Successful Reimplantation of Extruded Lead after Hypoglossal Nerve Stimulation Surgery

Infection and extrusion of hardware are known complications of hypoglossal nerve stimulation surgery. We present a unique case of an extruded hardware lead successfully managed with reimplantation without need for explantation and new device placement. The topic will be discussed in context of the body of literature related to extruded medical device management. Laryngoscope, 133:2821-2822, 2023.

Oral corticosteroid use and the risk of developing avascular necrosis; a large retrospective review

INTRODUCTION

The risk of adverse events, specifically avascular necrosis (AVN), associated with corticosteroid use is not well reported. The aim of this study was to evaluate the prevalence of AVN among patients with prior oral corticosteroid administration.

METHODS

An institutional database query recognized 113,734 adult patients with oral corticosteroid administration between 2006 and May 2017. A temporal query performed on this cohort determined that 789 had a diagnosis of AVN following oral corticosteroids. A retrospective review was performed on this cohort. Data collected included demographics, co-morbidities, date of initial oral corticosteroid exposure, and time-to-diagnosis of AVN. Records without radiographic confirmation of AVN were excluded from analysis. Patients with cumulative lifetime dosages greater than 10,000 mg prednisone were excluded from analysis.

RESULTS

789 patients with oral corticosteroid use prior to diagnosis of AVN were identified. 572 patients were excluded due to insufficient documentation of oral corticosteroid dosage, no radiographic evidence supporting the diagnosis of AVN, insufficient data confirming the temporal relationship between oral corticosteroids and AVN, and/or a cumulative dosing of > 10,000 mg prednisone. This left 217 patients included in the analysis. The mean duration of use prior to diagnosis of AVN was 219 (± 374) days and mean cumulative dose was 3314 (± 2908) mg prednisone-equivalents. Mean time between diagnosis of AVN and onset of pathologic fracture was 379 (± 1046) days.

CONCLUSION

For patients receiving low cumulative doses of oral corticosteroids, corticosteroids pose a small risk of development of AVN. More studies are required to better characterize risk. This article is protected by copyright. All rights reserved.

Parental and provider perspectives on social media about ankyloglossia

OBJECTIVES

To investigate and identify the concerns and opinions expressed in both parental and provider posts on social media about ankyloglossia.

METHODS

In this study, posts on Twitter between 1/1/2008 and 12/31/2018 were collected using search terms and hashtags specific to pediatric ankyloglossia. The search terms included a primary phrase to indicate ankyloglossia along with a pediatric identifier. Tweets that met inclusion criteria were analyzed qualitatively via conventional content analysis. After all tweets were categorized, descriptive statistics were completed to determine frequency of each theme.

RESULTS

In total, 5951 tweets were retrieved. Parents authored 982 (16.5%) of tweets, and 782 (13.1%) were by providers. The remaining 4187 tweets did not fit criteria for either the parent or provider groups. Amongst parents, the most common themes mentioned were feeding problems (309 tweets [32.4%]), followed by lip tie (215 [22.5%]), anxiety or emotion (207 [21.7%]), and maternal breastfeeding complications (127 [13.3%]). The number of tweets about ankyloglossia and frenotomy in 2018 had increased by 2395% since 2009. Amongst providers, 215 tweets were judged by the coders to provide an opinion on ankyloglossia, of which 94.4% had a pro-frenotomy sentiment. When a specialty was identified, tweets were most often by dentists (250 [31.9%]), followed by lactation consultants and International Board Certified Lactation Consultants (IBCLCs) (157 [29.7%]) and non-otolaryngologist physicians (79 [10.1%]). Otolaryngologists accounted for 8.7% (68 tweets) of posts about ankyloglossia.

CONCLUSION

Our findings demonstrate the spectrum of opinions that exist among both parents and providers about ankyloglossia. This can aid in shared-decision making by enabling the counseling provider to guide recommendations based on medical evidence with the understanding that there is a large amount of non-scientific information and opinions disseminated that may be shaping decisions.

