Tracheal A-frame deformity and suprastomal collapse after pediatric tracheostomy.

Objectives: To determine the incidence of A-frame deformity and suprastomal collapse after pediatric tracheostomy. Study design: Retrospective cohort. Methods: All patients (<18 years) that had a tracheostomy placed at a tertiary institution between 2015 and 2020 were included. Children without a surveillance bronchoscopy at least 6 months after tracheostomy were excluded. Operative reports identified tracheal A-frame deformity or suprastomal collapse. Results: A total of 175 children met inclusion with 18% (N = 32) developing A-frame deformity within a mean of 35.8 months (SD: 19.4) after tracheostomy. For 18 children (18/32, 56%), A-frame developed within a mean of 11.3 months (SD: 15.7) after decannulation. There were 96 children developing suprastomal collapse (55%) by a mean of 17.7 months (SD: 14.2) after tracheostomy. All suprastomal collapse was identified prior to decannulation. Older age at tracheostomy was associated with a lower likelihood of collapse (OR: 0.92, 95% CI: 0.86-0.99, p = .03). The estimated 5-year incidence of A-frame deformity after tracheostomy was 32.8% (95% CI: 23.0-45.3) and the 3-year incidence after decannulation was 36.1% (95% CI: 24.0-51.8). Highly complex children had an earlier time to A-frame development (p = .04). At 5 years after tracheostomy, the estimated rate of suprastomal collapse was 73.7% (95% CI: 63.8-82.8). Conclusions: Tracheal A-frame deformity is estimated to occur in 36% of children within 3 years after tracheostomy decannulation. Suprastomal collapse, which approaches 74% at 5 years after tracheostomy, is more common when tracheostomy is placed at a younger age. Surgeons caring for tracheostomy-dependent children should recognize acquired airway obstruction and appropriately monitor these outcomes. Level of evidence: 3.

Percutaneous Needle Fasciotomy versus Collagenase Injection for Dupuytren's Contracture: A Systematic Review of Comparative Studies.

Introduction The purpose of this study was to review and compare clinical outcomes between percutaneous needle fasciotomy (PNF) and collagenase Clostridium histolyticum (CCH) injection for the treatment of Dupuytren's contracture. Materials and Methods A systematic review was performed including all level I-III evidence studies investigating the clinical outcomes of PNF and CCH injection in the treatment of Dupuytren's contracture. Results Five studies (278 CCH patients, 225 PNF patients; 285 CCH fingers, 246 PNF fingers, 405 males, and 98 females) were analyzed. Two randomized studies were level I evidence, one randomized study was level II, and two nonrandomized studies were level III. Two studies analyzed a total of 205 patients, each demonstrating statistically superior outcomes in one outcome measure (contracture improvement and Michigan Hand Questionnaire (MHQ) satisfaction subscore) with PNF, while the remaining three studies demonstrated no significant differences in outcomes between the two techniques. Three studies reported a statistically higher rate of minor complications (local pain, edema, ecchymosis, lymphadenopathy, pruritis) with CCH, while the remaining two studies demonstrated no significant difference in complication rates. Conclusion For the treatment of Dupuytren's contracture, there is some evidence that suggests superior clinical outcomes of PNF compared with CCH and a higher minor complication rate with CCH.

Primary and Revision Rhinoplasty: A Single Surgeon Experience and Patient Satisfaction.

There is minimal information describing the common characteristics among patients seeking primary/revision rhinoplasty. Success is traditionally interpreted from the surgeon's viewpoint, without considering the patient's perspective. The study's aims were to (1) identify/compare anatomic and functional characteristics commonly found in patients seeking primary and revision rhinoplasties; (2) assess patient satisfaction using a survey; and (3) explore whether graft choice (auricular cartilage versus rib cartilage) affects patient satisfaction and outcome in revision rhinoplasty. METHODS: A retrospective review of all rhinoplasties by a single surgeon from June 2016 to January 2020 was performed, focusing on preoperative anatomic/functional characteristics and operative interventions performed. A survey was then used to assess patient satisfaction. Finally, survey outcomes were compared between patients who received auricular and rib cartilage grafts in revision rhinoplasty. RESULTS: A total of 102 rhinoplasties (53 primary and 49 revisions) were included. Primary rhinoplasties were noted to have more patients with "big" noses (P = 0.015) or humps (P < 0.010). Patients undergoing revision rhinoplasties more commonly exhibited middle vault collapse (P = 0.022). The survey response rate was 60%. Revision rhinoplasty patients had a higher incidence of dissatisfaction with their outcome. CONCLUSIONS: Several features among patients seeking revision rhinoplasties could have been created in the primary operation. The rhinoplasty surgeon should be careful to not introduce new issues or create worse deformities than those seen following the initial operation. Survey-based outcome analysis demonstrated that revision rhinoplasty patients are more likely to have a greater rate of dissatisfaction following their operation.

