Chronic Aspiration Pneumonitis Caused by Spontaneous Cerebrospinal Fluid Fistulae of the Skull Base

xlomafota13 shared this article with you from Inoreader Chronic Aspiration Pneumonitis Caused by Spontaneous Cerebrospinal Fluid Fistulae of the Skull Base Via The Laryngoscope Objectives/Hypothesis Spontaneous cerebrospinal fluid (CSF) leaks of the skull base are associated with obesity, multiparity, and elevated intracranial pressure. Although spontaneous CSF leaks often present with rhinorrhea, they can be an underdiagnosed cause of chronic aspiration pneumonitis, a complication that has not been previously reported in detail. Study Design Retrospective case series. Methods The authors retrospectively reviewed all patients undergoing surgical repair of CSF fistulae at the University of Southern California between 2011 and 2018 to identify those presenting with pulmonary symptoms including dyspnea, aspiration, chronic cough, and shortness of breath caused by chronic noniatrogenic CSF pneumonitis. Results Symptomatic chronic pneumonitis was evident in six of 20 patients with spontaneous CSF rhinorrhea. Five women (mean body mass index = 36) had CSF leaks arising from the fovea ethmoidalis (n = 4) and lateral sphenoid region (n = 1). One man had a middle fossa floor dehiscence draining through the eustachian tube. All patients had bilateral ground‐glass opacities in their lungs on computed tomography imaging that were attributed to spontaneous CSF fistulae arising from noniatrogenic skull base defects, and one patient underwent a biopsy of a lung lesion at another hospital showing chronic bronchiolitis and adjacent peribronchiolar metaplasia. Five patients underwent endoscopic endonasal repair using an autologous fascial graft and pedicled nasoseptal flap, and one underwent craniotomy for repair. All patients underwent successful repair with no complications or evidence of recurrence. Upon repair of the spontaneous CSF leaks, both pneumonitis symptoms and ground‐glass opacities on imaging resolved in all six cases. Conclusions Skull base CSF fistulae should be considered as a reversible cause of chronic pneumonitis that is not alleviated or worsens with standard treatment. Level of Evidence 4 Laryngoscope, 131:462–466, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Management and Outcomes of Sporadic Vestibular Schwannoma: A Longitudinal Study Over 12 Years

xlomafota13 shared this article with you from Inoreader Management and Outcomes of Sporadic Vestibular Schwannoma: A Longitudinal Study Over 12 Years Via The Laryngoscope Objectives To evaluate the management of sporadic vestibular schwannomas (VS) with a 12‐year follow‐up. Study Design Retrospective study of all VS patients initially treated in 2005 in a tertiary referent center. Methods Initial decision making for microsurgical resection (MSR) or wait‐and‐scan (WaS) was according to VS size and hearing; subsequently, MSR or stereotactic radiosurgery (SRS) was proposed dependent on VS growth and size, hearing, and patient's age or willingness. Results Two hundred and one sporadic VS were included. The first management apportionment was 120 WaS (61.5%), 72 MSR (37%), three SRS (1.5%), and six others refused MSR and were lost to follow‐up (LFU). Within 1 year, 95 (47%) VS were surgically removed; 17 (8.5%) were treated by SRS; and 35 (17.5%) were LFU. The proportions for SRS and LFU were virtually unchanged for the following years, and the proportion under MSR increased slightly within 3 years and then remained stable. Finally, at 12 years, 104 (51.5%) cases had been operated on, 21 (10.5%) treated by SRS, 23 (11.5%) still under WaS, and 53 (26.5%) LFU, which were mainly intracanalicular. The initially and subsequently operated cases presented similar hearing preservation rates and good facial nerve function outcomes. Conclusion This longitudinal study of a large number of VS, which were diagnosed over a short period of time and followed for 12 years, provides new information on both the natural history of these benign tumors and individual patient concerns. This study recommends use of the WaS policy for small and mid‐sized VS before active therapeutic decision making. Level of Evidence 3 Laryngoscope, 131:E970–E976, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Retropharyngeal Internal Carotid Artery Management in TORS Using Microvascular Reconstruction

