Cervical SCIs -- Select Braces Based on Level of Injury

Cervical SCIs -- Select Braces Based on Level of Injury

Acute Management of Spine Trauma: Part 1.

Ziad A. Hage, MD

In patients with cervical spinal cord injuries (SCIs) requiring immobilization and reduction, brace selection must be tailored according to the injury level and biomechanics.

(Card 1 of 4) Early management of spine trauma includes early spine immobilization and transport to a specialized facility. When considering spine clearance in patients presenting after trauma, spinal imaging is not required for sober, alert, and oriented patients without distracting injuries who are not sedated, not receiving pain medications, and not complaining of spine pain on exam. In all other patients, the spine should be immobilized until cleared. Thoracic/Lumbar Imaging: AP and lateral x-ray views of all vertebrae should be

performed to rule out deformity, malalignment, and fractures. No further workup is needed when the x-ray is normal or when spinous or transverse process fractures are seen in the asymptomatic patient. For questionable fractures, a CT scan is performed. Ligamentous injury without bony injury or malalignment is rare, but if pain or neurological deficit is persistent, an MRI is recommended. Cervical Spine Imaging: AP, lateral,

and odontoid-view x-rays can be performed. If the result is questionable, or if fractures are not seen, a CT scan can be performed. A CT scan is usually faster, especially if the head needs to be scanned. When imaging the cervical spine after trauma, the craniocervical and cervicothoracic junctions should always be included. Ligamentous injury is common. If findings are doubtful with other imaging studies, an MRI is always useful. If the patient is fully awake and not requiring any pain medications, the physician can clear the cervical spine with range-of-motion testing. If the patient has pain, an MRI is recommended at 48 hours. At that time, soft tissue edema noted on MRI is highly suggestive of ligamentous injury. If the MRI is negative, ligamentous injury is unlikely. C-Spine Immobilization & Reduction: For patients requiring immobilization and reduction of

the cervical spine, brace selection must be tailored according to the injury level and biomechanics. The hard C-collar is usually used to stabilize fractures or minor ligamentous injury from the occiput to T1, but it is best used to stabilize from the occiput to C3. The cervicothoracic orthotic (CTO) is usually used to stabilize from the occiput to T3. Halo fixation is usually used for stabilization from the occiput to T3 and is considered better than the CTO. The Lerman Minerva brace is usually used to stabilize from C2 to T3 or the cervicothoracic junction. The thoracolumbar spine orthotic (TLSO) brace is usually used to stabilize from T9 to S1, but has poor control of the lower lumbar and lumbosacral junction. The TLSO with a chin extender is usually used to stabilize from T2 to S1. The Jewett brace stabilizes from T8 to L2 or the thoracolumbar junction. Complications from these devices include pressure ulcers, intracranial hypertension from jugular compression, and pulmonary complications, such as restrictive lung disease. (Reviewer-Ziad A. Hage, MD).

Keywords: Spine Trauma, Acute Management

Print Tag: Refer to original journal article

ABCs, Stabilization, Assessment Are Keys to SCI Management


Ziad A. Hage, MD

In patients with an acute spinal cord injury, the ABCs should be performed, the entire spine should be stabilized until the spine is cleared, and the patient should be monitored in an ICU setting.

(Card 2 of 4) Closed Reduction for Cervical Dislocation: In patients with spinal cord injuries (SCIs), reduction of cervical facet dislocation is safe in conscious patients if rostral cervical SCIs or cranial fractures are not present. Of patients with fracture and subluxations, 30% to 50% have associated herniated discs at that level. There is no clear significance of this finding in association with reduction. Use of muscle relaxants and sedation is key during closed reduction. After tongs are placed, traction weights should be added in increments of 5 to 10 lbs per level. For example, 60 lbs of traction should be added for a C6-7 subluxation. An x-ray of the cervical spine should be obtained after adding each weight. Once reduced, weights should be decreased to prevent overdistraction, and the patient should be kept in traction or a brace until stabilized. A failed reduction may occur when the patient has persistence of neurological symptoms, cannot tolerate the procedure, or has overdistraction on imaging. In this situation, remove the weights, immobilize the spine, and perform further workup with MRI. Acute Assessment in Spine Trauma: In the event of an acute SCI, the ABCs should first be performed. Then, the entire spine should be stabilized until clinically or radiographically cleared, and the patient should be monitored in an ICU setting. Assessment of function or the level of injury can be performed using the ASIA score and the functional independence measure. ASIA Score: The ASIA scoring system is based on sensory and motor examinations. In the sensory exam, each dermatome is tested for light touch and pinprick sensations and labeled as NT (not testable) if it cannot be tested. Presence or absence of anal sensation is also noted. The following scores are given to each sensory point: 0 (absent sensation), 1 (impaired sensation), and 2 (normal sensation). In the motor exam, 5 key muscles in the upper limb and 5 in the lower limb are tested and scored on a 5-point muscle-grading scale. Upper-extremity muscles include elbow flexors, wrist extensors, elbow extensors, finger flexors, and finger abductors. Lower-extremity muscles include hip flexors, knee extensors, ankle dorsiflexors, long toe extensors, and ankle plantar flexors. Muscle strength is graded on a scale ranging from 0 (total paralysis) to 5 (active movement, full range of motion against gravity, and provides normal resistance). The sum of all 20 muscles yields a total motor score. Barthel Index: Assessment of outcome can be performed using the Barthel index, which is a scale that measures performance in 10 variables of the basic activities of daily living. For example, it assesses fecal and urinary incontinence and the help needed with climbing stairs, bathing, and dressing. (Reviewer-Ziad A. Hage, MD).

Keywords: Spine Trauma, Close Reduction, Assessment


SCI Patients Prone to Spinal Cord Ischemia


Ziad A. Hage, MD

In patients with traumatic spinal cord injuries, decreased blood flow to the spinal cord may be associated with hypotension, vascular injury, vasospasm, and neurogenic shock.

(Card 3 of 4) Methylprednisolone: Following initial assessment of the patient with acute spinal cord injury (SCI), IV methylprednisolone is usually started according to the following protocol: 30 mg/kg in an IV bolus for 15 minutes, and then, starting 45 minutes later, 5.4 mg/kg per hour for 23 hours. After that, it is administered at a dose of 4 mg/kg per hour for 24 hours. This protocol is preferably initiated within 8 hours of acute SCI. Other Medical Factors: Decreased blood flow to the cord may result from hypotension, vascular injury, and

vasospasm. In addition, SCI patients may present with neurogenic shock, which leads to loss of sympathetic tone, which in turn results in hypotension and spinal cord ischemia. Neurogenic shock is characterized by bradycardia and arrhythmias. It leads to decreased systemic vascular resistance, decreased mean arterial pressure (MAP), and decreased cardiac output. Therefore, systolic blood pressure should be maintained at >90 mm Hg, and MAP should be maintained at >85 mm Hg with IV fluid boluses and pressors as needed. The pressor of choice is dopamine. Pulmonary capillary wedge pressure is usually maintained between 12 to 18 mm Hg. Autonomic Dysreflexia: Autonomic dysreflexia is observed in 85% of patients with an SCI above T6.

