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Traditional assessments of the microbial flora associated with acute bacterial rhinosinusitis have relied on maxillary sinus punctures (taps) and culture. These taps are now considered the gold standard for obtaining cultures and are used as the method of identifying bacterial pathogens in antimicrobial trials. Maxillary sinus taps are limited by discomfort to the patients and technical concerns. Because of these factors, the standard of performing taps has limited antibiotic trials and microbial surveillance. Alternatives to maxillary sinus taps have been explored.We conducted a retrospective, systematic review of the literature from 1950 to 2000 of articles comparing culture techniques in the nose and paranasal sinuses for acute bacterial rhinosinusitis.Nasal cultures have poor correlation to maxillary sinus cultures, whereas there is 60% to 85% concordance between endoscopically guided middle meatal cultures and maxillary sinus cultures. These studies, however, are all limited by small sample sizes and therefore are inadequate to make any concrete recommendations regarding the relative role of endoscopically guided middle meatal cultures as a formal method of pathogen identification in acute bacterial rhinosinusitis.A formal prospective study with sufficient sample size to assess the concordance between the microbial flora of the maxillary sinus punctures and middle meatal cultures in acute rhinosinusitis is recommended.

Muscle is a convenient and accessible site for non-viral gene delivery, which can manufacture gene products and provide a long-duration of gene expression. The level of gene expression after administration of naked DNA plasmid or polymer-formulated DNA plasmid containing a reporter gene to muscle via syringe injection, however, is very low. As a result, no significant therapeutic effect can be detected after saline- or polymer-mediated gene delivery into muscle. In 1998, investigators published a striking new approach--electrotransfection--for intramuscular gene delivery (now commonly referred to as electroporation or electroinjection). Electroporation of a non-viral gene into the muscles of small animals has increased the level of gene expression by as much as two orders of magnitude, which is comparable to levels achieved with adenoviral gene delivery. Three years later, intramuscular electroporation gene delivery technology has blossomed. Treatments for different diseases using this approach in animal models have been reported. In this review, I discuss the applications of intramuscular electroporation gene therapy to treat malignancies, renal disease, and anemia, and to prevent drug toxicity to sensory nerves.

In light of recent events, anthrax has once again taken center stage in the world of science and the world in which we live. Because patients with anthrax may initially present to otolaryngology clinics, it is important for the otolaryngologist to know how to diagnose and treat this entity. This article will present current information on epidemiology, microbiology, pathogenesis/clinical manifestations, diagnosis, and treatment with a particular interest in the head and neck region.

To evaluate the impact of early versus delayed endoscopic sinus surgery (ESS) in terms of postoperative health care utilization, using a patient cohort with chronic rhinosinusitis (CRS).Retrospective administrative database analysis.US-based primary and secondary sites of care.CRS patients with ESS in 2010-with no other ESS before 2010 and with complete medical history from 2004 to 2012-were identified within the MarketScan database. Patients were characterized by time interval of first sinusitis or nasal polyposis diagnosis to ESS and grouped as following: group 1,1 year (n=818); group 2, 1 to2 years (n=247); group 3, 2 to3 years (n=274); group 4, 3 to4 years (n=364); group 5, 4 to5 years (n=595); and group 6, ≥5 years (n=535). Outpatient visits/procedures and prescriptions associated with sinusitis and/or nasal polyps were analyzed for 1 year preoperatively and 2 years postoperatively. Subanalyses were conducted on separate cohorts with or without asthma or polyps, within each group.Patients in group 1 had significantly fewer visits and prescriptions than patients in group 6 (postoperative visits: group 1, 4.45 [95% CI, 4.06-4.84]; group 6, 6.70 [95% CI, 6.10-7.30; prescriptions: group 1, 4.54 [95% CI, 4.12-4.96]; group 6, 7.61 [95% CI, 6.92-8.31]). Gradual increases in utilization were observed from groups 1 to 6. Subanalysis of patients with and without asthma or polyps showed similar findings.Early intervention after diagnoses of CRS, with or without asthma or polyps, is associated with lower health care utilization than intervention after many years of medical management.

Conclusions: Physician extenders are a valuable asset to an academic otolaryngology residency program. Their presence enhances patient access, and care. They have a positive impact on resident quality of life and augments resident education. The Otolaryngology Training Residency Program accepts 3 residents per year. The 5-year training program in Otolaryngology consists of 4 years of progressive training in Otolaryngology – Head and Neck Surgery, preceded by 1 year in general surgery. Each PGY-1 resident spends 3 months on the otolaryngology service. The PGY2 through PGY-5 residents are assigned to a rotation block based on their training level. Our rotations consist of General Otolaryngology, Head and neck Oncology, Facial Plastics, Pediatric Otolaryngology, Rhinology, Otology and Laryngology.

Background Rhinosinusitis (RS) is a complex group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses. Methods One of the problems with evaluating and treating RS is that there are often difficulties and controversies related to the means of diagnosis, which would prompt appropriate treatment. Results This is particularly true in chronic RS where multiple treatments may be chosen and often these decisions are somewhat empiric and are based on the associated history, symptoms, and prior treatment. This also creates problems with assessing response to treatment where there are multiple tools that are used to diagnose RS and to assess response to both treatment and nontreatment over time. Consistent and reproducible measures of outcome may be lacking. Conclusion The purpose of this study was to describe the various diagnostic criteria that are used to evaluate RS and their role in measuring outcomes.

