to pursue FPS, and changes in perception of their own facial aesthetics during COVID-19. RESULTS: The survey response rate was 41%. Overall increases in video conferencing for social (79% of respondents) and occupational (73%) purposes, and social media usage (82%) were noted. The most commonly cited motivating factors to pursue FPS during COVID-19 were having ample privacy from family, friends, and co-workers (77%) and not requiring extended leave of absence from work (69%) during the postoperative recovery period. Patients were more aware of their nose than any other facial feature during COVID-19 compared to prior. CONCLUSIONS: The popularity of FPS during COVID-19 can be partially attributed to increased usage of video conferencing and social media, digital applications which often accentuate personal and idealized facial aesthetics. As surgeons adjust to increased demand for FPS, a better understanding of patient perspectives and motivations can help optimize doctor-patient relations and the delivery of care.

Surface kinematic and depth-resolved analysis of human vocal folds in vivo during phonation using optical coherence tomography.

SIGNIFICANCE: The human vocal fold (VF) oscillates in multiple vectors and consists of distinct layers with varying viscoelastic properties that contribute to the mucosal wave. Office-based and operative laryngeal endoscopy are limited to diagnostic evaluation of the VF epithelial surface only and are restricted to axial-plane characterization of the horizontal mucosal wave. As such, understanding of the biomechanics of human VF motion remains limited. AIM: Optical coherence tomography (OCT) is a micrometer-resolution, high-speed endoscopic imaging modality which acquires cross-sectional images of tissue. Our study aimed to leverage OCT technology and develop quantitative methods for analyzing the anatomy and kinematics of in vivo VF motion in the coronal plane. APPROACH: A custom handheld laryngeal stage was used to capture OCT images with 800 A-lines at 250 Hz. Automated image postprocessing and analytical methods were developed. RESULTS: Novel kinematic analysis of in vivo, long-range OCT imaging of the vibrating VF in awake human subjects is reported. Cross-sectional, coronal-plane panoramic videos of the larynx during phonation are presented with three-dimensional videokymographic and space-time velocity analysis of VF motion. CONCLUSIONS: Long-range OCT with automated computational methods allows for cross-sectional dynamic laryngeal imaging and has the potential to broaden our understanding of human VF biomechanics and sound production.

Coupling Pressure Sensing with Optical Coherence Tomography to Evaluate the Internal Nasal Valve.

PURPOSE: To evaluate endoscopic long-range optical coherence tomography system combined with a pressure sensor to concurrently measure internal nasal valve cross-sectional area and intraluminal pressure. METHODS: A pressure sensor was constructed using an Arduino platform and calibrated using a limiter-controlled vacuum system and industrial absolute pressure gauge. Long-range optical coherence tomography imaging and pressure transduction were performed concurrently in the naris of eight healthy adult subjects during normal respiration and forced inspiration. The internal nasal valve was manually segmented using Mimics software and cross-sectional area was measured. Internal nasal valve cross-sectional area measurements were correlated with pressure recordings. RESULTS: Mean cross-sectional area during forced inspiration was 6.49 mm2. The mean change in pressure between normal respiration and forceful inspiration was 12.27 mmHg. The direct correlation between pressure and cross-sectional area as measured by our proposed system was reproducible among subjects. CONCLUSIONS: Our results demonstrate a direct correlation between internal nasal valve cross-sectional area and nasal airflow during inspiration cycles. Endoscopic long-range optical coherence tomography coupled with a pressure sensor serves as a useful tool to quantify the dynamic behavior of the internal nasal valve.

Telelecture Educational Series in Facial Plastic and Reconstructive Surgery.

