Cost-Effectiveness of Diffusion Weighted MRI Versus Planned Second-Look Surgery for Cholesteatoma.

OBJECTIVE: To compare the cost-effectiveness of serial non-echo planar diffusion weighted MRI (non-EP DW MRI) versus planned second look surgery following initial canal wall up tympanomastoidectomy for the treatment of cholesteatoma. METHODS: A decision-analytic model was developed. Model inputs including residual cholesteatoma rates, rates of non-EP DW MRI positivity after surgery, and health utility scores were abstracted from published literature. Cost data were derived from the 2022 Centers for Medicare and Medicaid Services fee rates. Efficacy was defined as increase in quality-adjusted life year (QALY). One- and 2-way sensitivity analyses were performed on variables of interest to probe the model. Total time horizon was 50 years with a willingness to pay (WTP) threshold set at $50 000/QALY. RESULTS: Base case analysis revealed that planned second-look surgery ($11 537, 17.30 QALY) and imaging surveillance with non-EP DWMRI ($10 439, 17.26 QALY) were both cost effective options. Incremental cost effectiveness ratio was $27 298/QALY, which is below the WTP threhshold. One-way sensitivity analyses showed that non-EP DW MRI was more cost effective than planned second-look surgery if the rate of residual disease after surgery increased to 48.3% or if the rate of positive MRI was below 45.9%. A probabilistic sensitivity analysis at WTP of $50 000/QALY found that second-look surgery was more cost-effective in 56.7% of iterations. CONCLUSION: Non-EP DW MRI surveillance is a cost-effect alternative to planned second-look surgery following primary canal wall up tympanomastoidectomy for cholesteatoma. Cholesteatoma surveillance decisions after initial canal wall up tympanomastoidectomy should be individualized. LEVEL OF EVIDENCE: V.

Relationship between socioeconomic status, exposure to airborne pollutants, and chronic rhinosinusitis disease severity.

BACKGROUND: Air pollution directly interacts with airway mucosa, yet little is known about how pollutants affect upper airway inflammation. Studies have shown increased incidence of chronic rhinosinusitis (CRS), rhinitis, and asthma in areas with higher traffic pollution, and these neighborhoods are often associated with lower socioeconomic status (SES). The Area Deprivation Index (ADI) assesses neighborhood-level SES by zip code. The purpose of this study was to assess the relationship between SES and exposure to inhaled pollutants and CRS disease severity. METHODS: CRS patients with and without nasal polyps (CRSwNP and CRSsNP, respectively) were identified (total patients = 234; CRSwNP patients = 138; CRSsNP patients = 96). Pollutant concentrations, including particulate matter 2.5 (PM2.5 ), black carbon (BC), and nitrogen dioxide (NO2 ), were measured at 70 sites within the defined countywide sites and used to estimate patient exposures. SES was measured by ADI state deciles. Disease severity metrics included the modified Lund-Mackay score (LMS), the need for systemic steroids, and functional endoscopic sinus surgery (FESS). Associations were analyzed and identified using linear, logistic, and Poisson multivariable regression. RESULTS: The distribution of CRSsNP and CRSwNP patients across ADI state deciles was similar. ADI, however, was a predictor of exposure to airborne pollutants (PM2.5 , BC, and NO2 ) with a 1.39%, 2.39%, and 2.49% increase in PM2.5 , BC, and NO2 per increasing decile increment (p < 0.0001), respectively, which demonstrated a direct correlation between deprived neighborhoods and higher levels of exposure to PM2.5 , BC, and NO2 with an increase in pollutant levels per increase in ADI decile. Furthermore, ADI was a predictor for increased steroid treatment. CONCLUSION: Lower SES predicted higher exposure to air pollution and increased disease severity in patients with CRS as demonstrated by the increased need for steroid treatment.

The true penalty of the waiting room: the role of wait time in patient satisfaction in a busy spine practice.

