Experience harvesting costal cartilage under IV sedation

IMPORTANCE

While numerous techniques for costal cartilage harvesting have been described, one consistency in the published literature is that the procedure is performed under general anesthesia. This is the first report to offer IV sedation as a safe alternative to general inhalational anesthesia in cases involving costal cartilage harvesting.

OBJECTIVE

To determine the feasibility and safety of costal cartilage harvest with IV sedation.

DESIGN

A retrospective chart review was performed of 116 rhinoplasty patients who underwent harvest of costal cartilage grafts under IV sedation from 2005 to 2019.

SETTING

Private practice of senior author (AF) at Lasky Clinical Surgical Center.

PARTICIPANTS

Consecutive patients who underwent cosmetic and/or functional rhinoplasty.

MAIN OUTCOME & MEASURES

The number of cases involving a pneumothorax, size of the pleural injury, radiographic findings, repair technique and treatment for pneumothorax were all recorded.

RESULTS

There were 7 cases involving a pleural tear (size range 3-8 mm) during costal cartilage harvest and each of these was repaired intra-operatively. All 7 patients remained clinically stable in recovery room on 2 L of oxygen. Although clinically stable, one patient had radiologic evidence of a pneumothorax of 50%, and thus she was transferred to a hospital for placement of a Heimlich tube with overnight observation.

CONCLUSIONS AND RELEVANCE

Although plenural tears can be attributed to surgical technique rather than the type of anesthesia, these cases do provide valuable insight to the fact that successful management of such complications can be accomplished without the need for general anesthesia.

Surgical and Nonsurgical Techniques in Forehead Rejuvenation

The periorbital and forehead regions are among the most expressive parts of the face. A thorough understanding of the complex facial anatomy and aesthetic norms are essential when evaluating and treating a patient for facial brow rejuvenation. Not only will knowledge of the anatomy enhance facial injection and surgical outcomes, but will also diminish potential complications. Combining nonsurgical and surgical techniques, including laser and skin rejuvenation, can yield the most natural and effective aesthetic brow improvements.

Cranioplasty Using a Mixture of Biologic and Nonbiologic Agents

Importance

A surgeon faces challenges with cranioplasty techniques to achieve a successful result with relatively few complications.

Objective

To describe a unique technique for incorporating both biologic autologous bone and nonbiologic allograft materials for defect coverage in cranioplasty with favorable outcomes and low occurrence of complications.

Design, Setting, and Participants

A retrospective medical records review of all 26 patients who underwent primary cranioplasty procedure with a modified technique between January 2011 and December 2015 at a high-volume head and neck oncologic reconstructive practice was conducted; data analysis was also performed during that period. After several years of experience with traditional cranioplasty maneuvers, the modified technique has evolved to incorporate both autologous bone grafts and alloplastic materials in the formation of a shapeable on-lay material. Data were collected on demographics, need for cranioplasty, materials used, outcomes, and risk factors.

Main Outcomes and Measures

Rates of infection, hematoma, flap loss or resorption, cerebrospinal fluid leak, hardware exposure or malfunction, and repeated reconstruction.

Results

Of the 26 patients, 21 (81%) were men; mean (SD) age was 65.8 (14.3) years. Eight (31%) patients had a history of diabetes, 4 (15%) patients were receiving immunosuppressive drugs, and 5 (19%) patients were active smokers at the time of surgery. Neoplasia was the most common cause of the calvarial defect seen, responsible for 20 of 28 (71%) operative defects and necessitated procedures. All but 1 patient achieved successful mineralization following primary cranioplasty with the modified technique; this success was verified based on physical examination and follow-up imaging. Complications were rare and involved only 3 patients who developed postoperative infection; 1 (4%) of these patients lost the integrity of the cranioplasty. Thus, the rate of infection was 11% and loss rate was 4%. Preoperative and postoperative radiotherapy appeared to have no bearing on graft survival.