xlomafota13 shared this article with you from Inoreader Retropharyngeal Internal Carotid Artery Management in TORS Using Microvascular Reconstruction Via The Laryngoscope Objectives Guidelines for transoral robotic surgery (TORS) have generally regarded patients with retropharyngeal carotid arteries as contraindicated for surgery due to a theoretical risk of intraoperative vascular injury and/or perioperative cerebrovascular accident. We aimed to demonstrate that careful TORS‐assisted resection and free flap coverage could not only avoid intraoperative injury and provide a physical barrier for vessel coverage but also achieve adequate margin control. Study Design: Retrospective cohort analysis. Methods Retrospective review of patients with oropharyngeal malignancies and radiologically confirmed retropharyngeal carotid arteries who underwent TORS, concurrent neck dissection, and free flap reconstruction between 2015 and 2019. Results Twenty patients were included, 19 (95.0%) with tonsillar tumors and one (5.0%) with a tongue base tumor with significant tonsillar extension. Eighteen patients (90.0%) received a radial artery forearm flap, one (5.0%) an ulnar artery forearm flap, and one (5.0%) an anteromedial thigh flap. All 20 (100%) flaps were inset through combined transcervical and transoral approaches without mandibulotomy. There were no perioperative mortalities, carotid injuries, oropharyngeal bleeds, cervical hematomas, or cerebrovascular accidents. One patient (5.0%) had a free flap failure requiring explant. All patients underwent decannulation and resumed a full oral diet. The mean length of hospitalization was 6.8 (standard deviation 1.2) days. One (5.0%) patient had a positive margin. Conclusion In this analysis, 20 patients with oropharyngeal malignancy and retropharyngeal carotid arteries underwent TORS, neck dissection, and microvascular reconstruction without serious complication (perioperative mortality, vascular injury, or neurologic sequalae) with an acceptable negative margin rate. These results may lead to a reconsideration of a commonly held contraindication to TORS. Level of Evidence 3 Laryngoscope, 131:E821–E827, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

The Relevance of and Surgical Approach to the Suprahyoid Region in Thyroglossal Duct Surgery

xlomafota13 shared this article with you from Inoreader The Relevance of and Surgical Approach to the Suprahyoid Region in Thyroglossal Duct Surgery Via The Laryngoscope Objectives Persistent or recurrent disease following excision of a thyroglossal duct cyst/sinus (TGDC) is often found in the suprahyoid region. Cadaver dissections were performed to identify and name important surgical landmarks in the suprahyoid area; a histopathologic analysis of surgical specimens was completed to determine the incidence and extent of microscopic disease; and clinical outcomes were compared to determine the efficacy of a specific anatomic dissection. Study Design Retrospective case series. Methods Standardized dissections of four adult cadavers were performed. Consecutive surgical specimens were examined for evidence of microscopic TDGC disease in the suprahyoid region, measuring the greatest width and length of disease. A retrospective review of all consecutive TGDC procedures was completed. Results The important surgical landmarks in the suprahyoid area were identified in all cadavers. Microscopic disease in the suprahyoid area was found in 79% (37 of 47) of surgical specimens. The mean greatest length and width of microscopic disease was 12.4 mm and 1.4 mm, respectively. Following identification of these landmarks, the incidence of recurrent or persistent disease decreased (P = .02) from 5% (8 of 159) to 0% (0 of 112). Conclusion The majority of pediatric patients with a TGDC will have microscopic disease in the suprahyoid area. The surgical landmark of the fascial plane between the geniohyoid and genioglossus muscles demarcates the anterior and lateral borders of resection in the suprahyoid area. This approach can be used as a reliable and easily reproducible technique in TGDC surgery to increase confidence of achieving complete removal of disease in the suprahyoid area, avoiding persistent or recurrent disease and a revision procedure. Level of Evidence 4 Laryngoscope, 131:553–558, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Management of the Acute Loss of a Free Flap to the Head and Neck—A Multi‐institutional Review

