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Purpose of Review Tracheostomy in a child demands critical pre-operative evaluation, deliberate family education, competent surgical technique, and multidisciplinary post-operative care. The goals of pediatric tracheostomy are to establish a safe airway, optimize ventilation, and expedite discharge. Herein we provide an update regarding timing, surgical technique, complications, and decannulation, focusing on a longitudinal approach to pediatric tracheostomy care. Recent Findings Pediatric tracheostomy is performed in approximately 0.2% of inpatient stays among tertiary pediatric hospitals. Mortality in children with tracheostomies ranges from 10–20% due to significant comorbidities in this population. Tracheostomy-specific mortality and complications are now rare. Recent global initiatives have aimed to optimize decision-making, lower surgical costs, reduce the length of intensive care, and eliminate perioperative wound complications. The safest road to tracheostomy decannulation in children remains to be both patient and provider dependent. Summary Recent literature provides guidance on safe, uncomplicated, and long-term tracheostomy care in children. Further research is needed to help standardize decannulation protocols.

OBJECTIVES/HYPOTHESIS To determine whether the presence of detectable upper respiratory infections (URIs) at the time of adenoidectomy/adenotonsillectomy is associated with increased morbidity, complications, and unexpected admissions. STUDY DESIGN Prospective double-blinded cohort. METHODS In this prospective cohort study, nasopharyngeal swabs were obtained intraoperatively from 164 pediatric patients undergoing outpatient adenoidectomy/tonsillectomy with or without pressure equalization tubes (PETs) and were analyzed with PCR for the presence of 22 known URIs, including SARS-CoV-2. Surgeons and families were blinded to the results. At the conclusion of the study, rates of detectable infection were determined and intraoperative and postoperative events (unexpected admissions, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, and postoperative presentation to an emergency department) were compared between infected and uninfected patients. RESULTS Of the 164 patients (50% male, 50% female, ages 8 mo-18 y), 136 patients (82.9%) tested positive for one or more URI at the time of surgery. Forty one patients (25.0%) tested positive for three or more URIs concurrently, and 11 (6.7%) tested positive for five or more URIs concurrently. There were no significant differences in admission rates, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, or postoperative presentation to an emergency department between positive and negative patients. No patients tested positive for SARS-CoV-2. CONCLUSIONS A recent positive URI test does not confer any additional intraoperative or postoperative risk in the setting of outpatient adenoidectomy/tonsillectomy in healthy patients. There is no utility in preoperative URI testing, and delaying surgery due to a recent positive URI test is not warranted in this population. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E2074-E2079, 2021.

The cricoid is a circular “ring” of cartilage in the airway. When the lateral walls of the cricoid approximate, it takes the shape of an ellipse. In severe cases, this also reduces the glottic aperture and causes respiratory distress, stridor, and failure to thrive. The elliptical cricoid has limited surgical options outside of open laryngotracheal procedures and tracheostomy. Recently, alternatives to autologous grafts have been utilized in airway reconstruction to reduce harvest site morbidity and increase operating room efficiency. Herein a case is presented that demonstrates the successful use of a resorbable plate in augmenting the posterior larynx in an infant with a severely elliptical cricoid to avoid a tracheostomy.

OBJECTIVES Develop multidisciplinary and international consensus on patient, disease, procedural, and perioperative factors, as well as key outcome measures and complications, to be reported for pediatric airway reconstruction studies. METHODS Standard Delphi methods were applied. Participants proposed items in three categories: 1) patient/disease characteristics, 2) procedural/intraoperative/perioperative factors, and 3) outcome measures and complications. Both general and anatomic site-specific measures were elicited. Participants also suggested specific operations to be encompassed by this project. We then used iterative ranking and review to develop consensus lists via a priori Delphi consensus criteria. RESULTS Thirty-three pediatric airway experts from eight countries in North and South America, Europe, and Australia participated, representing otolaryngology (including International Pediatric Otolaryngology Group members), pulmonology, general surgery, and cardiothoracic surgery. Consensus led to inclusion of 19 operations comprising open expansion, resection, and slide procedures of the larynx, trachea, and bronchi as well as three endoscopic procedures. Consensus was achieved on multiple patient/comorbidity (10), disease/stenosis (7), perioperative-/intraoperative-/procedure-related (16) factors. Consensus was reached on multiple outcome and complication measures, both general and site-specific (8 general, 13 supraglottic, 15 glottic, 17 subglottic, 8 cervical tracheal, 12 thoracic tracheal). The group was able to clarify how each outcome should be measured, with specific instruments defined where applicable. CONCLUSION This consensus statement provides a framework to communicate results consistently and reproducibly, facilitating meta-analyses, quality improvement, transfer of information, and surgeon self-assessment. It also clarifies expert opinion on which patient, disease, procedural, and outcome measures may be important to consider in any pediatric airway reconstruction patient. LEVEL OF EVIDENCE 5 Laryngoscope, 129:244-255, 2019.