Conclusions and Relevance

The results using a unique technique for incorporating both biologic autologous bone and nonbiologic allograft materials for defect coverage in cranioplasty are favorable, with satisfactory aesthetic outcomes and limited postoperative complications.

Level of Evidence

4.

Locoregional and Microvascular Free Tissue Reconstruction of the Lateral Skull Base

The goals of reconstruction following any oncologic extirpation are preservation of function, restoration of cosmesis, and avoidance of morbidity. Anatomically, the lateral skull base is complex and conceptually intricate due to its three-dimensional morphology. The temporal bone articulates with five other cranial bones and forms many sutures and foramina through which pass critical neural and vascular structures. Remnant defects following resection of lateral skull base tumors are often not amenable to primary closure. As such, numerous techniques have been described for reconstruction including local rotational muscle flaps, pedicled flaps with skin paddle, or free tissue transfer. In this review, the advantages and disadvantages of each reconstructive method will be discussed as well as their potential complications.

Osseointegrated Implants and Prosthetic Reconstruction Following Skull Base Surgery

Rehabilitation following ablative skull base surgery remains a challenging task, given the complexity of the anatomical region, despite the recent advances in reconstructive surgery. Remnant defects following resection of skull base tumors are often not amenable to primary closure. As such, numerous techniques have been described for reconstruction, including local rotational muscle flaps, pedicled flaps with skin paddle, or even free tissue transfer. However, not all patients are appropriate surgical candidates and therefore may instead benefit from nonsurgical options for functional and aesthetic restoration. Osseointegrated implants and biocompatible prostheses provide a viable alternative for such a patient population. The purpose of this review serves to highlight current options for prosthetic rehabilitation of skull base defects and describe their indications, advantages, and disadvantages.

Zika Virus-What the Otolaryngologist Should Know: A Review

Importance

Initially discovered in 1947, Zika virus infection received little notoriety as a tropical disease until 2015 when an outbreak of microcephaly cases was reported in Brazil. Zika is a single-stranded RNA arbovirus of the Flaviviridae family. The primary source of infection in humans stems from Aedes aegypti mosquito bites but can also occur through sexual, blood, and perinatal transmission. With expectations that 3 to 4 million people across the Americas will be infected over the next year, the World Health Organization has declared this event a Public Health Emergency of International Concern.

Observations

Although acute Zika virus infection is typically mild and self-limited, researchers have demonstrated serious neurologic complications associated with it such as microcephaly and Guillain-Barre syndrome. Otolaryngologists should be aware of head and neck manifestations which include conjunctivitis, retro-orbital pain, cephalgia, and odynophagia. The Centers for Disease Control and Prevention have developed specific molecular and serologic testing protocols and algorithms for follow-up care of suspected cases. Currently, the mainstay of management is conservative care while researchers attempt to develop a vaccine. Strategies to contain the Zika virus include vector control, travel restriction for women who are pregnant or trying to become pregnant, and avoidance of mosquito bites in endemic regions of the world.

Conclusions and Revelance

The future outlook regarding the current Zika virus outbreak in the Americas remains uncertain. What is certain is our need to promptly and efficiently address research gaps in our understanding of clinical outcomes from infection and environmental factors that influence emergence meanwhile improving diagnostic, therapeutic, and preventive measures against the disease.

Use of Giant Bilobed Flap for Advanced Head and Neck Defects

This article aims to review the use of giant bilobed flaps in the reconstruction of various large defects within the head and neck. A single case series study with chart review was performed. Various facial, neck, and mentum defects were documented, and closure was accomplished through a variety of medially and laterally based giant bilobed flaps. Preoperative and postoperative photography, as well as intraoperative planning, was performed. A total of 23 patients were able to achieve closure of facial, head, and neck defects with single-stage closure through the use of a giant bilobed flap. No tissue expanders, free tissue transfers, or skin grafts were required to achieve final closure, with acceptable cosmetic and functional results. Bilobed-shaped flaps allow for local tissue transfer in regions of otherwise limited tissue laxity and mobility, classically designed and utilized in the region of the nose. We describe its applicability to closure of large head and neck defects that may otherwise require free tissue transfer or the use of tissue expanders.

