Analysis of Intraoperative Radiographic Electrode Placement During Cochlear Implantation.

OBJECTIVE: To investigate the clinical value of intraoperative plain radiographs in determining correct placement of cochlear implants. PATIENTS: All cochlear implant insertions over a 10-year period by a single surgeon. INTERVENTIONS: Cochlear implantation with intraoperative imaging. MAIN OUTCOME MEASURE: Whether intraoperative imaging affects clinical/surgical management. RESULTS: A consecutive retrospective review of 207 cochlear implantations performed in 187 patients was performed. All implants performed had intraoperative plain film imaging. Etiology of hearing loss, surgical variations, gender, age, and implant type did not affect intraoperative imaging. Four cases were identified where variations in intraoperative imaging interpreted by the surgeon warranted further discussion. In one patient, the intraoperative x-ray interpretation missed an incorrectly placed electrode. Postoperative CT scan confirmed implant electrode within the superior semicircular canal. In three patients, intraoperative x-ray results aided management by confirming surgical findings; however, no subsequent clinical or surgical alterations were made based on imaging. One of these three patients experienced a noticeable function decline postoperatively that correlated with altered positioning of the cochlear implant on intraoperative radiographs. In all surgeries, no changes were made to the electrode placement based on the intraoperative radiographs. CONCLUSION: Intraoperative plain film imaging during cochlear implantation, although commonly employed, does not typically affect clinical management. For select cases, imaging may continue to be useful based on the surgeon's discretion and intraoperative findings for confirmatory purposes.

Endoscopic midfacial rejuvenation.

Early facial rejuvenation focused largely on the upper and lower thirds of the face. More recently, improvements in understanding of midfacial aging and anatomy have paralleled the development of endoscopic and minimally invasive surgical techniques. The midface is now understood to include both the lower lid subunit and the cheek down to the nasolabial fold. Many surgical techniques for midface rejuvenation have been used, including skin tightening with direct excision, skin-muscle flaps, isolated fat pad transposition, and subperiosteal lifting. The methods of endoscopic subperiosteal midface lifting and endoscopic malar fat pad lifting are discussed.

Volume rejuvenation of the facial upper third.

The next three articles in this issue take a unique approach to discussing volumetric restoration. Robert Glasgold has provided an assessment for each facial region and five different renowned authors (TK, SPS, RF, SML, and EFW) have been asked to speak on a particular volumetric product, of which they are considered an expert, as it applies to the different regions of the face. The articles are broken into the following: (1) upper third which corresponds to the upper eyelid, brow, temple, and forehead; (2) middle third which will cover lower eyelid, cheek, and perioral area; and (3) lower third which discusses the marionette, prejowl, and jawline. Our hope is that by placing differing opinions of experienced authors, organized by facial region together, the reader will have the opportunity to more readily compare the options. The contributing authors and their product area are as follows: Theda Kontis, MD-hyaluronic acid; Steve Smith, MD-calcium hydroxyl appetite; Rebecca Fitzgerald, MD-poly-L lactic acid; Sam Lam, MD-polymethyl methacrylate; and Edwin Williams, MD-Autologous Fat Transfer. If the author included general comments on the product, they are included in the article on the upper face only and are not repeated. Please note that other individuals may also have significantly assisted in the production of these articles, but those listed above are the senior authors.

Volume management of the middle third-lower orbit/midface.

This is the second of the three articles discussing volumetric rejuvenation of the face. The previous article, Volume Rejuvenation of the Facial Upper Third, focused on the upper one-third of the face while this article focuses on the middle one-third, primarily the lower eyelid, cheek, and perioral area. Again, the authors (RG, TK, SPS, RF, SL, and EFW) from the upper face article have provided a summary of rejuvenation utilizing a product of which they are considered an expert. Robert Glasgold has provided volumetric analysis of the region as an introduction.

Volume rejuvenation of the lower third, perioral, and jawline.

This is the third and final article discussing volumetric rejuvenation of the face. The previous two articles, Rejuvenation of the Upper Third and Management of the Middle Third, focused on the upper two-thirds of the face while this article focuses on the lower face, including the marionette area, jawline, and neck. Again, the authors of the previous two articles have provided a summary of rejuvenation utilizing a product of which they are considered an expert. Robert Glasgold has provided volumetric analysis of the region as an introduction.

Severe prolonged dysphagia following transoral resection of bilateral synchronous tonsillar carcinoma.

OBJECTIVES: Alert the reader to the complication of severe dysphagia following transoral laser microsurgery (TLM) or transoral robotic surgery (TORS) for bilateral simultaneous or synchronous tonsillar squamous cell carcinoma. METHODS: A case series of four patients treated at an academic tertiary center between 2008 and 2012 is presented; two treated with transoral laser microsurgery and two with transoral robotic surgery for biopsy-proven untreated bilateral primary squamous cell carcinoma. Main outcome measures included functional swallowing determined by the Functional Outcome Swallowing Scale. The incidence of significant postoperative complications was recorded. RESULTS: Two patients had surgery for discontiguous involvement of bilateral palatine tonsils with squamous cell carcinoma, while two patients had surgery for bilateral tonsillar squamous cell carcinoma with unilateral extension into the base of tongue. Complete swallowing failure as characterized by the Functional Outcome Swallowing Scale was seen postoperatively in 3/4 patients who underwent TLM or TORS for bilateral simultaneous tonsillar carcinoma, while one patient was lost to follow-up. CONCLUSIONS: Severe dysphagia in the setting of bilateral oropharyngectomy for simultaneous or synchronous tonsillar squamous cell carcinoma is rarely described but a significant concern. In an era with increased use of transoral surgery as de-escalation therapy, this unusual complication warrants consideration. We report that transoral bilateral pharyngectomy is quite harmful to near-term and intermediate-term swallowing outcomes. This paper serves to provide warning against primary surgical intervention in this setting, while demonstrating that non-surgical treatment may be the best viable option.

