Craniomaxillofacial Trauma Experience in Otolaryngology Residency: A National Survey of Program Directors

This article aimed to assess the depth and volume of craniomaxillofacial (CMF) trauma exposure and education in otolaryngology residency training in the United States. This is a cross-sectional survey. A 15-question web-based survey was distributed to program directors of 106 Accreditation Council for Graduate Medical Education (ACGME)-approved otolaryngology residency programs to inquire about program size and demographics, trauma coverage, case volume, and education. Responses were collected anonymously. A total of 77 responses were received, representing 73% of residency programs. Seventy-five programs (97%) reported that their residents rotated at a level 1 trauma center, and 72 (94%) covered CMF trauma. Sixty-one programs (79%) included pediatric CMF trauma. The majority of programs (76%) allocated less than 10% of residency-dedicated didactic lecture time to CMF trauma. Residents in all programs typically logged at least 11 to 20 cases before graduation with 24% of programs averaging more than 50 cases per resident. Ninety percent of respondents described the training as "somewhat" to "very adequate." CMF coverage by the otolaryngology department, number of cases, and dedicated didactic lecture time to CMF trauma were significant factors on the perception of adequate training. The majority of program directors felt that the training in CMF trauma was adequate. Reasons for this may include that most residents rotate at level 1 trauma centers, have exposure to pediatric trauma, encounter an adequate volume of cases, and have dedicated didactic time to CMF education

Combined endoscopic endonasal & transoral approach to transpatial lesion involving the infratemporal fossa and masticator space: A case study and literature review

Transpatial skull base lesions involving the infratemporal fossa (ITF) are challenging due to the complex neurovascular structures of the region. Open approaches have traditionally been utilized to access these spaces. We present a 55-year-old woman presented with a mesenchymal mass involving the left ITF and masticator space. A combined endoscopic endonasal transpterygoid approach was performed followed by an endoscopic transoral-transmandibular corridor to access and resect the tumor. The post-operative course was unremarkable with no recurrence during her follow-up. Combined endoscopic approaches for transpatial tumor resection offered sufficient exposure to access safely each space. Las lesiones de la base craneal con una distribución transespacial e involucrando la fosa infratemporal (ITF) representan un desafío debido a las complejas estructuras neurovasculares de dicha región. Los abordajes abiertos han sido empleados tradicionalmente para acceder a estas regiones. Presentamos el caso de una mujer de 55 años que consultó por una lesión mesenquimal localizada en la ITF izquierda y en el espacio masticatorio. Se realizó un abordaje combinado endoscópico transpterigoideo endonasal seguido de un abordaje endoscópico transoral-transmandibular para acceder y resecar el tumor. El curso postoperatorio fue anodino, y no ha presentado recidiva con 21 meses de seguimiento. Los abordajes endoscópicos combinados para la resección de lesiones tumorales, con una distribución transespacial involucrando la ITF, ofrecen una exposición suficiente para acceder de forma segura a cada espacio

Observation of Retropharyngeal Fluid Collection in 2 COVID-19 Positive Patients

Our understanding of the novel coronavirus, COVID-19, is growing; yet, there remains much we do not understand, and unique presentations are abundant. One potential presentation is retropharyngeal edema, defined as fluid in the retropharyngeal space. Multiplanar imaging with computed tomography or magnetic resonance imaging is ideal for characterizing and diagnosing these fluid collections rapidly as possible life-threatening complications may develop (eg, airway obstruction and mediastinitis). Here, we discuss the presentation, imaging identification, treatment, and recovery of retropharyngeal fluid collection in 2 COVID-19 cases. The significance of this article is to suggest conservative management as a viable treatment option for retropharyngeal fluid collection, as opposed to incision and drainage, in the setting of COVID-19

Upper Nasopharyngeal Corridor for Transclival Endoscopic-Assisted Access to the Petrous Apex in Patients with Conchal Sphenoidal Anatomy: Application in Cholesterol Granulomas

