Possible Skull Base Erosion After Prolonged Frontal Sinus Stenting.

Frontal sinus stenting is widely used with the goal of maintaining nasofrontal duct patency after sinus surgery. The general recommendation is to leave stents in place for 6 months; however, prolonged stenting up to 6 years has been reported with no complication. We present the first reported case of frontal sinus posterior table and skull base erosion following prolonged frontal sinus stenting. A 57-year-old female presented with chronic sinusitis and nasal obstruction. Imaging revealed pansinusitis with retained stents in each frontal sinus that were placed 8 years prior. On the right, there was an area of skull base erosion at the tip of the stent. The patient underwent functional endoscopic sinus surgery with polypectomy. The stents were removed, revealing posterior table erosion on the right side but intact mucosa. Two months after surgery, there were no signs or symptoms of cerebrospinal fluid leak or other complications. Recent literature has suggested that prolonged stenting is safe; however, this case highlights a complication with potentially serious outcomes that can result from prolonged stenting. We recommend stent removal once stable nasofrontal duct patency has been achieved. If prolonged stenting is utilized, patients should be closely monitored and consideration should be given to periodic imaging to evaluate stent position.

Implementation of submandibular gland transfer: A multi-institutional study of feasibility and time to treatment.

BACKGROUND: Submandibular gland transfer (SMGT) mitigates radiation-induced xerostomia but has yet to be widely adopted. We evaluate the feasibility of incorporating SMGT at multiple academic institutions and report the incidence of treatment delay. METHODS: Forty-nine patients were identified who underwent SMGT. Time points pertaining to diagnosis and key treatment events including SMGT, surgery, chemotherapy, and radiation were extracted. Treatment delay was defined as either >60 days from diagnosis to definitive therapy or >6 weeks between surgery and adjuvant therapy. RESULTS: Median time from diagnosis to primary treatment was 42 days (IQR, 32-54). Median time from surgery to adjuvant therapy was 33 days (IQR, 28-47). Delay in starting treatment was observed in 7/49 patients (14%). Six patients incurred a delay in postoperative radiation therapy (6/19; 32%). CONCLUSIONS: With appropriate care coordination, SMGT can be implemented into a clinical pathway with a goal of decreasing radiation-induced xerostomia without increasing treatment delays.

The Plication Technique to Enhance the Endoscopic Approach to Zenker's Diverticulum.

Endoscopic stapler approaches to Zenker's diverticulum often yield a persistent diverticulum and recurrent dysphagia up to 20%. A novel technique to reduce the postoperative diverticulum is described. Eight consecutive patients with Zenker's diverticulum who underwent endoscopic stapler diverticulotomy had adjunctive endoscopic plication of the diverticulum wall to functionally reduce the residual diverticulum size. On postoperative esophagram, there was no visible diverticulum in 4 of 7 patients (57%). The remaining 3 patients had a reduction in common wall of 76%, 50%, and 40% with a mean postoperative size of 1.0 cm. All patients had resolution or significant improvement in dysphagia. There were no complications or recurrences at a mean follow-up of 6.3 months. As an adjunct to endoscopic treatment of Zenker's diverticulum, the plication technique can reduce diverticulum size. Further studies will determine if the plication technique affects long-term recurrence of endoscopic stapler approaches.

Medial Approach for the Resection of Goiters with Suprahyoid, Retropharyngeal, or Substernal Extension.

BACKGROUND: Resection of massive goiters with suprahyoid, retropharyngeal, and substernal extension may not be amenable to standard approaches. This study evaluates a surgical approach allowing resection of massive goiters with minimal substernal and deep neck dissection. METHODS: Cases of thyroidectomy for goiters with substernal, retropharyngeal, or suprahyoid extension at a single institution from 2006 to 2017 were reviewed. The technique involves initial complete division of the medial thyroid tracheal attachments after identification of the RLN medial-inferiorly or superiorly. Deep components are then delivered into the superficial paratracheal region of the neck. RESULTS: Sixty patients were included, 46 of which had substernal and 14 had only suprahyoid or retropharyngeal extension. Mean substernal extension was 3.7 cm (range 1.5-7.5 cm). The medial approach was successful in identifying the RLN in 70 (83%) of 84 goiter sides (71% medial-inferiorly and 29% superiorly). Standard inferior/lateral approaches were used in 12 (14%) nerves or not found until after goiter removal in 2 (2.5%). No patients required sternotomy or tracheotomy. Complications included postoperative seroma/hematoma (n = 9, 15%) with one re-exploration, transient RLN injury (n = 4, 4% of all lobectomies), transient hypocalcemia (n = 6, 16% of total thyroidectomies), permanent hypocalcemia (n = 2, 5% of total thyroidectomies), and permanent RLN paralysis (n = 1, 1% of all lobectomies). CONCLUSION: Large suprahyoid, retropharyngeal, and substernal goiters were resected transcervically with low morbidity. Early complete division of Berry's ligament after medial-inferior RLN identification was achieved in a high proportion of patients, facilitating goiter delivery with minimal mediastinal and deep neck dissection.