OBJECTIVE: Most clinics collect routine data on performance metrics on physicians for outpatient visits. However, the relationship of these metrics with patient experience is unclear. The goal of this study was to investigate the relationships between the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey (CG-CAHPS), the standard patient experience survey, and clinic performance metrics to understand the determinants of patient satisfaction and identify targets for improving patient experience. METHODS: The authors performed a retrospective single-institution cohort review of spine surgeon metrics over 15 months including demographics, waiting-room times, in-room times, lead times, timely note closure, timely MyChart responses, and monthly patient volume. Kruskal-Wallis tests and mixed-model regression were used to determine the predictors of 3 domains of patient satisfaction-Global, Access, and Communication. RESULTS: Over 15 months, 22 surgeons conducted 27,090 visits. The average clinic visit total time was 85.17 ± 25.75 minutes. Increased wait times were associated with poor Global (p = 0.008), Access (p < 0.001), and Communication scores (p = 0.003) in univariate analysis. Every 10-minute increase in waiting time was associated with a 3%, 9.8%, and 2.4% decrease in Global, Access, and Communication scores, respectively. Increased in-room time was also an independent predictor of poor Access scores (p < 0.001). In multivariate analysis, increased wait times were negative predictors of Global (p = 0.005), Access (p < 0.001), and Communication (p = 0.002) scores. CONCLUSIONS: Excessive waiting-room time significantly impacts unexpected dimensions of the patient experience and impacts communication with patients. Understanding the complex relationship between the factors that inform the patient experience will help target effective interventions to improve clinic efficiency and patient satisfaction.

Computational Analysis of the Mature Unilateral Cleft Lip Nasal Deformity on Nasal Patency.

BACKGROUND: Nasal airway obstruction (NAO) due to nasal anatomic deformities is known to be more common among cleft patients than the general population, yet information is lacking regarding severity and variability of cleft-associated nasal obstruction relative to other conditions causing NAO. This preliminary study compares differences in NAO experienced by unilateral cleft lip nasal deformity (uCLND) subjects with noncleft subjects experiencing NAO. METHODS: Computational modeling techniques based on patient-specific computed tomography images were used to quantify the nasal airway anatomy and airflow dynamics in 21 subjects: 5 healthy normal subjects; 8 noncleft NAO subjects; and 8 uCLND subjects. Outcomes reported include Nasal Obstruction Symptom Evaluation (NOSE) scores, cross-sectional area, and nasal resistance. RESULTS: uCLND subjects had significantly larger cross-sectional area differences between the left and right nasal cavities at multiple cross sections compared with normal and NAO subjects. Median and interquartile range (IQR) NOSE scores between NAO and uCLND were 75 (IQR = 22.5) and 67.5 (IQR = 30), respectively. Airflow partition difference between both cavities were: median = 9.4%, IQR = 10.9% (normal); median = 31.9%, IQR = 25.0% (NAO); and median = 29.9%, IQR = 44.1% (uCLND). Median nasal resistance difference between left and right nasal cavities were 0.01 pa.s/ml (IQR = 0.03 pa.s/ml) for normal, 0.09 pa.s/ml (IQR = 0.16 pa.s/ml) for NAO and 0.08 pa.s/ml (IQR = 0.25 pa.s/ml) for uCLND subjects. CONCLUSIONS: uCLND subjects demonstrated significant asymmetry between both sides of the nasal cavity. Furthermore, there exists substantial disproportionality in flow partition difference and resistance difference between cleft and noncleft sides among uCLND subjects, suggesting that both sides may be dysfunctional.

Sinonasal Quality of Life Outcomes After Extended Endonasal Approaches to the Skull Base.

