The influence of obesity on operating room time and perioperative complications in cochlear implantation

ObjectiveThe rising incidence of obesity in the United States is associated with increased healthcare expenditures and resource allocation. Obesity has been associated with prolonged operating times during surgical procedures. The primary objective of this study is to compare body mass index (BMI) to length of surgery during cochlear implantation.MethodsA retrospective case control study from a tertiary academic referral center was performed. Patients included were adults who underwent primary, single-sided cochlear implantation with documented BMI and operating room (OR) times from January 2009 to July 2015. The following data were collected: BMI, total operating room time (TORT), surgical operating room time (SORT), ASA status, perioperative and postoperative complications, age, and gender.ResultsTwo hundreds and thirty-four patients were included and stratified into obese (BMI >30) and non-obese (BMI < 30) categories. Statistical analysis was performed comparing TORT against the obesity category along with other variables. Independent sample t-test demonstrated that obesity increases TORT and SORT by 16.8 min (P = 0.0002) and 9.3 min (P = 0.03), respectively, compared to the non-obese group. Multivariate linear regression analysis demonstrated no statistically significant impact of gender, or ASA status on total operating or surgical time. Obesity was associated with increased perioperative complications (odds ratio [OR], 6.21; 95% CI, 1.18–32.80; P = 0.03) and postoperative complications (OR, 3.97; 95% CI, 1.29–12.26; P = 0.02).ConclusionsObesity leads to longer TORT and SORT during primary cochlear implant surgery. Obesity is also associated with increased perioperative and postoperative complications compared to non-obese patients. These data have implications with utilization of operating room resources.     

Nasopharyngectomy with operating microscope: A case series

Background

Nasopharyngectomy for excision of nasopharyngeal tumors is challenging, as access to the nasopharynx is difficult. Recently our institution embarked on two new approaches – robotic nasopharyngectomy and open nasopharyngectomy with operating microscope (NOM) via maxillary swing approach. This article proposes that the novel approach of NOM via maxillary swing aids visualization for resection of locally invasive nasopharyngeal tumors.

Utility of response assessment PET-CT to predict residual disease in neck nodes: A comparison with the Histopathology

ObjectiveTo assess the ability of Positron Emission Tomography-Computed Tomography (PET-CT) scans to detect residual disease in neck nodes with the Histopathology (HPR) as the gold standard. To obtain a Standardized Uptake Value max cutoff in these patients to predict residual disease in neck.MethodsHead and neck squamous cell carcinoma patients who underwent Salvage neck dissection with or without primary site surgery post Concurrent Chemo-Radiotherapy (CCRT) during the period January 2008–December 2017 were included. All patients had response assessment PET-CT scan at 10–14 weeks. Agreement analysis was performed between PET-CT and HPR, fine needle aspiration cytology and HPR. Positive predictive value, Negative predictive value of PET-CT to detect residual neck nodal disease in comparison to HPR was analyzed. A Receiver Operating Characteristic (ROC) curve was plotted between the SUV max values and the HPR. A SUV max cutoff value was obtained from the ROC curve.ResultsA total of 75 patients were included. Thirty-one underwent salvage neck dissection along with surgery for primary disease and 45 underwent salvage neck dissection alone. PET-CT showed good agreement with the HPR to detect residual disease in neck nodes (Kappa = 0.604). PET-CT had a PPV and NPV of 87.5% and 79.15% respectively as compared against the HPR. A SUV max cutoff of 4.62 had a specificity of 92.3% and sensitivity of 73.5% to detect residual disease in neck nodes on the HPR.ConclusionPET-CT surveillance is an accepted treatment strategy. A neck node with SUV max of 4.62 and above is most likely to harbor residual nodal disease.Level of evidence: Level 2b     

Auditing of operating room times: A quality improvement project

Objective

A quality improvement project to evaluate operating room efficiency and utilization and to identify areas for improvement.

