Current opinion in otolaryngology & head and neck surgery, 2011
This review is set to revisit the pathogenesis of aspirin-exacerbated respiratory disease (AERD),... more This review is set to revisit the pathogenesis of aspirin-exacerbated respiratory disease (AERD), the diagnostic method used, and finally the real impact of aspirin desensitization on chronic sinusitis with nasal polyposis (CRSwNP) in aspirin intolerant patients. In AERD, increased baseline production of cysteinyl-leukotriene (Cys-LT) is associated with upregulation of Cys-LT receptors on nasal inflammatory cells. This is further aggravated by inhibition of cyclooxygenase-1 by aspirin and other NSAIDs. New-found genetic markers need further study. Oral aspirin challenge is still the gold standard of diagnosis and can be safely conducted in a specialized outpatient clinic. Oral and endonasal aspirin desensitization show positive impact on CRSwNP course with decreased polyp recurrence, decreased number of hospitalizations, and decreased need for corticosteroids. Modulation of arachidonic acid metabolism and inhibition of intracellular biochemical pathways in key inflammatory cells inv...
Journal of the American Academy of Audiology, 2016
Patients with cochlear malformations were long considered poor candidates for cochlear implantati... more Patients with cochlear malformations were long considered poor candidates for cochlear implantation (CI), and surgical approaches different than the standard facial recess approach were used to access the inner ear. There is no previous long-term follow-up of a patient with significantly malformed inner ear operated through an untraditional route and requiring a revision surgery. This case provides a long-term follow-up from the initial surgery, a short-term follow-up from the revision surgery, and it illustrates the evolving classification of inner ear malformations as well as the potential problems associated with nonstandard approaches to the cochlea. A case report. Herein, we report a case of revision CI in a patient with incomplete partition type I, through the round window via a facial recess approach, 18 yr after an initial implantation via a transmastoid labyrinthotomy approach. The patient had an uncomplicated surgery, and after activation, she noted auditory perception on all electrodes without facial stimulation. A sound field sound awareness threshold was obtained at 15 dB HL. As the prior generation of cochlear implant recipients ages, the probability of a revision surgery for various causes increases. Cochlear implant surgeons should be aware of the potential pitfalls associated in these often challenging cases.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, Jan 24, 2016
(1) To quantitatively assess the lateral skull base thickness in patients with superior semicircu... more (1) To quantitatively assess the lateral skull base thickness in patients with superior semicircular canal dehiscense (SSCD) using a standardized and validated radiographic measure and to compare it with that of a population with spontaneous cerebrospinal fluid otorrhea (CSFO). (2) To analyze demographic and clinical factors associated with skull base thickness in the SSCD group. Case series with chart review. Tertiary neurotologic referral center. Based on computed tomography imaging of the tegmen, mean skull base thickness was calculated for 16 patients with radiographic and clinical SSCD. Similar measures were performed in 4 comparison groups consisting of adults with spontaneous CSFO (n = 33), as well as 3 control groups recruited from our adult cochlear implant database: 30 obese controls (body mass index [BMI] >30 kg/m(2)), 11 overweight controls (BMI, 25-30 kg/m(2)), and 20 normal weight controls (BMI <25 kg/m(2)). The SSCD group had a significantly lower mean BMI (28.6 kg/m(2)) than the spontaneous CSFO group (37.7 kg/m(2); P = .0007). The mean skull base thickness of SSCD patients was 17% thinner than that of the CSFO group, 31% thinner vs obese controls, 49% thinner vs overweight controls, and 45% thinner vs normal weight controls. These differences were all statistically significant (P < .05). Patients with SSCD have a marked thinning of the lateral skull base, more so than patients with spontaneous CSF otorrhea and control groups with different BMIs. Skull base attenuation in SSCD patients did not correlate with BMI.