xlomafota13 shared this article with you from Inoreader Management of the Acute Loss of a Free Flap to the Head and Neck—A Multi‐institutional Review Via The Laryngoscope Objectives/Hypothesis To review the management of failed free tissue transfers among four large institutions over a 13‐year period to provide data and analysis for a logical, algorithmic, experience‐based approach to the management of failed free flaps. Study Design Retrospective case series. Methods A multi‐institutional retrospective chart review of free tissue transfers to the head and neck region between 2006 and 2019 was performed. Patients with a failed free flap during their hospitalization after surgery to the head and neck were identified and reviewed. Patient age, co‐morbidities, risk factors, flap characteristics, tumor specifics, and length of hospital stay were reviewed, collected, and analyzed. Results One hundred eighteen flap failures met criteria. The most common failed flap in this review was the osteocutaneous flap 52/118 (44%). The recipient site of the initial free flap (P < .001) was the only statistically significant parameter strongly correlated with management. Osteocutaneous flap failures, fasciocutaneous, bowel, and muscle‐only flaps tended to be managed most commonly with a second free flap. Myocutaneous flap failures were managed equally with either a second free flap or a regional flap. Conclusions The most important factor in management of a failed free flap is the recipient site. A second free flap is often the preferred treatment, but in the acute setting, local or regional flaps may be viable options depending on the recipient site, circumstances of flap loss, and patient‐ specific comorbidities. An algorithm for management of the acute flap loss is presented in this review. Level of Evidence 4 Laryngoscope, 131:518–524, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

What Is the Extent of Neck Dissection in Medullary Thyroid Carcinoma?

xlomafota13 shared this article with you from Inoreader What Is the Extent of Neck Dissection in Medullary Thyroid Carcinoma? Via The Laryngoscope View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Pretreatment High MCV as Adverse Prognostic Marker in Nonanemic Patients with Head and Neck Cancer

xlomafota13 shared this article with you from Inoreader Pretreatment High MCV as Adverse Prognostic Marker in Nonanemic Patients with Head and Neck Cancer Via The Laryngoscope Objective Mean corpuscular volume (MCV) has been shown in to be a reliable prognostic marker in other cancers; however, no evidence exists on its use in head and neck squamous cell carcinoma (HNSCC). This study aimed to investigate the association between MCV, hemoglobin, platelet count and albumin concentration, and survival in stage III/IVA‐B HNSCC treated with concurrent chemoradiotherapy. Study Design Retrospective cohort study. Methods In this multicenter retrospective study, we analyzed MCV, platelet count, hemoglobin concentration, and albumin concentration in peripheral blood samples from 260 patients with HNSCC undergoing organ preservation treatment with curative intent at the time of diagnosis. We then analyzed survival outcomes after accounting for confounders using multivariate analysis. Results After adjustment for potential confounders, patients with low hemoglobin had a 3.3‐fold higher risk of death (95% confidence interval [CI]: 2.26‐4.81) than those with normal hemoglobin. Patients with an elevated MCV had a 1.54‐fold higher risk of death (95% CI: 1.06‐2.24), independent of site, stage, and human papillomavirus status. Interestingly, the effect of MCV on overall and progression‐free survival was limited to those with a normal pretreatment hemoglobin. We identified no associations between pretreatment platelet count or albumin concentration and survival. Conclusion These findings suggest that pretreatment anemia and macrocytosis are independent predictors of lower overall and progression‐free survival in HNSCC patients undergoing organ preservation treatment. Level of Evidence III Laryngoscope, 131:E836–E843, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Can Ophthalmologic Examination Predict Abducens Nerve Recovery After Endoscopic Skull Base Surgery?