Sinonasal Phosphaturic Mesenchymal Tumor: A Rare and Misinterpreted Entity

Objectives Oncogenic osteomalacia is a paraneoplastic syndrome in which the tumor secretes a peptide-like hormone, fibroblast growth factor, resulting in urinary loss of phosphates. Methods We present the case of a 50-year-old woman with a benign phosphaturic mesenchymal tumor (PMT) involving the ethmoid sinus with obstruction of the ostiomeatal complex causing unilateral nasal airway obstruction. Results The tumor was initially thought to be an esthesioneuroblastoma based on primary pathology interpretation and on clinical and radiographic appearance. However, a benign PMT was later confirmed by further testing. Conclusion The tumor was removed entirely by the endoscopic transnasal approach, leading to a full resolution of symptoms.

Facial nerve trauma: evaluation and considerations in management

The management of facial paralysis continues to evolve. Understanding the facial nerve anatomy and the different methods of evaluating the degree of facial nerve injury are crucial for successful management. When the facial nerve is transected, direct coaptation leads to the best outcome, followed by interpositional nerve grafting. In cases where motor end plates are still intact but a primary repair or graft is not feasible, a nerve transfer should be employed. When complete muscle atrophy has occurred, regional muscle transfer or free flap reconstruction is an option. When dynamic reanimation cannot be undertaken, static procedures offer some benefit. Adjunctive tools such as botulinum toxin injection and biofeedback can be helpful. Several new treatment modalities lie on the horizon which hold potential to alter the current treatment algorithm.

Surgical Management of Spontaneous and Traumatic Anterior Skull Base Meningoceles: Technique and Pitfalls

Objectives:

A majority of anterior skull base meningoceles are often managed via the endoscopic endonasal approach (EEA) for the excision and repair of the cerebrospinal fluid (CSF) leak, in addition to the reconstruction of the skull base defect. The aim of the study was evaluation of an institutional case series to identify specific risks and strategies for successful management of anterior skull base meningoceles.

Methods:

Case series review of all surgical cases involving repair of any anterior skull base meningocele spanning 3 years.

Results:

A total of 18 patients were managed surgically for repair of meningocele with or without CSF rhinorrhea. All patients had postoperative follow-up to one year. EEA was used in 17 patients, and one had a combined transcranial with endoscopic approach. Four patients had meningoceles with a larger than 1.0-cm bony skull base defect. Large spontaneous meningoceles along the ethmoid were likely to include cerebrovascular structures within their intranasal component. Nasal airway obstruction was the initial presenting symptom in all large spontaneous ethmoid meningoceles, rather than CSF rhinorrhea (present in all large traumatic ones).

Conclusions:

The endoscopic technique is a safe and effective approach to repair of anterior skull base defects involving both ethmoid and sphenoid regions. Successful repair of lateral sphenoid wall defects depends on gaining sufficient access via incorporating extended approaches, such as trans-pterygopalatine approach. Preoperative angiography may be warranted, especially in spontaneously appearing anterior skull base meningoceles with a bony defect larger than 1.0 cm.

Dengue fever: a primer for the otolaryngologist

It has been estimated that more than 50 million cases of dengue occur worldwide each year, mostly in the tropics. In light of recent cases appearing in central and southern Florida, dengue has reemerged as a public health issue in the United States with respect to infection control and prevention. We review the course of dengue infection and its clinical presentation from the perspective of the practicing otolaryngologist, and we outline tactics for prevention and management.

Impact of pharyngeal closure technique on fistula after salvage laryngectomy

IMPORTANCE

No consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy. We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post-radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge.

OBJECTIVE

To determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx.

DESIGN

Multi-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers.

SETTING

Academic, tertiary referral centers.

PATIENTS

The study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up.

MAIN OUTCOMES AND MEASURES

Fistula incidence, severity, and predictors of fistula.