A novel technique for unilateral supraglottoplasty.

OBJECTIVES: Traditional supraglottoplasty for pediatric laryngomalacia is most commonly conducted with either CO2 laser or cold steel instruments. While the procedure enjoys high success rates, serious complications such as excessive bleeding, supraglottic stenosis and aspiration can occur. Unilateral coblation supraglottoplasty may reduce this risk, but data on respiratory and swallowing outcomes are lacking. This study reports our experiences with unilateral coblation supraglottoplasty. METHODS: Pediatric patients with severe congenital laryngomalacia who underwent unilateral supraglottoplasty at a single institution from 2013 to 2016 were retrospectively reviewed. Bipolar radiofrequency ablation (Coblation) was utilized with partial arytenoidectomy, aryepiglottoplasty, and advancement of mucosal flaps. Outcome measures included apnea-hypopnea index (AHI), weight-by-age percentile, and decannulation rate. RESULTS: Twelve patients were included with an average age of 13.1 months (range 2-28 months). In patients without tracheostomy, 88% had complete resolution of respiratory symptoms, while the remainder had significant improvement. In patients without gastrostomy tubes, there was an average increase in weight-age percentile of 6.1, 7.8, and 15.3 points at 1, 3, and 6 months postoperatively, respectively. Three patients had complete polysomnography data with a mean preoperative AHI of 19.3 and postoperative AHI of 4.0. Three of four patients with tracheostomy have been decannulated at a mean follow-up of 1.5 years. There were no early or late postoperative complications and no revision supraglottoplasty. CONCLUSION: Unilateral supraglottoplasty with bipolar radiofrequency ablation can improve respiratory symptoms and decrease OSA severity in severe congenital laryngomalacia. This technique is safe and can lead to substantial improvement in AHI in patients with OSA.

Pediatric tympanic membrane cholesteatoma: Systematic review and meta-analysis.

INTRODUCTION: Tympanic membrane cholesteatoma (TMC) is a rare anomaly found in pediatric patients with no significant otologic history. Its pathogenesis appears distinct from congenital mesotympanic cholesteatoma. This systematic review and meta-analysis evaluates the management of TMC. METHODS: Two authors independently conducted a systematic review using the PubMed-NCBI, Cochrane Library, and Web of Science databases. Studies describing cases of pediatric TMC were included. Patients with history of chronic otitis, otorrhea, trauma, or otologic surgery were excluded. RESULTS: Seventeen articles were included for a total of 45 patients. Mean age was 35.9 months with 56% female. Patients aged ≥36 months had significantly larger cholesteatomas than younger patients (4.2 vs 1.9 mm, p = 0.004). Nine patients (20%) had middle ear extension but none had middle ear or ossicular disease. CT scans influenced management in 1 of 26 patients. All patients were managed surgically by transcanal approach (93%) or retroauricular approach (7%). Surgery involved enucleation without TM perforation (80%) or complete excision with TM grafting (20%). In 23 patients, the fibrous TM remained intact, and there were no recurrences in this group at a mean follow-up of 11 months. Overall, there was 1 recurrence (2%), eventually requiring reoperation. No patients experienced persistent tympanic membrane perforation, chronic otitis, or hearing loss. CONCLUSION: TMC occurs in pediatric patients without an otologic history. Associated middle ear involvement has not been reported. CT scanning may not be necessary for work up and management of this disorder. A transcanal approach with enucleation is often sufficient treatment. Risk of recurrence appears lower than with congenital mesotympanic cholesteatoma.

A comparative study of cricotracheal resection and staged laryngotracheoplasty for adult subglottic stenosis.