It occurs early after SCI and is due to an increase in reflex sympathetic discharge that is triggered by noxious stimuli, such as bladder distension. This can be managed by using α- and β-blockers. Autonomic dysreflexia is usually characterized by increased blood pressure, tachycardia or bradycardia, headache, flushing, diaphoresis above the injury level, and pupillary changes. Pulmonary Complications: Other complications

observed with SCI include direct injury to the lungs with trauma or aspiration, neurogenic pulmonary edema, bronchospasm (related to increased bronchial mucus secretion), or obstructive sleep apnea. Another major pulmonary issue is denervation of respiratory muscles. In 1 study, 25% of patients on chronic positive-pressure ventilation were alive at 1 year, of which 60% were alive at 14 years. In these patients, paralysis of external intercostal muscles leads to an inward movement of the ribs during inspiration, thus preventing rib cage expansion. If abdominal muscle tone is lost, a decrease in diaphragmatic contraction and efficiency is seen. Operational Length Compensation: When a seated patient moves to a supine position, functional residual

capacity decreases and vital capacity increases. To compensate for alterations of operational length of the diaphragm, neural input to the diaphragm increases with time. When a patient is upright, abdominal pressure decreases. However, in SCI patients with decreased abdominal muscle strength, this response is exaggerated because operational length compensation is inadequate. Treatment requires an abdominal binder used to augment ventilation. (Reviewer-Ziad A. Hage, MD).

Keywords: Spine Trauma, Methylprednisolone, Medical & Pulmonary Complications


DVT, PE Present Major Concerns for SCI Patients


Ziad A. Hage, MD

In patients with a spinal cord injury (SCI), the level of injury determines whether ventilator support is necessary. Other important issues for SCI patients include deep venous thrombosis, pulmonary emboli, and vertebral artery injury.

(Card 4 of 4) Respiratory Complications vs Injury Level: In patients with spinal cord injuries (SCIs), high

cervical injuries are associated with the highest rate of respiratory complications, the lowest recovery rate, and the highest mortality rate. These patients have blunted response to hypercapnia and a small increase in respiratory drive. For injuries above C3, diaphragmatic pacing or ventilator support is usually required. For injuries between C3 and C5, diaphragmatic function is variably impaired. Ventilator support is usually needed for the acute phase only, because spinal cord edema will later resolve and accessory ventilatory muscles will increase in strength. In certain patients, glossopharyngeal breathing may help. Patients with an injury between C5 and C8 have an intact diaphragm. They use accessory muscles in the neck and clavicular portion of the pectoralis major to inhale, and they use passive recoil for exhalation. On pulmonary function testing, such patients have an increased residual volume due to a decreased exhalation, therefore having a restrictive pulmonary defect. In SCI patients, chest physical therapy decreases mucus plugs, atelectasis, and pneumonia. Early tracheostomy for chronic ventilator support has been shown to prevent laryngeal damage. DVT & Pulmonary Emboli: Other important issues for SCI patients are deep vein thrombosis (DVT) and pulmonary

emboli (PE) prophylaxis. The incidence of DVT in SCI is 2.1% within 1 year, and then 0.5% to 1.0% per year thereafter. Prophylaxis is achieved using subcutaneous heparin 5000 units 2 to 3 times daily. Other prophylaxis options include low-molecular-weight heparin or IVC filter placement that can later be removed. The mortality rate from PE is increased 500 times in SCI patients, which diminishes to a 20-time increase after 6 months from injury. Most PE cases occur at 2 to 3 months after SCI. If PE is diagnosed and anticoagulation is not contraindicated, a heparin drip is used (PTT goal: 60 to 80 seconds) followed by bridging with warfarin (INR goal: 2 to 3) for at least 3 months. Other management options include tissue plasminogen activator (for hemodynamically unstable patients with PE) or mechanical and open embolectomies. Vertebral Artery Injury: Vertebral artery (VA) injuries are seen in 11% of nonpenetrating cervical SCIs. These injuries are often due to fracture through the transverse foramen, facet fracture or dislocation, and vertebral subluxation. Dissection of the VA may lead to vertebral basilar insufficiency, ischemia, and posterior fossa stroke. However, most VA injuries are asymptomatic. In patients with a VA injury along with a posterior fossa stroke, treatment with IV heparin is usually recommended. In patients with an impaired posterior circulation with no stroke, observation versus heparin management can be recommended. In asymptomatic patients, no anticoagulation is necessary. (Reviewer-Ziad A. Hage, MD).

Keywords: Spine Trauma, Respiratory Complications, Deep Venous Thrombosis, Pulmonary Emboli, Vertebral Artery Injury


To Sheath or Not to Sheath -- That Is the Question

A Comparison of Two Methods for Preventing Cross-Contamination When Using Flexible Fiberoptic Endoscopes in an

Otolaryngology Clinic: Disposable Sterile Sheaths Versus Immersion in Germicidal Liquid.

Elackattu A, Zoccoli M, et al:

Laryngoscope 2010; 120 (December): 2410-2416

Disposable sheaths provide a level of protection from microbes that is similar to traditional cleaning techniques.

Background: Cross-contamination is a potential problem from use of a fiberoptic nasopharyngolaryngoscope

(FNPL). Potential solutions to this problem include procedures to decontaminate the scope between patients and using disposable sheaths.

Objective: To compare germicidal immersion with disposable sheaths as a method to clean FNPL between

patients.

Design: Prospective controlled trial.

Participants: 100 patients who were examined at the authors' otolaryngology clinic.

Methods: The scope used in this study was the Olympus ENF type P4. Scopes were alternately assigned to

either the traditional decontamination group or the sheath group. The decontamination group followed a multistep procedure that included submersion in an enzymatic detergent, followed by submersion in a high-level disinfectant for 12 minutes, after which the scope was rinsed and wiped with alcohol and then dried. The sheath group scopes followed a shorter procedure, where scopes were immersed in an enzymatic detergent then rinsed and disinfected with alcohol. Samples were collected from scopes at the control handle and at the end of the shaft that would be inserted into the patient. These samples were then swiped on blood agar plates and incubated for 72 hours then analyzed for growth.