To evaluate short- and long-term vocal outcomes after medialization laryngoplasty (ML) using a silastic implant in patients with unilateral vocal fold paralysis (UVFP).Prospective study of consecutive patients undergoing ML with silastic (MLS) diagnosed with UVFP from 2009 till 2012 and with at least 9 months follow-up. Pre- and post-treatment maximum phonation time (MPT) and voice handicap index (VHI) scores were compared to assess the impact of ML on these outcomes. Patients with high vagal lesions or lateralized vocal folds (very low MPT) were compared with the entire group and the literature.A total of 124 patients with UVFP underwent MLS. Forty-six patients were excluded as they either had a Gore-Tex implant (eight), short follow-up (20), or the primary case was a revision (18). Seventy-eight patients were included. Pretreatment mean VHI (total score) was 67 for the entire cohort. Postoperative VHI score was significantly lower both in short-term (3-8 weeks) follow-up, mean score 27 (paired t-test, P 0.05) and in long-term follow-up (9-12 months), mean score 22 (P 0.05). MPT was significantly improved from 8.3 pretreatment to 22.6 at short-term follow-up (P 0.05) and to 24.2 long-term follow-up (P 0.05). There were no significant differences between entire cohort and patients with a lateralized vocal fold or high vagal lesion. Comparable results were present when compared with the literature using similar metrics in patients undergoing an arytenoid procedure with/without medialization.MLS alone is effective in managing UVFP in most patients.

Objective To analyze the impact of endoscopic sinus surgery (ESS) on overall health care utilization for the treatment of chronic rhinosinusitis (CRS). Study design Retrospective administrative database analysis. Setting All US-based primary and secondary sites of care. Subjects and methods A cohort of patients with ESS (Current Procedural Terminology codes 31254-31288) in 2008 and at least 5 years of continuous medical and drug plan enrollment were included (n = 9105). Inpatient and outpatient medical history (including prescriptions) was analyzed from weeks -104 to +104 postoperatively. Results Health care utilization was constant up to -6 months preoperatively, at a per-patient per-week (PPPW) average of $11.75 (prescriptions, $2.44 [95% confidence interval (CI), $2.32-$2.56]; inpatient care, $ 0.82 [95% CI, $ 0.43-$1.20]; outpatient care, $8.49 [95% CI, $7.90-$9.08]). At -26 weeks preoperatively, a continuous increase from baseline levels was observed up to week -3, reaching an average PPPW of $95.37 (prescriptions, $13.74 [95% CI, $12.51-$14.96]; inpatient care, $2.73 [95% CI, $1.76-$3.70]; and outpatient care, $78.90 [95% CI, 73.65-$84.14]). From week -3 to surgery, outpatient events and prescriptions increased significantly, suggesting a decision to operate and costs associated with preoperative management. Postoperatively, costs declined rapidly, reaching baseline levels by 13 weeks postoperatively. Adverse events were reported in 388 patients (2.94% cases of hemorrhage, 0.14% cases of cerebrospinal fluid leak, 0.58% cases of orbital complications), and 572 (6.28%) patients had revision surgery. Conclusion Patients with CRS incur ongoing, baseline levels of health care utilization. Preoperatively, CRS-related health care needs are more than 8-fold greater than those at baseline. Following ESS, health care needs declined rapidly and reached baseline levels within 13 weeks postoperatively.

Bacterial rhinosinusitis in adults can be categorized into acute, subacute, and chronic forms. Acute bacterial rhinosinusitis is a common upper respiratory infection in adults. It is characterized by inflammation of the mucosa of the nose and paranasal sinuses of short duration. Chronic bacterial rhinosinusitis is defined as rhinosinusitis lasting for at least 12 weeks’ duration. The bacteria found in acute bacterial rhinosinusitis in adults are predominantly Streptococcus pneumoniae and Haemophilus influenzae. Staphylococcus aureus has also been found in some cases. There is an increase in bacterial resistance due to the frequent use of antibiotics in patients with presumed acute bacterial rhinosinusitis, and this has had an effect on the microbial spectrum of the disease. Biofilms may also play a role in the pathogenesis of acute and chronic bacterial rhinosinusitis.

Background A previous study on wound healing with a rabbit model showed thermal injury to sinus mucosa with complete respiratory re-epithelialization by postoperative day (POD) 29. This study was designed to further understand the pattern of injury using the bipolar radiofrequency plasma process used by the Coblator and evaluate postprocedure healing. Methods Based on experience with our rabbit model, three sheep underwent endoscopic sinus surgery. Coblation was applied to inferior turbinate mucosa in three areas for 2, 4, or 6 seconds. After resection of the contralateral middle turbinate and ethmoidectomy, Coblation was applied to the lateral wall or lamina papyracea for 2 seconds. The ethmoid and turbinate specimens were resected en bloc during necropsy immediately for the first sheep and on POD 14 for the others. Results Coblation resulted in immediate loss of surface respiratory epithelium and thermal-type injury to the underlying seromucinous glands. On POD 14, the Coblation site showed re-epithelialization with respiratory epithelium. The underlying seromucinous glands were replaced by mild fibrosis. A small, well-defined zone of injury was shown. Longer use did not result in a deeper injury. Rather, the depth of injury was dependent on the type of submucosal tissue present. Underlying bone was associated with reactive, regenerative changes. No histological changes were shown in the orbit. Conclusion The effects of Coblation on sheep mucosa show a similar injury and healing pattern to that shown on rabbit mucosa. Based on this work and the previous rabbit study, the Coblator may be an additional tool for use in endoscopic sinus surgery.

