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Objective To determine the efficacy of various eye protection measures during carbon dioxide laser laryngoscopy. Design A standard medical mannequin was equipped with indicator paper over the eyes and subjected to multiple passes of direct carbon dioxide laser beam contact at 400-mm focal length with powers ranging from 2.5 to 4.0 W during simulated laser microlaryngoscopy. Several different eye protection materials, including silk tape, paper tape, cloth tape, occlusive dressing, and eye pads, were used to cover the eyes and tested for their degree of protection against the laser beam. Thermal injuries were quantified and compared among these protective materials. Setting Academic medical center. Main Outcome Measure Degree of eye protection against the laser beam injury on a scale of 0 to 4. Results The carbon dioxide laser beam at both 2.5 and 4.0 W produced considerable thermal damage to the indicator paper in the absence of any protective barrier. Among the adhesive protective barriers, moistened cloth tape was the most effective adhesive material against laser beam–induced thermal damage (P<.001). Silk tape and paper tape offered poor protection. Moist eye pads, although not adhesive and therefore unable to maintain eye closure, were very effective barriers against the laser beam. Dry paper tape and dry eye pads were imminently flammable. Conclusion A combination of moistened cloth tape to maintain eye closure coupled with placement of well- moistened cotton-based eye pads over the tape provides excellent eye protection during carbon dioxide laser laryngoscopy. [ABSTRACT FROM AUTHOR]

Editorial. Presents a call for papers concerning the impact of technology advancements in medical practice.

Presents information on the silver anniversary meeting of the Society for Ear, Nose, and Throat Advances in Children on December 4 to 7, 1997 in Saint Petersburg Beach, Florida. Papers presented during the meeting; Seminars offered during the meeting; Information on new officers and members of the society.

Objectives: To assess the complications of ventilation tubes that were retained in children for 2 years or longer and the necessity of removal. Design: A retrospective chart review of all patients who underwent ventilation tube removal from 1997 to 2000, with the exclusion of patients with craniofacial anomalies. Setting: A tertiary children's hospital. Patients: One hundred twenty-six children with ventilation tubes that were retained for 2 years or longer. Interventions: Ventilation tube removal and tympanic membrane (TM) patching. Main Outcome Measures: Otorrhea, formation of granulation tissue, TM perforation, development of cholesteatomas, and tube reinsertion. Results: A total of 126 patients aged 2½ to 14 years (59 girls and 67 boys) underwent removal of their ventilation tubes after 2 years or more. The patients were divided into 2 groups. Group 1 included 67 patients (29 girls and 38 boys) who were younger than 7 years at the time of tube removal. The tubes were retained for 2 to 5½ years (mean retention time, 3.3 years). Group 2 included 59 patients (30 girls and 29 boys) aged 7 years and older at the time of tube removal. The tubes were retained for 2 to 10½ years (mean retention time, 4.2 years). Complications such as otorrhea, formation of granulation tissue, and TM perforation were seen in 10.3%, 13.8%, and 5.2% of the patients with tube retention of 2 to 3 years, compared with 40.0%, 40.0%, and 46.7% of patients with tube retention of more than 5 years. In group 1, transient otorrhea, formation of granulation tissue, and TM perforation occurred in 13.4%, 7.4%, and 6.0% of the patients, respectively, after 2 years of tube retention. In group 2, similar complications occurred in 23.7%, 25.4%, and 27.1% of the patients, respectively. Forty-six patients in group 1 underwent TM patching (31 with paper and 15 with absorbable gelatin film, with a success rate of 91.3%; however, 8 patients (11.9%) required tube reinsertion. In group 2,... [ABSTRACT FROM AUTHOR]

Objectives: To determine the effects of prolonged ventilation tube retention on tympanic membrane healing and the efficacy of patching procedures used concomitantly at the time of tube removal. Design: Retrospective chart review. Setting: Tertiary referral academic institution. Patients: Seventy-six patients aged 12 years and younger, with a total of 99 ears identified from January 1989 to December 1994. All patients underwent ventilation tube removal for prolonged tube retention or infection unresponsive to medical management. A minimum of 6 months of follow-up was required for inclusion. Intervention: Ventilation tube removal under general anesthesia, with or without concomitant patching. Outcome Measures: All medical charts were reviewed for age, sex, indications for tube removal, tube retention time, type of patch used (if any), type of tube, outcome after removal, other medical problems, and previous surgical history. Results: The perforation rate was significantly higher in children with tubes retained beyond 36 months (P=.02). History of previous adenoidectomy predicted poor outcome, with a rate of 47% vs 17% in patients with no such history (P=.002). Patching did not improve healing. No other patient factors significantly influenced the perforation rate. Conclusions: Ventilation tube retention longer than 36 months resulted in an increased perforation rate after surgical removal. Paper patching at the time of tube removal does not improve healing. Prospective studies are needed to confirm these findings and to determine the efficacy of other patching techniques. [ABSTRACT FROM AUTHOR]

Reconstruction of the microtic auricle is a difficult process requiring considerable experience and dedication to detail. It is a multistage proposition requiring the talents of both the reconstructive surgeon and the otologic surgeon. Reconstruction of the external ear usually precedes the reconstruction of the middle ear. Often, a template is used by the reconstructive surgeon to aid in this complicated process. Traditionally, templates used by the reconstructive surgeon have been 2 dimensional (usually x-ray paper) and made from the opposite normal ear or another normal ear in cases of bilateral microtia. Use of a 2-dimensional model only provides a rough estimate of the cartilage framework needed. Considerable experience is therefore needed to get this cartilage framework "just right." We have developed a number of 3-dimensional synthetic templates to aid in the creation of an accurate cartilage framework implant. These templates serve as a more accurate guide in the complex cartilage carving and assembly process. The use of 3-dimensional templates has improved our technical reconstructive results in a small number of patients. We present these results and propose future application of these ideas. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the incidence of Frey syndrome (auriculotemporal nerve syndrome) after parotidectomy with and without placement of a subcutaneous implant and to examine the relationship between different implants and postoperative wound complications (hematoma, seroma, salivary fistula). Design: A prospective nonrandomized controlled trial. Setting: A primary care and referral university hospital center. Patients: All patients scheduled for parotidectomy from April 1994 through August 1998 were eligible. Seventy patients were enrolled (2 refused). All 70 patients were evaluated for wound complications. Sixty patients with a follow-up of more than 1 year were evaluated for Frey syndrome. Intervention: The choice of implant was left to the individual surgeon: 24 patients had no implant; 7, lyophilized dura implant; 7, polyglactin 910–polydioxanone (Ethisorb) implant; and 32, expanded polytetrafluoroethylene (e-PTFE) implant. Outcome Measures: The incidence of Frey syndrome was evaluated (1) subjectively by history (clinical Frey syndrome) and (2) objectively by using 2 newly developed tests. Both hemifaces were tested, with the normal side being used as a control. Results: Clinical Frey syndrome was present in 12 patients: 11 without implants (11/24 [53%]) and 1 with an implant (1/46 [2%]) (P<.001). Objective tests were positive in 24 patients: 16 (76%) of 21 without implants and 8 (20%) of 39 with implants (P<.001). In the implanted patients, the objective tests were positive in 71% (5/7) of those with lyophilized dura, 14% (1/7) of those with Ethisorb, and 8% (2/29) of those with e-PTFE implants (P<.001). Wound complications included hematoma in 5 patients (7%), seroma in 4 patients (6%), and salivary fistula in 15 (21%). Salivary fistula occurred more frequently with Ethisorb (57%) and e-PTFE (25%) implants (P=.04). Conclusions: In patients without an implant, the incidence of Frey syndrome is 50% for subjective and 80% for objective evaluat... [ABSTRACT FROM AUTHOR]