Results: The results indicated that a few organisms grew from the handles and shafts of instruments cleaned using both methods. In both groups, this occurred in <10% of instruments and was not significantly different between cleaning methods. The time required to clean scopes using each method was compared. Using the endosheath, the total time was just under 90 seconds (1.5 minutes). Using the standard germicidal disinfectant technique, total time was 841 seconds (about 14 minutes). In both cases, the staff did not have difficulty following prescribed protocols, and no breaches in protocol were observed.

Conclusions: Disposal sheaths and germicidal immersion both provide adequate decontamination between

FNPL uses.

Reviewer's Comments: One of the major issues in choosing how to decontaminate laryngoscopes is cost,

which is not trivial to determine. A gallon of Cidex costs about $80, but it can be used for an extended period. Alternatively, each single-use endosheath costs about $15. Other factors include staff time spent cleaning the scope and wear or risk of damage to the scope imposed by each technique. (Reviewer-Benjamin T. Crane, MD).

Keywords: Laryngoscope, Cleaning, Practice Management


Deciphering Vestibular Migraine -- What Can Otologists, Neurologists Agree on?

Vestibular Migraine: Perspectives of Otology Versus Neurology.

Millen SJ, Schnurr CM, Schnurr BB:

Otol Neurotol 2011; 32 (February): 330-337

There is a consensus that vestibular migraine is a common cause of patients’ vertigo or dizziness symptoms, but the underlying physiology and best treatment remain controversial.

Background: A diagnosis that has recently become much more popular and seems to include a large number

of patients is migraine-associated vertigo. This diagnosis currently goes by several names, including vestibular migraine (VM), migraine-associated dizziness, and others. Publications on this diagnosis have become more common, but there remains significant controversy.

Objective: To compare perceptions of VM between otologists and neurologists.

Design: Prospective survey.

Participants: 256 practitioners who were members of either the International Headache Society (IHS) or the

American Neurotology Society (ANS) and who returned questionnaires.

Methods: An 18-question survey was mailed to all members of the IHS and ANS.

Results: Of 431 surveys sent to ANS members, 38% were returned. Of 465 surveys sent to IHS members,

24% were returned. Of ANS respondents, 92% were otologists, whereas 67% of IHS respondents were neurologists. ANS members tended to see more patients with dizziness as a primary complaint, with most respondents choosing the incidence of 21% to 40%. IHS members saw a larger fraction of headache patients. The majority of ANS members thought that <20% of their dizzy patients had migraine, and most IHS members thought >60% of their headache patients had migraine. More than 90% of ANS and IHS members were in agreement that migraine can cause vestibular symptoms, and >80% of both groups felt that dizziness symptoms could be caused by migraine, even if a headache was not present when the dizziness occurred. More than 75% of both groups had treated a patient with VM. The consensus weakened considerably when questions shifted to the physiologic basis of VM symptoms. A central origin of migraine-related dizziness was thought by 43% of ANS members and 62% of IHS members, although about one third of both groups said that they were not certain. Also interesting was that IHS members were 3 times more likely to associate motion sickness with VM when compared with ANS members. Both groups were about equally likely to treat these patients with antidepressants, β-blockers, or calcium-channel blockers. However, IHS members were much more likely to use anticonvulsants, which was the most common treatment of VM among IHS members but the least common in ANS members. Neurologists were also twice as likely to believe that triptans could be successful in treating VM.

Conclusions: Diagnosis of VM is recognized by the majority of ANS and IHS members, but there remains

significant controversy of the underlying pathophysiology and best treatment.

Reviewer's Comments: There seems to be consensus among neurologists and otologists that VM exists, and the majority of both specialties threat some patients with this disorder. However, there remains signif icant controversy around the underlying physiology and the best treatment. (Reviewer-Benjamin T. Crane, MD).

Keywords: Headache, Vertigo, Dizziness, Migraine


Ear Pain With Normal Exam -- Is It Migraine?

Otalgia Associated With Migraine.

Teixido M, Seymour P, et al:


Migraine can be manifested as ear pain. Treatment with migraine prophylaxis medications is successful in improving these symptoms.

Background: Ear pain, or otalgia, is a frequent symptom seen in otolaryngology practices. In at least half of

these cases, the source of pain is not the ear. In many of these cases, the temporomandibular joint (TMJ), ear, and upper aerodigestive tract have a normal examination.

Objective: To describe a relationship between otalgia and migraine, and to suggest a potential treatment.

Design: Retrospective survey and chart review.

Participants: Patients seen with otalgia at the authors' practice between 2003 and 2009 in whom clinical and radiographic examination revealed no source for pain. Initially, 48 patients were identified, but some were eliminated due to refusal of medical treatment, loss of follow-up, or insufficient documentation of symptoms. A total of 26 patients were included, 24 of whom were women.

Methods: Patients were encouraged to fill out a questionnaire before and after treatment. The questionnaire

included pain severity, duration in hours per day, and number of otalgia days per month. Symptom improvement was calculated by taking the difference between pretreatment and posttreatment scores.

Interventions: In patients with infrequent but long-lasting episodes of otalgia, dihydroergotamine nasal spray

was prescribed as an abortive medication when the patient had otalgia. Prophylaxis medications were also used and included tricyclic antidepressants, β-blockers, calcium-channel blockers, and sodium-channel blockers. Prophylaxis medications were generally used in patients with otalgia that was too brief or frequent to use abortive therapy.

Results: 92% of patients had at least a 50% reduction in at least 1 of their symptoms scores; 57% had a

complete resolution of their symptoms. All posttreatment scores were significantly better when compared with pretreatment scores, at the P <0.001 level. A headache history was present in 77% of patients, and 65% met

IHS criteria for migraine. In 65% of patients, otalgia could be elicited by typical migraine triggers, including food, weather changes, altitude change, or noise. Thirty-eight percent had head or sinus pressure, and 23% had migraine-associated vertigo by Neuhauser's criteria. Of patients, 92% were treated with migraine prophylaxis medications, and 2 received dihydroergotamine nasal spray. The nasal spray was effective in only 1 patient. Eighty percent responded to a single medication, which was most frequently nortriptyline, and 12% responded to a combination of medications. The delay in response time was 1.0 to 4.0 weeks, with a mean of 2.3 weeks.

Conclusions: Otalgia of unclear etiology is frequently caused by migraine and may be treated with migraine

medications.

Reviewer's Comments: This study is limited by lack of a control group, but the paper presents an approach

worthy of consideration. It would be interesting to know if lifestyle changes such as avoiding dietary triggers would also be effective in this population. (Reviewer-Benjamin T. Crane, MD).