Purpose: The goal was to critically examine evidence regarding the performance of diagnostic tests and the efficacy of antibiotic and other treatments for uncomplicated acute bacterial rhinosinusitis (ABR). Methods: Scientific literature was reviewed, and meta-analysis methods were used to assess diagnostic test and antibiotic efficacy. A decision analysis and cost-effective analysis were performed. Results: Although more sensitive than clinical examination for diagnosis of ABR, sinus radiograms are not cost-effective as an initial management strategy. Antibiotics reduce the incidence of clinical failures by one half compared to no treatment and, when coupled with clinical criteria-based diagnosis, present the most cost-effective treatment strategy. However, without antibiotics, symptoms in two thirds of patients improve by 14 days with no serious complications. The risk of treatment failure does not differ significantly between amoxicillin or folate inhibitors and newer, more expensive antibiotics. Conclusions: The current literature shows that treatment of uncomplicated ABR with amoxicillin or folate inhibitors and based on clinical criteria is the most cost-effective strategy. (Otolaryngol Head Neck Surg 2000;122:1-7.)

Bilateral vocal cord immobility can be life threatening for some patients. Others, who have an open glottic chink, may have a breathy dysphonia, intermittent dyspnea, and stridor. These signs and symptoms may also be found in a number of other conditions that cause weakness or paradoxical motion of the vocal cords that mimics paralysis. These other conditions include central nervous system diseases, neuromuscular disorders, laryngospasm, and psychogenic disorders. In addition, patients with cricoarytenoid joint immobility or interarytenoid scar can also have similar symptoms at presentation. It is critical to consider the differential diagnosis of an assumed bilateral vocal cord paralysis and understand the management of paradoxical movement, weakness, joint fixation, interarytenoid scar, laryngospasm, and psychogenic disorders. The treatment for bilateral immobility should proceed only after a thorough evaluation, which might include electromyography and/or examination during general anesthesia under dense anesthetic paralysis. Reconstructive procedures are the treatments of choice, and destructive procedures should be chosen only as a last resort.

Tobacco smoking and exposure to environmental tobacco smoke (ETS) have both been implicated in a number of acute and chronic medical problems including heart and lung disease and several cancers. The impact of tobacco smoke on disorders of the nose and paranasal sinuses is less well understood, although there is growing evidence that such exposure can have a significant impact on nasal and sinus function. A comprehensive review of the literature reveals that tobacco smoking is associated with acute and chronic rhinitis, but may actually be negatively correlated with the development of allergic rhinitis. In those patients with allergies, nasal and sinus symptoms may be exacerbated by tobacco smoking. ETS exposure is associated with acute and chronic nasal symptoms in adults and children, snoring in children and teenagers, and may be associated with an earlier onset and more significant symptoms for individuals with a predisposition to developing allergies. Both primary and environmental tobacco smoke are related to increases in nasal and sinus cancer. Tobacco smoking and ETS are associated with significant nasal and sinus disease and cancer.

Topical intranasal steroid spray is often used to treat allergic and nonallergic rhinitis, and epistaxis is a common side effect. The prospective, observational study described was designed to determine the incidence of epistaxis and the relationship between the side of bleeding and the hand used to administer the spray, as well as the handedness of the patient, in a noninvestigational, real-world setting. Of 559 consecutive patients using an intranasal steroid for more than 3 months, 28 patients (5%) reported epistaxis within the prior 2 months. Of the 32 reported sides of bleeding (unilateral and bilateral combined), 25 episodes (78%) were on the same side as the hand used to apply the spray. A strong correlation was found between the side of bleeding and both the hand used (p < 0.001) and the handedness of the patient (p < 0.002). Patient instruction on technique may reduce the incidence of epistaxis.

Bilateral vocal fold immobility presents a challenging problem for the otolaryngologist. Although some patients may be managed without intervention, most patients with bilateral true vocal fold immobility require airway management. The goals of such management are usually aimed at producing a safe tracheotomy-free airway, with preservation of deglutition and phonation. Two surgical treatment methods for bilateral true vocal fold immobility are presented: endoscopic submucosal arytenoidectomy with suture lateralization and endoscopic cordotomy with anterolateral arytenoidectomy. The two techniques with their indications, advantages, and complications are illustrated. These modified techniques have resulted in significantly lower rates of the troublesome complication of granuloma formation. Both methods yield a satisfactory glottic airway while maintaining both speech and swallowing.

Maximizing efficiency of staff and resources is one method of reducing costs without affecting quality. Using a methodology similar to that used to maximize efficiency of airline-gate use, we developed a model with which to evaluate nursing support staff and clinical examining-room resources in a general otolaryngology clinic. For 144 patients over 7 consecutive clinic days, with four otolaryngologists and various combinations of support staff and examining rooms, we measured space and staff resource use, including total clinic time, number of patients seen, patient waiting time, physician and nurse productivity, and examining-room use. A simulation model was used as the medium of analysis to define parameters of the patient encounter. We identified optimal efficiency when there were three examining rooms and one and one-half nursing staff per physician or five examining rooms and three nursing staff for two simultaneously practicing physicians. Compared with a model of two rooms and one nursing staff member, our ideal model increased the percentage of the physicians’ time spent in direct contact with patients from 84% to 92%. Visit length decreased from 81 minutes to 57 minutes, the average time from check-in to examination decreased from 47 to 16 minutes, and it became possible for three additional patients to be seen each day. Additional rooms and support staff, in comparison with the optimally efficient distribution, did not significantly affect these parameters. Maximizing efficiency with the use of this methodology can decrease waiting times for patients, resulting in greater patient satisfaction, improved physician productivity, total number of patients seen, and increased total contact time between physicians and patients. (Otolaryngol Head Neck Surg 1998;119:394-7.)

