Removal of a Wire Brush Bristle from the Hypopharynx Using Suspension, Microscope, and Fluoroscopy

Wire brush bristles are an increasingly recognized hazard that can present as a foreign body in the aerodigestive tract. Due to their small size and tendency to become embedded in surrounding tissue, these small metallic bristles present a unique operative challenge to otolaryngologists. Here we present a case of a 40-year-old woman who underwent endoscopic extraction of a wire bristle from the posterior pharyngeal wall using suspension, microscopy, and C-arm fluoroscopy. We believe this is the first published case of an endoscopic removal of a buried foreign body in the hypopharynx using these methods of localization concurrently. By leveraging multiple techniques for visualization, surgeons can avoid open exploration while ensuring complete removal of the object. Additionally, this case highlights the importance of regulatory oversight and consumer awareness of the hazards of grill brushes

Delayed Endovascular Coil Extrusion following Internal Carotid Artery Embolization

Internal carotid artery injury is a rare and devastating complication of endoscopic sinus and skull base surgery that has an associated mortality rate of 15%. This case describes a patient who developed massive epistaxis following routine sinus surgery and was eventually diagnosed with a pseudoaneurysm of the cavernous internal carotid artery. Endovascular coiling and Onyx (Covidien, Irvine, California, United States) liquid embolization were ultimately used to completely occlude the internal carotid artery with resolution of bleeding; however, the patient had an unexpected late complication of coil extrusion through the pseudoaneurysm sac into the sphenoid sinus and nasal cavity. The endoscopic skull base team safely excised the coils endoscopically without recurrent bleeding. We describe the multidisciplinary operative management of this case of endovascular coil extrusion to increase awareness of this potentially life-threatening complication

Geospatial and socioeconomic patterns of patients referred for cochlear implant candidacy evaluation in North Carolina

Despite the growing body of literature citing the public health and economic concerns of untreated hearing loss, hearing healthcare still faces disparities in access1,2. The issues of accessibility in the general healthcare system are widely recognized by clinicians and researchers; however, there is limited research on this topic specific to cochlear implantation. Previous research demonstrates that patient characteristics (e.g., socioeconomic status and place of residence) and provider characteristics (e.g., availability) impact access to hearing healthcare3-5. The intersectional and compounding nature of these variables make understanding individual barriers to care incredibly complex. As these studies demonstrate, disparities in access to care are particularly prevalent among patients with low socioeconomic status (SES) and those who reside in rural areas that are further from clinic sites4. It is likely that these disparities also influence access to the audiological and medical evaluations for cochlear implantation candidacy evaluation and associated postoperative care. To ameliorate barriers to cochlear implant (CI) access, clinicians must first examine the present demographic composition and spatial distribution of patients completing the candidacy evaluation. This study aims to elucidate potential barriers in hearing healthcare by examining the referral patterns and follow-up attendance of patients at an adult CI clinic in North Carolina to better understand hearing healthcare disparities from a geographic and socioeconomic perspective

Concurrent recording of the electrically-evoked compound action potential and the auditory brainstem response in cochlear implant users

Purpose and Technological Feasibility • In the ABR waveform, WI reflects activity in the 8th cranial nerve while WV reflects activity in the upper brainstem. The amplitude ratio between WI and WV is emerging as an important metric for auditory function. • In the electrically evoked ABR (eABR), eWI cannot be measured because of artifact associated with cochlear implant (CI) stimulation. The electrical eWI /eWV ratio therefore cannot be measured in a single test as the WI /WV ratio can for an acoustically evoked ABR. • For MED-EL Corporation CIs, the electrically evoked compound action potential (eCAP), equivalent to eWI, is measured with the Auditory nerve Response Telemetry (ART) test. The ART uses sequences of ‘masker’ and ‘probe’ biphasic pulses to extract an eCAP (see Fig. 1). Note that the ART also generates an external trigger

Traumatic incudomalleolar dislocation in a pediatric patient

Ossicular chain dislocation with associated conductive hearing loss often warrants surgical intervention such as ossiculoplasty. We present a case report of a 9-year-old male with a left longitudinal temporal bone fracture with associated asymmetric widening of the incudomalleolar joint and secondary hemotympanum. We document the patient's relevant clinical examination, testing, and imaging during clinic visits 2 weeks and 10 weeks after the inciting traumatic event. The patient was improved with no major medical or surgical intervention upon evaluation during the last follow-up visit. We discuss incudomalleolar joint dislocations and benefits of observation despite noting potential ossicular dislocation on imaging following the inciting event