We sought to evaluate the usefulness of a monthly telelecture educational series in facial plastic and reconstructive surgery for resident education and to identify potential areas for improvement. A monthly series of facial plastic and reconstructive surgery telelectures were hosted at our institution between 2016 and 2018. A web-based survey was sent to 13 residents and 7 invited faculty presenters. Resident survey questions included rating of presentation topics, interface, networking opportunities, and educational value. Faculty survey questions included satisfaction, temporal convenience, likelihood of future telelecture participation, and likelihood of telelecture series implementation at speaker's home institution. The survey response rate was 100%. All of the residents expressed satisfaction with topics presented, lecture duration, perceived enhancement of education, and overall satisfaction with the telelecture series. 46% of residents indicated that the telelecture format limited networking opportunities. 72% of faculty reported they would participate in a future telelecture, and 86% indicated interest in integrating telelectures into their home institution educational curriculum. Live virtual telelectures effectively allow experienced facial plastic surgeons to share their operative techniques and management pearls in an interactive and practical format. This is a contemporary solution to bridging knowledge gaps between expert facial plastic surgeons from all corners of the world and the next generation of surgeons.

Dynamic programming and automated segmentation of optical coherence tomography images of the neonatal subglottis: enabling efficient diagnostics to manage subglottic stenosis.

Subglottic stenosis (SGS) is a challenging disease to diagnose in neonates. Long-range optical coherence tomography (OCT) is an optical imaging modality that has been described to image the subglottis in intubated neonates. A major challenge associated with OCT imaging is the lack of an automated method for image analysis and micrometry of large volumes of data that are acquired with each airway scan (1 to 2 Gb). We developed a tissue segmentation algorithm that identifies, measures, and conducts image analysis on tissue layers within the mucosa and submucosa and compared these automated tissue measurements with manual tracings. We noted small but statistically significant differences in thickness measurements of the mucosa and submucosa layers in the larynx (p < 0.001), subglottis (p = 0.015), and trachea (p = 0.012). The automated algorithm was also shown to be over 8 times faster than the manual approach. Moderate Pearson correlations were found between different tissue texture parameters and the patient's gestational age at birth, age in days, duration of intubation, and differences with age (mean age 17 days). Automated OCT data analysis is necessary in the diagnosis and monitoring of SGS, as it can provide vital information about the airway in real time and aid clinicians in making management decisions for intubated neonates.

Evaluation of Safety and Efficacy for an Intranasal Airway Device in Nasal Surgery.

IMPORTANCE: Postoperative packing in nasal surgery often results in nasal obstruction and discomfort. Commercially available silicone intranasal airways (IAs) serve as dual-nasal airway tubes aimed at alleviating this process, but the safety and efficacy of these devices are unknown. OBJECTIVE: To evaluate the safety and efficacy of an intraoperatively placed IA device in rhinoplasty and nasal surgery. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective record review, the medical records of patients undergoing nasal surgery with insertion of the IA at a single institution from 2012 to 2017 were reviewed. After review of over 200 patients, a questionnaire was developed to assess device efficacy. EXPOSURES: Use of the IA device. The IA is 12 cm long, anchored across the columella, extends distally along the nasal floor, and has a proximal external portion used for cleaning and maintaining patency. Placed intraoperatively, the device aims to support air flow postoperatively in the face of edema, hemorrhage, and packing. RESULTS: A total of 302 operations in 300 patients were analyzed, including primary and revision septorhinoplasty. A total of 24 (7.9%) patients self-removed or inadvertently dislodged the IA. Minor acute postoperative complications not unique to airway insertion included cellulitis in 4 (1.3%) participants and epistaxis in 6 (2%). Postoperatively, 1 (0.3%) patient developed dehiscence along transcolumellar incisions. A total of 59 patients (100% compliance) completed the efficacy questionnaire. The mean breathing score was between good and average (2.9 of 5), comfort scores between comfortable and average (2.9 of 5), and mean ease of irrigation score was between very easy and easy (1.96 of 5). The device was irrigated on average 3.57 times per day. A total of 43 (76%) particpiants had full patency or only partial obstruction, compared with 13 (24%) patients with total obstruction. In all patients, with or without obstruction, the effect lasted an average of 4 days. CONCLUSIONS AND RELEVANCE: The device is safe and well-tolerated for maintaining patency of the nasal airway in patients undergoing rhinoplasty and nasal reconstruction without increased risk of incisional dehiscence. LEVEL OF EVIDENCE: 4.

Solid Variant of Aneurysmal Bone Cyst of the Temporal Bone.