Tumor suppressor genes play an important role in normal growth regulation. Loss or inactivation of these genes has been implicated in the development of squamous cell cancer and progression of neoplasia. Previous studies in our laboratories have implicated chromosome 18 long-arm deletions as a possible marker of progression in head and neck squamous cell cancer (HNSCC). To test this hypothesis, we evaluated DNA from 67 HNSCC patients for loss of heterozygosity (LOH) at 18q loci, and for association of LOH with survival. Tumor and normal DNA were extracted from fresh tissue and paraffin blocks and were amplified by PCR using primers for three microsatellite repeat polymorphisms in 18q (D18S336, D18S34, and MBP). A total of 27 (40%) patients had LOH of 18q, and these patients had a statistically significantly poorer two-year survival compared to those without 18q LOH (30% vs. 63%; P=0.008). In a Cox proportional hazards model in which time from diagnosis to death was the outcome variable, patients with 18q LOH had an unadjusted relative risk (RR) of death of 2.46 (P = 0.005). When 18q LOH was placed in a multivariate model controlling for possible confounders in the study, the RR for death was still elevated (RR = 2.10; P = 0.025). The observation of a prognostic association between 18q LOH and poor patient survival suggests that loss of an 18q tumor suppressor gene or genes is important in the progression of HNSCC. Genes Chromosomes Cancer 21:333–339, 1998. © 1998 Wiley-Liss, Inc.

Odontogenic ghost cell tumor is a rare, neoplastic form of calcifying odontogenic cyst (Gorlin cyst) whose cytologic features have not been previously reported. We present a case of odontogenic ghost cell tumor diagnosed by fine-needle aspiration biopsy (FNAB). The aspirate was characterized by (1) tissue fragments with basaloid epithelial cells, (2) "ghost" cells, (3) scattered multinucleated giant cells, (4) rare, eosinophilic, densely hyalinized "dentinoid" material in close association with the basaloid cells, and (5) calcific debris. The aspirate was diagnosed as "consistent with odontogenic ghost cell tumor." The cytologic features of odontogenic ghost cell tumor, as described, closely parallel the major histologic findings in this rare tumor. The differential diagnoses include other odontogenic tumors, squamous cell carcinoma, basaloid cell tumors of the salivary gland, and pilomatrixoma.

This study was designed to evaluate a disease-specific outcome measure for patients with selected voice disorders and to relate this instrument to a standardized quality of life measurement. In addition, the study attempts to document the degree of handicap for dysphonia patients globally, between different vocal pathologies, and in comparison to other chronic diseases. In this prospective, observational study, 260 adult patients evaluated for alterations of voice completed a general quality of life measure (the Medical Outcomes Trust Short Form 36-Item[SF-36]) and a voice-specific instrument (Voice Handicap Index [VHI]) pretreatment. The highest correlation was between the social functioning score of the SF-36 and the total score of the VHI and the physical, emotional, and functional subscales (p < 0.001) of the VHI. Significant correlation was also obtained for the SF-36 domains mental health (p < 0.01), general health (p < 0.01), and role functioning emotional (p < 0.017) with the three VHI domains and the total VHI score. Patients had significantly lower scores than the general U.S. population in five of the eight domains of SF-36. Patients with vocal fold paralysis had the highest level of pretreatment disability as measured on both the VHI and SF-36 among voice patients. The patients with dysphonia had a lower level of physical functioning than the patients with chronic sinusitis (p < 0.01), reflecting a greater handicap. In addition, the dysphonia group had lower levels of social functioning than the angina (p < 0.01) and sciatica (p < 0.01) groups and a lower score for mental health than the angina group (p < 0.01). The SF-36 correlates with the VHI in the domains of social functioning, mental health, and role functioning emotional. The baseline handicap for voice disorders represents a significant disability even in comparison to conditions such as angina pectoris, sciatica, and chronic sinusitis.

To date, no instruments exist to quantify the psychosocial consequences of voice disorders. The aim of the present investigation was the development of a statistically robust Voice Handicap Index (VHI). An 85-item version of this instrument was administered to 65 consecutive patients seen in the Voice Clinic at Henry Ford Hospital. The data were subjected to measures of internal consistency reliability and the initial 85-item version was reduced to a 30-item final version. This final version was administered to 63 consecutive patients on two occasions in an attempt to assess test-retest stability, which proved to be strong. The findings of the latter analysis demonstrated that a change between two administrations of 18 points represents a significant shift in psychosocial function.