RESULTS

Of the 359 patients, fistula occurred in 94 (27%). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P < .001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P < .001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34%. For the interposed free flap group, the fistula rate was lower at 25% (P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15% (P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks).

CONCLUSIONS AND RELEVANCE

Pharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.

Activation of the NOTCH pathway in head and neck cancer

NOTCH1 mutations have been reported to occur in 10% to 15% of head and neck squamous cell carcinomas (HNSCC). To determine the significance of these mutations, we embarked upon a comprehensive study of NOTCH signaling in a cohort of 44 HNSCC tumors and 25 normal mucosal samples through a set of expression, copy number, methylation, and mutation analyses. Copy number increases were identified in NOTCH pathway genes, including the NOTCH ligand JAG1. Gene set analysis defined a differential expression of the NOTCH signaling pathway in HNSCC relative to normal tissues. Analysis of individual pathway-related genes revealed overexpression of ligands JAG1 and JAG2 and receptor NOTCH3. In 32% of the HNSCC examined, activation of the downstream NOTCH effectors HES1/HEY1 was documented. Notably, exomic sequencing identified 5 novel inactivating NOTCH1 mutations in 4 of the 37 tumors analyzed, with none of these tumors exhibiting HES1/HEY1 overexpression. Our results revealed a bimodal pattern of NOTCH pathway alterations in HNSCC, with a smaller subset exhibiting inactivating NOTCH1 receptor mutations but a larger subset exhibiting other NOTCH1 pathway alterations, including increases in expression or gene copy number of the receptor or ligands as well as downstream pathway activation. Our results imply that therapies that target the NOTCH pathway may be more widely suitable for HNSCC treatment than appreciated currently.

Recurrence patterns and management of oral cavity premalignant lesions

OBJECTIVE

To gain an understanding of head and neck mucosal premalignant recurrence and progression based on histology, treatment modality, and risk factors.

DESIGN

Retrospective chart review.

SETTING

Academic medical center.

PATIENTS

Patients who were followed or treated for oral cavity dysplasia/carcinoma in situ.

MAIN OUTCOMES MEASURES

Comparisons with clinical features, degree of dysplasia, anatomical location, rate of recurrences as well as malignant transformation and overall outcome were made.

RESULTS

Of the 136 patients who were included in the study, 20% (n = 27) initially presented with mild dysplasia, 39% (n = 53) with moderate dysplasia, 21% (n = 29) with severe dysplasia, and 20% (n = 27) with carcinoma in situ. Wide local excision (HR 0.54, p = 0.05) was associated with reduced local recurrence in comparison to observation. In comparison to observation, both wide local excision (HR 0.43, p = 0.04) and CO(2)/NO Yag laser treatment (HR 0.14, p = 0.02) of dysplastic lesions significantly reduced progression to cancer. Management of mild dysplasia included observation (n = 13), excision (n = 10) and laser therapy (n = 3). Six of the 13 observed patients suffered a premalignancy recurrence, whereas only 4 of the 13 patients who underwent excision/laser treatment experienced a recurrence. Similarly, 5/13 observed patients eventually progressed to malignancy in comparison to only 2/13 patients who underwent initial excision/laser treatment.

CONCLUSION

Wide excision and/or ablation of head and neck mucosal premalignancy is more effective than observation in preventing recurrence of premalignancy and progression to malignancy. Mild dysplasia has a potentially high rate of recurrence and progression to malignancy when observed, and may be treated by wide excision or ablation.

Epidemiology of Chronic Rhinosinusitis in Children

Objective: Although chronic rhinosinusitis (CRS) is common in children, the role of race/socioeconomic status (SES) has not been evaluated. We describe the epidemiology of children with CRS in an urban pediatric otolaryngology clinic and evaluate demographic differences compared to a group representative of the general pediatric otolaryngology population.

Method: Observational study (retrospective cohort with comparison group) of all new/consult patients (March 3, 2008, to July 1, 2011) in an urban tertiary pediatric otolaryngology clinic with diagnosis of CRS. The comparison group consisted of all new/consult patients seen in the same clinic over a 3-month period. Records were evaluated for demographics/insurance. Characteristics were compared between groups using Mann-Whitney and Fisher’s exact tests.