Introduction Endoscopic endonasal skull base surgery (EESBS) leads to significant alterations in sinonasal anatomy and physiology. However, there is limited data available on quality of life (QOL) outcomes following EESBS. Methods A retrospective review of patients undergoing EESBS from January 2014 to April 2017 was performed. Records were reviewed for clinical history, operative details, and 22-item Sinonasal Outcomes Test (SNOT-22) scores. Unadjusted and adjusted linear regression models were utilized to compare change in SNOT-22 scores from baseline in patients who underwent a simple sella approach (SA) or an extended beyond sella approach (BSA). Results A total of 108 patients were in the SA group, while 61 patients were in the BSA group. SNOT-22 scores were available at baseline and 3 months for 84 patients, while 6-month scores were available for 49 patients. SNOT-22 scores for all patients were not significantly different at 3 months ( p = 0.40) or at 6 months ( p = 0.58). Unadjusted linear regression model did not show an association between the type of approach and change in SNOT-22 score at 3 months ( p = 0.07) and 6 months ( p = 0.28). Adjusted regression model showed a significant decrease in SNOT-22 scores at 3 months ( p = 0.04) for the BSA group, but there was no significant change in SNOT-22 score at 6 months ( p = 0.22). Conclusion Patients undergoing EESBS had no significant change in outcomes at 3 and 6 months. A more extensive BSA was not associated with worse QOL outcomes as measured by SNOT-22.

Pleomorphic Mantle Cell Lymphoma of the Tongue Base Presenting With Dysphagia.

OBJECTIVES: We aim to increase awareness of pleomorphic mantle cell lymphoma as a rare, but aggressive form of lymphoma with propensity for recurrence in secondary locations. METHODS: We report the case of a 70-year-old man who presented with chronic post-nasal drainage, dysphagia, and voice changes caused by a tongue base mass. RESULTS: Partial excision and pathology showed a pleomorphic mantle cell lymphoma, and radiation treatment was completed. A regional recurrence was detected 3 years later and treated with radiation. He had no evidence of disease 17 months after treatment of the recurrence and is under close surveillance. CONCLUSIONS: Pleomorphic mantle cell lymphoma is an aggressive subtype of non-Hodgkin lymphoma that can affect the head and neck. Confirming the diagnosis with immunotyping and genotyping from fresh specimens can guide appropriate treatment and then close clinical follow-up.

Factors associated with opioid use after endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Responsible prescribing of postoperative pain medications is necessary in combatting the current opioid epidemic in the United States. The goal of this study was to determine which clinical factors affect opioid usage following functional endoscopic sinus surgery (FESS). STUDY DESIGN: Retrospective medical records study. METHODS: This is a single-institution retrospective study of subjects undergoing FESS by the senior author between September 2016 and December 2017. Opioid usage was assessed for each patient at the first postoperative visit. Univariate and multivariable analyses were performed to investigate factors associated with pain medication usage. Patients using opioids prior to surgery were excluded. RESULTS: A total of 136 patients were stratified into three groups based on number of opioid tablets taken during the first week after surgery: 31 patients (23%) took no opioids, 61 patients (45%) took one to five tablets, and 44 patients (32%) took more than five tablets. Gender, extent of surgery, revision surgery, polyp status, and cystic fibrosis did not significantly vary between the three groups. Multinomial logistic regression analysis with backward stepwise variable selection method revealed that those who had septoplasty (odds ratio [OR]: 4.84, 95% confidence interval [CI]: 1.68-13.98; P < .01) or were of younger age (OR 0.96, 95% CI: 0.93-0.99; P = .01) had significantly higher odds of taking >5 tablets. CONCLUSIONS: The majority of patients undergoing FESS did not take more than 5 opioid tablets after surgery. Concurrent septoplasty and younger age were associated with increased opioid usage. Knowledge of such factors can help surgeons to assess opioid prescribing patterns and to counsel their patients on postoperative pain. Laryngoscope, 129:1751-1755, 2019.

Recurrent and Progressive Facial Baroparesis on Flying Relieved by Eustachian Tube Dilation.