Background: A systemic reaction to mycobacteria biases the balance of T helper cell types 1 and 2 toward T helper cell type 1. BCG vaccination mimics some characteristics of mycobacterial infection. Children who have undergone tuberculin conversion after BCG vaccination seem to be more likely to lose their atopic symptoms. Inhibition of both allergic response and airway hyperreactivity after vaccination for mycobacteria has been observed in animal experiments. Objective: To evaluate the effects that BCG vaccination has on the serological status of allergic people. Participants and Methods: This study included 20 volunteers with a history of allergic rhinitis who were required to undergo BCG vaccination by Italian law. Epicutaneous allergy testing with a panel of common seasonal and perennial inhalational allergens and 2 blood withdrawals were performed. The serum total IgE levels and the serum allergen-specific IgE levels of each individual were measured just before BCG vaccination and again 4 months later. Total IgE levels were determined using the paper radioimmunosorbent test, and allergenspecific IgE levels were determined using the radioallergosorbent test. Results: Total IgE and allergen-specific IgE levels were significantly decreased after BCG vaccination (P = .004 and P < .001, respectively). Conclusion: BCG, an effective stimulus for cellmediated immunity, deserves further study to evaluate its ability to modulate the immune response associated with allergic rhinitis. [ABSTRACT FROM AUTHOR]

The article presents news from the Annual Meeting of the American head and neck society. The American Head and Neck Society (AHNS) held its annual meeting in Washington, DC, during the Sixth International Conference on Head and Neck Cancer,which it sponsored, under the leadership of President Jonas T. Johnson, MD. Ashok R. Shaha, MD, served as conference chairman, and Ernest A. Weymuller, Jr, MD, was program chairman. Byron J. Bailey, MD, was honored as the guest of honor. Jatin Shah, MD, received a lifetime achievement award, and distinguished service awards were presented to Marc D. Coltrera, MD, Richard L. Carrau, MD, Carl H. Snyderman, MD, and Robin L. Wagner, BS.

Objective: To establish whether the results of a 2004 trial on the effectiveness of adenotonsillectomy in children with mild to moderate symptoms of throat infection or adenotonsillar hypertrophy affected physicians.- beliefs about the benefits of the operation and influenced clinical practice. Design: Prospective prior-posterior study. Setting: Academic research. Participants: We evaluated beliefs prior and posterior to the 2004 trial regarding the benefits of adenotonsillectomy in a random sample of 120 Dutch otolaryngologists and 120 Dutch general practitioners. Main Outcome Measure: Physicians were asked to give their estimates of the probability of recovery during 1 year after adenotonsillectomy or a nonsurgical strategy in 3 scenarios of children aged 3 to 4 years with recurrent throat infection, upper respiratory tract infection (with or without fever), or sleep-related breathing disorder. Results: Ninety-four percent of otolaryngologists (n=46) and 31% of general practitioners (n=14) were familiar with the 2004 trial results. Posterior beliefs of otolaryngologists and general practitioners did not differ substantially from prior beliefs; overall expectations regarding the benefits of adenotonsillectomy remained high. Conclusion: Dissemination of the 2004 trial results did not seem to affect the beliefs of physicians regarding the benefits of adenotonsillectomy. [ABSTRACT FROM AUTHOR]

The article examines the case of a hypopharyngeal foregut duplication cyst containing both gastric and pancreatic tissue. The case involved a neonate who was born with stridor and cyanosis and who required immediate intubation because of airway obstruction due to a large hypopharyngeal mass. Magnetic resonance imaging and computed tomography were helpful in localizing the lesion. The foregut gives rise to the pharynx and its associated structures as well as to the lower respiratory tract, esophagus, stomach, duodenum, and hepatobiliary tract. This paper also review the literature and discuss the pathogenesis of foregut duplication cysts.

Objective: To evaluate the effectiveness of endoscopic cauterization as definitive treatment for fourth branchial cleft sinuses. Design: Retrospective chart review with follow-up questionnaire. Setting: Tertiary care children's hospital. Patients: Ten children (age range, 10 months to 10 years) with fourth branchial cleft sinuses treated with endoscopic cauterization between 1995 and 2002. Main Outcome Measure: Recurrence of neck infections after endoscopic cauterization of fourth brachial cleft sinus tracts. Results: Seven of the 10 patients treated with endoscopic cauterization of the fourth branchial cleft sinuses showed no recurrence with an average follow-up of 3 years. Three of the patients were unavailable for followup, but medical records of the hospital showed no additional admissions for those patients for neck masses. No morbidity of the procedure was identified. All patients were discharged the day of surgery. Conclusions: Endoscopic cauterization of fourth branchial cleft sinuses appears to be an effective alternative to open excision. [ABSTRACT FROM AUTHOR]