Microsurgical Clipping of a Posterior Inferior Cerebellar Artery Aneurysm Following Failed Pipeline Stent.

Aneurysms of the posterior inferior cerebellar artery (PICA) are rare, with limited consensus on appropriate management. These aneurysms have been noted to have a faster growth rate and are more prone to rupture. Accessing these aneurysms for microsurgical clipping is challenging, and has traditionally required significant removal of the occipital condyle, putting the patient at risk for future complications. Therefore, some have opted to utilize minimally invasive techniques such as a pipeline stent, though these methods can fail to cause complete occlusion of the aneurysm. The current case describes a patient who was found to have a PICA aneurysm that was initially managed with a pipeline stent. However, upon further follow up, the aneurysm showed continued filling, leading to the decision to clip the aneurysm. In this case, we describe the use of a far lateral approach for accessing and clipping a PICA aneurysm with minimal removal of the occipital condyle. The patient successfully tolerated the surgery and was discharged home.

Sinonasal complications associated with endoscopic orbital decompression.

OBJECTIVE: Characterize sinonasal complications associated with endoscopic orbital decompression for thyroid eye disease (TED). METHODS: Retrospective analysis of patients who underwent endoscopic orbital decompression at Houston Methodist Hospital by two otolaryngologists and one ophthalmologist between May 2016 and February 2020 for TED. Patient ethnicity, age, laterality, operative approach (middle turbinectomy vs middle turbinate sparing), and history of prior sinusitis were collected. RESULTS: One hundred and forty-five orbital decompressions met the inclusion criteria. Postoperative obstructive sinusitis where herniated orbital fat caused obstruction of the sinus ostium occurred in 5.5% of operations. Patients who had a prior history of sinusitis were more likely to develop postoperative obstructive sinusitis (P = .02). The middle turbinectomy approach was more likely to show a reduced incidence of postoperative sinusitis (P = .014). CONCLUSION: Given the increased difficulty of managing sinonasal complications in the context of a decompressed orbit, efforts should be made to identify factors that might reduce the incidence of postoperative endonasal complications. The current study suggests that resection of the middle turbinate may allow for increased space for orbital fat herniation and lead to a decreased incidence of postoperative obstructive sinusitis. LEVEL OF EVIDENCE: IV.

Multiple Anterior and Posterior Circulation Intracranial Fenestrations presenting With Aneurysmal Subarachnoid Hemorrhage.

Background and Importance: Intracranial artery fenestrations are very rare, however, when found, there is a high association with cerebral aneurysms. Clinical Presentation: This report describes a patient with multiple anterior and posterior circulation intracranial artery fenestrations and an anterior communicating artery aneurysm presenting with a thunderclap headache found to have a subarachnoid hemorrhage (SAH). The patient was treated with open surgery via clipping after a diagnostic angiography and did very well. Conclusion: There is an association between cerebral fenestrations and aneurysms, but it has not been studied in a prospective manner. This case is unusual in that the patient had both anterior and posterior circulation fenestrations, which is uncommon. Clinicians should have a high index of suspicion in patients being evaluated for SAH who have a cerebral artery fenestration with no aneurysm found.

Dissecting the Lymphatic System to Predict Melanoma Metastasis.

Melanoma is the most lethal form of skin cancer in the United States. Current American Joint Committee on Cancer (AJCC) staging uses Breslow depth and ulceration as the two primary tumor factors that predict metastatic risk in cutaneous melanoma. Early disease stages are generally associated with high survival rates. However, in some cases, patients with thin melanomas develop advanced disease, suggesting other factors may contribute to the metastatic potential of an individual patient's melanoma. This review focuses on the role of the lymphatic system in the metastasis of cutaneous melanoma, from recent discoveries in mechanisms of lymphangiogenesis to elements of the lymphatic system that ultimately may aid clinicians in determining which patients are at highest risk. Ultimately, this review highlights the need to integrate pathological, morphological, and molecular characteristics of lymphatics into a "biomarker" for metastatic potential.

Microengineered Human Vein-Chip Recreates Venous Valve Architecture and Its Contribution to Thrombosis.