Results: 177 children with CRS were compared to 430 control patients. Compared to the general pediatric otolaryngology population, children with CRS were younger (5.9 ± 4.8 vs 8.2 ± 4.4, P < .0001) and more commonly male (62% vs 52%, P = .025). Compared to controls, more children with CRS were white (CRS 77% white; 10% black; 13% other vs control 47% white; 33% black; 20% other, P < .0001). Likewise, children with CRS were less commonly insured with Medical Assistance (CRS 14% vs control 43%, P < .0001).

Conclusion: Compared to the general population of children seen in this setting, children with CRS were more likely to be white/privately insured. This study is the first to evaluate race/SES in relation to pediatric CRS. Future research should employ nationally representative data to assess true variation of demographic factors in children with CRS.

Abstract 723: Detection of TIMP3 promoter hypermethylation in salivary rinse as an independent predictor of local recurrence-free survival in head and neck cancer

Objective: To validate a panel of methylation-based salivary rinse biomarkers (P16, CCNA1, DCC, TIMP3, MGMT, DAPK, and MINT31) previously shown to be independently associated with poor overall survival and local recurrence in a larger, separate cohort of patients with head and neck squamous cell carcinoma (HNSCC). Methods: One hundred ninety-seven patients were included. All pre-treatment saliva DNA samples were evaluated for the methylation status of the gene promoters by quantitative methylation-specific PCR. The main outcome measures were overall survival, local recurrence-free survival and disease-free survival. Results: In univariate analyses, the detection of hypermethylation of CCNA1, MGMT, and MINT31 was significantly associated with poor overall survival; the detection of hypermethylation of TIMP3 was significantly associated with local recurrence-free survival; and the detection of hypermethylation of MINT31 was significantly associated with poor disease-free survival. In multivariate analyses, detection of hypermethylation at any single marker was not predictive of overall survival in patients with HNSCC; detection of hypermethylation of TIMP3 in salivary rinse had an independent, significant association with local recurrence-free survival (Hazard Ratio, 2.51, 95% CI, 1.10 to 5.68); and none of the studied markers was significantly associated with disease-free survival. Conclusions: The detection of promoter hypermethylation of the seven genes in salivary rinse as an independent prognostic indicator of overall survival in patients with HNSCC was not validated. Detection of promoter hypermethylation of TIMP3 in pretreatment salivary rinse is independently associated with local recurrence-free survival in patients with HNSCC and may be a valuable salivary rinse biomarker for HNSCC recurrence. Such a test could potentially refine our ability to identify HNSCC patients at a high risk for recurrence.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 723. doi:1538-7445.AM2012-723

Comparison of promoter hypermethylation pattern in salivary rinses collected with and without an exfoliating brush from patients with HNSCC

BACKGROUND

Salivary rinses have been recently proposed as a valuable resource for the development of epigenetic biomarkers for detection and monitoring of head and neck squamous cell carcinoma (HNSCC). Both salivary rinses collected with and without an exfoliating brush from patients with HNSCC are used in detection of promoter hypermethylation, yet their correlation of promoter hypermethylation has not been evaluated. This study was to evaluate the concordance of promoter hypermethylation between salivary rinses collected with and without an exfoliating brush from patients with HNSCC. METHODOLGY: 57 paired salivary rinses collected with or without an exfoliating brush from identical HNSCC patients were evaluated for promoter hypermethylation status using Quantitative Methylation-Specific PCR. Target tumor suppressor gene promoter regions were selected based on our previous studies describing a panel for HNSCC screening and surveillance, including P16, CCNA1, DCC, TIMP3, MGMT, DAPK and MINT31.