Objective: To determine the efficacy of computed tomography in creating custom nasal septal buttons. Design: Retrospective chart review and telephone follow-up. Setting: Tertiary care referral center. Subjects: Ninety-five patients with symptomatic septal perforations repaired with custom Silastic septal buttons fashioned from reformatted computed tomographic images. Follow-up greater than 1 month was obtained in 74 patients (range, 1 month to 17 years; mean, 44.6 months). Interventions: Custom septal buttons were placed intranasally under local or general anesthesia. Main Outcome Measures: Patients were evaluated for resolution of preoperative symptoms related to the septal perforation, new symptoms related to the button, and duration of button retention. Results: The average perforation was 2.6 cm in diameter (range, 6 mm to 6.0 cm). Nine buttons (12%) came out unexpectedly. Nine buttons were removed because of patient intolerance, and 14 buttons were lost or removed after 5 years, longer than the projected button life span. Excluding buttons that were removed because of patient intolerance, 56 (86%) of 65 buttons were in place for longer than 5 years or at the most recent follow-up. Most patients experienced improved breathing (60%) and a considerable reduction in epistaxis (77%) and nasal crusting (59%). Conclusion: Custom septal buttons created using computed tomography are effective in relieving symptoms from large septal perforations. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the outcomes of a new surgical approach in children with acute sinusitis and medial orbital subperiosteal abscess. Design: Case series. Setting: Tertiary pediatric hospital. Patients: Eleven children aged 6 weeks to 13 years with orbital subperiosteal abscess and acute sinusitis who met indication for surgery by visual compromise and/or refractory course to medical therapy. Intervention: The medial orbital abscess was drained via a transcaruncular approach, which provided access to the medial orbital wall. An endoscopic ethmoidec-tomy was also performed. Main Outcome Measures: Judgment of cosmetic appearance by surgeon and family, resolution of symptoms, length of hospital stay, and complications. Results: All children had prompt resolution of symptoms after surgical drainage. Cosmetic outcome was excellent in all patients with no cutaneous scar or eyelid mal-position. After edema and cellulitis had resolved, no family member could tell a difference in appearance between the eyes. No complications of these combined procedures were identified. One patient who had initially undergone trans-nasal endoscopic orbital drainage alone experienced a recurrence of infection 17 days later. He was then treated by the combined transcaruncular and endoscopic approach with prompt resolution of his symptoms. One of 4 patients treated initially with transcaruncular approach alone without endoscopic ethmoidectomy had recurrence of acute sinusitis and orbital abscess 16 months later and was successfully treated with an endoscopic approach. Conclusions: The combined endoscopic and transca-runcular surgical approach to medial orbital subperios-teal abscess and acute sinusitis provides a cosmetically superior outcome compared with standard orbital approaches requiring a cutaneous incision. The transca-runcular approach can be considered as an alternative or adjunct approach to the medial orbit, with the same cosmetic advantages as transnasal endoscopic drainage. [ABSTRACT FROM AUTHOR]

Background: The apposing mucosa of the oral cavity makes the computed tomographic identification of a clinically obvious mass difficult. Contrast distension techniques have been used in radiology to evaluate for presence of a "hidden" mass. Objective: To illustrate the utility of distending the oral cavity with air, water, or contrast to display otherwise obscure oral cavity lesions. Patients and Methods: In 3 normal subjects and 5 patients with biopsy-proved oral cavity lesions, serial contiguous 3-mm axial and coronal computed tomographic scans were obtained before and after distension of the oral cavity using intraoral air or water. Air distension was achieved by having the subjects perform a modified Valsalva maneuver during the scan acquisitions. Fluid distension was obtained using approximately 40 mL of water. Results: In each case, the contrast successfully distended the oral cavity, separating the mucosal surfaces. Gingivobuccal lesions that were obscured by apposition of the lips and cheeks to the gums and teeth, or by apposition of the tongue to the inner margins of the gums and teeth, were clearly demonstrated. Lesions involving or extending into the retromolar trigone were also well demonstrated using this distension technique. Conclusions: Computed tomographic display of the anatomy and pathology of the oral cavity can be improved simply by distending the oral cavity using air or water as a contrast medium. This technique successfully shows lesions that are obscured by the apposing surfaces of the vestibule and the oral cavity proper, improving computed tomographic diagnosis. [ABSTRACT FROM AUTHOR]

Comments on the utilization of vestibular testing in children who are being evaluated for sensorineural hearing loss.

Branchial anomalies present with a wide range of pathologic characteristics, including cysts, fistulas, and sinuses of the head and neck region. Branchial cysts are most commonly diagnosed during the second through fourth decades of life, while branchial sinuses and fistulas are diagnosed almost exclusively in children with infection episodes. Only rarely has an internal sinus of a third or fourth branchial anomaly manifested in adults as a noninfectious swelling in the neck during swallowing. In this report, we describe our experience treating a 21-year-old man with a left-sided swallowing-induced neck protrusion of 10 years' duration. Findings of physical examination, videolaryngoscopy, and a pharyngoesophagogram confirmed the diagnosis of internal sinus of the pyriform fossa, with uncertain origin of a third or fourth branchial anomaly. The patient underwent regular follow-up as an outpatient and experienced no further infectious episodes. [ABSTRACT FROM AUTHOR]

The article presents instructions for authors who wish to contribute research papers in the forthcoming issues of the journal "Archives of Otolaryngology--Head & Neck Surgery." If authorship is attributed to a group, all members of the group must meet the full criteria and requirements for authorship described in these Instructions. A group must designate at least I or more individuals as authors or members of a writing group who meet full authorship criteria and requirements and who will take responsibility for the group, in which case the other group members are not authors, but may be listed in an acknowledgment.

Presents a letter to the editor about imaging literature and terminology.

Objective: To determine the perceived value of survivorship care plans (SCPs) (cancer treatment summaries and follow-up recommendations). Design: Survey of patients and their physicians between 3 and 4 years after receipt of the SCP. Setting: Ambulatory, tertiary care medical center. Patients: Aconvenience sample of head and neck cancer survivors living 3 years after each had been maileda personal SCP shortly after completion of cancer treatment. Twenty survivors were contacted, and all agreed to participate. Interventions: Institutional review board-approved, scripted telephone survey to determine whether patients and their primary care physicians still had their SCPs and found them useful. Main Outcome Measures: Survey responses. Results: Only 2 of 20 survivors and 11 of 21 physicians or dentists were able to locate or remember having received the SCPs 3 years later. Eighteen of 20 survivors were unsure of the value of SCPs. Conclusions: Despite a widely held belief that patients benefit from receiving SCPs, our initial attempt found little awareness of these documents by either the head and neck cancer survivors or their primary care physicians. [ABSTRACT FROM AUTHOR]