Objective: To examine the incidence of postoperative bleeding after coblation and noncoblation tonsillectomy and to use postoperative bleeding as an outcome measure to determine the presence of a learning curve with this new surgical technique. Study Design: A retrospective review of records from January 1999 to April 2003 to determine type of tonsillectomy performed and the presence of postoperative bleeding. A chi-square analysis was used to determine a statistical difference between the postoperative bleed rate of coblation and noncoblation procedures. The examined time period was divided into 3-month intervals, and the coblation postoperative bleeds were tallied for each interval. The Cochraine-Armitage test of linear trend was used to assess change in the postoperative bleeds. Results: One thousand seven hundred sixty-two tonsillectomies were performed. The postoperative bleed rate for noncoblation tonsillectomy was 6.1% (74/1,216). The bleeding rate for coblation tonsillotomy was 5.9% (18/303) and 5.4% (13/239) for coblation tonsillectomy. There was no statistical difference (P = .93) between bleed rates for coblation versus noncoblation techniques. There was no difference in the need for operative intervention to control postoperative bleeding: 16.2% (12/74) for noncoblation technique and 25.85 (8/31) for coblation procedures (P = .25). The postoperative coblation bleed rates for the 3-month periods did not reveal an increasing or decreasing trend in the postoperative bleed rate (P = .49). Conclusion: Coblation is a safe procedure for performing tonsil surgery with no significant difference in postoperative bleeding from previous techniques and no increased need for operative intervention to control postoperative bleeding. A learning curve could not be identified when using postoperative bleeding as an outcome measure for coblation tonsillectomy.

Restylane is a relatively new material being used for temporary vocal fold medialization. Few studies have evaluated the safety, complication rate, and length of benefit derived from Restylane injection medialization. We report on 64 patients who underwent office-based injection medialization with Restylane to establish the safety of and length of benefit from this material.Retrospective review.Retrospective review of patients who underwent office-based injection medialization with Restylane during a 2-year period was performed.Eighty-two injections in 64 patients were reviewed. Five total adverse events occurred (3.88%). The average length of benefit from injection medialization with Restylane was 12.2 weeks. No inflammatory or hypersensitivity reactions to Restylane occurred. A trend toward avoidance of permanent medialization was observed in patients injected6 months from time of injury compared with patients injected6 months after (P = 0.0511).Restylane is a safe and effective temporary material for office-based injection medialization with an average length of benefit of 12.2 weeks. This represents the largest series to date using Restylane and no hypersensitivity or granulomatous reactions were observed. Our data showed a trend toward avoidance of permanent medialization in patients who were injected6 months after nerve injury, which supports the findings of others.

Objectives:Hospital readmissions are an important focus of national quality and cost containment efforts. With increased emphasis on readmissions in the current healthcare climate, it is critical to evaluate factors contributing to readmission rates and strategies aimed at reducing these rates. The objectives of this study are to analyze the reasons for hospital readmission within 30 days of discharge and discuss methods implemented to reduce readmissions.Methods:A retrospective chart analysis was performed from 2010 to 2012 at a tertiary-care medical center. A quality plan was developed and implemented during this time to reduce readmissions. All patients who were admitted to an otolaryngology inpatient service and readmitted within 30 days of discharge were identified.Results:There were 763, 820, and 804 admissions during the years 2010, 2011, and 2012, respectively. The number of readmissions during this time were 51 (6.7%), 54 (6.6%), and 28 (3.5%), respectively. Common diagnoses for readmissions incl...

Objectives:1) Analyze healthcare use of chronic rhinosinusitis (CRS) patients requiring endoscopic sinus surgery (ESS) based on co-morbidities (asthma, polyposis, and prior surgery) in an all-comer population. 2) Evaluate the effectiveness of ESS by sub-populations, using healthcare use pre- and post-surgery as a proxy for improvement.Methods:A retrospective database analysis was conducted using Marketscan. All patients with ESS (CPT 31254-31288) in 2008 and at least 5 years continuous enrollment (medical and drug coverage) were included (n=8,827). Patients were grouped based on diagnoses of asthma, polyposis, or prior surgery. In- and outpatient medical and prescription history for all sinonasal procedures or diagnoses was analyzed. All costs were calculated on a per-patient, per-quarter basis.Results:Total cost of care 9-12 months prior to surgery was: No comorbidity (NC): $195 (95% Confidence interval (95%CI) $178.24-$205.13), Polyps (P): $183.60 (95%CI $164.17-$203.03), Asthma (A): $484.56 (95%CI $443...

Program Description:Adequate exposure in suspension microlaryngoscopy can be challenging. This miniseminar will review the principles of microlaryngoscopy and discuss the various techniques used to provide adequate operative exposure. Panel members will be from multiple institutions and training backgrounds and will share their combined experience. Case scenarios will be presented and operative techniques will be discussed. Audience participation will be solicited.Educational Objectives:1) Recite the principles and techniques of suspension microlaryngoscopy. 2) Prepare for difficult microlaryngeal exposures. 3) Employ a number of strategies to facilitate exposure and management of laryngeal pathology.

Objectives:Analyze the impact of endoscopic sinus surgery (ESS) on overall healthcare use for treatment of chronic rhinosinusitis (CRS), and evaluate the effectiveness of ESS based on pre- and post-operative healthcare use.Methods:A retrospective database analysis was conducted using Marketscan. All patients with ESS (CPT 31254-31288) in 2008 and at least 5 years continuous medical and drug plan enrollment were included (n=8,827). In- and outpatient medical history including prescriptions but excluding pain medication (potentially less disease-specific) for all sinonasal procedures or diagnoses was analyzed. All costs were determined on a per-patient, per-quarter basis, from 4 quarters pre-surgery to 8 quarters post-surgery.Results:During the 4th quarter pre-surgery (9-12 months pre-operative), healthcare use included ~1.95 prescriptions (95% confidence interval [CI] 1.89-2.00), 1.92 visits or procedures per patient (95%CI: 1.83-2.01), and total average cost of US$ 399.10 (95%CI: US$391.24-US$406.96). The...

Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient's voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period.The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well.The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient's voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient's voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient's voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.

Scarring of the vocal folds can occur as the result of blunt laryngeal trauma or, more commonly, as the result of surgical, iatrogenic injury after excision or removal of vocal fold lesions. The scarring results in replacement of healthy tissue by fibrous tissue and can irrevocably alter vocal fold function and lead to a decreased or absent vocal fold mucosal wave. The assessment and treatment of persistent dysphonia in patients with vocal fold scarring presents both diagnostic and therapeutic challenges to the voice treatment team. The common causes of vocal fold scarring are described, and prevention of vocal fold injury during removal of vocal fold lesions is stressed. The anatomic and histologic basis for the subsequent alterations in voice production and contemporary modalities for clinical and objective assessment will be discussed. Treatment options will be reviewed, including nonsurgical treatment and voice therapy, collagen injection, fat augmentation, endoscopic laryngoplasty, and Silastic medialization.

A three-year retrospective study was performed on 494 patients to compare the effects of two techniques of tonsillectomy, with respect to rates of postoperative bleeding. One surgeon performed primarily mechanical dissections, while the other primarily performed electrocautery dissections. Intraoperative blood loss was assessed and correlated to the age and gender of the patient and to the size of the tonsil. Postoperative bleeding was seen in 2.8% of patients who underwent electrocautery tonsillectomy and in 7.6% of patients who underwent mechanical tonsillectomies. Patients undergoing electrocautery dissection lost an average of 37 ml of blood intraoperatively, whereas those undergoing mechanical dissection lost 105 ml. Mechanical tonsillectomies exhibited higher intraoperative blood loss than electrocautery tonsillectomies. A higher rate of postoperative bleeding was seen in mechanical tonsillectomies, but this difference was lost when peritonsillar abscesses were removed from the study.

Background. Stage IV inoperable head and neck cancer has a 2-year mortality rate of greater than 70% when treated with conventional radiotherapy. A Phase II study was undertaken to evaluate the effects of concomitant chemotherapy and accelerated, interrupted, twice-a-day radiotherapy on tumor response, locoregional control, survival, and morbidity. Methods. Thirty-four patients with Stage IV inoperable squamous cell carcinoma of the head and neck and a minimum follow-up of 36 months were evaluated. Concomitant chemoradiotherapy was administered during weeks 1, 3, and 5 (with planned breaks during weeks 2 and 4), consisting of cisplatin 60 mg/m2 on Day 1, continuous 5-day infusion of 5-fluorouracil, 750 mg/m2 per day, and radiotherapy, 2 Gy twice a day, more than 6 hours apart, followed by 3 days of radiation therapy alone (final “boost”) in week 6, for a total dose of 70 Gy and treatment duration of 5½ weeks (38 days). Results. Twenty-seven patients achieved a clinical complete response (82%). Actuarial locoregional control at 3 years was 73% and the actuarial 3-year survival probability, including all deaths, was 38%. All locoregional recurrences were manifested within 12 months. Of the 20 deaths, 12 were tumor related (locoregional and/or metastatic), 3 were treatment related, and 5 were due to other causes. Acute toxicity consisted of grade 3 mucositis and dysphagia and grade 2–3 leukopenia, not requiring treatment interruption or cessation. Conclusion. Concomitant accelerated radiation therapy and chemotherapy is a feasible treatment approach in this prognostically poor patient population, yielding dramatic tumor responses and impressive locoregional control at the cost of somewhat increased acute toxicity. Although serious late complications have not been observed, caution should be exercised in view of the relatively short follow up. Cancer 1995; 76:1655–61.

OBJECTIVE AND DESIGN: A prospective evaluation of the effectiveness of otolaryngology evaluation, treatment, and referral guidelines developed collaboratively by otolaryngologists and primary care physicians on referrals and access to otolaryngology. Comparisons of appropriate to unnecessary referrals, the percentage of patients referred with disorders addressed to those without disorders addressed in the guidelines, access to otolaryngology, and questionnaire evaluations of primary care physician and patient satisfaction were measured before and after guideline implementation. RESULTS: A significant decrease in appropriate to unnecessary referrals was seen, from 55% before to 12% after guidelines. The percentage of patients seen within 1 month of scheduling improved from 39% to 59%. Guideline-addressed disorders decreased from 63% to 40%. The need for patients to see another physician for the referred symptom while waiting to see an otolaryngologist decreased from 31% to 3%. Patient satisfaction with wait times improved. Eighty-six percent of the primary care physicians used the guidelines, and 85% wanted to expand the guidelines to other specialty areas. CONCLUSIONS: Management and referral guidelines are effective in improving patient access and the ratio of appropriate to unnecessary referrals. Such guidelines are well accepted and used by primary care practitioners in this setting. (OTOLARYNGOL HEAD NECK SURG 1995;113:446-52.)