OBJECTIVES: Facial baroparesis is a rare phenomenon of seventh cranial nerve palsy traditionally reported in divers, with only 11 cases reported in aviation so far. It is important to correctly diagnose facial baroparesis given the differential diagnosis of stroke and decompression disease and offer appropriate treatment for recurrent cases. METHODS: The authors present the case of a patient with recurrent and progressive facial baroparesis treated with Eustachian tube balloon dilation. Institutional medical records were reviewed, and analysis of the current literature was performed. RESULTS: A 37-year-old woman experienced recurrent and progressive left facial paralysis on descent from altitude on commercial airline flights, with resolution between flights. The patient flew frequently for work-related trips and for the past 7 years had noted facial paralysis that began with mild asymmetry of the face and progressed to an inability to close her left eye. She denied any otologic symptoms other than ear fullness and pressure causing left otalgia. The right side was not involved. After treatment with Eustachian tube dilation, the patient has been on numerous flights with complete resolution of symptoms. CONCLUSIONS: This study presents a rare case of facial baroparesis on commercial flight descent that resolved after left Eustachian tube dilation. Although unilateral facial palsy can be concerning for stroke, a history of ear fullness and pressure may suggest facial baroparesis instead. For recurrent and progressive cases, Eustachian tube dilation should be considered for treatment.

Chief complaints and feedback from clinic satisfaction tool: Thematic analysis of a new outpatient communication tool.

OBJECTIVES: Up to half of all patients leave their outpatient clinic visit with an uncommunicated need. We designed the clinic satisfaction tool (CST) as a low-cost, highly utilised assessment of the spine clinic experience that improved communication in our multidisciplinary spine practice. The purpose of this study was to qualitatively analyse chief complaints and feedback from the CSTs to determine how spine clinic patients used the form, identify the most prevalent concerns and mark areas for improvement. METHODS: Institutional retrospective review of CSTs. Chief complaints and feedback were inductively coded to create a framework for patient complaints. RESULTS: 832 patients presented to clinic, and 100 sets of chief complaints coded before reaching thematic saturation. Patients used the chief complaint section of CST to canvas four themes: symptoms, questions about their disease, management and treatment. Twenty-nine patients left mostly positive feedback but also wrote additional concerns about care. CONCLUSION: Spine patients have a predictable pattern of chief complaints and with the CST were able to have all these complaints addressed. The CST efficiently collects practice-specific chief complaints that can be used to guide physician behaviour and design educational clinical tools that are useful for patients.

Airway findings in children with tracheostomies: When is diagnostic bronchoscopy and laryngoscopy indicated?

OBJECTIVES: To determine the utility of diagnostic laryngoscopy and bronchoscopy in children with tracheostomies and to describe the incidence of airway findings. METHODS: Retrospective cohort study examining children with tracheostomies who underwent direct laryngoscopy and bronchoscopy (DLB) at Duke University Hospital between 2008 and 2016. RESULTS: A total of 81 patients who underwent 114 bronchoscopies met inclusion criteria. The median time between tracheostomy and first DLB was 13 months (IQR 4.25-14.75). Sixty-six patients were diagnosed with findings on DLB (81.5%). Suprastomal granulation tissue was the most common complication (59.0%), followed by increased tracheal secretions (23%), stomal and peristomal granulation (13.2%), tracheal ulcer (3.3%), and suprastomal collapse (1.6%). The proportion of patients with airway findings who underwent endoscopy >6 months post-tracheostomy was higher than those <6 months post-tracheostomy, although this did not reach statistical significance (90.6% vs. 75.5%, p = 0.087). However, when examining tracheostomy-related findings, the proportion of patients with airway findings who underwent DLB >6 months post-tracheostomy (61%) compared to <6 months post-tracheostomy (36%) was significantly different (p = 0.026). Patients who were symptomatic before bronchoscopy were more likely to have positive findings (91.9% vs. 72.7%, p = 0.027) and patients were more likely to be symptomatic if they had DLB >6 months after tracheostomy versus <6 months after tracheostomy (68.8% vs. 30.6%; p < 0.001). CONCLUSION: The high incidence of airway findings, especially tracheostomy-related findings, noted on DLB supports the continued use of airway endoscopies in children post-tracheostomy. Timing of DLB may play a role in determining utility with evaluation and symptomatic patients should be more closely monitored as they demonstrate higher rates of airway findings.