Malignant pediatric tracheal tumors are rare and often present with non-specific findings. Here we present the first case of a primary Ewing tracheal sarcoma in a pediatric patient. Initial presentation, surgical management, post-operative care, and a review of the literature are discussed.

OBJECTIVE Determine if overnight stenting is warranted after pharyngeal flap for management of velopharyngeal insufficiency (VPI) in pediatric patients METHODS: This is a retrospective age-matched cohort study from a single tertiary pediatric facility. Patients who underwent a posterior pharyngeal flap for VPI from January 1, 2013, to December 31, 2016, were included. Two equal groups were constructed based on when their nasal stents were removed, that is, postoperative day (POD) 0 or POD 1. Primary outcome measure was oxygen desaturation after surgery. Secondary outcome measures were total length of stay, need for narcotics, and oral intake based on POD. Additional information was gathered and evaluated as possible prognostic variables. RESULTS There were 27 matched pairs included in the study. One patient from each group required supplemental oxygen during the night of surgery. No escalation of care was needed in either case. The group whose stents were removed on POD 0 were discharged earlier than the group whose stents were removed on POD 1, P < 0.0001. The POD 0 group took significantly more oral intake on POD 0 than the POD 1 group, P = 0.03. The POD 0 group had significantly more genetic syndromes than the POD 1 group, P = 0.02. CONCLUSION There was no benefit with overnight stenting. Earlier discharge from the hospital was achieved in the POD 0 group. No patient experienced need for reintubation, escalation of clinical care, postoperative hemorrhage, or death. LEVEL OF EVIDENCE 4. Laryngoscope, 128:750-755, 2018.

Acquired laryngomalacia in the pediatric population is rare, especially from a neurogenic cause. This case report describes a pediatric patient who developed laryngomalacia following a neurologic insult. A proposed physiologic pathway is reviewed. A thorough literature review was performed to identify cases of acquired laryngomalacia ascribed to a neurologic cause and are compared to this case.

Congenital deficiency of distal tracheal rings is a rare anomaly and has been previously reported in the literature. Here we report the first case deficient tracheal rings confined to the cervical trachea. Patient was transferred to our institution for management of what was initial thought to be complete tracheal rings. The patient was successfully managed with a tracheal resection and short segment cervical slide tracheoplasty. Presentation, surgical approach, histological findings, and literature review are described.

Objectives/Hypothesis This study aimed to determine the incidence of major complications following both primary and revision transsphenoidal pituitary surgery. Major complications included endocrinopathic, skull base, orbital, hemorrhagic and thromboembolic complications, respiratory failure, and death. Secondarily, this study aimed to examine factors associated with the occurrence of complications. Study Design Retrospective cohort analysis of California and Florida all-payer databases from 2005 to 2008. Methods The major complication rate following both primary and revision transsphenoidal pituitary surgery was calculated. Bivariate analyses were performed to investigate the relationship of patient characteristics with complication occurrence, and a multivariate model was constructed to determine risk factors associated with these complications. Results There were 5,277 primary cases and 192 revision cases that met inclusion criteria. There was a nonsignificant absolute difference of 3.09% (95% confidence interval [CI]: −11.00 to 16.14) between the rate of complications following primary (n = 443, 8.39%) and revision (n = 22, 11.46%) surgeries. Multivariate analyses showed that patients with Medicare (odds ratio [OR]:1.74, 95% CI: 1.17 to 2.61), Medicaid (OR: 2.13, 95% CI: 1.59 to 2.86), or a malignant neoplasm (OR: 3.10, 95% CI: 1.62 to 5.93) were more likely to have complications. Conclusions The rate of major complications following transsphenoidal pituitary surgery is lower than earlier retrospective reports. The overall complication rate following revision surgery was not significantly different from primary surgery. Insurance status and a diagnosis of a malignant neoplasm were associated with a higher rate of complications. Level of Evidence 2C Laryngoscope, 125:311–317, 2015