Keywords: Otalgia, Migraine


How Long Should We Wait for TM Perforations to Heal?

Natural History of Pediatric Tympanic Membrane Perforation.

Rollin M, Rogers P, Robinson P:


Tympanic membrane perforations that do not heal after 2 years have little chance of healing later.

Background: Tympanic membrane (TM) perforations are a common problem in children that can occur due to

trauma, tube placement, or infection. Many of these perforations will heal spontaneously, so determining how long to wait is an active area of controversy.

Objective: To describe the natural history of TM perforation.

Design: Retrospective database review and observational study.

Participants: 1761 children (41% female; average age at diagnosis, 6 years; 2701 TM perforations) in the

Bristol, England, area.

Methods: The authors reviewed the clinical database of a pediatric audiology center for patients seen from the

mid-1980s to 2006. Although the database contained 2865 perforations, some had to be excluded due to poor follow-up or limited data.

Results: Overall, 74% of perforations closed, and the rate of closure did not depend on gender. Median time to

closure was 1.1 years, which did not depend on patient gender, whether the perforation was caused by a tympanostomy tube, or on laterality. Patients who were older at the time of diagnosis tended to have a longer healing time, with the healing time increasing by 7% for each year of patient age. The rate of closure changes very little after 2 years.

Conclusions: The authors suggest that there is little chance of spontaneous TM healing beyond 2.5 years.

Reviewer's Comments: This paper represents one of very few studies on the natural history of TM perforation in children. However, we must use some caution in interpreting these results. The database used for this study was not designed to address TM perforation, and it has some limitations. One major limitation is that the database does not include any data on interventions, so it is possible that some perforations that healed did not do so spontaneously. Another limitation is that the interval between follow-up visits is unclear, and because the TM was assessed only during follow-up, it will bias the healing time toward longer periods. For instance, if patients were seen only once per year, the healing time will be recorded as 1 year, even if the perforation healed after 1 week. This may also explain why perforations tended to take longer to heal in older children, as older children are usually followed less frequently. The study also gives us no information about size of the perforation or degree of hearing loss, which are important factors in determining when to operate. Because of these issues, I am reluctant to accept the conclusions of this study. Although I would be willing to wait 2.5 years to repair a small asymptomatic perforation, I would probably repair it sooner if it were larger and associated with a significant conductive hearing loss. (Reviewer-Benjamin T. Crane, MD).

Keywords: Pediatric Tympanic Membrane Perforation, Eustachian Tube, Tympanostomy Tube


Are Resorbable Plates Strong Enough for Orbital Blowout Fractures?

Repair of Orbital Floor Fractures Using Bioresorbable Poly-L/DL-Lactide Plates.

Lieger O, Schaller B, et al:

Arch Facial Plast Surg 2010; 12 (November/December): 399-404

Resorbable polylactide plate is reliable for repair of small- to medium-sized orbital blowout fractures.

Background: A large variety of alloplastic materials and autogenous grafts have been used in the

reconstruction of orbital floor fractures to restore normal orbital volume and contour. Polylactides were first introduced for orbital repair 15 years ago. Depending on the ratio of the optic isomer, the polymer exhibits different properties and degradation time.

Objective: To investigate long-term clinical stability of a commercially available bioresorbable polylactide

implant in the repair of orbital floor and wall fractures.

Participants/Methods: 46 patients with orbital blowout fractures were included in this retrospective study. Indications for surgical reconstruction included diplopia, enophthalmos, restricted globe motility, and fracture size of at least 1.5 cm2. Surgery was performed within 2 weeks of injury with a commercially available triangular polylactide plate. CT imaging was obtained on all patients preoperatively and 1 year postoperatively. Clinical assessments were performed at 3-, 6-, and 12-month intervals. An additional imaging evaluation was done in 17 patients between 2 and 3 years postoperatively.

Results: Mean age of patients was 40 years, and 80% were male. Optimal results were seen in small defects.

The repair became less accurate with enlargement of the defect secondary to misplacement of the plate. In defects involving the floor and medial wall, the plate was not sufficiently supported and was placed into the ethmoid sinus. No evidence of clinical foreign-body reactions, infections, or sagging of the reconstructed area was seen. Mild enophthalmos was seen in 2 patients at 1 year. Six patients reported diplopia 3 months postoperatively but normalized in 5 patients at 6 months.

Conclusions: The polylactide polymer resorbable plate is a well-tolerated and reliable material for repair of

orbital floor defects. The plate appears to leave a stable ridge of tissue support even after complete degradation.

Reviewer's Comments: The polylactide plate used in this study retained approximately 68% of its strength at

8 weeks, 30% at 6 months, and was completely resorbed at 2 years. This study provides some useful long-term follow-up data in orbital floor repair with resorbable polymer material. Data from this study suggest that small- to medium-sized orbital floor defects can be satisfactorily repaired with a resorbable orbital floor plate. Larger defects, particularly those involving the medial wall, may require reconstruction with more rigid fixation. However, more investigations and long-term data are necessary. (Reviewer-Tang Ho, MD).

Keywords: Orbital Blowout Fractures, Resorbable Plate, Polymer


How Close Can You Get When Excising Basal Cell Carcinoma?

What Is the Best Surgical Margin for a Basal Cell Carcinoma: A Meta-Analysis of the Literature.

Gulleth Y, Goldberg N, et al:

Plast Reconstr Surg 2010; 126 (October): 1222-1231

A 3-mm surgical margin achieves a 95% cure rate in basal cell carcinoma.

Background: Basal cell carcinoma is the most common cancer, and 85% occurs in the head and neck region.

The incidence of basal cell carcinoma increases dramatically after age 40 years. Risk factors include sun exposure, radiotherapy, male gender, and genetic predisposition. While Mohs’ surgery offers the smallest overall defect size with the lowest recurrence rate, it is not always available or feasible. For standard surgical excision, the necessary surgical margin has been based largely on retrospective data and case series.

Objective: To present a systematic meta-analysis from a pool of published literature to determine the ideal

surgical margin for basal cell carcinoma.

Methods: A meta-analysis was performed and analyzed 89 studies from a pool of 973 published articles in

PubMed. The total number of patients analyzed was 10,261, with an average age of 67.7 years (range, 60.0 to 77.0 years). The total number of lesions studied was 16,066.