Clinic Satisfaction Tool Improves Communication and Provides Real-Time Feedback.

BACKGROUND: Patient-reported assessments of the clinic experience are increasingly important for improving the delivery of care. The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey is the current standard for evaluating patients' clinic experience, but its format gives 2-mo delayed feedback on a small proportion of patients in clinic. Furthermore, it fails to give specific actionable results on individual encounters. OBJECTIVE: To develop and assess the impact of a single-page Clinic Satisfaction Tool (CST) to demonstrate real-time feedback, individualized responses, interpretable and actionable feedback, improved patient satisfaction and communication scores, increased physician buy-in, and overall feasibility. METHODS: We assessed CST use for 12 mo and compared patient-reported outcomes to the year prior. We assessed all clinic encounters for patient satisfaction, all physicians for CG-CAHPS global rating, and physician communication scores, and evaluated the physician experience 1 yr after implementation. RESULTS: During implementation, 14 690 patients were seen by 12 physicians, with a 96% overall CST utilization rate. Physicians considered the CST superior to CG-CAHPS in providing immediate feedback. CG-CAHPS global scores trended toward improvement and were predicted by CST satisfaction scores (P < .05). CG-CAHPS physician communication scores were also predicted by CST satisfaction scores (P < .01). High CST satisfaction scores were predicted by high utilization (P < .05). Negative feedback dropped significantly over the course of the study (P < .05). CONCLUSION: The CST is a low-cost, high-yield improvement to the current method of capturing the clinic experience, improves communication and satisfaction between physicians and patients, and provides real-time feedback to physicians.

Factors Associated with Revision Surgery after Balloon Sinuplasty.

OBJECTIVE: Although balloon sinuplasty (BSP) is increasing in popularity, little is known about which patients are the ideal candidates. The objective of this study is to investigate factors that may be associated with BSP failure. STUDY DESIGN: Retrospective review. SETTING: Academic center. SUBJECTS AND METHODS: This is a 6-year (July 2011-June 2017) retrospective review of patients who underwent BSP or revision endoscopic sinus surgery (rESS) after BSP within a single tertiary health system. Demographics, clinical findings, and radiographic findings were investigated for association with rESS via univariate analyses and a multivariable backward elimination selection procedure. RESULTS: A total of 154 patients were identified (median age, 53 years): 146 patients underwent BSP at a single health system, with 16 (11%) undergoing rESS; 8 patients underwent BSP at an outside institution and underwent rESS with the senior author. Mean ± SD follow-up was 12.8 ± 16.6 months. Univariate analyses revealed that prior endoscopic sinus surgery, polyps, allergic rhinitis, and gram-negative infection were significantly associated with rESS. As for radiographic findings, a higher Lund-Mackay score, neo-osteogenesis, moderate or complete opacification, and hyperdensities were associated with rESS. The final model after multivariable selection showed that higher radiographic scores (odds ratio, 1.08; 95% CI, 1.01-1.17) and neo-osteogenesis (odds ratio, 5.25; 95% CI, 1.68-16.42) were associated with higher odds for rESS. CONCLUSIONS: This study identifies several clinical and radiographic factors that may be associated with the need for rESS after BSP. Surgeons can take these factors into consideration when deciding whether a patient should forego BSP and undergo conventional FESS.

Noninvasive optical spectroscopy for identification of non-melanoma skin cancer: Pilot study.