Background: Cholesterol granulomas are benign cystic lesions arising in the petroclival region. Petroclival cholesterol granulomas (PCCGs) can be treated via traditional approaches such as infralabyrinthine, transcanal infracochlear, translabyrinthine, middle cranial fossa, and retrosigmoid routes or through less invasive endoscopic-assisted endonasal transphenoidal approaches. The latter approach requires access to the sphenoid sinus, visualization of the clival recess and bony landmarks to access the petrous apex (PA). However, in patients with poorly pneumatized (choncal) sphenoid sinus, access to the sphenoid sinus using the endoscopic endonasal transphenoidal approach is technically difficult and may not be feasible, necessitating an alternative approach. Methods: In this report, we present a case of a low-lying petroclival cholesterol granuloma in a patient with a conchal sphenoid and describe an alternative access corridor via an upper nasopharyngeal exposure that facilitated an endoscopic-assisted fenestration and drainage of the lesion. Presentation: A 55-year-old woman presented with hearing loss and tinnitus. CT showed a conchal sphenoid and a large lytic expansile mass with soft tissue density centered in the right PA with osseous remodeling. (Fig. 1–C) MRI showed a nonenhancing right PA mass that measured 22 ×18 ×19 mm with increased T1 and T2 signal, consistent with PCCG. (Fig. 1 D–F). A transclival endoscopic-assisted approach was planned. Operative Technique: A standard image-guided approach including a right maxillary antrostomy, uncinectomy, and middle turbinectomy was performed. The upper nasopharyngeal mucosa and adenoid bed were then completely removed using coblation. A pedicled nasoseptal flap was harvested and mobilized toward the right maxillary sinus. A transclival exposure was performed with a high-speed diamond drill located inferior and medial to the vidian nerve. Intraoperative ultrasound and neuronavigation confirmed the course of the petroclival internal carotid arteries. Dissection of paraclival structures proceeded in a standard fashion until the cyst contents were reached. Following cyst evacuation, extensive drilling was performed medially, superiorly, and inferiorly to enlarge the size of the outflow tract and facilitate placement of the nasoseptal flap. Successful resection was verified by postoperative CT and MRI. (Fig. 2) Postoperative nasal endoscopy verified mucosalization of the drainage tract. Conclusion: In patients with a conchal sphenoid, an upper nasopharyngeal corridor provides adequate visualization for an endoscopic-assisted transclival approach, which was successfully used to treat a PCCG. Fig. 1 Preoperative CT showing lytic expansile soft tissue mass (A–C) and preoperative MRI (D–F) showing T1–T2 hyperintensity consistent with cholesterol granuloma. Fig. 2 Postoperative CT and MR imaging showing postsurgical changes and resection cavity

Endoscopic Sinus Surgery in Adults With Cystic Fibrosis Effect on Lung Function, Intravenous Antibiotic Use, and Hospitalization

Objective: To ascertain the effect of endoscopic sinus surgery (ESS) on lung function, intravenous (IV) antibiotic use, and hospitalization in adults with cystic fibrosis (CF). Design: Retrospective analysis. Settings: Tertiary care center. Patients: Fifteen adults with a diagnosis of CF undergoing ESS between March 1, 2006, and June 31, 2008. Main Outcome Measures: Twelve-month preoperative and 12-month postoperative pulmonary function testing ( forced vital capacity [FVC] and forced expired volume in 1 second [FEV1]), number of IV antibiotic courses, total number of days of intravenous antibiotic use, and number of inpatient hospital days (IHDs) were assessed. Results: Twenty-two adults with CF underwent ESS; 15 patients had adequate data for evaluation. No significant differences were found between mean preoperative and postoperative FEV1 (61.3% vs 59.5%; P =. 41) or FVC (76.4% vs 76.1%; P =. 97) or between best preoperative and postoperative FEV1 (67.4% vs 67.0%; P =. 95) or FVC (84.2% vs 83.0%; P =. 86) (paired samples t test). The number of IV antibiotic courses and the total number of days of IV antibiotic use did not differ between the preoperative and postoperative periods (Wilcoxon signed rank test P =. 61 and P =. 10, respectively). However, the number of IHDs was significantly lower in the 1-year postoperative period (36.7 days) vs the 1-year preoperative period (59.1 days) (Wilcoxon signed rank test, z =-2.20, P =. 03). Conclusions: This preliminary study of ESS in adult CF patients indicates significant reduction in the number of IHDs in the postoperative period. However, there is no evidence that ESS improved lung function or the need for IV antibiotics. Arch Otolaryngol Head Neck Surg. 2012;138(12):1167-117

Review of Orbital Fractures in an Urban Level I Trauma Center

Objective: To perform a comprehensive review and analysis of surgically treated orbital fractures. Study Design: Retrospective cohort chart review study for surgically treated orbital fractures during 5 years. Results: A total of 173 patients (average age 41.6 years) were diagnosed with orbital fractures. Most were male with a ratio of 3.3:1. Most fractures were caused by assault (39.3%); 22.5% of the cases were bilateral. The left orbit (40.5%) was fractured more than the right. The orbital floor (97.1%) was the most common anatomic location and the maxilla (65.3%) was the most commonly involved bone. The average time from trauma to surgical intervention was 8.7 +/- 14.6 days and the average time from surgical intervention to discharge was 5.1 +/- 9.0 days. The transconjunctival incision (63%) was the most commonly used incision, and nonresorbable implant (92.7%) was the most commonly used implant. Finally, the length of stay for the repair of a simple orbital fracture was less than for complex orbital fracture (1.5 days and 5.9 days, respectively). Conclusion: Understanding the patterns and mechanisms of injury associated with orbital fractures can assist in developing standardized treatment protocols across all surgical specialties. This would ultimately allow for a uniform high quality of surgical care for patients with maxillofacial fractures