Sinonasal mucormycosis is a rare fulminant disorder that typically affects immunocompromised pati... more Sinonasal mucormycosis is a rare fulminant disorder that typically affects immunocompromised patients. This article focuses primarily on the clinical manifestations and the importance of early diagnosis and treatment of this disease. Four pediatric cases of sinonasal mucormycosis encountered over an 8-year-period in our institution are reported. The initial presenting symptoms, physical examination, computed tomography, intraoperative, and histopathologic findings are described. The underlying immunosuppressive diseases are also outlined. The most common signs and symptoms were fever, rhinorrhea, facial erythema and edema, and very pale nasal mucosa. Despite these manifestations, the diagnosis of sinonasal mucormycosis was delayed, except in one child. Computed tomography scan findings were nonspecific and did not correlate well with surgical and pathologic findings. Treatment consisted in a combination of antifungal agents, multiple aggressive surgical debridements, and control of the underlying disease. In the postoperative course, 1 child died of the disease, 1 developed a persistent unilateral blindness, 1 was lost to follow-up, and the last 1 was cured with no sequelae. Sinonasal mucormycosis in the immunocompromised pediatric population is an uncommon but potentially fatal disease. A high index of suspicion is of utmost importance to decrease its related morbidity and mortality.
Otology Neurotology Official Publication of the American Otological Society American Neurotology Society and European Academy of Otology and Neurotology, 2014
To report the use of the retrofacial approach for cochlear implantation in three cases of malform... more To report the use of the retrofacial approach for cochlear implantation in three cases of malformed ears with inaccessible round windows through the standard facial recess. Two children with bilateral profound sensorineural hearing loss who were cochlear implant candidates. One patient had bilateral sequential cochlear implantations and the other a unilateral implant. Retrofacial approach to access the posterior mesotympanum and visualize the round window. Ability to complete the surgery with full insertion of the implant and no complications such as facial nerve injury. We implanted three ears in two patients with multiple external and middle ear malformations with an aberrant facial nerve or a posteriorly displaced round window niche. The standard facial recess approach did not allow visualization of the round window. We resorted to a retrofacial approach to access the posterior mesotympanum and proceeded with the surgery through an anterior and inferior cochleostomy or through the round window. In cases with an aberrant facial nerve or inaccessible round window through the facial recess, the retrofacial approach is a good alternative but requires a certain level of expertise and familiarity with temporal bone anatomy. The decision to use an unconventional approach should be considered before surgery, but the ultimate decision may require intraoperative assessment.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2016
The primary objective is to report long-term hearing outcomes (>2 years) after titanium ossicu... more The primary objective is to report long-term hearing outcomes (>2 years) after titanium ossiculoplasty in patients with chronic otitis media. Case series with chart review. Tertiary care hospital. In total, 156 patients with chronic otitis media undergoing titanium ossiculoplasty were included. The primary outcome measure was the long-term postoperative ABG. The stability of hearing over time was determined by comparing short-term and long-term postoperative air-bone gap (ABG). Secondary outcome measures included ΔABG, postoperative speech reception thresholds, air-conduction pure-tone average (AC PTA), word recognition scores, and percentage of patients achieving ABG ≤20 dB. Revision and extrusion rates were examined. At short-term follow-up (<6 months), mean postoperative ABG was 18.4 ± 10.6 dB and AC PTA was 31.7 ± 15.2 dB; 67% of patients achieved ABG ≤20 dB. At long-term follow-up (>2 years), mean ABG was 20.0 dB ± 15.4 and AC PTA was 35.3 ± 16.1 dB; 60% of patients ac...
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, Jan 23, 2016
(1) Correlate skull base thickness with perioperative outcomes for spontaneous cerebrospinal flui... more (1) Correlate skull base thickness with perioperative outcomes for spontaneous cerebrospinal fluid (CSF) otorrhea. (2) Augment perioperative counseling of patients with abnormally thin skull bases. Case series with chart review. Tertiary center. Patients with spontaneous CSF otorrhea have thin skull bases. This is associated with obesity and/or idiopathic intracranial hypertension. The influence of skull base thinning on perioperative outcomes is unknown. A retrospective review was conducted from 2004 to 2014. Forty-eight cases of spontaneous CSF otorrhea met the inclusion criteria of primary surgery by the senior authors: preoperative dedicated temporal bone computed tomography, absence of other leak etiologies, and follow-up &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;6 months. Patients were stratified into thin (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.9 mm) and thick (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;0.9 mm) groups based on computed tomography measures of their tegmen. Primary outcomes measures were as follows: postoperative meningitis, recurrent leak, second site leak (contralateral ear/anterior fossa), and permanent shunt placement. Hearing outcomes were not assessed in this study. Thirty and 15 patients composed the thin and thick groups, respectively. Both the incidence (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001) and the rate (P = .005) of adverse outcomes were significantly higher in the thin group. Only 2 patients in the thick group experienced an adverse outcome. Eleven patients underwent multiple procedures for spontaneous leaks. The recurrence rate was 14.5%. All but 1 recurrence occurred in the thin group. An abnormally thin tegmen was significantly associated with adverse perioperative outcomes in cases of spontaneous CSF otorrhea. A thick skull base and the presence of an encephalocele may be protective against recurrence. The effect of untreated intracranial hypertension on the results is unknown.