Objective: To analyze a new categorization of chronic rhinosinusitis with nasal polyposis (CRSwNP) according to severity and controller therapy, modified from the 2007 stepwise treatment for asthma. Design: Prospective categorization of 50 new or established patients over a 3-month period. Setting: Tertiary center of Hô tel-Dieu de France Hospital, Beirut, Lebanon. Patients: Fifty consecutive adult patients with nasal polyposis referred by primary care physicians for sinonasal complaints or by pulmonologists for worsening lower airway control including asthma. Interventions: All patients were categorized according to CRSwNP severity scale and treated with stepwise therapy based on the study schematic. Main Outcome Measures: The Modified Sinonasal Questionnaire and the visual analog scale were used to assess patients' response to the treatment regimen and to modify the severity scale and the step treatment accordingly. Results: Ten new medication-naïve patients with CRSwNP were categorized by severity, which directed the subsequent treatment plan. All patients showed improvement in severity with the stepwise treatment plan. Thirty-seven of 40 patients with established CRSwNP seen in follow-up were easily categorized by degree of control, and subsequent treatment directed by therapy guidelines resulted in improvement. Conclusions: Initial categorization of medicationnaïve patients with CRSwNP and patients with established CRSwNP facilitated delivery of successful directed stepwise therapy that resulted in improvement of classification of severity in most patients. This proposed classification may provide a useful template for future studies comparing patients with CRSwNP. [ABSTRACT FROM AUTHOR]

Objectives: To present a technique for reconstruction of the vertical partial laryngectomy defect using a vascularized carrier consisting of a temporoparietal free flap, cartilage graft, and buccal mucosal graft; to evaluate the oncologic outcomes with respect to locoregional control and overall survival; and to provide an assessment of patient quality of life and functional outcomes. Design: Retrospective medical record review and prospective cross-sectional analysis of functional outcomes. Setting: Princess Margaret Hospital-University Health Network and the Odette Cancer Centre-Sunnybrook Health Sciences Centre. Methods: We collected data on patient demographic characteristics, tumor staging, initial treatment, recurrence, management, and follow-up. Prospectively, a crosssectional study was performed using the European Organization for Research and Treatment of Cancer Quality of Life of Cancer Patients Questionnaire C30 and HN35 module and voice and swallowing results using the Voice Handicap Index and Swallowing Quality of Life index. Main Outcome Measures: Local recurrence-free survival, cause-specific survival, and overall survival. Results: Forty men met inclusion criteria (median age, 65.0 years). Local recurrence-free survival was 84% at 3 years and 75% at 5 years. Cause-specific survival was 88% at 3 years and 78% at 5 years. Thirty-eight patients were successfully decannulated; all patients tolerated oral intake after the surgical procedure. The C30 and HN35 symptomatic results were comparable with patients with standardized stages I and II head and neck tumors. The Voice Handicap Index results were comparable with patients with functional dysphonia. Patients' swallowing was in the normal range. Conclusions: Patients receiving vertical partial laryngectomy with temporoparietal free flap reconstruction for recurrent glottic carcinoma following radiation treatment failure have high rates of locoregional control. The use of the temporoparietal free flap in this patient population produces high-quality voice results and normal swallowing and has no major effect on quality of life. [ABSTRACT FROM AUTHOR]

Objective: To evaluate retrospectively the efficacy of the mandibular advancement device (MAD) in patients with obstructive sleep apnea in terms of positional dependency. Design: Retrospective analysis. Setting: Academic tertiary referral center. Patients: One hundred patients with obstructive sleep apnea treated with the MAD at the Department of Otorhinolaryngology sleep clinic were included from January 1, 2005, through December 31, 2010. Interventions: All patients underwent nocturnal fullnight polysomnography before and at least 3 months after intraoral MAD application. Main Outcome Measures: Treatment results and prognostic factors deciding the success of MAD application. Results: Of the 100 patients, 80 showed positional dependency and 20 showed nondependency. In the position-dependent obstructive sleep apnea group, the median (interquartile range) apnea-hypopnea index (AHI) decreased from 32.1 (24.4-41.9) to 8.6 (3.7-13.8) (P<.001); in the nondependent group, from 56.4 (26.2-71.5) to 15.7 (6.8- 30.7) (P<.001). The success rate (AHI reduction ⩾50% and AHI<10) was 57.5% and 30.0% in position-dependent and position-nondependent groups, respectively (P=.04). Conclusion: Identifying patients with obstructive sleep apnea as position dependent or nondependent may have important therapeutic implications in predicting the outcome of MAD treatment. [ABSTRACT FROM AUTHOR]

Objective: To review our experience with the surgical treatment of frontoethmoidal osteomas, focusing on the osteomas that were either localized laterally in the frontal sinus or showing intraorbital involvement. Design: Retrospective evaluation. Setting: Tertiary care center. Patients: Patients with symptomatic frontoethmoidal or intraorbital osteomas who had been treated surgically from 1996 through 2011. Intervention: Sixty frontoethmoidal osteomas were treated surgically. The lesion involved the far lateral portion of the frontal sinus in 23 cases and the orbital region in 6 cases. In 31 cases, a purely endoscopic approach was performed while a combined procedure was used in 25 patients. In 4 patients, an exclusively external approach was required. Main Outcome Measure: No recurrence of osteoma. Results: Radical resection was obtained, except in the case of 2 lesions. No osteoma recurrence was observed during a mean follow-up of 72.6 months. Conclusions: The size of the osteoma, far lateral extension of the tumor in the frontal sinus beyond the lamina papyracea, and intraorbital involvement are no longer absolute contraindications for purely transnasal endoscopic resection. What is important is that the surgeon should not be dogmatic but rather be ready to change his or her mind during surgery, shifting to an external approach when required. [ABSTRACT FROM AUTHOR]

Objective: To use intraoperative confocal endomicroscopy for early detection and resection of squamous cell carcinoma (SCC) of the head and neck. A preliminary report. Design: Prospective case series. Setting: Tertiary referral hospital. Patients: Fifteen consecutive patients with SCC of the oral cavity, hypopharynx, and larynx were included from the Department of Otolaryngology-Head and Neck Surgery, HSK Dr Horst Schmidt Kliniken GmbH, Wiesbaden, Germany Interventions: Confocal endomicroscopy was performed during diagnostic and therapeutic procedures with a prototype of a rigid laser endoscope in combination with the already available technology of autofluorescence. Main Outcome Measures: Real-time visualization of cellular and subcellular details during endoscopy. Diagnostic scores were applied to differentiate dysplastic and malignant mucosal changes of SCC of the head and neck from normal squamous cell mucosa using this method. Results were correlated with the well-established gold standard, histologic analysis. Results: Dysplastic and malignant changes of head and neck squamous cell mucosa were endoscopically determined by this unique in vivo application of confocal laser endomicroscopy using a rigid probe. Conclusions: We present preliminary and descriptive data using this novel technology in vivo. Considering the impact of a virtual real-time histologic analysis, this technology points to a very promising development. It may carry potential for quicker intraoperative diagnosis, less need for multiple frozen sections, and more precise resection margins. [ABSTRACT FROM AUTHOR]