Successful treatment of vocal nodules is primarily accomplished through the direction of voice-language pathologists and teachers of music and speech. Rarely is surgical treatment necessary, although recent reports have suggested a correlation between vocal nodules and failed voice training with anterior commissure microwebs. One hundred fifteen consecutive patients with vocal nodules were evaluated. Eight anterior commissure microwebs were identified (7%), four of these in performers. Of the 96 patients with sufficient follow-up, 65 (68%) had complete resolution of their nodules and 17 (18%) had sufficient improvement to return to normal vocalization without surgical treatment. Nine patients required surgery, two of these with anterior commissure microwebs. All eight patients with microwebs had resolution of their nodules with either nonsurgical or surgical therapy. In total, 94% of patients were able to return to normal voice function, while the 6% of failures either did not receive or were noncompliant with voice therapy. Microwebs were found to be uncommon in patients with vocal nodules. Microwebs and other laryngeal pathologies in patients with nodules may be associated with a higher incidence of patients failing conservative voice therapy treatment.

Two synchronously arising primary squamous cell carcinomas (SCC) originating from separate sites in the anterior floor of mouth (FOM) and the pyriform sinus (PS) were evaluated by karyotype and fluorescence in situ hybridization (FISH) to determine whether they were of common or independent ancestry. The primary tumors were designated Henry Ford Hospital (HFH)-SCC-8a (FOM) and HFHSCC-9a (PS), and the respective recurrent tumors after chemotherapy and radiation were designated -8b and -9b. HFH-SCC-8a and -8b were cultured and had closely related hypotetraploid karyotypes of monoclonal origin. Karyotypes could not be obtained from the second primary tumor HFH-SCC-9a or its recurrence -9b. However, we used karyotypes from HFH-SCC-8a and -8b as a guide to select FISH probes for the histological evaluation of genetic markers in tumor sections. Fluorescence in situ hybridization on metaphase chromosomes from the cell cultures was useful in modifying the tumor karyotypes. Fluorescence in situ hybridization identified a chromosome Y rearrangement that was not obvious from the HFH-SCC-8a and -8b karyotypes, and this Y rearrangement served as a unique clonal marker. Using two probes for the Y chromosome we showed that all four tumors shared the same Y rearrangement with loss of Yq (DYZ1) and retention of Ycen (DYZ3). Furthermore, FISH showed that all four tumors had the same aneuploidy patterns for chromosomes X, Y, 7, 9, 15, 16, and 17. From karyotypic and FISH analysis disomy for X and 9 centromere regions and the rearranged Y were all predicted and observed in the tumor tissue sections. Tetrasomy and trisomy for 7, 15, 16, and 17 were predicted from the karyotypes and this also was observed using FISH in all four tumors. These FISH aneuploidy patterns and the presence of a clonal Y marker in all four tumor samples indicate that the synchronous primaries and their recurrences were of monoclonal origin.

Open bedside tracheotomy (OBT) in the intensive care unit (ICU) has been advocated as a safe and more cost-effective alternative to tracheotomy performed in the operating room. The objective of this study is to determine predictive factors for postoperative outcomes, including decannulation and in-hospital mortality following OBT.Retrospective chart review.The charts of 330 consecutive adult patients who underwent OBT at a tertiary care medical center between January, 2005, and April, 2011, were reviewed. Perioperative variables including demographics, comorbidities, serological markers, and time to tracheotomy were collected and analyzed in relation to the endpoints of in-hospital mortality and decannulation rate.A total of 218 patients were included in the final analysis. The decannulation rate was 26.1% and inpatient mortality was 24.2%. On multivariate analysis, the inpatient mortality rate was significantly increased and the decannulation rate was significantly decreased among patients with concomitant cardiac or respiratory disease, or a coincident diagnosis of malignancy. ICU length of stay was increased by 4.5 days for each unit increase in cardiac comorbidity count.Admitting diagnosis and serological markers did not predict the rates of decannulation or in-hospital mortality. However, the presence of cardiac disease and/or oncologic comorbidities played a significant role in predicting hospital mortality or eventual decannulation. Several comorbidity combinations resulted in a greater than 60% likelihood of inpatient mortality. In this population, the overall benefit of an OBT may be debatable. Despite very high overall acuity levels, there were no serious procedural complications, indicating that bedside tracheotomy is safe in ill patients.

There are several specific issues that significantly affect the anesthetic management for patients undergoing thyroid surgery. In addition to the general considerations pertaining to anesthesia, specific attention should be directed to the assessment of thyroid function, the size and location of the thyroid gland, its relationship to the trachea and adjacent vascular structures, and the co-existence of a multiple endocrine neoplasia. Hyperparathyroidism due to an adenoma or hyperplasia is the most common presenting symptom of multiple endocrine neoplasia 1 syndrome. Patients at risk of iatrogenic hypoparathyroidism should have ionized calcium levels monitored postoperatively until calcium levels demonstrate that parathyroid function is intact. Primary hyperparathyroidism may result from benign parathyroid adenoma, multiple gland hyperplasia and carcinoma of the parathyroid glands. Clinical signs include carpopedal spasm during cuff inflation, facial twitching by tapping over the facial nerve at the parotid gland, and a prolonged QT interval on the ECG.