Outcomes of Stapedotomy With Heat-Crimped Prostheses

Background: Theoretical disadvantages are associated with the use of heat-crimped piston prostheses in stapedotomy. Loose crimping could result in prosthesis displacement or slippage. Alternatively, overly tight crimping may cause trauma to the incus with resultant necrosis. Objectives: 1) Analyze outcomes of patients undergoing stapedotomy with heat-activated piston-style prostheses, and 2) compare outcomes between prostheses made by different manufacturers. Study Design: Retrospective. Setting: Vanderbilt Medical Center. Patients and Methods: Cases undergoing stapedotomy between 2005 and 2016 were reviewed. Audiometric assessments were recorded in accordance with American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) guidelines. Patients who lacked audiometric follow-up before 6 months or after 1 year were excluded. Intervention(s): Diagnostic, therapeutic, and rehabilitative. Main Outcome Measure(s): Postoperative air-bone gap (ABG) and achievement of an ABG is less than or equal to 10dB. Results: Three hundred fifty-eight patients met inclusion criteria. At short-term follow-up (\u3c6 mo), the mean ABG was 11 8 dB in the entire cohort; this did not differ based on manufacturer (p ¼ 0.13). The majority of patients (63%) achieved an ABG less than or equal to 10 dB. At longer-term follow-up, the mean ABG was 9 7 dB; again no differences were noted when comparing prosthesis manufacturer (p ¼ 0.20). 70% of patients achieved an ABG less than or equal to 10 dB at longer-term follow-up. When comparing short- to long-term follow-up, ABG did not significantly change over time (p ¼ 0.76). The overall revision rate was 1.9% (n ¼ 7). Conclusion: Favorable hearing outcomes are obtained both short- and long-term following stapedotomy and placement of heat-crimped piston prostheses. Both prosthesis groups appear stable in the middle ear environment long-term, as evidenced by a 1.9% revision rate among them

Surgical management of a hemorrhagic pediatric brainstem cavernous malformation – A case report

Vascular malformations of the central nervous system such as cavernous malformations and arteriovenous malformations are rare lesions with controversial management recommendations in the pediatric population. We report a case of a 3-year-old male who presented with multiple discrete episodes of focal neurological deficits including ataxia and an abducens nerve palsy. Imaging revealed a 1.5 cm hemorrhagic mass located in the pons that was concerning for a cavernous malformation. This lesion was completely excised via a combined transpetrosal approach, and the patient had complete resolution of neurologic symptoms at three-month follow-up

Content Validity of a High-Fidelity Surgical Middle Ear Simulator: A Randomized Prospective International Multicenter Trial

OBJECTIVE: After demonstration of face validity of a surgical middle ear simulator (SMS) previously, we assessed the content validity of the simulator with otolaryngology residents. STUDY DESIGN: Multicenter randomized prospective international study. SETTING: Four academic institutions. METHODS: Novice participants were randomized into control, low-fidelity (LF), and high-fidelity (HF) groups. Control and LF produced 2 recordings from 2 attempts, and HF produced 4 recordings from 10 attempts, with trials 1, 4, 7, and 10 used for scoring. Three blinded experts graded videos of the simulated stapedectomy operation using an objective skills assessment test format consisting of global and stapedotomy-specific scales. RESULTS: A total of 152 recordings from 61 participants were included. Baseline characteristics did not differ significantly between groups. Depending on the step of the operation, inter-rater reliability ranged from 24 to 90%. For LF and HF, years of training was significantly associated with improved scores in certain objective skills assessment test subparts. HF outperformed the control group on stapes and global scores (p \u3c 0.05). The HF group demonstrated improvement in global score over trials, but plateaued after four trials. Scores varied greatly for participants from different institutions in certain operative steps, such as transecting incudostapedial joints, likely due to differences in instrumentation and time elapsed since manufacture. CONCLUSION: Practice with SMS led to better performance in both global and stapes-specific scores. Further studies are needed to examine construct validity and to create otology-appropriate grading systems. Variables like instrumentation and decline in flexibility of the simulator after 12 months greatly affect performance on the simulator