PRINCIPAL FINDINGS

In salivary rinses collected with and without brush, frequent methylation was detected in P16 (8.8% vs. 5.2%), CCNA1 (26.3% vs. 22.8%), DCC (33.3% vs. 29.8%), TIMP3 (31.6% vs. 36.8%), MGMT (29.8% vs. 38.6%), DAPK (14.0% vs. 19.2%), and MINT31 (10.5% vs. 8.8%). Spearman's rank correlation coefficient showed a positive correlation between salivary rinses collected with and without brush for P16 (ρ = 0.79), CCNA1 (ρ = 0.61), DCC (ρ = 0.58), TIMP3 (ρ = 0.10), MGMT (ρ = 0.70), DAPK (ρ = 0.51) and MINT31 (ρ = 0.72) (P<0.01). The percent agreement of promoter methylation between salivary rinses with brush and without brush were 96.5% for P16, 82.5% for CCNA1, 78.9% for DCC, 59.7% for TIMP3, 84.2% for MGMT, 84.2% for DAPK, and 94.7% for MINT31.

CONCLUSIONS

Our study demonstrated strong correlations of gene promoter hypermethylation between salivary rinses collected with and without an exfoliating brush. Salivary rinse collection without using an exfoliating brush may offer a cost effective, rapid, non-invasive, and reliable means for development of epigenetic salivary rinse biomarkers.

Detection of TIMP3 promoter hypermethylation in salivary rinse as an independent predictor of local recurrence-free survival in head and neck cancer

PURPOSE

To validate a panel of methylation-based salivary rinse biomarkers (P16, CCNA1, DCC, TIMP3, MGMT, DAPK, and MINT31) previously shown to be independently associated with poor overall survival and local recurrence in a larger, separate cohort of patients with head and neck squamous cell carcinoma (HNSCC).

EXPERIMENTAL DESIGN

One hundred ninety-seven patients were included. All pretreatment saliva DNA samples were evaluated for the methylation status of the gene promoters by quantitative methylation-specific PCR. The main outcome measures were overall survival, local recurrence-free survival, and disease-free survival.

RESULTS

In univariate analyses, the detection of hypermethylation of CCNA1, MGMT, and MINT31 was significantly associated with poor overall survival; the detection of hypermethylation of TIMP3 was significantly associated with local recurrence-free survival; and the detection of hypermethylation of MINT31 was significantly associated with poor disease-free survival. In multivariate analyses, detection of hypermethylation at any single marker was not predictive of overall survival in patients with HNSCC; detection of hypermethylation of TIMP3 in salivary rinse had an independent, significant association with local recurrence-free survival (HR = 2.51; 95% CI: 1.10-5.68); and none of the studied markers was significantly associated with disease-free survival.

CONCLUSION

The detection of promoter hypermethylation of the seven genes in salivary rinse as an independent prognostic indicator of overall survival in patients with HNSCC was not validated. Detection of promoter hypermethylation of TIMP3 in pretreatment salivary rinse is independently associated with local recurrence-free survival in patients with HNSCC and may be a valuable salivary rinse biomarker for HNSCC recurrence.

Correlation of mucociliary clearance and symptomatology before and after adenoidectomy in children

OBJECTIVE

The goal of this study is to better understand the role of adenoid hypertrophy and its impact on mucociliary clearance as it relates to the symptoms of chronic sinusitis in children. More specifically, the goal is to better understand which symptoms of chronic rhinosinusitis might be most likely to improve in children undergoing an adenoidectomy.

METHODS

We conducted this study on 35 healthy children (>3 and <18 years of age), either male or female, who underwent adenotonsillectomy or adenoidectomy (with or without tympanostomy tube insertion). Eighteen patients completed pre- and postoperative surveys, with 10 also completing the Andersen's saccharine test (AST). The nasal mucociliary clearance will be evaluated with the AST, in which a saccharin particle (1.5mm diameter) is carefully placed on the floor of the nasal cavity approximately 1cm behind the anterior end of the inferior turbinate. The time taken by the subjects from placement of particle to the perception of the sweet taste will be taken as mucociliary clearance time (MCT). The length of the nasal cavity is measured intraoperatively as the distance between the upper medial incisor and the inferior edge of the soft palate. From these two values nasal mucociliary clearance velocity (MCV) (cm/min) can be calculated and assessed. This study took place at an academic institution.