xlomafota13 shared this article with you from Inoreader Can Ophthalmologic Examination Predict Abducens Nerve Recovery After Endoscopic Skull Base Surgery? Via The Laryngoscope Objectives While abducens nerve palsy (ANP) is a known risk in the setting of some endoscopic endonasal skull base surgery (ESBS), frequency and prognosis of post‐operative palsy remain unknown. Our goals were to determine the frequency and prognosis of ANP after high‐risk ESBS, and identify factors associated with recovery. Methods Retrospective case series of all patients with pathology at highest risk for abducens nerve injury (pituitary adenoma, chordoma, meningioma, chondrosarcoma, cholesterol granuloma) generated a list of patients with abducens nerve palsy after ESBS performed from 2011–2016. A validated ophthalmologic clinical grading scale measuring lateral rectus duction from 0 to −5 (full motion to inability to reach midline) was measured at multiple time points to assess recovery of ANP. Results Of 655 patients who underwent ESBS with increased risk of abducens injury, 40 (6.1%) post‐operative palsies were identified and 39 patients with dedicated examination at multiple time points were included in subsequent analysis. Complete resolution was noted in 25 patients (64%) within 12 months. While 19 of 23 (83%) with a partial palsy had complete resolution, only six of 16 (38%) with a complete palsy resolved entirely (P = .005; Fisher's exact test). All six patients with delayed onset of palsy resolved (P = .070; Fisher's exact test). Meningioma and chordoma had higher rates of both temporary and permanent post‐operative ANP (P < .0001; Fisher's exact). Conclusions The frequency of post‐operative ANP following ESBS is low, even in high‐risk tumors. While only a minority of complete abducens nerve palsies recover, patients with partial or delayed palsy post‐operatively are likely to recover function without intervention. Level of Evidence IV Laryngoscope, 131:513–517, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Cervical Fibrosis as a Predictor of Dysphagia

xlomafota13 shared this article with you from Inoreader Cervical Fibrosis as a Predictor of Dysphagia Via The Laryngoscope Objective Radiotherapy of head and neck cancer (HNCA) causes dysfunction through radiation‐induced fibrosis (RIF). We hypothesize that the degree of cervical fibrosis is associated with swallowing dysfunction. This study evaluated the association between cervical fibrosis and swallowing dysfunction in patients after radiation therapy for HNCA. Study Design Cross sectional study. Methodology A convenience sample of patients with dysphagia who were at least 1 year post radiation therapy for HNCA underwent simultaneous cervical ultrasound (US) and video‐fluroscopic swallow study (VFSS). US determinants of fibrosis were measurements of sternocleidomastoid fascia (SCMF) thickness bilaterally at the level of the cricoid. Primary and secondary outcome variables on VFSS were pharyngeal constriction ratio, a validated measure of pharyngeal contractility, and penetration aspiration scale (PAS). A qualitative assessment of lateral neck rotation was performed as a functional measure of neck fibrosis. Results Simultaneous cervical US and VFSS examinations were performed on 18 patients with a history of radiotherapy for HNCA and on eight controls. The mean (±SD) age of the entire cohort (N = 26) was 66 (±10) years. Individuals with a history of radiation had significantly thinner mean SCMF (0.26 [±0.04 mm]) compared to controls (0.48 [±0.06 mm]; P < .05). Individuals with thinner SCMF were more likely to have moderate to severe restriction in lateral neck rotation, a higher PCR, and a higher PAS (P < .05). Conclusion Thinner sternocleidomastoid fascia on ultrasound in patients having undergone radiotherapy for head and neck cancer was associated with reduced lateral neck movement, poorer pharyngeal constriction and greater penetration/aspiration scale. The data suggest that cervical fibrosis is associated with swallowing dysfunction in head and neck cancer survivors and support the notion that, "As the neck goes, so does the swallow." Level of Evidence 3. Laryngoscope, 131:548–552, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Organic vs. Inorganic Tracheobronchial Airway Foreign Body Aspiration: Does Type/Duration Matter?

xlomafota13 shared this article with you from Inoreader Organic vs. Inorganic Tracheobronchial Airway Foreign Body Aspiration: Does Type/Duration Matter? Via The Laryngoscope Objective We sought to determine the time course of clinical and histologic differences between aspirated inorganic and organic foreign bodies. Study Design In‐vivo. Methods Twenty Sinclair miniature swine (Sus scrofa domesticus) were divided into two groups—inorganic or organic foreign bodies. Either an organic (peanut) or an inorganic (Lego) foreign body was placed within a bronchus and left for 3, 5, 7, 14 or 21 days. The airway was reassessed at the predetermined endpoint at which time endoscopic, gross, and histopathological findings were documented. Specimens were scored with a pathologic scoring system to assess injury severity from the foreign body. Results Foreign bodies were successfully placed in all 20 swine. Two animals required early euthanasia due to respiratory compromise. The foreign body was identified grossly in eight (40%) animals. An additional three (15%) had microscopic evidence suggestive of a previous foreign body of an undetermined duration. There was no difference in injury severity between organic and inorganic foreign bodies. The 3‐day group had injuries limited to the bronchial lining, whereas the longer duration groups had bronchial and adjacent lung parenchymal involvement. There was no difference in injury severity between days 5 and 21. Conclusions Airway foreign bodies initially cause bronchial damage. After 5 days, the foreign body causes lung parenchymal changes. There was no difference in airway lesion severity between organic and inorganic foreign bodies. Level of Evidence N/A Laryngoscope, 131:490–495, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Parenteral Bevacizumab for the Treatment of Severe Respiratory Papillomatosis in an Adult Population