Methods

A retrospective assessment of a single surgeon's surgical cases over a 6-month period at a tertiary children's hospital. Primary outcomes included case timing defined as T1, T2, T3 and T4. (T1)—Patient enters OR-to-procedure start. (T2)—Procedure start-to-procedure end. (T3)—Procedure end-to-patient exits OR. (T4)—Patient exits OR-to-next patient enters OR (turnover). Comparison to existing literature was performed and results were presented to stakeholders.

Results

A total of 180 surgical cases were reviewed, 92 adenotonsillectomies (T&A), 33 Bilateral Pressure Equalization Tube Placement (PET) and 55 microlaryngoscopies and bronchoscopies (MLB). All outcomes were calculated by case type, except T4, and compared to available published data. T2 was compared to published benchmarks for otolaryngology demonstrating favorable operative times for T&A and PET. However, T4 was considerably longer at our institution (average 31.09). Overall OR efficiency was 20.58%.

Conclusions

The operating room represents one of a hospital's most costly resources. Ensuring that this resource is designed, staffed and utilized efficiently is of major importance to both the quality of patient care and financial productivity. Surgeons are key components of operating room efficiency, utilization and other measurements of institutional performance. How surgeons schedule and perform cases directly impacts, and is impacted by, these measurements of performance. For fields dominated by high volume, short duration procedures such as pediatric otolaryngology, T4 may be the most important variable in determining OR efficiency. By utilizing modern electronic medical records, surgeons can easily track OR time points thereby determining the potential causes of and solutions for OR inefficiency.     

A retrospective review of 14 cases of malignant otitis externa

BackgroundMalignant otitis externa is an inflammatory condition of the external ear which has the propensity to spread to the skull base. It can be a difficult entity to treat as clinical presentation varies and response to treatment differs between patients. We reviewed cases of malignant otitis externa in our setup to document the epidemiology and outcome of management.MethodsThis is a retrospective case review observational study from January 2013–December 2017. Fourteen patients diagnosed with malignant otitis externa in our tertiary referral centre were included in the study. Based on hospital protocol, empiric treatment was started. After discharge, the patients follow up visits to the hospital were also documented.ResultsOtalgia was the most common symptom. Edema and congestion of the external auditory canal were observed in most cases. Diabetes was present in all patients. Three cases had associated facial palsy, and one patient had involvement of 7th, 9th, 10th, 11th and 12^th cranial nerve. Two patients with facial palsy recovered. Pseudomonas aeuroginosa was the most common organism isolated (50%).ConclusionsIn our series, malignant otitis externa invariably presented with severe otalgia. Lower cranial palsies were also seen. Methods to evaluate complete eradication of disease should be centered on clinical symptoms and signs, but the measurement of erythrocyte sedimentation rate or radiological imaging may be used as a useful adjunct when there is uncertainty.     

Peripheral neck nerve tumor: A 73-case study and literature review

ObjectivesPeripheral neck nerve tumors are rare and mostly benign neoplasms. The exceptional malignant forms are very aggressive, and diagnosis is difficult. The objective of this study was to evaluate diagnostic and therapeutic management and identify possible predictive factors.Material and methodsA retrospective study was conducted of 73 patients treated for peripheral neck nerve tumor between 1995 and 2015.ResultsMean age was 44 years. The main presenting symptom was a cervical mass, isolated or associated with signs related to the affected nerve structure. Diagnosis was suspected by slow progression of a firm mass, featuring T1 hyposignal and T2 hypersignal on magnetic resonance imaging. Surgery was performed in 99% of cases, completed by adjuvant chemotherapy in case of malignant neuroblastic tumor. Type 1 neurofibromatosis and sudden increase in mass with or without associated pain suggested malignant transformation. Age below 10 years suggested neuroblastic tumor.ConclusionNeck nerve tumors are very often benign with low degenerative potential. Surgery is the treatment of choice after risk/benefit analysis. However, there is no clearly defined consensus regarding the timing of surgery for these lesions.     