A case of balloon frontal sinuplasty in a 12-year old male with intracranial abscess from acute sinusitis is presented. The patient experienced photophobia, fever, headache, nausea and vomiting. Frontal sinusitis with intracranial abscess was diagnosed on imaging. The patient was taken to the operating room for drainage with left frontal balloon sinuplasty. The patient showed immediate clinical improvement, did not suffer from any complications of surgery and was further managed with long term intravenous antibiotics. We believe that balloon frontal sinuplasty is potentially safe and effective in the treatment of complicated acute frontal sinus obstruction in children.

Objectives/Hypothesis The goal of this study was to determine the incidence of major complications following primary and revision functional endoscopic sinus surgery (FESS). In addition, this study aimed to determine factors associated with the occurrence of complications including patient and provider characteristics and the use of image guidance system (IGS) technology. Study Design Retrospective cohort analysis of California and Florida all-payer databases from 2005 to 2008. Methods The rates of major surgical complications (skull base, orbital, and hemorrhagic) after primary and revision FESS were calculated, and bivariate analyses were performed to investigate relationships of complications with demographic and clinical characteristics. A multivariate model was used to determine risk factors for the occurrence of major complications. Results Among 78,944 primary FESS cases, 288 major complications were identified representing a complication rate of 0.36% (95% CI 0.32%–0.40%). The major complication rate following revision cases (n = 19; 0.46%) and primary cases (n = 288; 0.36%) was similar (OR = 1.26; 95% CI 0.79–2.00). Multivariate analysis showed that patients who were >40 years old, had a primary payer of Medicaid, had surgery involving the frontal sinus, or had image guidance during surgery were at higher risk for major complications. Conclusion The rate of major complications (0.36%) associated with primary FESS is lower than earlier reports. The rate of major complications following revision FESS (0.46%) was found to be similar to primary cases. IGS, insurance status, age, and extent of surgery were found to be associated with an increased risk of major complications following FESS. Level of Evidence 2C. Laryngoscope, 124:838–845, 2014

Objectives/Hypothesis: Subjective, chronic tinnitus is a common but poorly understood condition. The heterogeneity within tinnitus has hindered the development of functional severity measures and effective treatment. Tinnitus at least partially results from maladaptive cortical processes that are associated with cognitive deficits. This study examined whether cognitive processing speed might serve as a novel objective measure of tinnitus severity, and whether the psychiatric comorbidities of depression and somatization are predictive of self-reported tinnitus severity. Study Design: Cross-sectional study of 92 chronic tinnitus participants. Methods: The Tinnitus Handicap Inventory (THI) captured the self-reported severity of tinnitus. Cognitive processing speed was objectively measured by the Brain Speed Test (BST), a short computerized test from Posit Science. Somatization and depression were captured by the Whiteley-7 and Patient Health Questionnaire-9 scales. The results of these tests were combined into a Composite Psychiatric State (CPS) variable. The ability of BST z score and CPS level to predict THI was assessed. Results: There was a significant correlation (r = 0.54, P < .001) between BST z scores and THI in those with bothersome tinnitus (THI ≥ 30). Additionally, BST z score was correlated with the validated neurocognitive tests. Multivariate analysis identified BST z score and CPS level as independent predictors of THI. Conclusions: In severe tinnitus, BST provides an objective measure of the functional impact of tinnitus. Cognitive processing speed and psychiatric state are independent predictors of self-reported tinnitus severity. These measures help define clinical subgroups within tinnitus: one subgroup whose functional impact is primarily cognitive and another whose functional impact is primarily psychiatric. Laryngoscope, 2012