RESULTS

Symptomatic improvement was seen in all categories, as measured by the mean score improvement postoperatively. The greatest improvements were seen in nasal obstruction (mean=2.67 points ± .59) on the symptom survey, and emotional distress (mean=2.56 ± .47) on the SN5 survey. Quality of life improved by a mean=2.61 ± .49. Both MCT and MCV improved postoperatively (mean 3.64 min ± .84 and mean 1.96 cm/min ±.90, respectively).

CONCLUSIONS

We believe this study has the potential to provide otolaryngologists across the country with a benchmark to communicate the specific symptomatic benefits from adenoidectomy.

"Redo" fundoplications: satisfactory symptomatic outcomes with higher cost of care

INTRODUCTION

With ever greater numbers of fundoplications being undertaken, inevitably there will be an increase in the number of failed fundoplications, which will be considered for operative revision. This study was undertaken to compare the hospital costs of and outcomes after "redo" fundoplications to those of "first time" fundoplications.

METHODS

Patients undergoing anti-reflux surgery were prospectively followed. From 2000 to 2006, costs of and outcomes after 76 "redo" fundoplications were compared with 76 concurrent "first time" fundoplications. Prior to and after fundoplication, patients scored the frequency and severity of many symptoms, including dysphagia, chest pain, regurgitation, choking, and heartburn, using a Likert scale (0 = none/never, 10 = severe/always). The cost of care, including medical equipment, operating room expenses, and anesthesia was determined with standardization to 2006 cost and dollars. Data are presented as median (mean +/- standard deviation) where appropriate.

RESULTS

Prior to "redo" fundoplications, patients reported significantly greater dysphagia frequency and severity scores and significantly greater chest pain severity. DeMeester scores for patients undergoing "redo" fundoplications versus "first time" fundoplications were similar (45 (62 +/- 55.6) versus 39 (44 +/- 27.7)). After fundoplication, dysphagia frequency and severity significantly improved for all patients. Length of stay was significantly longer for patients requiring "redo" fundoplications [3 d (6 +/- 8.5) versus 1 d (3 +/- 7.6)]. Hospital costs for patients undergoing "redo" fundoplications were significantly greater.

CONCLUSIONS

Patients requiring re-operative fundoplications report more frequent and severe symptoms, especially of dysphagia, when compared with patients undergoing "first-time" fundoplications. Laparoscopic "redo" fundoplications are technically challenging, more expensive, and more morbid (e.g., longer hospital stays). However, symptoms of reflux and dysphagia are ameliorated with "redo" fundoplications and application of "redo" fundoplication is warranted.

Upright, supine, or bipositional reflux: patterns of reflux do not affect outcome after laparoscopic Nissen fundoplication

INTRODUCTION

This study was undertaken to determine if the body position in which gastroesophageal reflux occurs before fundoplication--i.e., pattern of reflux--affects symptoms before or after laparoscopic Nissen fundoplication.

METHODS

A total of 417 patients with gastroesophageal reflux disease (GERD) underwent pH studies, and the severity of reflux in the upright and supine positions was determined. The percent time with pH less than 4 was used to assign patients to one of four groups: upright reflux (pH < 4 more than 8.3% of time in upright position, n = 80), supine reflux (pH < 4 more than 3.5% of time in supine position, n = 73), bipositional reflux (both supine and upright reflux, n = 163), or neither (n = 101). Before and after laparoscopic Nissen fundoplication, the frequency and severity of symptoms of reflux (e.g., dysphagia, regurgitation, choking, heartburn, chest pain) were scored on a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). For each patient, symptom scores before versus after fundoplication were compared using the Wilcoxon matched pairs test; comparisons of symptom scores among patients grouped by reflux patterns were made using Kruskal-Wallis test.