Depression and anxiety levels in mothers of children with epistaxis: A controlled study

IntroductionPediatric epistaxis is very common. A child's illness can lead to depression and anxiety in the parents. The association between pediatric epistaxis and mothers’ anxiety has not been well documented.ObjectiveThe present study is aimed at measuring depression and anxiety levels in mothers of children with mild, recurrent epistaxis.MethodsThis prospective, clinical, questionnaire-based study examined 43 mothers of children with recurrent epistaxis and 42 mothers of healthy children. The depression and anxiety levels of the mothers in both the groups were assessed with the Beck Depression Inventory (BDI), the state-trait anxiety inventory–state (STAI-S), and the state-trait anxiety inventory–trait (STAI-T).ResultsNo statistically-significant differences were found between the two groups of mothers in terms of educational level, employment, age, or economic status. The mean STAI-S scores were higher in the mothers of children with epistaxis (p = .010). However, no statistically-significant differences were found between the two groups for the BDI and STAI-T scores.ConclusionsThe results of this comparative study suggest that mild, recurrent epistaxis in children can significantly increase their mothers’ state anxiety levels, but epistaxis has no significant effect on either depression or trait anxiety.     

Oral benign neoplasms: A retrospective study of 790 patients over a 14-year period

Introduction and objectiveOral benign neoplasms (OBNs) exhibit some features that can guide the professionals to the correct diagnosis and best treatment. Through retrospective studies, medical records can be reviewed to better describe a given population and, furthermore, help clinicians in routine practice. In this context, the objective of this paper was to analyze the cases of OBNs of an oral pathology referral department, from 2003 to 2017, in order to better understand their epidemiological and clinicopathological characteristics.MethodsA total of 8355 histopathological reports were analyzed. Lesions diagnosed as OBNs were selected and the following variables were recorded: gender, age, histological type of the lesion, anatomical location, rate and pattern of growth, type of base, color, symptomatology and diagnostic hypotheses on clinical examination.ResultsOBNs represented 9.4% of all lesions diagnosed. The most frequent histopathological types were fibroma (39.9%), papilloma (22%), fibroblastoma (13.1%), lipoma (10.2%) and hemangioma (6.1%). Overall, most cases affected females (n = 518; 65.6%) and in the fifth decade of life (n = 148; 18.7%). The oral mucosa was the most common site (n = 265; 33.5%). The most common features of each OBN were also highlighted.ConclusionThe most common OBNs were fibroma, papilloma, fibroblastoma, lipoma and hemangioma. Overall, the OBN presented common clinical features; however, in particular cases, there are some characteristics that can lead the professionals to the correct diagnosis. Nevertheless, in general, histopathological analysis must be performed to confirm diagnosis. Intraosseous tumors and large lesions may require imaging tests to help diagnosis.     

Intraoperative bacterial analysis in nasal polyposis: Clinical and functional impact

BackgroundThe impact of Staphylococcus aureus on onset of nasal polyposis has been the focus of numerous studies, but there have been few studies of other germs found in the ethmoid of operated patients or of their impact on post-operative results.Material and methodsAll patients undergoing endoscopic radical ethmoidectomy for nasal polyposis in the teaching hospital of Nantes (France) between 2006 and 2016 had intraoperative ethmoid cavity bacterial sampling. Phenotypic characteristics, pre- and post-operative symptoms and endoscopic findings were analyzed. Mann–Whitney tests and Kruskal–Wallis correlation analysis were used to assess clinical/bacteriological correlations.ObjectivesThe main objective was to describe bacterial colonization of patients undergoing surgery for nasal polyposis, and to assess correlations with phenotypic features, functional results and postoperative clinical course.ResultsOne hundred and seven patients were included. A total of 26% were not infected, 55% mono-infected and 19% multi-infected. In 27.3%, staphylococci were isolated; in 30.5%, isolates were gram-negative bacilli. There were no significant correlations between presence or type of pathogen and symptom profile.ConclusionThis study confirmed the high rate of pathogenic bacteria in nasal cavities in case of polyposis, with high frequencies of S. aureus but also of gram-negative bacilli, raising the question of their involvement in the inflammatory reactions underlying the nasal polyposis.     