To determine changes in cortical neural networks as defined by resting-state functional connectivity magnetic resonance imaging during voluntary modulation of tinnitus with orofacial maneuvers.Cross-sectional study.Academic medical center.Participants were scanned during the maneuver and also at baseline to serve as their own control. The authors chose, a priori, 58 seed regions to evaluate previously described cortical neural networks by computing temporal correlations between all seed region pairs. Seed regions whose correlations significantly differed between rest and maneuver (P.05, uncorrected) entered into a second-stage analysis of computing the correlation coefficient between the seed region and time courses in each of the remaining brain voxels. A threshold-free cluster enhancement permutation analysis evaluated the distribution of these correlation coefficients after transformation to Fisher z scores and registration to a surface-based reconstruction using Freesurfer.The median age for the 16 subjects was 54 years (range, 27-72 years), and all had subjective, unilateral or bilateral, nonpulsatile tinnitus for 6 months or longer. In 9 subjects who could voluntarily increase the loudness of their tinnitus, there were no significant differences in functional connectivity in any cortical networks. A separate analysis evaluated results from 3 patients who decreased the loudness of their tinnitus. Four subjects were excluded because of excessive motion in the scanner.The absence of significant differences in functional connectivity due to voluntary orofacial maneuvers that increased tinnitus loudness failed to confirm prior reports of altered cerebral blood flows during somatomotor behaviors.

To describe the mechanical rationale and clinical application of prototype right-angle reduction forceps.A pair of prototype right-angle reduction forceps was designed and manufactured specifically to improve the consistency and ease of fracture reduction. It was used to reduce mandible fractures of the mandible body, parasymphysis, and symphysis in 4 patients. The fractures ranged from minimally displaced to comminuted and displaced fractures.The pilot monocortical holes used for insertion of the right-angle reduction forceps into the mandible were easier to drill than the old method of drilling angled holes for standard reduction forceps. The older method required constant guesswork as to the correct angle of the hole relative to the tines of the curved reduction forceps. The right-angle reduction forceps required no guesswork because the pilot hole is drilled at a right angle to the surface of the outer bone cortex and at more than 1 cm laterally on each side of the fracture line. There were no episodes of outer cortical bone avulsion or any necessity for redrilling new pilot holes. These forceps provided sufficient force for excellent reduction of the fracture edges. The design also provided improved access for plating superior and inferior to its shaft while it was engaged.Although curved bony reduction forceps are standard in most mandibular plating sets, they provide less predictable and efficient reduction of fractures than the right-angle reduction forceps. Prototype reduction forceps require little to no additional training to use properly.

To evaluate the impact of a Mindfulness Based Stress Reduction (MBSR) program in patients with chronic bothersome tinnitus on the (1) severity of symptoms of tinnitus and (2) functional connectivity in neural attention networks.Open-label interventional pilot study.Outpatient academic medical center.A total of 13 adult participants with a median age of 55 years, suffering from bothersome tinnitus.An 8-week MBSR program was conducted by a trained MBSR instructor. The primary outcome measure was the difference in patient-reported tinnitus symptoms using the Tinnitus Handicap Index (THI) and Tinnitus Functional Index (TFI) between pre-intervention, post-MBSR, and 4-week post-MBSR assessments. Secondary outcomes included change in measurements of depression, anxiety, mindfulness, and cognitive abilities. Functional connectivity magnetic resonance imaging (MRI) was performed at pre- and post-MBSR intervention time points to serve as a neuroimaging biomarker of critical cortical networks.Scores on the THI and TFI showed statistically significant and clinically meaningful improvement over the course of the study with a median ΔTHI of -16 and median ΔTFI of -14.8 between baseline and 4-week follow-up scores. Except for depression, there was no significant change in any of the secondary outcome measures. Analysis of the resting state functional connectivity MRI (rs-fcMRI) data showed increased connectivity in the post-MBSR group in attention networks but not the default network.Participation in an MBSR program is associated with decreased severity in tinnitus symptoms and depression and connectivity changes in neural attention networks. MBSR is a promising treatment option for chronic bothersome tinnitus that is both noninvasive and inexpensive.