OBJECTIVES: Aneurysmal bone cysts (ABC) are benign, rapidly growing osteolytic lesions. Solid variant of ABC (SVABC) is a rare subtype of ABC that has not been reported in the temporal bone. METHODS: We report the case of a 6-year-old boy presenting with a slowly enlarging bony protuberance over the right zygomatic/malar eminence region. Computed tomography and magnetic resonance imaging demonstrated a 2.6 × 5.8 × 5.1 cm temporal bone mass involving the right mastoid, petrous, and temporal squamosal calvarium, with extradural intracranial extension to the middle cranial fossa. RESULTS: The patient underwent preoperative embolization of feeder arteries followed by combined neurosurgical and neurotologic resection. Histopathology revealed characteristic ABC features with interspersed areas of intralesional osteoid formation. CONCLUSION: Solid variant of ABCs are rare lesions of the skull base that present a diagnostic challenge given their unique radiographic and histologic features. Thorough cytogenetic evaluation is warranted to rule out potential malignant secondary causes. Early surgical resection is essential due to the risk of intracranial extension. This is the first report of ABC of any type with concurrent involvement of the squamous, mastoid, and petrous portions of the temporal bone and the first report of SVABC of the temporal bone.

Inefficiencies in Computed Tomography Sinus Imaging for Management of Sinonasal Disease.

Objective A subset of patients with sinonasal disease who obtain a diagnostic computed tomography (CT) sinus scan may require repeat preoperative CT due to the inadequacy of diagnostic CT for image-guided sinus surgery (IGSS). This leads to increased CT utilization, health care costs, and patient exposure to ionizing radiation. The objective of this study is to determine the frequencies of diagnostic CT sinus studies that were inadequate for IGSS and repeat CT studies for purposes of IGSS. Study Design A retrospective chart study was performed between May 2012 and August 2013. Setting Tertiary care rhinology practice. Subjects and Methods New patients with any sinonasal diagnosis who presented with CT sinus scans acquired from outside institutions were included. CT scans were considered inadequate for IGSS for any of the following reasons: >1.5-mm slice thickness, oblique axial planes due to gantry tilt, and incompletely defined or missing IGSS anatomic landmarks. Results Of 183 patients, 85 (46%) presented with diagnostic CT sinus scans that were inadequate for IGSS. Seventy-one patients met indications for IGSS, of which 37 (52%) required repeat CT due to an IGSS-inadequate diagnostic scan. Conclusion The frequency of repeat preoperative CT sinus imaging may be high at tertiary care centers where IGSS is performed. A standardized IGSS-adequate CT sinus protocol may avoid the need for repeat preoperative scans. Potential advantages include improved efficiency, decreased health care costs, and reduced ionizing radiation exposure to the patient.

Evaluation of the American college of surgeons thyroid and parathyroid ultrasound course: Results of a web-based survey.

OBJECTIVES/HYPOTHESIS: The American College of Surgeons Thyroid and Parathyroid Ultrasound Skills-Oriented Course (TPUSC) was designed to teach surgeons how to interpret and perform office-based head and neck ultrasound (HNUS). The objective of this study was to survey attendees of the TPUSC to evaluate the usefulness of the course, to track surgeon performed HNUS practice patterns, and to help identify potential roadblocks to incorporation of HNUS into a surgeon's practice. STUDY DESIGN: Cross-sectional survey. METHODS: A Web-based survey was sent to 952 surgeons who completed the TPUSC between 2010 and 2014. Questions included surgeon specialty, practice type, Likert scale rating of the TPUSC, competency with different HNUS procedures, and current HNUS practice patterns. RESULTS: The response rate was 24%. On a scale from 1 (not useful) to 5 (extremely valuable), the mean course usefulness rating was 4.2. Educational goals were met for 194 (92%) surgeons, and 162 (77%) surgeons reported performing HNUS in their practice. Of 48 surgeons not performing HNUS, 24 (50%) attributed insufficient time in their clinic schedule, and 21 (44%) attributed high equipment costs. CONCLUSIONS: The TPUSC is a valuable educational experience for surgeons seeking to gain proficiency in HNUS. The majority of TPUSC graduates gain competency with at least one type of HNUS procedure following the course. LEVEL OF EVIDENCE: NA Laryngoscope, 127:1950-1958, 2017.