Music theater singers (MTS) typically have a heavy vocal load, but the impact on their voices has not been previously evaluated. A group of 49 MTS from two professional productions were administered the Singing Voice Handicap Index (SVHI). Responses for the SVHI demonstrated that, although the SVHI supported the performers' self-report of healthy vocal status, it lacked the sensitivity to detect potential subtle fluctuations or changes in physical functioning of the voice for working singers. Secondarily, descriptive data regarding professional working singers' perspectives were collected regarding how their singing voices typically responded to performing in a music theater production after a show, across a working week, and across a production season. Seventy-nine currently performing MTS were involved in a series of focus group interviews (n=43) or a written survey (n=36) to detail their perception of the impact of performing in an eight-show per week professional production on their vocal function and vocal health. Thematic analysis revealed the MTS commonly perceived transient and variable changes in their singing voice status in both positive and negative directions after heavy vocal load. Based on these data, a list of 97 descriptors of these perceptual changes was generated using the singers' own terminology and experiences. These included symptoms of vocal impairment and vocal fatigue but also some novel descriptors of positive vocal changes to the physical functioning of the singing voice as a perceived consequence of heavy vocal load. This study offers new and valuable insights into performers' perceptions of the impact of performing in a musical theater production on physical aspects of vocal function.

Objective: 1) Understand the presentation, etiology, and management of bilateral vocal fold immobility. 2) Understand the utility, technique, and advantage of endoscopic coblation vocal cordotomy for patients with bilateral vocal fold immobility. 3) Compare the use of the laryngeal coblator with the laser.Method: Case series using endoscopic coblation to perform vocal cordotomy in patients with bilateral vocal fold immobility is presented. Seven patients underwent suspension microlaryngoscopy with either initial or revision vocal cordotomy with or without partial arytenoidectomy. Routine follow-up was performed and wound healing was documented via distal chip videolaryngoscopy.Results: Seven patients underwent suspension microlaryngoscopy with vocal cordotomy as part of airway management for bilateral vocal fold immobility. The laryngeal coblator was used to perform a transverse cordotomy. The procedure was completed in approximately 5 minutes. No laser protection is required reducing operative set-up and...

Swimmers often complain of nasal dryness, and reports have suggested that swimmers may have an increased incidence of chronic rhinosinusitis (“Swimmer's Sinusitis”). To assess the affect of swimming pool and ocean water on mucociliary transport, a saccharine-particle test was used after spraying the noses of 10 subjects under four test conditions: control, water, hypertonic saline (the concentration of ocean water), and swimming pool water. Nasal transit time was significantly prolonged after administration of swimming pool water, in comparison to the other three test conditions. Although hypertonic saline also prolonged transit times in comparison to water and control, these differences were not significant. The relationship between exercise, swimming pool water, and mucociliary transport will be discussed.

OBJECTIVE To describe the incidence of HPV in diffuse high grade pre-cancerous lesions of the larynx. METHODS Patient charts were searched for those who presented between October 2008 and June 2009 with diffuse vocal fold leukoplakia. Biopsy proven laryngeal lesions with high grade dysplasia or carcinoma-in-situ (CIS) were examined for patient characteristics and presence of high-risk type HPV detected by in situ hybridization technique. RESULTS Fifteen patients with precancerous lesions were identified. Average age was 63 years and 13 were male. One lesion was identified as positive for high-risk HPV, all other lesions were negative. At current follow up, no patient has demonstrated progression to invasive carcinoma. CONCLUSION HPV may not play a role in non-progressing diffuse high-grade lesions of the larynx.

An animal model was used to compare the surgical treatment of chronic sinusitis by opening the natural ostium vs. inferior antrostomy. Fifteen rabbits had surgical occlusion of the natural maxillary sinus ostia to induce sinusitis. At a second operation, the sinuses were entered and in each animal the natural ostia was reopened on one side and an inferior antrostomy was performed on the opposite sinus. Eight weeks after these operations the sinuses were evaluated. No differences were found in antrostomy patency rates, gross evidence of acute or chronic inflammation, or light or electron microscopic findings between sinuses with natural ostiotomy and those with lower antrostomy. The gross appearances and light and electron microscopic findings are discussed.

Panendoscopy is commonly used for diagnosing synchronous primary neoplasms of the head and neck, although the yield and cost effectiveness has been questioned. To compare symptom-directed selective endoscopy to panendoscopy, 100 consecutive patients with newly diagnosed and untreated squamous cell carcinoma were prospectively evaluated. Symptoms were used to select which studies might have been performed to discover synchronous primary lesions. All patients were subsequently evaluated with chest x-ray, barium esophagram, direct pharyngolaryngoscopy, esophagoscopy, and bronchoscopy with bronchial washings. Seven synchronous primary neoplasms were discovered in six patients with one patient having three separate tumors. There were five synchronous pharyngeal and one oral cavity neoplasms with two of the pharyngeal tumors being asymptomatic. Two primary cervical esophageal tumors and one synchronous esophageal tumor were found in three patients all of whom had symptoms of dysphagia and odynophagia. Two pulmonary metastasis were discovered by chest x-ray in patients with normal bronchoscopies with bronchial washings. Selective symptomatic evaluations would have resulted in one-third savings in total cost and would have minimized excessive procedures and potential morbidity. Direct pharyngolaryngoscopy and chest x-rays are recommended for patients with squamous cell carcinoma of the head and neck but esophagoscopy, esophagogram, and bronchoscopy might be reserved for patients with associated symptoms. Bronchial washings are not recommended.