Objective: To evaluate students' overall assessment and effectiveness of the web-based blended learning conception "Unified Patient Project" (UPP) for medical students rotating on their otolaryngology internship (ear, nose, and throat [ENT] tertiary). Design: Prospective comparison group design of the quasiexperimental type. Setting: Medical education. Subjects: The experimental group (preintervention test [pretest], intervention, and postintervention test [posttest]) comprised 117 students, and the comparison group (pretest, alternative intervention, and posttest), 119. Interventions: In the experimental group, lecturing of case studies was replaced by the blended learning concept UPP. A standardized questionnaire evaluated students' overall assessment of teaching otolaryngology. A pretest and posttest using multiple choice questions was administered to clarify whether the UPP has led to a knowledge gain. Results: The comparison group was more satisfied with their teaching; however, this was not statistically significant (P=.26) compared with the UPP. Students with higher preknowledge benefitted from the UPP, while students with lower preknowledge did not (P=.01). On average, posttest results in the experimental group exceeded those of the comparison group by 8.7 percentage points for a 75% preknowledge of the maximum attainable score, while they fell below those of the comparison group by 8.1 percentage points for a 25% preknowledge. Conclusions: Students' satisfaction with the blended learning concept UPP was lower than in the face-to-face teaching, although this was not statistically significant. The new web-based UPP leads to an improved knowledge in clinical otolaryngology for all students. Students with lower preknowledge benefitted more from face-to-face teaching than from the UPP, while students with higher preknowledge benefitted more from the UPP. This implies students with poor preknowledge need special promotion programs. [ABSTRACT FROM AUTHOR]

Objective: To study differences between aspirintolerant patients and aspirin-intolerant patients concerning vascular endothelial growth factor (VEGF) expression. Recent publications strongly suggest the involvement of VEGF and its receptors in the pathophysiologic process of nasal polyps. Design: We subjected 43 polyp specimens to semiquantitative immunohistochemical analysis. We quantified VEGF and its receptors (Flk, Flt, and neuropilin) in all samples. To gain insight into potential VEGF-mediated cellular responses, we determined proliferative (Ki67) and apoptotic (caspase 3) indices. Patients: Polyp samples were obtained from 22 aspirinintolerant patients and from 21 aspirin-tolerant patients, and control specimens were obtained from 24 subjects with healthy nasal respiratory mucosa. Setting: Laboratory; Department of Otorhinolaryngology- Head and Neck Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany. Main Outcome Measures: Expression levels of VEGF, VEGF receptors. and proliferative and apoptotic indices. Results: We found higher expressed levels of VEGF and neuropilin and stronger proliferation in nasal polyps from aspirin-tolerant and aspirin-intolerant patients compared with controls. In polyps from aspirin-intolerant patients, VEGF was expressed at considerably higher levels compared with those from aspirin-tolerant subjects. Apoptotic activity remained unchanged in all 3 groups. Conclusions: Nasal polyps from aspirin-tolerant and aspirin- intolerant patients are characterized by strong proliferation and high levels of VEGF and neuropilin expression. Nasal polyps from aspirin-intolerant patients show distinctly increased VEGF levels. The relevance of these findings for future therapeutic approaches is yet to be determined. [ABSTRACT FROM AUTHOR]

Objective: To compare thulium:YAG laser-assisted transoral robotic surgery (TY:TORS) and conventional electrocautery- equipped TORS (EC:TORS) in patients undergoing transoral resection of upper aerodigestive tract malignant neoplasms. Design: Prospective matched cohort study. Setting: Tertiary academic referral center. Patients: Fifteen patients undergoing TY:TORS were matched on the basis of tumor site, clinical T stage, sex, and age with 30 control subjects undergoing EC:TORS. Main Outcome Measures: The primary outcome was a comparison between the feasibility of TY:TORS compared with EC:TORS. The secondary outcome was a comparison between the safety and functional outcome of TY:TORS compared with EC:TORS in patients undergoing resection of upper aerodigestive tract malignant neoplasms. Results: All the tumors underwent complete excision with negative margins. Estimated blood loss was minimal (<150 mL) for 87% of TY:TORS patients (13 of 15) and 63% of EC:TORS controls (19 or 30). Intraoperative pharyngotomy was reported in 8% of TY:TORS patients (1 of 13) and 42% of EC:TORS controls (11 of 30) (P=.03). Postoperative pain was greater in EC:TORS compared with TY:TORS (P=.02). No statistically significant differences were noted in hemostasis, postoperative bleeding rates, or other complications. Conclusions: Compared with EC:TORS, TY:TORS seems feasible and safe. In addition, TY:TORS resulted in fewer intraoperative pharyngotomies and less postoperative pain than did EC:TORS, which may be because of decreased collateral thermal damage, improved visualization, and finer cutting using the thulium laser. [ABSTRACT FROM AUTHOR]