ABSTRACT Intranasal narcotic delivery is increasingly frequent due to avoidance of intravenous in... more ABSTRACT Intranasal narcotic delivery is increasingly frequent due to avoidance of intravenous injection from fear of HIV and because of availability of prescription drugs to treat chronic pain syndromes. Extensive destruction of the midfacial structures has been reported for over a decade.This is the first reported case of clival erosion related to intranasal narcotic abuse. Radiologists and clinicians should be aware of this potential complication because delayed detection and ongoing abuse can result in progressive damage and diminished success of attempted surgical repair
Length of stay is a marker of quality and efficiency of health care delivery. The objective of th... more Length of stay is a marker of quality and efficiency of health care delivery. The objective of this study was to identify preoperative, intraoperative, and postoperative variables that impact length of stay after lateral skull base surgery. Methods/Procedures: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases from 2009-2012 were analyzed, and patients undergoing elective lateral skull base surgery for benign lesions of cranial nerves were identified. The primary outcome measure of interest was length of hospital stay. Protracted length of stay was defined as ≥75th percentile of length of stay for all patients. The impact of demographic factors, intraoperative variables, and postoperative complications on length of stay was assessed. In total, 252 patients were included. Almost half of the patients (41.2%) were classified as obese (body mass index ≥30). Patients who were obese had significantly longer lengths of stay (5.6 ± 3.9 days) when compared to patients who were not obese (4.6 ± 3.4 days, p = 0.006). Multivariate regression analysis demonstrated that operative time, reoperation within 30 days of initial surgery, and obesity were independent predictors for protracted length of stay. National multi-institutional data from the ACS-NSQIP suggest that operative time, reoperation, and obesity are predictors of longer hospital stays after lateral skull base approaches for benign cranial nerve neoplasms.
Current opinion in otolaryngology & head and neck surgery, 2011
This review is set to revisit the pathogenesis of aspirin-exacerbated respiratory disease (AERD),... more This review is set to revisit the pathogenesis of aspirin-exacerbated respiratory disease (AERD), the diagnostic method used, and finally the real impact of aspirin desensitization on chronic sinusitis with nasal polyposis (CRSwNP) in aspirin intolerant patients. In AERD, increased baseline production of cysteinyl-leukotriene (Cys-LT) is associated with upregulation of Cys-LT receptors on nasal inflammatory cells. This is further aggravated by inhibition of cyclooxygenase-1 by aspirin and other NSAIDs. New-found genetic markers need further study. Oral aspirin challenge is still the gold standard of diagnosis and can be safely conducted in a specialized outpatient clinic. Oral and endonasal aspirin desensitization show positive impact on CRSwNP course with decreased polyp recurrence, decreased number of hospitalizations, and decreased need for corticosteroids. Modulation of arachidonic acid metabolism and inhibition of intracellular biochemical pathways in key inflammatory cells inv...