Comparison of carbon dioxide laser-assisted versus stapler-assisted endoscopic cricopharyngeal myotomy.

OBJECTIVES: We directly compared endoscopic carbon dioxide (CO2) laser and stapler treatment methods for both cricopharyngeal hypertrophy (CPH) and Zenker's diverticulum (ZD). METHODS: We performed a single-institution retrospective chart review of 153 patients who underwent either CO2 laser-assisted or stapler-assisted endoscopic cricopharyngeal myotomy (CPM). RESULTS: Isolated CPH was more likely to be treated with the CO2 laser than by stapler techniques. The ZD pouch size decreased significantly after surgery in both laser (p = 0.04) and stapler (p = 0.008) groups. The average duration of the procedure for CPM was longer for the laser than for the stapler (p = 0.01). Both techniques were successful when used in revision procedures. The overall complication rates were not statistically significantly different. Laser surgery trended toward a higher rate of major complications (2.4% versus 0%). Symptomatic recurrence was more likely after stapler surgery (p = 0.002). The rates of revision surgery were similar in the two groups (3.3% for laser and 4.3% for stapler). CONCLUSIONS: In the treatment of isolated CPH or ZD, stapler-assisted endoscopic surgery results in a shorter operative time, whereas laser-assisted CPM results in a decreased incidence of symptomatic recurrence.

Analysis of postoperative bleeding and risk factors in transoral surgery of the oropharynx.

IMPORTANCE: With an increasing incidence of oropharyngeal carcinoma and prevalence of transoral surgical techniques, postoperative bleeding, with its associated risk factors, deserves evaluation. OBJECTIVE: To classify and review postoropharyngectomy hemorrhage rates and associated risk factors. DESIGN, SETTING, AND PARTICIPANTS: Single-institution, multicenter retrospective medical chart review analyzing surgical procedures in 906 patients treated with transoral surgery for oropharyngeal carcinoma at a tertiary care, academic referral center from 1994 to 2012. Tumor stage, previous treatment, resection method, and transcervical external carotid branch ligation were analyzed in relationship to postoperative hemorrhage rate, and severity. A novel classification system was created, grading bleeding episodes as minor, intermediate, major, or severe based on management method and related sequelae. RESULTS: Postoperative bleeding occurred in 5.4% of patients (49 of 906) with 67.3% of these (33 of 49) requiring operative intervention. Severe bleeding episodes were very rare (1.1% of patients). Transcervical external carotid system vessel ligation was performed with the primary resection in 15.6% of patients with no overall difference in bleeding rate or severity of bleeding in patients who underwent ligation vs those who did not (P = .21 and P = .66, respectively). Vessel ligation was performed more frequently in patients with a higher T stage (P = .002). In previously treated patients, severity of bleeding was decreased if vessels were ligated (P > .05). Higher T-stage tumors had a higher bleeding rate (P = .02). Bleeding rates were similar between those treated with laser (5.6%) and robotic (5.9%) oropharyngectomy (P = .80); however, patients with significantly higher T-stage tumors were treated with laser vs robot techniques (P < .001). CONCLUSIONS AND RELEVANCE: Transoral resection of oropharyngeal carcinoma is safe, and severe life-threatening hemorrhage is rare. Although transcervical vessel ligation did not result in an overall decrease in bleeding rate, there is a trend toward reduced postoropharyngectomy bleeding severity with ligation. We recommend ligation for higher T-stage tumors, primary tonsil tumors, and patients undergoing revision surgery.

Operative time and cost of resident surgical experience: effect of instituting an otolaryngology residency program.

OBJECTIVE: Describe the procedure length difference between surgeries performed by an attending surgeon alone compared with the resident surgeon supervised by the same attending surgeon. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care center and residency program. SUBJECTS AND METHODS: Six common otolaryngologic procedures performed between August 1994 and May 2012 were divided into 2 cohorts: attending surgeon alone or resident surgeon. This division coincided with our July 2006 initiation of an otolaryngology-head and neck surgery residency program. Operative duration was compared between cohorts with confounding factors controlled. In addition, the direct result of increased surgical length on operating room cost was calculated and applied to departmental and published resident case log report data. RESULTS: Five of the 6 procedures evaluated showed a statistically significant increase in surgery length with resident involvement. Operative time increased 6.8 minutes for a cricopharyngeal myotomy (P = .0097), 11.3 minutes for a tonsillectomy (P < .0001), 27.4 minutes for a parotidectomy (P = .028), 38.3 minutes for a septoplasty (P < .0001), and 51 minutes for tympanomastoidectomy (P < .0021). Thyroidectomy showed no operative time difference. Cost of increased surgical time was calculated per surgery and ranged from $286 (cricopharyngeal myotomy) to $2142 (mastoidectomy). When applied to reported national case log averages for graduating residents, this resulted in a significant increase of direct training-related costs. CONCLUSION: Resident participation in the operating room results in increased surgical length and additional system cost. Although residency is a necessary part of surgical training, associated costs need to be acknowledged.