Objective: To look for genetic mutations that might predict central compartment lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC) using strict criteria for N0 and N1 disease. Design: We identified patients with PTC from our institution's pathology archives. Strict criteria were used for assessing the presence or the absence of central neck LNM. Disease was classified as N0 only if a comprehensive ipsilateral and pretracheal central neck dissection was performed and if pathological analysis revealed no evidence of LNM. Primary tumor samples were analyzed for a panel of known or suspected PTC-associated molecular markers, including BRAF, RET-PTC, KRAS, NRAS, HRAS, PIK3CA, and their variants. Setting: Academic medical center. Patients: Three hundred eighty-nine patients with PTC. Main Outcome Measure: Molecular mutations in tumors with and without LNM. Results: Of 389 identified cases, 209 fit the inclusion criteria, with 158 classified as node positive (N1) and 51 as node negative (N0). The follicular variant histological type was present in 7 of 158 N1 tumors (4.4%) and 24 of 51 N0 tumors (47.1%) and thus was strongly associated with lack of central neck metastasis in this study (odds ratio, 0.05;95%CI, 0.02-0.14). Predictive factors for centralLNM included extracapsular extension, angiolymphatic invasion, and higher T stage (T3 and T4). The BRAF mutation was more prevalent in the classicPTChistological type than the follicular variant. None of the molecular marker mutations that were analyzed in this study, including the BRAF mutation, predicted LNM in classic PTC. Conclusions: Positive risk factors for central LNM include male sex, extracapsular extension, angiolymphatic invasion, and advanced T stage. The follicular variant histological type has a significantly lower incidence of central neck metastasis. In contrast to recent studies, the BRAF mutation was not significantly associated with central neck LNM from PTC when using a strict definition of a central neck dissection. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the utility of fluorescence to assess penetration of quinolone ear drops (EDs) through tympanostomy tubes (TTs), the middle ear, eustachian tube, and into the oropharynx. Design: Before-and-after trial. Setting: Academic, tertiary care hospital. Patients: Young children undergoing TT placement for otitis media and adolescents or adults undergoing repair of tympanic membrane (TM) perforations were included. Interventions: Fluorescence of ofloxacin otic solution and serial dilutions was assessed with a Wood's lamp in vitro. Passage of ototopically administered ofloxacin into the pharynx was assessed in patients at the time of TT placement or TM repair. The oropharynx was visualized for fluorescence with a UV light for up to 2 hours after otic instillation. Main Outcome Measure: Oropharyngeal fluorescence. Results: Ofloxacin otic fluorescence was visible at up to a 1:4 dilution. Fluorescence was confirmed in vivo by placing 1 drop of ofloxacin into the posterior pharynx and visualizing it transorally. Fluorescence was not identified in any of 20 patients after TT placement and in any of 6 patients prior to tympanoplasty. Two patients undergoing tympanoplasty reported tasting the EDs. Conclusion: Fluorescence is not a satisfactory method of assessing quinolone ED penetration through TTs and TM perforations, the middle ear, and into the nasopharynx. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate hyaluronic acid fat graft myringoplasty (HAFGM) for different tympanic membrane perforation (TMP) sizes and to compare its success rate with that of the underlay and overlay techniques. Design: Prospective study. Setting: Tertiary care pediatric center. Patients: Two hundred eight children aged 4 to 16 years (mean age, 11.84 years) with TMPs. Interventions: The HAFGM is a new technique for TMP repair in an outpatient pediatric population using local anesthesia. All the patients in groups 1 (underlay) and 2 (overlay) were operated on using general anesthesia, whereas group 3 (HAFGM) was operated on at the outpatient office using local anesthesia. Main Outcome Measures: Postoperative status of the eardrum, hearing improvement, and incidence of complications. Results: Patients with TMP were divided into 3 groups: group 1 had 75 patients; group 2, 65; and group 3, 73. The global success rate was 87% in group 3, with no difference with the remaining 2 groups. Successful closure of different TMP sizes was the same for the 3 groups. Postoperatively, air-bone gap improvement was better for group 3. No bone conduction threshold worsening was noted. The mean duration of the operative procedure was 65, 74, and 18 minutes for groups 1, 2, and 3, respectively (P=.02). Mean postoperative follow-up was 20.7, 17.5, and 14.6 months for groups 1, 2, and 3, respectively. Identification of the anterior perforation rim is mandatory to perform HAFGM. Conclusions: The HAFGM did not require hospitalization for pediatric patients. It had the advantage of being feasible in children using local anesthesia. Its success rate was comparable with that of conventional techniques. [ABSTRACT FROM AUTHOR]

Objective: To investigate the reproducibility of quality indicators in the care of patients undergoing operations for head and neck cancer. Design: A review of specialty-specific surgical quality indicators in a cohort undergoing procedures for definitive treatment of head and neck cancer, stratified by high and low acuity of the surgical procedures and compared with established benchmarks. Setting: A large tertiary care institution and an associated multidisciplinary cancer center. Patients: Fifty randomly selected patients with evaluable data who were diagnosed as having head and neck cancer that was definitively treated using any of the 3 modalities (surgical procedures, chemotherapy, and/or radiotherapy) during a 15-month period at our center. Twenty-one patients who underwent operations form the basis of this report. Main Outcome Measures: Procedures were stratified by acuity on the basis of the extent of the operation. Data were centered on quality indicators designed to reflect length of stay, readmission within 30 days postoperatively, return to the operating room within 7 days of surgery, use of blood products, 30-day mortality, adequacy of reports on surgical pathologic findings, and surgical site infection. Results: Diagnoses in the cohort included carcinoma of the oral cavity in 19 patients (39%), oropharynx in 14 (29%), larynx in 13 (27%), and hypopharynx in 3 (6%). High- and low-acuity surgical procedures were performed in 12 and 7 patients, respectively. No statistically significant differences in the measures for quality indicators were found between the cohort and the calculated benchmarks. Conclusion: Our findings demonstrate the applicability of quality indicators to the care of patients with head and neck cancer treated by surgical intervention stratified by acuity and compared with established benchmarks. [ABSTRACT FROM AUTHOR]

Objective: To correlate patient reports of olfactory dysfunction after surgical intervention for allergic fungal rhinosinusitis (AFRS) with endoscopic findings, psychophysical testing, and quality-of-life scores. Design: A prospective cohort study. Setting: A tertiary care rhinology clinic at St Paul's Hospital, Vancouver, British Columbia, Canada. Patients: Eighty-one patients with AFRS seen at routine postoperative follow-up. Main Outcome Measures: The Sniffin' Sticks test and a visual analog scale for the perceived olfactory ability of patients with AFRS were administered, along with a 36-Item Short-Form Health Survey. An endoscopic staging score was assigned for each patient. Results: Forty men and 41 women with AFRS underwent olfactory testing; 52 of these individuals completed all parts of the assessment. The mean threshold, discrimination, and identification score was 19 (hyposmic), with a significant correlation between patients' performance on the Sniffin' Sticks test and endoscopic staging, as well as their reported olfactory ability (P<.001 for all 3 tests). The mean score for the 36-Item Short- Form Health Survey was 71, but there was a poor correlation between it and the threshold, discrimination, and identification score; visual analog scale; and endoscopic scores (P<.05 for all 3 tests). Conclusion: All patients with AFRS should be evaluated with olfactory testing and treated according to the results. [ABSTRACT FROM AUTHOR]