Quantitative Evaluation of Adult Subglottic Stenosis Using Intraoperative Long-range Optical Coherence Tomography.

OBJECTIVES: To determine the feasibility of long-range optical coherence tomography (LR-OCT) as a tool to intraoperatively image and measure the subglottis and trachea during suspension microlaryngoscopy before and after endoscopic treatment of subglottic stenosis (SGS). METHODS: Long-range optical coherence tomography of the adult subglottis and trachea was performed during suspension microlaryngoscopy before and after endoscopic treatment for SGS. The anteroposterior and transverse diameters, cross-sectional area (CSA), distance from the vocal cords, and length of the SGS were measured using a MATLAB software. Pre-intervention and postintervention airway dimensions were compared. Three-dimensional volumetric airway reconstructions were generated using medical image processing software (MIMICS). RESULTS: Intraoperative LR-OCT imaging was performed in 3 patients undergoing endoscopic management of SGS. Statistically significant differences in mean anteroposterior diameter (P < .01), transverse diameter (P < .001), and CSA (P < .001) were noted between pre-intervention and postintervention data. Three-dimensional airway models were viewed in cross-sectional format and via virtual "fly through" bronchoscopy. CONCLUSIONS: This is the first report of intraoperative LR-OCT of the subglottic and tracheal airway before and after surgical management of SGS in humans. Long-range optical coherence tomography offers a practical means to measure the dimensions of SGS and acquire objective data on the response to endoscopic treatment of SGS.

In vivo cross-sectional imaging of the phonating larynx using long-range Doppler optical coherence tomography.

Diagnosis and treatment of vocal fold lesions has been a long-evolving science for the otolaryngologist. Contemporary practice requires biopsy of a glottal lesion in the operating room under general anesthesia for diagnosis. Current in-office technology is limited to visualizing the surface of the vocal folds with fiber-optic or rigid endoscopy and using stroboscopic or high-speed video to infer information about submucosal processes. Previous efforts using optical coherence tomography (OCT) have been limited by small working distances and imaging ranges. Here we report the first full field, high-speed, and long-range OCT images of awake patients' vocal folds as well as cross-sectional video and Doppler analysis of their vocal fold motions during phonation. These vertical-cavity surface-emitting laser source (VCSEL) OCT images offer depth resolved, high-resolution, high-speed, and panoramic images of both the true and false vocal folds. This technology has the potential to revolutionize in-office imaging of the larynx.

Long-Range Optical Coherence Tomography of the Neonatal Upper Airway for Early Diagnosis of Intubation-related Subglottic Injury.

RATIONALE: Subglottic edema and acquired subglottic stenosis are potentially airway-compromising sequelae in neonates following endotracheal intubation. At present, no imaging modality is capable of in vivo diagnosis of subepithelial airway wall pathology as signs of intubation-related injury. OBJECTIVES: To use Fourier domain long-range optical coherence tomography (LR-OCT) to acquire micrometer-resolution images of the airway wall of intubated neonates in a neonatal intensive care unit setting and to analyze images for histopathology and airway wall thickness. METHODS: LR-OCT of the neonatal laryngotracheal airway was performed a total of 94 times on 72 subjects (age, 1-175 d; total intubation, 1-104 d). LR-OCT images of the airway wall were analyzed in MATLAB. Medical records were reviewed retrospectively for extubation outcome. MEASUREMENTS AND MAIN RESULTS: Backward stepwise regression analysis demonstrated a statistically significant association between log(duration of intubation) and both laryngeal (P < 0.001; multiple r(2) = 0.44) and subglottic (P < 0.001; multiple r(2) = 0.55) airway wall thickness. Subjects with positive histopathology on LR-OCT images had a higher likelihood of extubation failure (odds ratio, 5.9; P = 0.007). Longer intubation time was found to be significantly associated with extubation failure. CONCLUSIONS: LR-OCT allows for high-resolution evaluation and measurement of the airway wall in intubated neonates. Our data demonstrate a positive correlation between laryngeal and subglottic wall thickness and duration of intubation, suggestive of progressive soft tissue injury. LR-OCT may ultimately aid in the early diagnosis of postintubation subglottic injury and help reduce the incidences of failed extubation caused by subglottic edema or acquired subglottic stenosis in neonates. Clinical trial registered with www.clinicaltrials.gov (NCT 00544427).