Journal of the American Academy of Audiology, 2016
Patients with cochlear malformations were long considered poor candidates for cochlear implantati... more Patients with cochlear malformations were long considered poor candidates for cochlear implantation (CI), and surgical approaches different than the standard facial recess approach were used to access the inner ear. There is no previous long-term follow-up of a patient with significantly malformed inner ear operated through an untraditional route and requiring a revision surgery. This case provides a long-term follow-up from the initial surgery, a short-term follow-up from the revision surgery, and it illustrates the evolving classification of inner ear malformations as well as the potential problems associated with nonstandard approaches to the cochlea. A case report. Herein, we report a case of revision CI in a patient with incomplete partition type I, through the round window via a facial recess approach, 18 yr after an initial implantation via a transmastoid labyrinthotomy approach. The patient had an uncomplicated surgery, and after activation, she noted auditory perception on all electrodes without facial stimulation. A sound field sound awareness threshold was obtained at 15 dB HL. As the prior generation of cochlear implant recipients ages, the probability of a revision surgery for various causes increases. Cochlear implant surgeons should be aware of the potential pitfalls associated in these often challenging cases.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, Jan 24, 2016
(1) To quantitatively assess the lateral skull base thickness in patients with superior semicircu... more (1) To quantitatively assess the lateral skull base thickness in patients with superior semicircular canal dehiscense (SSCD) using a standardized and validated radiographic measure and to compare it with that of a population with spontaneous cerebrospinal fluid otorrhea (CSFO). (2) To analyze demographic and clinical factors associated with skull base thickness in the SSCD group. Case series with chart review. Tertiary neurotologic referral center. Based on computed tomography imaging of the tegmen, mean skull base thickness was calculated for 16 patients with radiographic and clinical SSCD. Similar measures were performed in 4 comparison groups consisting of adults with spontaneous CSFO (n = 33), as well as 3 control groups recruited from our adult cochlear implant database: 30 obese controls (body mass index [BMI] &amp;amp;amp;amp;gt;30 kg/m(2)), 11 overweight controls (BMI, 25-30 kg/m(2)), and 20 normal weight controls (BMI &amp;amp;amp;amp;lt;25 kg/m(2)). The SSCD group had a significantly lower mean BMI (28.6 kg/m(2)) than the spontaneous CSFO group (37.7 kg/m(2); P = .0007). The mean skull base thickness of SSCD patients was 17% thinner than that of the CSFO group, 31% thinner vs obese controls, 49% thinner vs overweight controls, and 45% thinner vs normal weight controls. These differences were all statistically significant (P &amp;amp;amp;amp;lt; .05). Patients with SSCD have a marked thinning of the lateral skull base, more so than patients with spontaneous CSF otorrhea and control groups with different BMIs. Skull base attenuation in SSCD patients did not correlate with BMI.
Sinonasal mucormycosis is a rare fulminant disorder that typically affects immunocompromised pati... more Sinonasal mucormycosis is a rare fulminant disorder that typically affects immunocompromised patients. This article focuses primarily on the clinical manifestations and the importance of early diagnosis and treatment of this disease. Four pediatric cases of sinonasal mucormycosis encountered over an 8-year-period in our institution are reported. The initial presenting symptoms, physical examination, computed tomography, intraoperative, and histopathologic findings are described. The underlying immunosuppressive diseases are also outlined. The most common signs and symptoms were fever, rhinorrhea, facial erythema and edema, and very pale nasal mucosa. Despite these manifestations, the diagnosis of sinonasal mucormycosis was delayed, except in one child. Computed tomography scan findings were nonspecific and did not correlate well with surgical and pathologic findings. Treatment consisted in a combination of antifungal agents, multiple aggressive surgical debridements, and control of the underlying disease. In the postoperative course, 1 child died of the disease, 1 developed a persistent unilateral blindness, 1 was lost to follow-up, and the last 1 was cured with no sequelae. Sinonasal mucormycosis in the immunocompromised pediatric population is an uncommon but potentially fatal disease. A high index of suspicion is of utmost importance to decrease its related morbidity and mortality.
Otology Neurotology Official Publication of the American Otological Society American Neurotology Society and European Academy of Otology and Neurotology, 2014
To report the use of the retrofacial approach for cochlear implantation in three cases of malform... more To report the use of the retrofacial approach for cochlear implantation in three cases of malformed ears with inaccessible round windows through the standard facial recess. Two children with bilateral profound sensorineural hearing loss who were cochlear implant candidates. One patient had bilateral sequential cochlear implantations and the other a unilateral implant. Retrofacial approach to access the posterior mesotympanum and visualize the round window. Ability to complete the surgery with full insertion of the implant and no complications such as facial nerve injury. We implanted three ears in two patients with multiple external and middle ear malformations with an aberrant facial nerve or a posteriorly displaced round window niche. The standard facial recess approach did not allow visualization of the round window. We resorted to a retrofacial approach to access the posterior mesotympanum and proceeded with the surgery through an anterior and inferior cochleostomy or through the round window. In cases with an aberrant facial nerve or inaccessible round window through the facial recess, the retrofacial approach is a good alternative but requires a certain level of expertise and familiarity with temporal bone anatomy. The decision to use an unconventional approach should be considered before surgery, but the ultimate decision may require intraoperative assessment.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2016
The primary objective is to report long-term hearing outcomes (>2 years) after titanium ossicu... more The primary objective is to report long-term hearing outcomes (>2 years) after titanium ossiculoplasty in patients with chronic otitis media. Case series with chart review. Tertiary care hospital. In total, 156 patients with chronic otitis media undergoing titanium ossiculoplasty were included. The primary outcome measure was the long-term postoperative ABG. The stability of hearing over time was determined by comparing short-term and long-term postoperative air-bone gap (ABG). Secondary outcome measures included ΔABG, postoperative speech reception thresholds, air-conduction pure-tone average (AC PTA), word recognition scores, and percentage of patients achieving ABG ≤20 dB. Revision and extrusion rates were examined. At short-term follow-up (<6 months), mean postoperative ABG was 18.4 ± 10.6 dB and AC PTA was 31.7 ± 15.2 dB; 67% of patients achieved ABG ≤20 dB. At long-term follow-up (>2 years), mean ABG was 20.0 dB ± 15.4 and AC PTA was 35.3 ± 16.1 dB; 60% of patients ac...