Results: Size of the lesions ranged from 3.0 to 30.0 mm, with a mean diameter of 11.7 mm. Surgical margins

ranged from 1.0 to 10.0 mm, with a mean of 3.9 mm. The rate of negative surgical margins ranged from 45% to 100%, with a mean of 86%. Overall recurrence rates ranged from 0% to 9.7%, with a mean of 2.0%. A decrease in resection margin increases the recurrence rate. The hazard ratio for 4-, 3-, and 2-mm margins are 4.2, 6.5, and 10.0, respectively. The difference in cure rate was significant for the 2-mm margin group compared to the other groups. The mean recurrence rate for positive surgical margins was 27%.

Conclusions: For nonmorpheaform-type basal cell carcinomas <2 cm in size, a 3-mm surgical margin can be used to obtain a 95% cure rate. The mean recurrence rate for lesions with a positive surgical margin was 27%.

Reviewer's Comments: Basal cell carcinoma is commonly encountered in the head and neck region. While a

wider margin obviously implies a greater cure rate, this is not always feasible on the face. Many studies, mainly retrospective, have examined the issue of determining the minimal margin that can be safely used to obtain a reasonable cure rate. Since this is a meta-analysis, limitations were the same as those in other included studies in the analysis, including selection and reporting bias. However, the pooled analysis does shed some new light on the issue. Based on data from this study, a 3-mm surgical margin may be considered in anatomically sensitive areas to achieve a reasonable cure rate. (Reviewer-Tang Ho, MD).

Keywords: Basal Cell Carcinoma, Surgical Margins


Flap Reconstruction Favored for Older Patients With Hypopharyngeal Cancer

Comparison of Pharyngeal Stenosis Between Hypopharyngeal Patients Undergoing Primary Versus Salvage

Laryngopharyngectomy.

Tsou Y-A, Lin M-H, et al:

Otolaryngol Head Neck Surg 2010; 143 (October): 538-543

Pharyngeal closure with flap reconstruction is strongly recommended for advanced hypopharyngeal cancer patients aged >65 years.

Background: Development of pharyngeal stenosis after pharyngolaryngectomy is a troublesome complication

in the late postoperative period and is extremely difficult to treat. Suspected risk factors include concurrent chemoradiation therapy, tumor stage, and type of pharyngeal closure.

Objective: To identify risk factors for pharyngeal stenosis in advanced hypopharyngeal cancer patients who

underwent primary or salvage laryngopharyngectomy.

Design: Retrospective case series.

Participants: 160 stage III and IV hypopharyngeal cancer patients who underwent laryngopharyngectomy. A total of 112 patients were treated first with surgery, while 48 had surgical salvage after chemoradiation failure. Median age was 57 years.

Methods: Rates and risk factors for pharyngeal stenosis were compared between patients treated with surgery first and those treated with salvage surgery. The follow-up period ranged from 11 to 56 months. Pharyngeal stenosis was defined as need for persistent nasogastric tube feeding with abnormal barium swallow study, with barium pooling above the neopharynx 6 months after surgery.

Results: A total of 104 patients received primary closure for pharyngeal reconstruction, and the other 56 patients were reconstructed with flaps. The flaps included 25 pectoralis major myocutaneous flaps, 13 gastric pull-ups, 4 free jejunum, and 14 anterolateral thigh free flaps. The pharyngeal stenosis rate was 21.2% in the primary closure reconstruction group, compared to 5.3% in the flap reconstruction group (P =0.01). Comparison between groups demonstrates an increased rate of postoperative fistula and pharyngeal stenosis in patients who failed chemoradiation. However, in multivariate analysis, only age >65 years and primary closure reconstruction were statistically significant risk factors for pharyngeal stenosis (P <0.01). Only 1 of 25 patients who developed pharyngeal stenosis was treated surgically, while others remained on nasogastric tube or gastrotomy feeding.

Conclusions: Primary closure for pharyngeal reconstruction is discouraged in advanced hypopharyngeal

cancer patients aged >65 years.

Reviewer's Comments: Pharyngeal stenosis after laryngopharyngectomy is an extremely debilitating and

difficult problem to treat, and prevention remains the best therapy. It is interesting in this study that prior chemoradiation therapy was not a statistically significant risk factor for pharyngeal stenosis, although this is likely due to the relatively small number of surgical salvage patients in this study. The data presented in this study appear to favor increased use of flap reconstruction in pharyngeal closure after laryngopharyngectomy, even when primary closure is possible. (Reviewer-Tang Ho, MD).

Keywords: Pharyngeal Stenosis, Chemoradiation Failure, Laryngopharyngectomy


Can We Trust What’s on Otolaryngology Residency Applications?

Publication Misrepresentation Among Otolaryngology Residency Applicants.

Beswick DM, Man L-X, et al:

Otolaryngol Head Neck Surg 2010; 143 (December): 815-819

Almost 10% of otolaryngology residency applicants who reported a publication on their application had misrepresented a publication.

Background: Otolaryngology applications have become increasingly competitive, with recent applicants

outnumbering spots by 41%. Having publications can improve the strength of an application, but how accurate are these publication claims?

Objective: To determine the accuracy of reports of research publications by otolaryngology applicants.

Design: Prospective observational study.

Participants: 325 applicants to the University of Pittsburgh Otolaryngology Residency.

Methods: The sections of residency applications were reviewed under "peer-reviewed journal articles." Articles reported were searched for in PubMed and Google Scholar. If not found, they were searched for by a professional librarian. If still not found, the journal was searched for in an international library, and/or foreign libraries were consulted. Those whose articles were not found were emailed by the residency program director to inquire about the publication in question.

Results: Of 325 applications received, 53% reported peer-reviewed publications that were in print, accepted,

or provisionally accepted. Four types of misrepresentations were identified: journals incorrectly listed as being peer reviewed, misrepresenting the applicant as the first author, listing a publication that could not be verified, and misrepresenting the article’s acceptance status. Seventeen applicants (9.8% of those who reported a publication) misrepresented a total of 22 publications. Multivariate analysis revealed that misrepresented publications were significantly more likely (P <0.05) to be reported by foreign medical graduates and males. Of medical graduates from the United States who misrepresented publications, all were male and from a medical school not ranked in the top 50 by U.S. News & World Report.

Conclusions: Almost 10% of residency applicants who reported publications on their otolaryngology residency application made misrepresentations.

Reviewer's Comments: When reviewing resident applications, I think most of us look not only at the number

of publications but also the quality of these publications, including the journal they were published in. I think, in most cases, it would be fairly obvious if an applicant tried to fake a high-profile paper in a widely read journal. My guess is that many of these misrepresented publications wouldn't have carried much weight even if they had not been discovered. (Reviewer-Benjamin T. Crane, MD).

Keywords: Resident Training, Publications, Ethics


What Suture Is Best for UPP Surgery?

Clinical and Biomechanical Analyses to Select a Suture Material for Uvulopalatopharyngeal Surgery.