Objective: To determine if pretonsillectomy injection of local anesthetics with and without clonidine reduces pain following tonsillectomy in children. Design: A prospective, randomized, double-blind, placebo- controlled trial. Setting: Tertiary care academic medical center. Patients: A total of 120 children, ages 3 to 17 years, presenting for tonsillectomy. Interventions: Patients were randomized to 1 of 3 pretonsillectomy injection groups: (1) saline, (2) lidocaine plus bupivacaine, or (3) lidocaine plus bupivacaine plus clonidine. Main Outcome Measures: The total number of analgesic doses consumed on postoperative days (PODs) 1, 3, 5, and 7. Secondary outcome variables included total time and intravenous analgesic doses required in the recovery room, visual analog scale pain scores, and maximum tolerated diet on postoperative days 1, 3, 5, and 7. Results: The total number of analgesic doses on PODs 1, 3, 5, and 7 were not significantly different between the randomization groups (P=.53). The median numbers (interquartile ranges) of analgesic doses were 12.0 (9.0- 16.8) for the lidocaine plus bupivacaine plus clonidine group, 12.0 (10.0-16.5) for the lidocaine plus bupivacaine group, and 14.0 (9.0-15) for the placebo group. The placebo group was found to have a more advanced diet on POD 1 (P=.04) and significantly less pain on POD 3 (P=.02). Multivariable analysis showed children in the lidocaine plus bupivacaine plus clonidine group were significantly less likely to need intravenous pain medication in the recovery room compared with children in the placebo group and again showed that the placebo group achieved a significantly more advanced diet and had less pain on PODs 1 and 3. Conclusion: Pretonsillectomy injection of lidocaine, 1%, and bupivacaine, 0.5%, with or without clonidine (25 μg) is not recommended for the reduction of posttonsillectomy pain. [ABSTRACT FROM AUTHOR]

Objectives: To determine the incidence and to describe wound complications and associated risk factors of pediatric tracheotomy. Design: Retrospective case series. Setting: Freestanding tertiary care academic pediatric hospital. Patients: Sixty-five consecutive children undergoing tracheotomy over 15 months. Main Outcome Measures: Postoperative wound complications objectively and independently documented by an advanced practice nurse specializing in tracheotomy care. Secondary outcome measures included comorbidities, mortality rates, and wound status after subsequent examinations and management. Results: The mean (SEM) patient age at tracheotomy was 45 (8.7) months (median age, 9.1 months). The most common indication for tracheotomy was pulmonary disease (36.9%), followed by neurologic impairment and laryngeal abnormalities. There were 19 patients (29%) with and 46 patients (71%) without wound complications. There were no significant differences between the 2 groups in age (P=.68) or weight (P=.55); however, infants younger than 12 months had an increased complication rate (39% vs 17%, P=.04). The type of tracheotomy tube was predictive of postoperative wound complications (P=.02). All patients with wounds received aggressive local wound care. Five of 13 patients had complete resolution of stomal wounds, whereas 8 patients had persistent wound issues. There were 5 non-wound-related mortalities. Conclusions: With attempts to classify tracheotomy wound breakdowns as reportable events, including never events, increasing emphasis is being placed on posttracheotomy care. This study demonstrates that wound breakdown in pediatric tracheotomy patients is common. These complications can be mitigated, although not prevented completely, with aggressive wound surveillance and specialized wound care. [ABSTRACT FROM AUTHOR]

Objectives: To determine how often the pediatric otolaryngology service is involved in the initial care of infants with an apparent life-threatening event (ALTE), to assess the usefulness of bronchoscopy and laryngoscopy in diagnosing the underlying etiology, and to describe the long-term airway outcomes and whether these patients were seen by the pediatric otolaryngology service over a 5-year follow-up period. Design: Retrospective observational study. Setting: Tertiary children's hospital affiliated with a university hospital. Patients: Screened were 187 903 patient visits for infants younger than 12 months. A total of 1148 infants with an ALTE were identified, 471 of whom met study inclusion criteria. To identify the study population, these infants were cross-referenced against a database of 5156 patients who underwent airway evaluation by the pediatric otolaryngology service. Main Outcome Measures: Airway evaluation with or without intervention. Results: Four hundred seventy-one infants with an ALTE met study inclusion criteria, 9 of whom subsequently underwent airway evaluation via bronchoscopy, laryngoscopy, or both. Three were referred during their initial ALTE admission, and 6 were seen later in childhood. Five of 9 patients had normal findings, 3 patients had laryngomalacia (including 2 with laryngeal edema), and 1 patient had adenotonsillar hypertrophy. Interventions consisted of 2 supraglottoplasties and 1 adenotonsillectomy. Conclusions: Among well-appearing infants hospitalized with an ALTE, 98.1% (462 of 471) did not undergo subsequent airway evaluation, and only 0.6% (3 of 471) ultimately required pediatric otolaryngologic surgical intervention during 5 years after the event. This study shows that otolaryngologists are not frequently consulted for well-appearing infants with an ALTE and that airway abnormalities are rare. [ABSTRACT FROM AUTHOR]

Objective: To examine the effectiveness and safety of low-frequency repetitive transcranial magnetic stimulation (rTMS) to the temporoparietal junction in a cohort of patients with bothersome tinnitus. Design: Crossover, double-blind, randomized clinical trial. Setting: Outpatient academic medical center. Participants: Fourteen adults aged 42 to 59 years with subjective, unilateral or bilateral, nonpulsatile tinnitus of 6 months' duration or longer and a score of 38 or greater on the Tinnitus Handicap Inventory (THI). Interventions: Low-frequency (1-Hz) 110% motor threshold rTMS or sham treatment to the left temporoparietal junction for 2 weeks. Main Outcome Measure: The difference in the change of the THI score between active and sham rTMS. Results: Active treatment was associated with a median (95% confidence interval) reduction in THI score of 5 (0-14) points, and sham treatment was associated with a median reduction in THI score of 6 (-2 to 12) points. The difference in THI scores between the change associated with active and sham rTMS ranged from a 34- point reduction in THI score after active treatment to a 22-point increase after sham treatment, with a median difference change of only 1 point (-6 to 4 points). Conclusions: Daily low-frequency rTMS to the left temporoparietal junction area for 2 weeks is no more effective than placebo for patients with chronic bothersome tinnitus. Possible explanations for the negative findings are short duration of treatment, failure of rTMS stimulation over the temporoparietal area to affect the auditory cortex buried within the Sylvian fissure, or more widespread cortical network changes associated with severe bothersome tinnitus not amenable to localized rTMS effects. [ABSTRACT FROM AUTHOR]