Spondylodiscitis after transoral robotic surgery: Retrospective 7-case series from the GETTEC group

BackgroundCervical spondylodiscitis is a rare but severe complication of pharyngeal surgery.Material and methodsThis multicenter retrospective study reported all patients in the database of the French head and neck tumor study group (GETTEC) affected by cervical spondylodiscitis after transoral robotic surgery (TORS) for malignant pharyngeal tumor from January 2010 to January 2017.ObjectivesTo describe cases of post-TORS cervical spondylodiscitis, identify alarm signs, and determine optimal management of these potentially lethal complications.ResultsSeven patients from 6 centers were included. Carcinomas were located in the posterior pharyngeal wall. Tumor stage was T1 or T2. All patients had risk factors for spondylodiscitis. Mean time to diagnosis was 12.6 days. The interval between surgery and spondylodiscitis diagnosis ranged from 20 days to 4.5 months, for a mean 2.1 months. The most common symptom was neck pain (87%). Infections were polymicrobial; micro-organisms were isolated in 5 cases and managed by intravenous antibiotics, associated to medullary decompression surgery in 3 cases. Follow-up found favorable progression in 4 cases, and 3 deaths (mortality, 43%).ConclusionThis French multicenter study found elevated mortality in post-TORS spondylodiscitis, even in case of limited resection. Surgeons must be aware of this complication and alerted by persistent neck pain, fever, asthenia, impaired or delayed posterior pharyngeal wall wound healing or elevation of inflammatory markers. MRI is the most effective diagnostic radiological examination.     

Pyogenic granuloma of the larynx: A rare cause of hemoptysis

Pyogenic granuloma (PG) may involve gingival mucosa (granuloma gravidarum) in pregnancy but rarely involves the airway. This case report is perhaps the only reported presentation of PG in the larynx causing hemoptysis at a late stage of pregnancy. On laryngoscopic exam, a vascular, right false vocal fold neoplasm was identified with pathological characteristics consistent with PG. Conclusions: Pyogenic granuloma is a relatively common tumor of pregnancy but rarely involves the larynx. In the case of airway involvement during pregnancy, it is best managed in coordination with the high-risk obstetrical team and can be removed safely via standard microsurgical techniques.     

Cystic form of cervical lymphadenopathy. Guidelines of the French Society of Otorhinolaryngology - Head and Neck Surgery (SFORL). Part 1: Diagnostic procedures for lymphadenopathy in case of cervical mass with cystic aspect

ObjectivesThe authors present the guidelines of the French Society of Otorhinolaryngology - Head and Neck Surgery Society on diagnostic procedures for lymphadenopathy in case of a cervical mass with cystic aspect.MethodsA multidisciplinary work-group was entrusted with a review of the scientific literature on the topic. Guidelines were drawn up, then read over by an editorial group independent of the work-group, and the final version was drawn up. Guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence.ResultsIn adults presenting a cystic cervical mass, it is recommended to suspect cervical lymphadenopathy: in order of decreasing frequency, cystic metastasis of head and neck squamous cell carcinoma, of undifferentiated nasopharyngeal carcinoma, and of thyroid papillary carcinoma (Grade C). On discovery of a cystic cervical mass on ultrasound, architectural elements indicating a lymph node and a thyroid nodule with signs of malignancy should be screened for, especially if the mass is located in levels III, IV or VI (Grade A). Malignant lymphadenopathy should be suspected in case of cervical mass with cystic component on CT (Grade B), but benign or malignant status cannot be diagnosed only on radiological data (CT or MRI) (Grade A), and 18-FDG PET-CT should be performed, particularly in case of inconclusive ultrasound-guided fine needle aspiration biopsy (Grade C).     