Importance Tinnitus affects more than 40 million people in the Unites States, and cognitive difficulties are among the most commonly associated symptoms. Objective To test the feasibility and preliminarily the effectiveness of using a putative neuroplasticity-enhancing drug, D-cycloserine, to facilitate a computer-assisted CT program for improving tinnitus bother and related cognitive difficulties. Design, Setting, and Participants Double-blind, randomized clinical trial at an outpatient academic medical center of 34 participants aged 35 to 65 years with subjective, unilateral or bilateral, nonpulsatile tinnitus of at least 6 months’ duration. Interventions Five weeks of twice-weekly computer-based CT with either 250 mg D-cycloserine or placebo orally prior to computer CT sessions. Main Outcomes and Measures Difference in the change in Tinnitus Functional Index (TFI) score between the 2 groups. Results After excluding 1 participant lost to follow-up, 1 who withdrew, 1 who did not complete 90% of sessions, and 1 outlier, 30 participants were included in the analysis. The D-cycloserine plus CT group showed a significant improvement in median TFI score (−5.8 [95% CI, −9.4 to −1.1]) and self-reported cognitive deficits (−4.5 [95% CI, −11.5 to −1.0]), but the placebo group did not (−1.0 [95% CI, −11.7 to 4.9] and −2.0 [95% CI, −5.1 to 2.0], respectively). After controlling for age and duration of tinnitus, there was no significant difference in TFI score change between the 2 groups ( P = .41). After confounders were controlled for, the D-cycloserine group demonstrated a significantly greater improvement in self-reported cognitive deficits as compared with the placebo group ( P = .03). No serious adverse events were reported. Conclusions and Relevance Use of a computer-based CT program with a putative neuroplasticity-sensitizing drug, D-cycloserine, was feasible and well tolerated. With the limited sample size, the adjuvant use of D-cycloserine was no more effective than placebo at improving tinnitus bother. The finding that D-cycloserine use was more effective than placebo at improving self-reported cognitive difficulties could be important given the high rate of concern for cognitive deficits in patients with tinnitus. D-cycloserine and other putative neuroplasticity-facilitating agents could be investigated in the future as a strategy to enhance neuroplasticity–based tinnitus treatments. Trial Registration clinicaltrials.gov Identifier:NCT01550796

To assess functional connectivity in cortical networks in patients with nonbothersome tinnitus compared with a normal healthy nontinnitus control group by measuring low-frequency (0.1 Hz) spontaneous blood oxygenation level-dependent (BOLD) signals at rest.Case-control.Academic medical center.Nonbothersome, idiopathic subjective tinnitus for at least 6 months (n = 18) and a normal healthy nontinnitus control group (n = 23).Functional connectivity differences in 58 a priori selected seed regions of interest encompassing cortical loci in the default mode, attention, auditory, visual, somatosensory, and cognitive networks.The median age of the 18 subjects was 54 years (interquartile range [IQR], 52-57), 66% were male, 90% were white, median Tinnitus Handicap Inventory (THI) score was 8 (IQR, 4-14), and a median Beck Depression Index score was 1 (IQR, 0-5). The median age for the control group was 46 years (IQR, 39-54), and 52% were male. Of the 58 seeds analyzed, no regions had significantly different functional connectivity among the nonbothersome tinnitus group when compared with the control group.Among nonbothersome tinnitus patients, the tinnitus percept does not appear to alter the functional connectivity of the auditory cortex or other key cortical regions. Trial Registration ClinicalTrials.gov Identifier: NCT01049828.

Objective: Examine the relationship between severity of tinnitus, as measured by the Tinnitus Handicap Inventory (THI), and performance on a computer-based objective test of cognition (ie, Brain Speed Test (BST)) and investigate the impact of a Brain Fitness Program (BFP) on tinnitus patients.Method: Cross-sectional study of 60 adults with tinnitus. BST was completed by all participants. Results were transformed to z scores (BSTZ) based on age-matched control data. Fifteen subjects continued in a longitudinal study using BFP. Attention, memory, and bother scores were assessed in addition to THI score and BST post-training.Results: Duration of tinnitus for the 60 participants (average age, 54 years; 51% males) ranged from 6 months to 47 years (median, 7 years). THI ranged from 0 to 80 (median, 26). Severe tinnitus was present in 27 (46%) of participants. A significant relationship between severity of tinnitus and BSTZ was identified in the group of participants with severe tinnitus (Spearman rho = 0.52, P ...

Objective: Tinnitus is a ubiquitous problem with no effective cure, yet only a minority of sufferers are “bothered.” Neurocognitive testing of these “bothered” patients reveals poor performance in verbal learning and attention. The goal of the present investigation was to assess the effects of non-bothersome tinnitus on standardized neurocognitive tests.Method: Cross-sectional study of 13 nonbothersome tinnitus participants (age 18-60 years) with subjective, unilateral or bilateral, non pulsatile tinnitus for at least 6 months’ duration, and a score 38). Each participant underwent comprehensive neurocognitive assessment.Results: Thirteen participants (9 male) with a mean age of 55 years (range, 47-60 years) were enrolled. Median THI was 9 (range, 0-20), median tinnitus duration was 11 years (range, 2-35 years), and all had hearing loss. A comprehensive neurocognitive battery was performed. Participants were found to score higher than a vetted normative sample on the Stroop Color Test (P =.002) and Conners...