OBJECTIVE: Optical spectroscopy offers a noninvasive alternative to biopsy as a first-line screening tool for suspicious skin lesions. This study sought to define several optical parameters across malignant and benign tissue types. STUDY DESIGN: Prospective pilot trial utilizing the Zenalux IM1 optical spectroscopy device from April 2016 to February 2017. For each skin lesion, provider pre-biopsy probability of malignancy was compared to histolopathologic diagnosis. Optical data were characterized across basal cell carcinoma (BCC; n = 9), squamous cell carcinoma (SCC; n = 5), actinic keratosis (AK; n = 4), scar tissue (n = 6), nevus (n = 2), and neurofibroma (NF; n = 1). Across all patients, agreement was determined between control measurements collected adjacent to the lesion and from the upper extremity. METHODS: Prospective single center pilot study. The optical properties of 27 cutaneous lesions were collected from 18 adult patients presenting to Otolaryngology and Dermatology clinics with suspicious skin lesions warranting biopsy. Spectroscopy measurements were recorded for each lesion: two at the lesion site, two at an adjacent site (internal control), and one at the central medial upper extremity (arm control). Variables of interest included absolute oxygenated hemoglobin (Hb), Hb saturation, total Hb concentration, and Eumelanin concentration. For each lesion, internal control averages were subtracted from lesion averages to provide delta parameter values, and lesion averages were divided by internal control averages to provide ratio parameter values. RESULTS: Mean percent difference between pre-biopsy probability of malignancy and histology was 29%, with a difference of 75% or greater seen in 5 of 25 lesions. Mean values for BCC, SCC, AK, and scar tissue varied most between extracted mean reduced scatter estimate (µa'; cm- ) delta values (BCC: -2.2 ± 3.8; SCC: -3.9 ± 2.0; AK: -3.3 ± 4.2, Scar: -1.7 ± 1.2) and total Hb (µM) ratio (BCC: 2.0 ± 3.3; SCC: 3.0 ± 1.3; AK: 1.1 ± 0.6; Scar: 1.4 ± 1.1). Agreement between local and arm controls was poor. CONCLUSION: This pilot trial utilizes optical spectroscopy as a noninvasive method for determining cutaneous lesion histology. Effect sizes observed across optical parameters for benign and malignant tissue types will guide larger prospective studies that may ultimately lead to prediction of lesional histology without need for invasive biopsy. Lasers Surg. Med. 50:246-252, 2018. © 2018 Wiley Periodicals, Inc.

Correlation between sinus and lung cultures in lung transplant patients with cystic fibrosis.

BACKGROUND: Lung transplantation has revolutionized the treatment of end-stage pulmonary disease due to cystic fibrosis. However, infection of the transplanted lungs can lead to serious complications, including graft failure and death. Although many of these patients have concurrent sinusitis, it is unclear whether bacteria from the sinuses can infect the allograft. METHODS: This is a single-institution retrospective study of all patients who underwent lung transplantation for cystic fibrosis from 2005 to 2015 at Duke University Hospital. Pre- and posttransplant nasal and pulmonary cultures obtained via nasal endoscopy and bronchoalveolar lavage (BAL), respectively, were analyzed. RESULTS: A total of 141 patients underwent 144 lung transplants. Sinus cultures were available for 76 patients (12 pretransplant, 42 posttransplant, 22 both pre- and posttransplant). Pretransplant BAL cultures were available for 139 patients, and posttransplant BAL cultures were available for all patients. Pseudomonas aeruginosa (PsA) and methicillin-resistant Staphylococcus aureus (MRSA) were the most common organisms cultured. There was a significant correlation between pretransplant sinus and posttransplant BAL cultures for PsA (p = 0.003), MRSA (p = 0.013), and Burkholderia cepacia (p = 0.001). CONCLUSION: There was a high correlation between pretransplant sinus cultures and posttransplant BAL cultures for PsA, MRSA, and Burkholderia sp. This suggests that the paranasal sinuses may act as a reservoir for allograft colonization in patients with cystic fibrosis. Further studies are needed to determine whether treatment of sinusitis affects allograft colonization and transplant outcomes.

Investigating the effects of laryngotracheal stenosis on upper airway aerodynamics.