Deep vein thrombosis (DVT) and its consequences are lethal, but current models cannot completely dissect its determinants-endothelium, flow, and blood constituents-together called Virchow's triad. Most models for studying DVT forego assessment of venous valves that serve as the primary sites of DVT formation. Therefore, the knowledge of DVT formed at the venous cusps has remained obscure due to lack of experimental models. Here, organ-on-chip methodology is leveraged to create a Vein-Chip platform integrating fully vascularized venous valves and its hemodynamic, as seen in vivo. These Vein-Chips reveal that vascular endothelium of valve cusps adapts to the locally disturbed microenvironment by expressing a different phenotype from the regions of uniform flow. This spatial adaptation of endothelial function recreated on the in vitro Vein-Chip platform is shown to protect the vein from thrombosis from disturbed flow in valves, but interestingly, cytokine stimulation reverses the effect and switches the valve endothelium to becoming prothrombotic. The platform eventually modulates the three factors of Virchow's triad and provides a systematic approach to investigate the determinants of fibrin and platelet dynamics of DVT. Therefore, this Vein-Chip offers a new preclinical approach to study venous pathophysiology and show effects of antithrombotic drug treatment.

Nasal angiomyolipoma causing persistent nasal congestion.

Angiomyolipomas are benign tumors composed of blood vessels, adipose tissue, and smooth muscle. Usually, these lesions are located in the kidney and are found in association with tuberous sclerosis. The current case describes the rare presence of an angiomyolipoma within the nasal vestibule, leading to nasal obstruction. Surgical resection of the lesion was curative, and the patient's nasal congestion improved postoperatively. Consistent with previous findings in the literature, the patient's angiomyolipoma had not recurred at subsequent postoperative visits.

Loss to Follow-Up Among Patients With Proliferative Diabetic Retinopathy in Clinical Practice.

PURPOSE: To determine the proportion of patients with proliferative diabetic retinopathy (PDR) who were counted as loss to follow-up (LTFU) patients and to investigate predictive factors. DESIGN: Retrospective cohort study. METHODS: Information was collected for 4,423 patients with PDR between April 30, 2012, and April 30, 2017. Two definitions of LTFU were used. Complete LTFU referred to the population who never returned to care within the study period. Interval LTFU referred to the population who did not adhere to clinical recommendations and missed scheduled appointments, resulting in intervals longer than 6 months or 1 year between 2 appointments. Age, average gross income, and insurance were assessed as potential predictors of interval LTFU. RESULTS: Among 4,423 patients with PDR, 2,407 (54.4%) and 2,320 (52.4%) were complete LTFU at 6 months and 1 year, respectively; 782 (17.7%) and 468 (10.6%) patients were interval LTFU for 6 months and 1 year, respectively. Age and average gross income were not found to be significant predictors of interval LTFU. Compared to self-pay, government and private insurance patients were more likely to be interval LTFU at 6 months (government, P = .035; private, P = .005). Private insurance patients were also more likely to be interval LTFU at 1 year (P = .003). CONCLUSIONS: The identified complete LTFU rates were notably high and warrant further study. More than 1 of 6 patients were interval LTFU for at least 6 months, and 1 of 10 patients was interval LTFU for more than 1 year. Insurance status was significant in determining interval LTFU status. Consistent with other analyses, these results indicate that compliance with clinical appointments among patients with PDR is a substantial clinical challenge.

Emergent Transcatheter Aortic Valve Replacement (TAVR) Performed on Patient With DiGeorge Syndrome.

Emergent Transcatheter Aortic Valve Replacement (TAVR) is a strategy that has been used for management of severely decompensated patients who are unlikely to tolerate an open procedure (Kolte et al., 2018). Recently, in the context of degenerated valve bioprosthesis, valve-in-valve (ViV) transcatheter aortic valve replacement has become an acceptable management strategy (Kalra et al., 2019 [2]). Here, we present this rare case of a 25-year-old, post-partum female with DiGeorge Syndrome, who presented with severe bioprosthetic valve stenosis leading to heart failure. She initially had received a biologic valve in order to have children; however, following delivery of her child, she developed valve failure that was severe enough to preclude her from receiving a surgical aortic valve replacement. ViV TAVR was performed emergently to improve heart failure and bridge the time to definitive treatment, when she would be able to safely receive a mechanical valve. After valve placement, echocardiogram showed no evidence of aortic regurgitation or paravalvular leak with a mean gradient of 2 mmHg, and she was ultimately discharged. Our patient was recovering well at her two-month follow up appointment. This case highlights the need for further research in the use of ViV TAVR in younger patient populations in emergent situations.