Objectives: To correlate the recurrence of temporalis fascia graft perforation and retraction in adults and children after tympanoplasty for chronic tubotympanic otitis and deep attic retraction pockets with age, pathologic process, mucosal lesions, mucociliary transport time, chronic sinusitis, and lateral attic wall reconstruction. Design: Retrospective study. Setting: Tertiary referral center. Patients: Two hundred seventy-four adult ears and 41 child ears were operated on for chronic tubotympanic otitis, 50 adult ears were operated on for traumatic tympanic membrane rupture, and 56 adult ears were operated on for attic retraction pockets. Interventions: Underlay tympanoplasty with or without mastoidectomy and lateral attic wall reconstruction for attic retraction pockets. Mucociliary transport time was investigated using saccharin testing. Main Outcome Measures: Recurrent perforation, recurrent attic retraction, and temporalis fascia graft retraction were evaluated. Results: Higher incidences of recurrent perforation were found in adults operated on for tubotympanic otitis vs traumatic tympanic membrane rupture (P=.02) and in children (P=.004), especially those 9 years and younger (P=.02). A risk factor in adults was chronic sinusitis (risk ratio, 35.0; 95% confidence interval, 32.1-38.2; P=.004). Temporalis fascia graft retraction correlated with slower mucociliary transport time in adults (P<.001). A lower incidence of recurrent attic retraction was associated with lateral attic wall reconstruction (P<.001). Conclusions: Recurrent temporalis fascia graft perforation after tympanoplasty for tubotympanic otitis may be related to age and coexisting chronic sinusitis. Temporalis fascia graft retraction correlates with slower mucociliary transport time in the eustachian tube. Lateral attic wall reconstruction minimizes recurrent attic retraction in adults. [ABSTRACT FROM AUTHOR]

Objective: To compare the 3-year results of 2 endoscopic surgical approaches in the management of nasal polyposis. Design: Retrospective medical record review. Setting: Private or institutional practice. Patients: A total of 127 patients with nasal polyposis were operated on by the same surgeon between January 1, 2003, and September 31, 2005. Intervention: The patients underwent radical ethmoidectomy (n=77) and polypectomy (n=50). Main Outcome Measures: Outcome measures were global functional score, calculated by summing the scores (0-3) of each symptom (congestion, rhinorrhea, anosmia, hyperreactivity, and pain); global anatomical score (GAS), calculated by summing the score of polyp development for each nasal cavity; computed tomography score; adherence to corticosteroid therapy; oral corticosteroid consumption; and complication and subsequent operation rate. Efficacy was evaluated by comparing these data preoperatively and postoperatively (at 3 months, 1 year, and 3 years). Results: The global functional score and GAS were significantly improved 3 years after these techniques were performed (global functional score changes from 8.65 to 3.11 for ethmoidectomy and from 8.15 to 4.2 for polypectomy; GAS, from 5.95 to 1.83 for ethmoidectomy and from 6.57 to 3.58 for polypectomy). Congestion, pain, and GAS were improved to a significantly greater extent in the ethmoidectomy group. The subsequent operation rate for symptomatic polyp recurrence was comparable (9.1% vs 8.0%), with fewer local complications in the polypectomy group. Conclusion: Polypectomy seems to represent a valuable alternative in the armamentarium of first-hand surgical procedures for treating nasal polyposis. [ABSTRACT FROM AUTHOR]

Objectives: To compare the prevalence of congenital cytomegalovirus (CMV) infection in Washington State in children with hearing loss (HL) and the general population and to compare the characteristics of HL in children with and without congenital CMV infection. Design: Matched case-control; case cohort. Setting: Regional pediatric hospital, Washington State Department of Health (WSDOH). Patients: Cases were children 4 years and older with HL born in Washington State. Control individuals matched for demographic characteristics were identified at random through the WSDOH. Main Outcome Measures: Congenital CMV status determined using quantitative polymerase chain reaction testing on newborn heel stick blood spots archived by the WSDOH. Audiologic data were used to characterize HL. Results: Congenital CMV testing was performed for 222 matched cases and controls. Congenital CMV infection was detected in 1.4% of controls and in 9.9% of cases (odds ratio, 10.5;95%confidence interval, 2.6-92.4).An estimated 8.9% of HL in children in Washington can be attributed to CMV infection. After inclusion of an additional 132 children with HL (for a total of 354 cases in the case cohort), we observed that children with congenitall CMV had more severe HL(P<.001)and higher proportions of progressive (P=.02) and unilateral (P=.002) HL compared with children without congenital CMV infection. In the 35 children with congenital CMV infection, there was no relationship between neonatal CMV load and severity of HL. Conclusions: In Washington State, children with HL had a far higher prevalence of congenital CMV viremia than did the general pediatric population, and CMV infection seems to be responsible for an appreciable fraction of pediatric HL in Washington State. [ABSTRACT FROM AUTHOR]

Objective: To assess whether dynamically modulating endotracheal tube (ETT) cuff pressure, by decreasing it during each ventilatory cycle instead of maintaining a constant level, would reduce the extent of intubationrelated laryngotracheal injury. Design: Single-blind, randomized controlled animal study using a previously validated live porcine model of accelerated intubation-related tracheal injury. Setting: Animal research facility. Patients: Ten piglets (weight, 16-20 kg each) were anesthetized and underwent intubation using a cuffed ETT. Interventions: The animals were randomized into the following 2 groups: 5 pigs had a novel device to modulate their cuff pressure from 25 cm H2O during inspiration to 7 cm H2O during expiration, and 5 pigs had a constant cuff pressure of 25 cm H2O. Both groups underwent ventilation under hypoxic conditions for 4 hours. Main Outcome Measure: Laryngotracheal mucosal injury after blinded histopathological assessment. Results: The modulated-pressure group showed significantly less overall laryngotracheal damage than the constantpressure group (mean grades, 1.2 vs 2.1; P<.001). Subglottic damage and tracheal damage were significantly less severe in the modulated-pressure group (mean grades, 1.0 vs 2.2;P<.001, and 1.9 vs 3.2;P<.001, respectively). There was no significant difference in glottic or supraglottic damage between the groups (P=.06 and .27, respectively). Conclusions: This novel device reduces the risk of subglottic and tracheal injury by modulating ETT cuff pressure in synchronization with the ventilatory cycle. This finding could have far-reaching implications for reducing the risk of airway injury in patients undergoing longterm intubation. Further clinical study of this device is warranted. [ABSTRACT FROM AUTHOR]