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, Jan 23, 2016
(1) Correlate skull base thickness with perioperative outcomes for spontaneous cerebrospinal flui... more (1) Correlate skull base thickness with perioperative outcomes for spontaneous cerebrospinal fluid (CSF) otorrhea. (2) Augment perioperative counseling of patients with abnormally thin skull bases. Case series with chart review. Tertiary center. Patients with spontaneous CSF otorrhea have thin skull bases. This is associated with obesity and/or idiopathic intracranial hypertension. The influence of skull base thinning on perioperative outcomes is unknown. A retrospective review was conducted from 2004 to 2014. Forty-eight cases of spontaneous CSF otorrhea met the inclusion criteria of primary surgery by the senior authors: preoperative dedicated temporal bone computed tomography, absence of other leak etiologies, and follow-up &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;6 months. Patients were stratified into thin (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.9 mm) and thick (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;0.9 mm) groups based on computed tomography measures of their tegmen. Primary outcomes measures were as follows: postoperative meningitis, recurrent leak, second site leak (contralateral ear/anterior fossa), and permanent shunt placement. Hearing outcomes were not assessed in this study. Thirty and 15 patients composed the thin and thick groups, respectively. Both the incidence (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001) and the rate (P = .005) of adverse outcomes were significantly higher in the thin group. Only 2 patients in the thick group experienced an adverse outcome. Eleven patients underwent multiple procedures for spontaneous leaks. The recurrence rate was 14.5%. All but 1 recurrence occurred in the thin group. An abnormally thin tegmen was significantly associated with adverse perioperative outcomes in cases of spontaneous CSF otorrhea. A thick skull base and the presence of an encephalocele may be protective against recurrence. The effect of untreated intracranial hypertension on the results is unknown.
ABSTRACT Intranasal narcotic delivery is increasingly frequent due to avoidance of intravenous in... more ABSTRACT Intranasal narcotic delivery is increasingly frequent due to avoidance of intravenous injection from fear of HIV and because of availability of prescription drugs to treat chronic pain syndromes. Extensive destruction of the midfacial structures has been reported for over a decade.This is the first reported case of clival erosion related to intranasal narcotic abuse. Radiologists and clinicians should be aware of this potential complication because delayed detection and ongoing abuse can result in progressive damage and diminished success of attempted surgical repair
Length of stay is a marker of quality and efficiency of health care delivery. The objective of th... more Length of stay is a marker of quality and efficiency of health care delivery. The objective of this study was to identify preoperative, intraoperative, and postoperative variables that impact length of stay after lateral skull base surgery. Methods/Procedures: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases from 2009-2012 were analyzed, and patients undergoing elective lateral skull base surgery for benign lesions of cranial nerves were identified. The primary outcome measure of interest was length of hospital stay. Protracted length of stay was defined as ≥75th percentile of length of stay for all patients. The impact of demographic factors, intraoperative variables, and postoperative complications on length of stay was assessed. In total, 252 patients were included. Almost half of the patients (41.2%) were classified as obese (body mass index ≥30). Patients who were obese had significantly longer lengths of stay (5.6 ± 3.9 days) when compared to patients who were not obese (4.6 ± 3.4 days, p = 0.006). Multivariate regression analysis demonstrated that operative time, reoperation within 30 days of initial surgery, and obesity were independent predictors for protracted length of stay. National multi-institutional data from the ACS-NSQIP suggest that operative time, reoperation, and obesity are predictors of longer hospital stays after lateral skull base approaches for benign cranial nerve neoplasms.
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