Huang TW, Cheng PW, et al:

Otolaryngol Head Neck Surg 2010; 143 (November): 655-661

Monocryl suture demonstrates the ideal clinical profile for use in uvulopalatopharyngeal surgeries.

Background: Uvulopalatopharyngeal (UPP) surgery presents unique challenges for selection of suitable

suture materials given the complex oral environment. Challenges include presence of saliva, microbial accumulation within the suture, and friction caused by speech, mastication, and swallowing.

Objective: To attempt to identify the most appropriate suture for use in UPP surgery by analyzing clinical and

biomechanical characteristics of 4 different types of absorbable sutures.

Design: Randomized open-label study conducted at a tertiary academic medical center.

Participants/Methods: 80 patients underwent microdebrider-assisted extended uvulopalatoplasty and were randomized into 4 different suture groups including polyglycolide (Dexon) and other biodegradable polymers including Polysorb, Monocryl, and Maxon. Data including handling characteristics, surgical outcomes, reduction of Young's modulus, and morphologic changes were analyzed.

Results: Of sutures tested, Monocryl (poly[glycolide-co-ε-caprolactone]) was found to have the most optimal

clinical characteristics, as it exhibited 2-stage degradation process. Hence, the Monocryl suture allows for adequate wound healing given its ability to maintain sufficient tensile strength at the beginning, but then degrades rapidly to minimize mucosal irritation. The other sutures primarily exhibited single-stage degradation process. Multifilament sutures (Dexon and Polysorb) were found to shed a large amount of debris.

Conclusions: The poly(glycolide-co-ε-caprolactone) suture appears to possess desirable clinical

characteristics for use in UPP surgeries.

Reviewer's Comments: The ideal suture material for UPP surgeries would provide sufficient tensile strength

for wound healing early on and then degrade rapidly to avoid mucosal irritation. Among all commonly used sutures for this purpose, the authors found that Monocryl sutures, given their 2-stage degradation process, maintained high tensile strength for the first week and dissolved rapidly during the second week. In addition, compared to the multifilament sutures such as Dexon and Polysorb, monofilament suture such as Monocryl was also less likely to harbor necrotic debris. This finding may be applicable to other surgeries of the oral cavity. (Reviewer-Tang Ho, MD).

Keywords: Uvulopalatopharyngeal Surgery, Suture Selection


Appropriate Selection of Free Flap Allows for Best Functional, Esthetic Outcomes

A Strategic Approach for Tongue Reconstruction to Achieve Predictable and Improved Functional and Aesthetic

Outcomes.

Engel H, Huang JJ, et al:

Plast Reconstr Surg 2010; 126 (December): 1967-1977

Radial forearm and anterolateral thigh perforator flaps are suitable for hemiglossectomy defects, while larger defects are best reconstructed with myocutaneous anterolateral thigh flaps.

Background: The tongue is one of the most difficult oral cavity structures to reconstruct given its role in

articulation, deglutination, and airway protection.

Objective: To evaluate clinical outcomes of oral tongue reconstruction with different free flaps tailored to different size defects.

Design: Prospective clinical study.

Participants/Methods: 104 patients with a mean age of 49 years underwent free flap reconstruction for T2 –

T4 oral tongue post-ablative defects. Defects were classified into 3 groups based on size of defect. Group A (n=42), composed of hemiglossectomy defects, was reconstructed with 33 radial forearm free flaps and 9 anterolateral thigh perforator flaps. Group B (n=50), composed of subtotal glossectomy defect, was reconstructed with 44 anterolateral thigh perforator flaps and 6 anterolateral thigh myocutaneous flaps. Group C (n=12), composed of total glossectomy defects, was reconstructed with 12 pentagonal anterolateral thigh myocutaneous free flaps.

Results: The flap patency rate was 98.1% with 2 flap failures. Two additional patients developed partial flap

skin loss. Mean follow-up was 46 months. Among 33 patients available for follow-up, normal speech was achieved in 13 patients, intelligible speech in 9 patients, and slurred speech in 11 patients. Among these patients, 16 were able to tolerate a normal diet, 8 were on a soft diet, while 7 were on a liquid diet and 2 were tube-feeding dependent (P =0.28). Cosmetic outcome was rated as excellent in 19, good in 9, and fair in 5 patients (P =0.76).

Conclusions: Appropriate selection of free flap type tailored toward the defect allows for the best functional

and esthetic outcome. The pentagonal design anterolateral thigh myocutaneous free flap produces acceptable functional results for total glossectomy patients.

Reviewer's Comments: Much of the existing literature on oral tongue reconstruction with free tissue transfer

focuses on a single surgeon's experience with 1 type of flap. This study provides a refreshing perspective by proposing an algorithm to follow. If a glossectomy defect leaves >33% to 50% of the native tongue tissue, the emphasis is to maintain mobility by using a thin pliable flap such as radial forearm or anterolateral thigh perforator flaps. When <33% of the native tongue remains, the objective becomes one of bulk restoration to direct secretions laterally toward the oropharynx and provide contact with the palate, which can most easily achieved by a myocutaneous anterolateral thigh flap. (Reviewer-Tang Ho, MD).

Keywords: Glossectomy, Radial Forearm Free Flap, Anterolateral Thigh Flap


RCRS Is a Challenging Clinical Entity

High Prevalence of Humoral Immunodeficiency Patients With Refractory Chronic Rhinosinusitis.

Alqudah M, Graham SM, Ballas ZK:

Am J Rhinol Allergy 2010; 24 (November): 409-412

A high prevalence of functional humoral immunodeficiency can be seen in patients with refractory chronic rhinosinusitis.

Background: Patients with refractory chronic rhinosinusitis (RCRS) have consistently posed a diagnostic and

therapeutic challenge. Many different possible causes for the refractory nature of this disease have been proposed.

Objective: To evaluate the prevalence of quantitative and functional humoral immunodeficiency in a group of

patients with RCRS.

Design: Retrospective chart review.

Participants: 67 patients who failed to respond to intensive medical treatment for their RCRS and who also underwent endoscopic sinus surgery (ESS) were evaluated. Patients with allergic fungal sinusitis, human immunodeficiency virus, or other causes of secondary immunodeficiency were excluded from the study.

Methods: All patients had allergy skin tests to a standard battery of 39 aeroallergens. Serum immunoglobulins and immunoglobulin subclasses were measured using a variety of laboratory techniques. Low levels were defined as being <2 standard deviations below the age-adjusted mean. Functional antibody responses were assessed by examining response to the unconjugated pneumococcal polysaccharide vaccine. A normal response was defined as >4-fold increase in post-immunization antibody titer level for at least 7 of the 14 pneumococcal antigen serotypes tested.