xlomafota13 shared this article with you from Inoreader Parenteral Bevacizumab for the Treatment of Severe Respiratory Papillomatosis in an Adult Population Via The Laryngoscope Objectives/Hypothesis Recurrent respiratory papillomatosis (RRP) is a rare, potentially life‐threatening, disease that impacts the voice, breathing, and quality of life of patients. Frequent surgical interventions may be needed to control symptoms. We examined the safety and efficacy of utilizing parenteral bevacizumab in the management of severe RRP in adults. Study Design This is a retrospective review of clinical management approaches in a group of patients with severe RRP defined as having a high disease burden, frequent need for debridement, and/or tracheobronchial disease. Patients were initially treated with 15 mg/kg of bevacizumab at 3‐week intervals. Bevacizumab dosing and frequency was then individually titrated down. Results Fourteen adults received a median of 8.5 (range 2–17) bevacizumab infusions over approximately 24 months. All had a history of laryngeal RRP with 6/14 having additional tracheobronchial lesions. Patients required a median of 4 (range 2–11) procedures in the year prior to treatment. Only 3/10 (30%) patients who continued therapy required any additional procedures. Bevacizumab administration was generally well tolerated, with four patients discontinuing therapy. Medical reasons included severe epistaxis and hypertension and thrombocytopenia in an individual with systemic lupus erythematosus. Common side effects included hypertension (grade 2), headache (grades 1–2), elevated creatinine (grades 1–2), and epistaxis (grade 3). Conclusions Intravenous bevacizumab for the primary treatment of severe RRP in adults appears clinically effective and safe. Expected and typically mild side effects related to bevacizumab were observed. Continued investigation of bevacizumab through a prospective clinical trial is warranted. Level of Evidence 4. Laryngoscope, 131:E921–E928, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

A Novel Endoscopic Arytenoid Medialization for Unilateral Vocal Fold Paralysis

xlomafota13 shared this article with you from Inoreader A Novel Endoscopic Arytenoid Medialization for Unilateral Vocal Fold Paralysis Via The Laryngoscope Objectives/Hypothesis Arytenoid adduction (AA) has been indicated for unilateral vocal fold paralysis (UVFP) patients with vertical vocal fold height mismatch and/or large posterior glottic gaps that are unable to be adequately addressed by anterior medialization techniques. Although AA offers several advantages over other methods, it is technically challenging and involves significant laryngeal manipulation of the cricoarytenoid joint. A novel, minimally invasive endoscopic arytenoid medialization technique is presented for the closure of the posterior commissure. Study Design Prospective case series. Methods Seventeen consecutive patients were diagnosed and treated with unilateral endoscopic arytenoid medialization (EAM) combined with injection laryngoplasty because of unilateral vocal fold paralysis. Jitter, shimmer, harmonics‐to‐noise ratio (HNR), maximum phonation time (MPT), fundamental frequency (F0), Voice Handicap Index (VHI), peak inspiratory flow (PIF), and quality of life (QoL) were evaluated preoperatively, 1 month, and 1 year after EAM. Results Jitter, shimmer, HNR, and MPT significantly improved and remained stable 1 year after the intervention. F0 and PIF remained unchanged. Significant improvements in VHI and QoL demonstrated patient satisfaction with voicing and respiratory functions. Conclusions Endoscopic arytenoid medialization is a quick, minimally invasive solution for unilateral vocal fold paralysis. With simultaneous augmentation of the vocal fold, it provides a complete glottic closure along the entire vocal fold in UVFP patients. Level of Evidence 4 Laryngoscope, 131:E903–E910, 2021 View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.