The folded postauricular flap: A novel approach to reconstruction of large full thickness defects of the conchal bowl

Extensive subtotal full-thickness auriculectomy defects pose a challenge for the reconstructive surgeon. The posterior island flap (PIF), based on the posterior auricular artery, has been described as a reconstructive option for auricular defects, with reports describing a “pull-through” or “revolving door” technique to reconstruct subtotal partial thickness and full thickness auricular defects. These techniques may result in posterior “pinning” of the auricle. This patient is an 87-year-old male who presented after Mohs excision of squamous cell carcinoma of the conchal bowl, which resulted in a 4x4cm subtotal auriculectomy defect. A folded PIF was used to reconstruct the large full thickness defect, in a multistage manor. Post-operatively, the patient had a reconstructed auricle that was suitable for wearing hearing aids and glasses. We describe a novel technique of the folded PIF for an extensive full-thickness auricular defect, which utilizes a single, well camouflaged donor site, provides well-vascularized local tissue with excellent color match, and allows for the restoration of the post-auricular sulcus.     

The profound oral cavity cancer burden in the United States Commonwealth of the Northern Mariana Islands: A global health opportunity

PurposeBetel nut consumption contributes to higher rates of oral cavity cancer throughout Micronesia. The purpose of this study is to review local surveys and cancer data to further characterize these issues in the Northern Mariana Islands (CNMI).MethodsTwo commonwealth-wide health inquiries were reviewed: The Non-Communicable Diseases Survey (NCDS), 2016 and The Youth Risk Behavior Survey (YRBS), 2013. Data pertaining to betel nut, tobacco and alcohol use was extracted. Relevant cancer data from the Commonwealth Healthcare Corporation (CHC) of Saipan and the Surveillance, Epidemiology, and End Results (SEER) databases was assessed.ResultsBetel nut chewing was reported by 43% of Asian Pacific Islander (API) adults, with 88% adding tobacco to the chew. Adults aged 20–30 had significantly higher rates of chewing relative to older groups (p < .0001). Tobacco smoking and alcohol use were reported by 25% and 23% of adults, respectively. Betel nut chewing was reported by 33% of high school students. From 2007 to 2016, oral cavity cancers contributed to 9% of all cancer diagnoses and 13% of cancer-related mortalities. SEER data supported oral cavity cancer diagnoses at younger ages in APIs.ConclusionThese results demonstrate concerning trends regarding alcohol, tobacco and betel nut use in the CNMI. Betel nut use is prevalent among APIs of nearly all ages, with the majority adding tobacco to their chew. The available data suggests a drastic oral cavity cancer burden in the CNMI. Efforts should be made to evaluate for effective means of primary and secondary prevention in API regions.     

Carcinoma ex pleomorphic adenoma: A review of incidence,demographics, risk factors,and survival

PurposeIdentify variables that are independent predictors of survival in carcinoma ex pleomorphic adenoma (CXPA) of the major salivary glands using a population-based database and evaluate the incidence and management strategies for this rare malignancy.Materials and MethodsThe Surveillance, Epidemiology, and End Results (SEER) database was queried for all cases of major salivary gland CXPA from 1973 to 2015.ResultsOf the 619 patients identified, the parotid gland was the most common site of involvement (76.9%, 476/619). The reported incidence of CXPA has risen in the past decade (2005–2015, 0.24 to 0.63 per 1,000,000). The 2-year and 5-year disease-specific survival (DSS) rates were 90.3% and 80.4%, respectively. On univariate analysis, facial nerve sacrifice was not a statistically significant predictor of survival (HR = 1.213, 95% CI [0.588–2.058], P = 0.602). Patients with a tumor size >4 cm, multiple positive lymph nodes, and distant metastatic disease had a 2 to 4-fold statistically significant increase in mortality using a multivariate analysis. Statistical significance was not demonstrated in the DSS of patients who underwent partial versus total parotidectomy procedures.ConclusionsCXPA is a rare salivary malignancy that has a reported increased incidence in the last decade. Tumor size >4 cm, multiple positive lymph nodes, and distant metastatic disease are predictors of disease-specific mortality. Further research should be conducted to improve early detection and survival strategies for this salivary cancer.Level of Evidence: 4.