Results: Low immunoglobulin levels were observed for IgG in 6 patients, IgA in 2 patients, and IgM in 8

patients. Overall, 14 patients (27%) were found to have low levels of at least 1 major immunoglobulin isotype. IgG subclass typing was performed in 31 patients. Low IgG2 was observed in 1 patient, low IgG3 in 3 patients, and low IgG4 in 3 patients. Fifty-one patients received the unconjugated pneumococcal vaccine. A good response to the vaccine was noted in 17 patients (33%), while a poor response was noted in 34 patients (67%). Twenty-eight patients had at least 1 positive allergy skin test. Eleven patients were found to have an elevated IgE level.

Conclusions: Patients with RCRS have a high prevalence of humoral antibody deficiency. Based on these results, quantitative and functional assessments of humoral antibody responses should be considered in patients with CRS who are refractory to aggressive medical and surgical therapy.

Reviewer's Comments: RCRS is a challenging clinical entity. The etiology of this clinical scenario is likely

multifactorial in nature. Dysfunction of the innate or acquired immune system has been proposed as a possible causative factor in both refractory and non-refractory CRS. The current study looks specifically at deficiencies in humoral immunity, and notes a high prevalence in both quantitative and functional humoral responses. Interestingly, while a minority of patients demonstrated a quantitative deficiency, a majority showed a poor functional antibody response. While this study is retrospective and lacks a control group, it does suggest that assessment of functional antibody response may be useful in some patients. A role for immunoglobulin subtype or isotype deficiencies in CRS or RCRS is currently not supported in the literature. (Reviewer-Justin H. Turner, MD, PhD).

Keywords: Rhinosinusitis, Allergy, Sinusitis, Refractory, Immunodeficiency, Humoral Immunity


Head Position, Ostial Size Affect Sinus Irrigation Penetrance

Effect of Head Position and Surgical Dissection on Sinus Irrigant Penetration in Cadavers.

Singhal D, Weitzel EK, et al:


Increasing ostial size during surgical dissection of the maxillary and sphenoid sinus is important to optimize sinus irrigation and topical medication delivery.

Background: Effective treatment of chronic rhinosinusitis now focuses largely on topical treatments and

irrigations of the sinonasal cavity. Recent evidence suggests that delivery of sinus irrigants may be more efficient in the postoperative population.

Objective: To determine the effect of sinus ostial size and head position on nasal irrigation delivery.

Design: Cadaveric study.

Methods: 10 cadaver heads were dissected in a staged manner. At each stage (0 to 3), sinus squeeze-bottle

irrigation was performed in 3 different head positions (0° to 90°). Ostial penetration was evaluated using an endoscope and a graded outcome scale.

Results: The maxillary sinus showed significantly worse penetration than the sphenoid and frontal sinus. The

difference was most pronounced at early stages of surgery. A significant increase in penetration was noted for increasing stages of dissection. The sphenoid sinus also showed a statistically significant improvement in irrigation with dissection stage. No significant difference in penetration was noted for the frontal sinus. Only the frontal sinus showed improvement in irrigation penetration with specific head positioning. When data on sinus penetration were pooled for all sinuses, the optimum ostial size was found to be 4.7 mm.

Conclusions: Increasing ostial size during surgical dissection of the maxillary and sphenoid sinus is important

to optimize sinus irrigation and topical medication delivery. The same benefit is not observed for the frontal sinus. Head positioning affects only sinus penetration in the frontal sinus, where the angled forward position is superior to the nose to wall position.

Reviewer's Comments: Paranasal sinus irrigation and topical medication delivery is an important component

of therapeutic regimens directed at recalcitrant chronic rhinosinusitis. The current study is the first to directly assess sinus penetration based on surgical dissection and head position. The results suggest that, in general, larger ostia are better than smaller ostia. This observation only holds to a certain point, however, with enlargement beyond 4.7 mm offering limited additional benefit. The results further show that only the frontal sinus is affected by head positioning. The ideal position corresponds to the patient leaning over a sink and irrigating with the nose pointed at the sink. These results should be taken into account when performing endoscopic sinus surgery and counseling patients on the proper use of sinus irrigants. (Reviewer-Justin H. Turner, MD, PhD).

Keywords: Rhinosinusitis, Sinusitis, Frontal Sinusitis, Sinus Irrigation, Topical Therapy


How Is the Double-Eyelid Created?

A Transcutaneous, Subcutaneous, and Intratarsal Suturing Procedure in Double Eyelid Surgery.

Liu X, Fan D, et al:

Plast Reconstr Surg 2010; 126 (December): 2133-2139

A non-incisional method of creating the double-eyelid appears to offer a reliable way of creating stable long-lasting results.

Background: Double-eyelid surgery, or commonly referred to as Asian blepharoplasty, involves repositioning

of the connection between levator aponeurosis and the skin/dermal fascia via formed scar or suture. Both incision and non-incision methods have been described. The non-incision method has the advantage of creating a natural crease with minimal recovery time. However, the supratarsal crease formed is usually not long lasting.

Objective: To review the authors’ experience with the non-incisional method in this study.

Methods: The authors used a suturing technique that involved 5 stab incisions in the new supratarsal crease using a transcutaneous-subcutaneous-intratarsal suturing technique. A 7-0 nylon suture was passed deeply from the tarsal plane to the dermis superficially. The suture was tightened and buried underneath the skin to form the new supratarsal crease. A total of 118 patients were reviewed between 2003 and 2008.

Results: 106 patients underwent follow-up from 3 to 36 months. Patient satisfaction was 90%. Reasons for

dissatisfaction included regression of the double eyelid (2.8%), unhappiness with shape and height of the new supratarsal crease (4.7%), and mild asymmetry of the formed eyelid (2.8%).

Conclusions: The transcutaneous-subcutaneous-intratarsal suturing technique, as described by the authors,

appears to offer a simple method of successfully creating a natural supratarsal crease.

Reviewer's Comments: Double-eyelid surgery is among the most common cosmetic surgical procedures

performed on the Asian population. There have been numerous techniques described, generally falling into either an incisional versus non-incisional technique. The surgeries are usually performed under local anesthesia and the non-incisional technique has been popular due to the short recovery time and reliable outcome. However, there have been concerns regarding the duration of the outcome with the non-incisional method. The authors offered their modification of the non-incisional technique, which appears to offer a stable outcome over time. (Reviewer-Tang Ho, MD).

Keywords: Asian Blepharoplasty, Non-Incisional Method


Fully Review Sinonasal CT Anatomy in All Patients

Computed Tomographic Analysis of Frontal Recess Anatomy and Its Effect on the Development of Frontal Sinusitis.