OBJECTIVE: Very little is known about the impact of laryngotracheal stenosis (LTS) on inspiratory airflow and resistance, especially in air hunger states. This study investigates the effect of LTS on airway resistance and volumetric flow across three different inspiratory pressures. METHODS: Head-and-neck computed tomography scans of 11 subjects from 2010 to 2016 were collected. Three-dimensional reconstructions of the upper airway from the nostrils to carina, including the oral cavity, were created for one subject with a normal airway and for 10 patients with LTS. Airflow simulations were conducted using computational fluid dynamics modeling at three different inspiratory pressures (10, 25, 40 pascals [Pa]) for all subjects under two scenarios: 1) inspiration through nostrils only (MC), and 2) through both nostrils and mouth (MO). RESULTS: Volumetric flows in the normal subject at the three inspiratory pressures were considerably higher (MC: 11.8-26.1 L/min; MO: 17.2-36.9 L/min) compared to those in LTS (MC: 2.86-6.75 L/min; MO: 4.11-9.00 L/min). Airway resistances in the normal subject were 0.051 to 0.092 pascal seconds per milliliter (Pa.s)/mL (MC) and 0.035-0.065 Pa.s/mL (MO), which were approximately tenfold lower than those of subjects with LTS: 0.39 to 0.89 Pa.s/mL (MC) and 0.45 to 0.84 Pa.s/mL (MO). Furthermore, subjects with glottic stenosis had the greatest resistance, whereas subjects with subglottic stenosis had the greatest variability in resistance. Subjects with tracheal stenosis had the lowest resistance. CONCLUSION: This pilot study demonstrates that LTS increases resistance and decreases airflow. Mouth breathing significantly improved airflow and resistance but cannot completely compensate for the effects of stenosis. Furthermore, location of stenosis appears to modulate the effect of the stenosis on resistance differentially. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:E141-E149, 2018.

Recurrent post-tonsillectomy bleeding due to an iatrogenic facial artery pseudoaneurysm.

This is a report of an illustrative case of recurrent post-tonsillectomy bleeding that was caused by an iatrogenic facial artery pseudoaneurysm and controlled by endovascular embolization. A 37 year-old female who underwent bilateral tonsillectomy for chronic tonsillitis had recurrent secondary hemorrhage despite multiple operative interventions to control the bleeding. Because of the recurrent nature of the bleeding, an angiography of the external carotid artery was performed demonstrating a pseudoaneurysm of the left facial artery with active extravasation. This was successfully embolized with ethylene vinyl alcohol copolymer and the bleeding did not recur. Most post-operative bleeds can be managed with bedside or intraoperative interventions. However, pseudoaneurysms should be considered in the differential diagnosis of recurrent bleeds refractory to surgical control.

Penetrating Craniomaxillofacial Injury Caused by a Pneumatic Nail Gun.

Craniomaxillofacial injuries can be complex, requiring a multidisciplinary approach. The primary survey is always the first step in trauma management prior to proceeding with further evaluation and treatment. A 26-year-old man presented with a penetrating nail gun injury through the oral and nasal cavities. He did not present in extremis but required elective endotracheal intubation for intraoperative assessment and treatment. Airway management was enhanced by the use of lingual nerve and inferior alveolar nerve blocks via the Vazirani-Akinosi technique to maintain spontaneous respiration while the tongue was distracted from the palate. The nail was removed and rapid sequence induction initiated for orotracheal intubation. Local nerve blocks can be an effective tool in the armamentarium of the craniomaxillofacial trauma surgeon in managing blunt and penetrating injuries. We demonstrate its utility in airway management when a penetrating foreign body in the upper airway precludes orotracheal or nasotracheal intubation.

Humor therapy: relieving chronic pain and enhancing happiness for older adults.

The present study examined the effectiveness of a humor therapy program in relieving chronic pain, enhancing happiness and life satisfaction, and reducing loneliness among older persons with chronic pain. It was a quasiexperimental pretest-posttest controlled design. Older persons in a nursing home were invited to join an 8-week humor therapy program (experimental group), while those in another nursing home were treated as a control group and were not offered the program. There were 36 older people in the experimental group and 34 in the control group. Upon completion of the humor therapy program, there were significant decreases in pain and perception of loneliness, and significant increases in happiness and life satisfaction for the experimental group, but not for the control group. The use of humor therapy appears to be an effective nonpharmacological intervention. Nurses and other healthcare professionals could incorporate humor in caring for their patients.