Is Nebulized Lidocaine Adequate Topical Anesthesia for Diagnostic Transnasal Tracheoscopy?

OBJECTIVES: To evaluate if nebulized 4% lidocaine alone provides adequate laryngopharyngeal anesthesia for office-based diagnostic transnasal tracheoscopy (TNT). METHODS: A retrospective chart review (January 2011 to June 2014) and a prospective case series (July 2014 to December 2014) of patients who underwent diagnostic TNT were performed at a university voice and swallowing center. TNT cases were categorized by method of topical laryngopharyngeal anesthesia: nebulized 4% lidocaine and 4% lidocaine drip (phase I) and nebulized 4% lidocaine only (phase II). RESULTS: TNT was performed a total of 59 times on 38 patients. Eleven (69%) of 16 phase I TNT procedures involved significant patient discomfort and severe cough following the lidocaine drip. Forty-two (98%) of 43 phase II TNT procedures were completed comfortably; 1 case required additional anesthesia by lidocaine drip. Retrospectively, 100% (n=8) of patients who underwent both phase I and phase II TNTs were noted to prefer anesthesia with nebulizer alone. In a prospective case series of 14 phase II TNT cases, 6 (86%) of 7 patients who previously underwent phase I TNT reported preference for anesthesia with nebulizer alone. CONCLUSIONS: Nebulized lidocaine appears to provide sufficient laryngopharyngeal anesthesia for diagnostic TNT. It is preferred by patients over laryngeal drip.

A novel device for measurement of subglottic stenosis in 3 dimensions during suspension laryngoscopy.

IMPORTANCE: A challenge in treating subglottic stenosis is assessment of airway caliber before and after management. At present, surgeons lack a simple, efficient, and precise method of measuring subglottic stenosis intraoperatively. We present a novel, easily reproducible tool for measurement of the diameter, location, and length of subglottic stenosis during suspension laryngoscopy. METHODS AND OBSERVATIONS: A set of 5 Kirschner wires (30-cm length and 1.6-mm diameter) were bent 90° at both ends to produce a series of 10 short ends designed to measure airway diameter (0.3- to 2.1-cm length with 2-mm intervals). Short, bent ends of the measuring sticks were designed to measure airway diameter. Hash marks at 2-mm intervals were created along the long axis of the measuring sticks to measure subglottic stenosis length and location relative to the vocal cords. The measuring stick was tested in 10 adult patients undergoing suspension microlaryngoscopy for endoscopic treatment of subglottic stenosis between September 2012 and July 2013. The accuracy of the measuring stick was evaluated using an airway phantom. The measuring stick enabled easy and precise quantification of subglottic stenosis diameter (82.5% agreement with reference; interobserver agreement, r = 0.995; P < .001), length (72.5%; r = 0.995; P < .001) and location during suspension laryngoscopy. CONCLUSIONS AND RELEVANCE: The measuring stick is inexpensive and simple to construct. It allows for safe, accurate, and practical measurement of subglottic stenosis diameter, length, and location during suspension laryngoscopy.

Intraoperative long range optical coherence tomography as a novel method of imaging the pediatric upper airway before and after adenotonsillectomy.