Dermal Fillers for Tear Trough Rejuvenation: A Systematic Review

There is significant variation in treatment parameters when treating the infraorbital region. Thorough knowledge of these pertinent factors, choice of the optimal filling material, and proper understanding of the anatomy of this unforgiving region will contribute to a safe, effective, and natural result. We aim to conduct a systematic review of published literature related to soft tissue fillers of the tear trough and infraorbital region. A search of published literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and included PubMed, Embase, and Science Direct databases. The Medical Subject Headings (MeSH) terms used were "tear trough" OR "infraorbital" AND "dermal filler" OR "hyaluronic acid" OR "poly-L-lactic acid" OR "calcium hydroxyapatite" OR "Restylane" OR "Radiesse" OR "Perlane" OR "Juvéderm" OR "Belotero." Different combinations of these key terms were used. The initial search identified 526 articles. Six additional articles were identified through references. Two-hundred twenty-five duplicates were removed. A total of 307 studies were screened by title and abstract and 258 studies were eliminated based on inclusion and exclusion criteria. Forty-nine articles underwent full-text review. The final analysis included 23 articles. Patient satisfaction was high, and duration of effect ranged from 8 to 12 months. Restylane was most commonly used. Injection technique varied, but generally involved placing filler pre-periosteally, deep to orbicularis oculi muscle, anterior to the inferior orbital rim via serial puncture or retrograde linear threading with a 30-gauge needle. Topical anesthetic was most commonly used. Side effects were generally mild and included bruising, edema, blue-gray dyschromia, and contour irregularities. Nonsurgical correction of the tear trough deformity with soft tissue filler is a minimally invasive procedure with excellent patient satisfaction with long-lasting effects. It is essential to have a fundamental understanding of the relevant anatomy and ideal injection technique to provide excellent patient outcomes and prevent serious complications.

Nocardia farcinica Brain Abscess in an Immunocompetent Host With Pulmonary Alveolar Proteinosis: A Case Report and Review of the Literature

A 55-year-old immunocompetent male presented with new-onset seizures and acute respiratory failure requiring intubation and a stay in the medical intensive care unit. Magnetic Resonance Imaging (MRI) of the brain revealed ring-enhancing lesions, and Computed Tomography (CT) chest showed ground-glass opacity. The patient underwent craniotomy and bronchoscopy, followed by culture of the purulent aspirate from lesions in the brain and bronchoalveolar lavage (BAL). After extensive infectious workup, the patient was diagnosed with a Nocardia farcinica brain abscess plus underlying pulmonary alveolar proteinosis (PAP). Based on a recommendation from an infectious disease expert, the patient was treated with trimethoprim-sulfamethoxazole (TMP/SMX).

This case highlights the importance of understanding that, though rare, infections such as nocardiosis can present in immunocompetent patients and cause severe morbidity.

Does my patient have a pulmonary embolism? The Wells vs. PISA 2 rule in orthopedic patients

The diagnosis of venous thromboembolism is difficult in the postoperative setting because signs such as hypoxemia, leg pain, and swelling are so common. CTPA can also detect subsegmental PE (SSPE), of which the clinical significance has been widely debated. Clinical decision rules (CDR), such as the Wells and PISA 2, have been developed to identify symptomatic patients at low risk for PE who could forgo imaging. We performed this study in order to (1) compare the performance of the Wells and PISA 2 CDR in orthopedic patients; (2) compare CDR scores in patients with subsegmental PE (SSPE) versus larger clots; and (3) identify variables that improve performance of the Wells in orthopedic patients. This retrospective cohort study included all orthopedic surgery patients that underwent computerized tomographic pulmonary angiography at a single institution from 1/1/13 to 12/31/14 and had data to calculate both Wells and PISA 2 scores. CDR sensitivity, specificity and c-statistics were calculated. Multivariable logistic regression was used to identify variables that improved CDR performance. 402 patients were included in the study. The Wells rule (cutoff > 4) had sensitivity 74% and specificity 45%. PISA 2 (cutoff 0.6) had sensitivity 90% and specificity 11%. The Wells performed better than PISA 2: c-statistic 0.60 vs. 0.50; p = 0.007. The mean Wells score was 5.20 ± 1.68 for patients with SSPE and 5.41 ± 1.86 for patients with larger clots. Adding the variables prior smoking and varicose veins improved the performance of the Wells rule (c-statistic 0.66 vs. 0.60, p = 0.008). The Wells rule (cutoff > 4) performs better than PISA 2 in orthopedic patients. Neither can distinguish patients with SSPE from those with larger clots. Although adding past smoking and varicose veins to the Wells improves its performance, this requires validation in other populations.