PURPOSE OF REVIEW In the last year, several groups have used various methods to calculate economic costs to patients with early- and late-stage head and neck cancer, cost comparisons of palliative treatments, patient time costs associated with cancer care, and the impact of new diagnostic technologies which need formal cost-effectiveness assessment to determine their value. RECENT FINDINGS Late-stage oral and oropharyngeal cancer treatment is more expensive than early-stage. Photodynamic therapy is cost-effective for esophageal cancer. Head and neck cancer patients spend more time receiving care than control cancer. Multimodal therapy for oropharynx cancer has a higher inpatient utilization than a radio (chemo) approach. Positron emission tomography in combination with computed tomography has a high accuracy, positive predictive value, and ability to find unknown primaries. Soluble CD44 and methylation status are highly sensitive and specific for detecting head and neck cancer. The Washington University head and neck cancer comorbidity index was successful at predicting 5-year costs of head and neck cancer. SUMMARY Evidence-based studies to inform head and neck cancer care providers are limited. As this available literature proliferates, it should inform providers and policy makers about optimizing the quality and cost of healthcare expenses.

Importance This research examines the impact of 4 weeks of repetitive transcranial magnetic stimulation (rTMS) stimulation to the temporoparietal junction and compares the results of this longer duration of treatment with a similar stimulus protocol of only 2 weeks' duration. Objective To examine the effectiveness and safety of 4 weeks of low-frequency rTMS to the left temporoparietal junction in a cohort of patients with bothersome tinnitus. Design Crossover, double-blind, randomized controlled trial. Setting Outpatient academic medical center. Participants The study population comprised 14 adults aged between 22 and 59 years with subjective, unilateral or bilateral, nonpulsatile tinnitus of 6 months' duration or greater and a score of 34 or greater on the Tinnitus Handicap Inventory (THI). Interventions Low-frequency (1 Hz) 110% motor threshold rTMS or sham to the left temporoparietal junction for 4 weeks. Main Outcome and Measure The difference of the change in the THI score between active rTMS and sham rTMS. Results Active treatment was associated with a median reduction in THI score of 10 (range, −20 to +4) points, and sham treatment was associated with a median reduction of 6 (range, −24 to +12) points. The median difference in THI score between the change associated with active and sham rTMS was 4 (95% CI, −9 to 10; and range, −32 to +14) points. Conclusions and Relevance Daily low-frequency active rTMS to the left temporoparietal junction area for 4 weeks was no more effective than sham for patients with chronic bothersome tinnitus. Possible explanations for this negative study include the failure of rTMS to stimulate deeper parts of auditory cortex within the sylvian fissure and more widespread cortical network changes not amenable to localized rTMS effects. Trial Registration clinicaltrials.gov Identifier: NCT00567892

Objectives To reexamine the “Norman rule” (affected parathyroid gland would contain at least 20% radioactivity compared with background), report normative radiation data, offer alternative ratios, and explore the effect of lapsed time on minimally invasive parathyroidectomy (MIRP). Design Retrospective analysis. Setting Tertiary care academic medical center. Patients A total of 116 consecutive patients who had a diagnosis of primary hyperparathyroidism, positive findings on sestamibi scan, and complete study data from 2000 to 2005 at a single institution. Interventions Minimally invasive radio-guided parathyroidectomy (MIRP) for primary hyperparathyroidism. Main Outcome Measures Ten-second gamma radiation counts at key procedural steps. Various ratios of measured radioactivity counts were studied. Results A total of 116 patients who underwent MIRP had complete data; 91 patients waited 4 or more hours until surgery (78%), with some waiting 8 or more hours. Every patient had a successful surgery and was observed for 1 year thereafter. The Norman ratio of radiation counts (ex vivo to background) was compared with other radiation ratios using Spearman correlation; the comparisons included skin to background (ρ = 0.579), in vivo to background (ρ = 0.770), basin to background (ρ = 0.525), and in vivo–basin to background (ρ = 0.788). Regression analysis indicated that the Norman ratio decreased over time at 11% per hour ( P = .31). Conclusions Alternative ratios to the Norman ratio are reported. An ex vivo to background ratio greater than 20% as a rule of successful parathyroid adenoma excision was observed in all but 2 cases in our series.