Patterns of head and neck cancer incidence, mortality, and survival in the U.S. Hispanic population

Abstract only e13084 Background: To compare the incidence, mortality, and survival of head and neck cancer (HNCA) in the U.S. Hispanic population to other racial/ethnic groups. Methods: Using the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program, we compared the incidence and mortality of cancer of the oral cavity, pharynx, and larynx between the U.S. Hispanic population versus other racial and ethnic subgroups, as well as the annual percent change between 2000-2013. A comparative analysis for different groups stratified by age and sex was performed. Survival analysis was performed using Kaplan-Meier estimate and logistic regression analysis. Results: The incidence of oral cavity, pharyngeal, and laryngeal cancers were significantly lower in Hispanics compared to Non-Hispanics (p < 0.05). The incidence of laryngeal cancer decreased significantly at a rate of 2.5% annually (p < 0.05), while incidence of oral cavity and pharyngeal cancers remained unchanged in U.S. Hispanics. The mortality rate for oral cavity, pharyngeal, and laryngeal cancers in the U.S. Hispanic population were 1.4 per 100,000, 1.1 per 100,000, and 1.2 per 100,000 respectively. Mortality rates in Hispanics were significantly lower compared to Non-Hispanics (p < 0.05). Non-Hispanics Blacks had the highest HNCA-related mortality among all the compared groups. The mortality of HNCA was significantly declining annually in the U.S. Hispanic population (p < 0.05). Conclusions: The incidence and mortality of HNCA in the U.S. Hispanic population appears to be declining and is significantly lower compared to Non-Hispanics

House dust mite allergen Der p 1 effects on sinonasal epithelial tight junctions

Background: Epithelial permeability is highly dependent upon the integrity of tight junctions, which are cell-cell adhesion complexes located at the apical aspect of the lateral membrane of polarized epithelial cells. We hypothesize that sinonasal epithelial exposure to Der p 1 house dust mite antigen decreases expression of tight junction proteins (TJPs), representing a potential mechanism for increased permeability and presentation of antigens across the sinonasal epithelial layer. Methods: Confluent cultured primary human sinonasal epithelial cells were exposed to recombinant Der p 1 antigen vs control, and transepithelial resistance measurements were performed over 24 hours. Antibody staining for a panel of TJPs was examined with immunofluorescence/confocal microscopy and Western blotting. Tissue for these experiments was obtained from 4 patients total. Results: Der p 1 exposed sinonasal cells showed a marked decrease in transepithelial resistance when compared to control cells. In addition, results of Western immunoblot and immunofluorescent labeling demonstrated decreased expression of TJPs claudin-1 and junction adhesion molecule-A (JAM-A) in Der p 1-exposed cultured sinonasal cells vs controls. Conclusion: Der p 1 antigen exposure decreases sinonasal epithelium TJP expression, most notably seen in JAM-A and claudin-1 in these preliminary experiments. This decreased TJP expression likely contributes to increased epithelial permeability and represents a potential mechanism for transepithelial antigen exposure in allergic rhinitis. (C) 2013 ARS-AAOA, LLC

Upper Nasopharyngeal Corridor for Transnasal Endoscopic Drainage of Petroclival Cholesterol Granulomas: Alternative Access in Conchal Sphenoid Patients

Background  Cholesterol granulomas arising at the petrous apex can be treated via traditional open surgical, endoscopic, and endoscopic-assisted approaches. Endoscopic approaches require access to the sphenoid sinus, which is technically challenging in patients with conchal sphenoidal anatomy. Clinical Presentation  A 55-year-old woman presented with intermittent headaches and tinnitus. Formal audiometry demonstrated moderately severe bilateral hearing loss. CT of the temporal bones and sella revealed a well-demarcated expansile lytic mass. MRI of the face, orbit, and neck showed a right petrous apex mass measuring 22 × 18 × 19 mm that was hyperintense on T1- and T2-weighted images without enhancement, consistent with a cholesterol granuloma. The patient had a conchal sphenoidal anatomy. Operative Technique  Herein, we present an illustrative case of a low-lying petroclival cholesterol granuloma in a patient with conchal sphenoidal anatomy to describe an alternative high nasopharyngeal corridor for endoscopic transnasal transclival access. Postoperative Course  Postoperatively, the patient's symptoms recovered and no complications occurred. Follow-up imaging demonstrated a patent drainage tract without evidence of recurrence. Conclusion  In patients with a conchal sphenoid sinus, endoscopic transnasal transclival access can be gained using a high nasopharyngeal approach. This corridor facilitates safe access to these lesions and others in this location