BACKGROUND/OBJECTIVES: While upper airway obstruction is a common problem in the pediatric population, the first-line treatment, adenotonsillectomy, fails in up to 20% of patients. The decision to proceed to surgery is often made without quantitative anatomic guidance. We evaluated the use of a novel technique, long-range optical coherence tomography (LR-OCT), to image the upper airway of children under general anesthesia immediately before and after tonsillectomy and/or adenoidectomy. We investigated the feasibility of LR-OCT to identify both normal anatomy and sites of airway narrowing and to quantitatively compare airway lumen size in the oropharyngeal and nasopharyngeal regions pre- and post-operatively. METHODS: 46 children were imaged intraoperatively with a custom-designed LR-OCT system, both before and after adenotonsillectomy. These axial LR-OCT images were both rendered into 3D airway models for qualitative analysis and manually segmented for quantitative comparison of cross-sectional area. RESULTS: LR-OCT images demonstrated normal anatomic structures (base of tongue, epiglottis) as well as regions of airway narrowing. Volumetric rendering of pre- and post-operative images clearly showed regions of airway collapse and post-surgical improvement in airway patency. Quantitative analysis of cross-sectional images showed an average change of 70.52mm(2) (standard deviation 47.87mm(2)) in the oropharynx after tonsillectomy and 105.58mm(2) (standard deviation 60.62mm(2)) in the nasopharynx after adenoidectomy. CONCLUSIONS: LR-OCT is an emerging technology that rapidly generates 3D images of the pediatric upper airway in a feasible manner. This is the first step toward development of an office-based system to image awake pediatric subjects and thus better identify loci of airway obstruction prior to surgery.

Long-range Fourier domain optical coherence tomography of the pediatric subglottis.

BACKGROUND: Acquired subglottic stenosis (SGS) most commonly results from prolonged endotracheal intubation and is a diagnostic challenge in the intubated child. At present, no imaging modality allows for in vivo characterization of subglottic microanatomy to identify early signs of acquired SGS while the child remains intubated. Fourier domain optical coherence tomography (FD-OCT) is a minimally invasive, light-based imaging modality which provides high resolution, three dimensional (3D) cross-sectional images of biological tissue. We used long-range FD-OCT to image the subglottis in intubated pediatric patients undergoing minor head and neck surgical procedures in the operating room. METHODS: A long-range FD-OCT system and rotary optical probes (1.2mm and 0.7mm outer diameters) were constructed. Forty-six pediatric patients (ages 2-16 years) undergoing minor upper airway surgery (e.g., tonsillectomy and adenoidectomy) were selected for intraoperative, trans-endotracheal tube FD-OCT of the subglottis. Images were analyzed for anatomical landmarks and subepithelial histology. Volumetric image sets were rendered into virtual 3D airway models in Mimics software. RESULTS: FD-OCT was performed on 46 patients (ages 2-16 years) with no complications. Gross airway contour was visible on all 46 data sets. Twenty (43%) high-quality data sets clearly demonstrated airway anatomy (e.g., tracheal rings, cricoid and vocal folds) and layered microanatomy of the mucosa (e.g., epithelium, basement membrane and lamina propria). The remaining 26 data sets were discarded due to artifact, high signal-to-noise ratio or missing data. 3D airway models were allowed for user-controlled manipulation and multiplanar airway slicing (e.g., sagittal, coronal) for visualization of OCT data at multiple anatomic levels simultaneously. CONCLUSIONS: Long-range FD-OCT produces high-resolution, 3D volumetric images of the pediatric subglottis. This technology offers a safe and practical means for in vivo evaluation of lower airway microanatomy in intubated pediatric patients. Ultimately, FD-OCT may be applied to serial monitoring of the neonatal subglottis in long-term intubated infants at risk for acquired SGS.

Overexpression of EphB4, EphrinB2, and epidermal growth factor receptor in papillary thyroid carcinoma: A pilot study.

BACKGROUND: The purpose of this study was to examine the differential expression of EphB4, EphrinB2, and epidermal growth factor receptor (EGFR) genes in papillary thyroid carcinoma (PTC) and evaluate their association with lymph node metastasis. METHODS: EphB4, EphrinB2, and EGFR expression in 21 matched tumors and surrounding normal thyroid tissues were evaluated by complementary DNA (cDNA) microarray, Western blot, and immunohistochemistry (IHC). RESULTS: We noted a statistically significant overexpression of EphB4, EphrinB2, and EGFR in tumor versus normal tissue based on cDNA microarray, Western blot, and IHC analysis. EphB4 and EphrinB2 overexpression were significantly associated with the presence of lymph node disease. CONCLUSION: Overexpression of EphB4, EphrinB2, and EGFR are associated with PTC, whereas EphB4 and EphrinB2 overexpression are associated with lymph node metastases. These genes may be potential biomarkers for identification of subclinical lymph node involvement in PTC and potential small-molecule targets for pharmacotherapy research.