OBJECTIVE: Cricotracheal resection (CTR) and laryngotracheoplasty (LTP) are open surgical treatments for severe subglottic stenosis. This study aims to compare the applications and outcomes of these techniques. METHOD: Patients with subglottic stenosis at a tertiary academic institution from 2000 to 2012 were identified by diagnosis codes. Patients who underwent LTP or CTR were included. Records were reviewed for treatment data and outcomes. Patients with a history of head and neck malignancy or stenosis without cricoid involvement were excluded. RESULT: Sixty-one and 20 patients underwent LTP and CTR, respectively. When comparing patients receiving LTP and CTR, there was a significant difference in stenosis etiology (P=.014). The groups were similar in Cotton-Myer grade (P=.102). At last follow-up, 80.3% of LTP patients and 90.0% of CTR patients were decannulated. On multivariate analysis, there was a significant association between stenosis grade and decannulation in the LTP group (P=.01). Decannulation was not associated with stenosis grade in the CTR group. In both groups, there was no significant association between decannulation and sex, stenosis etiology, or stenosis length. CONCLUSION: Cricotracheal resection and LTP have both shown excellent long-term decannulation rates. Etiology and stenosis grade are likely to be determining factors when recommending specific surgical interventions for subglottic stenosis.

Staged laryngotracheoplasty in adult laryngotracheal stenosis: predictors of long-term decannulation.

IMPORTANCE: This study reviews a single center's experience of performing staged laryngotracheoplasty (LTP) for the treatment of laryngotracheal stenosis with the ultimate goal of attaining long-term airway patency without restenosis. OBJECTIVE: To identify staged LTP as an efficacious surgical treatment option for laryngotracheal stenosis. DESIGN, SETTING, AND PARTICIPANTS: From January 2000 to January 2012, patients at a tertiary care academic institution presenting with diagnoses of laryngeal or laryngotracheal stenosis were retrospectively identified. Medical records from adult patients were inspected, and patient demographics, clinical data, and clinical outcomes were recorded. All patients undergoing staged LTP were initially included. Patients with history of head and neck malignant neoplasm were excluded. INTERVENTIONS: Staged LTP. MAIN OUTCOMES AND MEASURES: The primary outcome was long-term decannulation, defined as decannulation for duration of at least 6 months. RESULTS: Sixty-one patients were included in this study. The mean (SD) patient age was 47.1 (16.7) at the time of first-stage LTP and had a mean (range) follow-up of 5.32 (0.5-17.3) years from the first-stage reconstruction. Etiology of stenosis included prolonged intubation in 27 patients (44%), autoimmune disease in 9 (15%), idiopathic causes in 11 (18%), blunt laryngeal trauma in 10 (16%), and other causes in 4 (7%). Forty-nine patients (80%) were successfully decannulated, while to date 12 (20%) remain tracheostomy or tympanostomy tube dependent. Univariate analyses showed no significant association between decannulation and age (P = .35), sex (P = .52), history of intubation (P = .22), surgeon (P = .20), etiology of stenosis (P = .91), or length of stenosis (P = .31). Multivariate logistic regression analysis showed a significant inverse relationship between grade of stenosis and probability of decannulation (P = .01). CONCLUSIONS AND RELEVANCE: Staged LTP is an option for the reconstruction laryngotracheal stenosis. Our experience shows excellent decannulation rates in the selected patients with stenosis, many of whom have failed treatment with other surgical modalities.

Direct surgical repair of spondylolysis in athletes: indications, techniques, and outcomes.

OBJECT: Athletes present with back pain as a common symptom. Various sports involve repetitive hyperextension of the spine along with axial loading and appear to predispose athletes to the spinal pathology spondylolysis. Many athletes with acute back pain require nonsurgical treatment methods; however, persistent recurrent back pain may indicate degenerative disc disease or spondylolysis. Young athletes have a greater incidence of spondylolysis. Surgical solutions are many, and yet there are relatively few data in the literature on both the techniques and outcomes of spondylolytic repair in athletes. In this study, the authors undertook a review of the surgical techniques and outcomes in the treatment of symptomatic spondylolysis in athletes. METHODS: A systematic review of the MEDLINE and PubMed databases was performed using the following key words to identify articles published between 1950 and 2011: "spondylolysis," "pars fracture," "repair," "athlete," and/or "sport." Papers on both athletes and nonathletes were included in the review. Articles were read for data on methodology (retrospective vs prospective), type of treatment, number of patients, mean patient age, and mean follow-up. RESULTS: Eighteen articles were included in the review. Eighty-four athletes and 279 nonathletes with a mean age of 20 and 21 years, respectively, composed the population under review. Most of the fractures occurred at L-5 in both patient groups, specifically 96% and 92%, respectively. The average follow-up period was 26 months for athletes and 86 months for nonathletes. According to the modified Henderson criteria, 84% (71 of 84) of the athletes returned to their sports activities. The time intervals until their return ranged from 5 to 12 months. CONCLUSIONS: For a young athlete with a symptomatic pars defect, any of the described techniques of repair would probably produce acceptable results. An appropriate preoperative workup is important. The ideal candidate is younger than 20 years with minimal or no listhesis and no degenerative changes of the disc. Limited participation in sports can be expected from 5 to 12 months postoperatively.