RESULTS

Before fundoplication, the patterns of reflux did not affect the frequency or severity of reflux symptoms. After laparoscopic fundoplication, all symptoms of bipositional reflux improved, and essentially all symptoms of isolated supine or upright reflux or neither improved.

CONCLUSIONS

Preoperatively, regardless of the patterns of reflux, symptoms among patients were similar. After fundoplication, symptoms of GERD improved for all patterns of reflux. Laparoscopic fundoplication imparts dramatic and broad relief of symptoms of GERD, regardless of the patterns of reflux. Application of laparoscopic Nissen fundoplication is encouraged.

Results after Laparoscopic Fundoplication: Does Age Matter?

Antireflux fundoplications are undertaken with hesitation in older patients because of presumed higher morbidity and poorer outcomes. This study was undertaken to determine if symptoms of gastroesophageal reflux disease (GERD) could be safely abrogated in a high-risk/reward population of older patients. One hundred eight patients more than 70 years of age (range, 70–90 years) underwent laparoscopic Nissen fundoplications undertaken between 1992 and 2005 and were compared with 108 concurrent patients less than 60 years of age (range, 18–59 years) to determine relative outcomes. Before and after fundoplication, patients scored the severity of reflux and dysphagia on a Likert Scale (0 = minor, 10 = severe). Before fundoplication, older patients had lower reflux scores ( P < 0.01), but not lower dysphagia scores or DeMeester scores. One patient (86 years old) died from myocardial infarction; otherwise, complications occurred infrequently, inconsequentially, and regardless of age. At similar durations of follow-up, reflux and dysphagia scores significantly improved ( P < 0.01) for older and younger patients. After fundoplication, older patients had lower dysphagia scores ( P < 0.01) and lower reflux scores ( P < 0.01). At the most recent follow-up, 82 per cent of older patients rated their relief of symptoms as good or excellent. Similarly, 81 per cent of the younger patients reported good or excellent results. Ninety-one per cent of patients 70 years of age or more versus 85 per cent of patients less than 60 years would undergo laparoscopic Nissen fundoplication again, if necessary. With fundoplication, symptoms of GERD improve for older and younger patients, with less symptomatic dysphagia and reflux in older patients after fundoplication. Laparoscopic fundoplication safely ameliorates symptoms of GERD in elderly patients with symptomatic outcomes superior to those seen in younger patients.

Results after laparoscopic fundoplication: does age matter?

Antireflux fundoplications are undertaken with hesitation in older patients because of presumed higher morbidity and poorer outcomes. This study was undertaken to determine if symptoms of gastroesophageal reflux disease (GERD) could be safely abrogated in a high-risk/reward popu lation of older patients. One hundred eight patients more than 70 years of age (range, 70-90 years) underwent laparoscopic Nissen fundoplications undertaken between 1992 and 2005 and were compared with 108 concurrent patients less than 60 years of age (range, 18-59 years) to determine relative outcomes. Before and after fundoplication, patients scored the severity of reflux and dysphagia on a Likert Scale (0 = minor, 10 = severe). Before fundoplication, older patients had lower reflux scores (P < 0.01), but not lower dysphagia scores or DeMeester scores. One patient (86 years old) died from myocardial infarction; otherwise, complications occurred infrequently, inconsequentially, and regardless of age. At similar durations of follow-up, reflux and dysphagia scores significantly improved (P < 0.01) for older and younger patients. After fundoplication, older patients had lower dysphagia scores (P < 0.01) and lower reflux scores (P < 0.01). At the most recent follow-up, 82 per cent of older patients rated their relief of symptoms as good or excellent. Similarly, 81 per cent of the younger patients reported good or excellent results. Ninety-one per cent of patients 70 years of age or more versus 85 per cent of patients less than 60 years would undergo laparoscopic Nissen fundoplication again, if necessary. With fundoplication, symptoms of GERD improve for older and younger patients, with less symptomatic dysphagia and reflux in older patients after fundoplication. Laparoscopic fundoplication safely ameliorates symptoms of GERD in elderly patients with symptomatic outcomes superior to those seen in younger patients.