Surgical management of coccidioidomycosis of the spine: clinical article.

OBJECT: Coccidioides immitis is a dimorphous fungus endemic in the southwestern US and northern Mexico. While its primary presentation is pulmonary, it can have devastating neurological sequelae. METHODS: The authors provide a retrospective review with long-term follow-up between 1986 and 2008 at a single institution. RESULTS: The authors identified 27 patients between 13 and 81 years old (mean 41.4 years) with spinal coccidioides who were treated surgically at the Barrow Neurological Institute between 1986 and 2008. There were 24 males (89%) and 3 females (11%). Eleven patients (41%) had cervical spine involvement, 15 (56%) had thoracic involvement, 7 (26%) had lumbar involvement, and 2 (7%) had sacral involvement. All 27 patients presented with localized or radiating pain. Nine patients (33%) had myelopathic symptoms at presentation, 5 (19%) had radiculopathy, 4 (15%) had fever, and 12 (44%) had progressive kyphosis. The disease was most frequently seen among African American patients (14 patients [52%]), followed by Caucasians (5 patients [19%]), Asians (3 patients [11%]), and Hispanics (3 patients [11%]). Ten patients (37%) required multiple operations at the same level. Follow-up was available in 19 patients (70%) (mean 9.8 months, range 1-39 months). Sixteen (84%) of these 19 patients improved from their preoperative baseline states, 1 (5%) was stable on examination, 1 patient's condition (5%) deteriorated compared with the preoperative examination, and 1 patient (5%) died in the postoperative period. CONCLUSIONS: Although spinal involvement of coccidioidomycosis is relatively uncommon, a high index of suspicion and aggressive therapy are warranted to prevent devastating neurological injury, and lifelong antifungal therapy is often warranted.

Neuroblastoma-like schwannoma of lumbar spinal nerve root.

Neuroblastoma-like schwannoma is a rare nerve sheath tumor with histological features resembling a neuroblastoma. A comprehensive literature review identified only 10 previous case reports of this condition. The authors present the first reported case of a neuroblastoma-like schwannoma at a spinal nerve root. The patient, a 61-year-old woman, presented with severe pain in the right lower extremity that failed to resolve after conservative management. Magnetic resonance imaging revealed an intradural enhancing lesion extending out of the right neural foramen at L1-2. A right L1-2 hemilaminectomy and facetectomy with gross-total resection of the tumor was performed without complications. Neuroblastoma-like schwannoma was diagnosed based on histopathological examination of the biopsied tumor specimen. A postoperative course of serial examination and imaging was chosen based on a suspected benign postoperative course as in the case of a completely resected schwannoma. The authors present the novel case of neuroblastoma-like schwannoma at a lumbar spinal nerve root and describe the distinguishing pathological features of this rare lesion.

Needlestick injuries among medical students: incidence and implications.

PURPOSE: To determine the incidence of needlestick injuries in medical school and to examine the behaviors associated with reporting injuries to an occupational health office. Medical students have underdeveloped surgical skills and are at high risk of needlestick injuries. METHOD: Recent medical school graduates enrolled in a surgery residency at 17 medical centers were surveyed regarding needlestick injuries that they sustained during medical school. The survey asked about the circumstances and cause of injury and postinjury reporting. RESULTS: Of 699 respondents, 415 (59%) reported having sustained a needlestick injury as a medical student; the median number of injuries per injured respondent was 2 (interquartile range: 1-2). Respondents who sustained a needlestick injury in medical school were more likely to sustain a needlestick injury during residency than those who did not experience a needlestick injury in medical school (odds ratio [OR]: 2.57; 95% CI: 1.84, 3.58). Of 89 residents who sustained their most recent needlestick injury during medical school, 42 (47%) did not report their injury to an employee health office. CONCLUSIONS: Needlestick injuries and underreporting of these injuries are common among medical students and place them at risk for hepatitis and human immunodeficiency virus. Strategies aimed at improving reporting systems and creating a culture of reporting should be implemented by medical centers.