Lien CF, Weng HH, et al:


Some pneumatized cells surrounding the frontal sinus can contribute to development of frontal sinusitis.

Background: The frontal recess is a complex space. Variations in pneumatization patterns in this area have

been associated with development of frontal sinusitis. Identifying these anatomical differences preoperatively can improve the safety and efficacy of endoscopic sinus surgery.

Objective: To determine the association of certain frontal recess cells with development of frontal sinusitis.

Design: Retrospective chart review.

Participants: 192 patients who underwent CT scanning at a single tertiary care medical center.

Methods: Frontal sinus anatomy was evaluated on 363 sides from 192 patients. Frontal sinusitis was considered to be present if frontal sinus mucosal thickening of >3 mm was observed within the entire sinus or the dependent portion of the sinus. Images were evaluated for presence of various anatomical pneumatization patterns.

Results: The most commonly identified cells were agger nasi cells (89.0% of sides), recessus terminalis

(43.8%), frontal cell types 1 to 4 (39.7%), and suprabullar cells (39.1%). By univariate analysis, suprabullar cells and recessus terminalis were found to have a statistically significant association with the development of frontal sinusitis. The presence of suprabullar cells, supraorbital ethmoid cells, frontal bullar cells, and recessus terminalis were all found to be statistically associated with frontal sinusitis by multivariate analysis.

Conclusions: Cells posterior and posterolateral to the frontal recess (suprabullar, frontobullar, and

supraorbital ethmoid cells) may have a greater role in the development of frontal sinusitis than cells anterior to the frontal recess.

Reviewer's Comments: Previous studies that have evaluated anatomical differences in sinonasal

pneumatization patterns have generally failed to identify specific contributors to the development of chronic sinusitis. Most of these studies have not reached adequate patient numbers to make any significant conclusions. This study evaluates CT scans from almost 200 patients and specifically looks at development of frontal sinusitis. Their conclusions are quite interesting and should be of interest for clinicians who treat such patients. The study also does a reasonably good job of reviewing the anatomy of the frontal sinus and recess, as well as different anatomical variants in frontal sinus pneumatization. Knowing that cells posterior and/or posterosuperior to the frontal recess may contribute to the development of chronic frontal sinusitis would suggest that these areas should be targeted during surgery. It also may help predict which patients who already have chronic sinusitis may go on to further develop chronic frontal disease as well. Regardless, the study reinforces the need to fully review sinonasal CT anatomy in all patients. (Reviewer-Justin H. Turner, MD, PhD).

Keywords: Rhinosinusitis, Sinusitis, Frontal Sinus, CT


Is NMT Required in Transsphenoidal Surgery?

Middle Turbinectomy for Exposure in Endoscopic Endonasal Transsphenoidal Surgery: When Is It Necessary?

Guthikonda B, Nourbakhsh A, et al:


Middle turbinectomy is rarely necessary for exposure in endoscopic endonasal transsphenoidal surgery.

Background: Endoscopic transsphenoidal approaches to the sellar and suprasellar skull base have gained

acceptance over the last several years, and are now preferred at many centers. Resection of one or both middle turbinates has been proposed by many investigators as a way of gaining better surgical exposure.

Objective: To evaluate the necessity of middle turbinate resection for adequate exposure of skull base

structures.

Design: Anatomical cadaver study.

Methods: 20 cadaver heads were examined. The extent of skull base exposure was compared for approaches without middle turbinectomy (NMT), with unilateral turbinectomy (UMT), or with bilateral turbinectomy (BMT). Access to preselected target points including the sella turcica, tuberculum sella, planum sphenoidale, clivus, and ipsilateral sphenopalatine artery were compared.

Results: When the middle turbinate was preserved, the sella turcica, tuberculum sella, planum sphenoidale,

upper third of clivus, and carotid protuberances could be visualized and dissected in 100% of specimens. The ability to access the middle third of the clivus and the sphenopalatine artery was obtained in 45% and 20% of specimens, respectively. The same targets were accessed in 100% of UMT and BMT procedures. A UMT was sufficient to access any of the preselected targets.

Conclusions: Most midline skull base anatomy can be accessed and dissected without removal of the middle

turbinate. Enhanced exposure of the middle third of the clivus and sphenopalatine artery was achieved with UMT. BMT did not provide any additional exposure compared with UMT.

Reviewer's Comments: UMT or BMT has been advocated by many centers in order to improve access during

skull base procedures. Removal of one or both middle turbinates can enlarge the surgical corridor and allow for more efficient use of a bi-nostril, 2-surgeon technique. The current cadaver study shows that middle turbinectomy is rarely necessary to access most structures of the midline skull base. While this may be the case in a cadaver, removal of one or both middle turbinates undoubtedly improves the access and safe dissection of certain areas of the skull base. Many recent studies, most of which have evaluated the effect of middle turbinectomy during endoscopic sinus surgery, have failed to show any substantial morbidity related to middle turbinate removal. It does, however, remove an important landmark, should subsequent revision surgery become a necessity. In general, the decision to remove the middle turbinate should be made on a case-by-case basis, based, in part, on surgeon comfort and experience. (Reviewer-Justin H. Turner, MD, PhD).

Keywords: Transsphenoidal, Skull Base, Middle Turbinate, Endoscopic Sinus Surgery


Pharyngeal Packing Doesn’t Reduce PONV

Effect of Pharyngeal Packing During Nasal Surgery on Postoperative Nausea and Vomiting.

Korkut AY, Erkalp K, et al:

Otolaryngol Head Neck Surg 2010; 143 (December): 831-836

Pharyngeal packing has no significant benefit in reducing postoperative nausea and vomiting in nasal surgeries.

Background: The incidence of postoperative nausea and vomiting (PONV) after nasal surgery has been

reported to be 34% to 65% in various studies. Pharyngeal packs are used to block blood drainage with potent emetic effects into the aerodigestive passage, though its effectiveness in reducing PONV has not been proven.

Objective: To evaluate the efficacy of pharyngeal packing in reducing PONV in nasal surgeries.

Design/Methods: This was a prospective randomized controlled trial at a tertiary referral center performed

between August 2009 and January 2010. Inclusion criteria included patients between the ages of 18 and 60 years who underwent nasal and paranasal sinus surgeries under general anesthesia. A total of 100 patients were included in the study; 50 patients received pharyngeal packing while the other 50 patients did not. Incidences of PONV within 24 hours after surgery were evaluated.

Results: PONV was seen in 58% of the packing group and 66% of the control group 2 hours after surgery (P =0.41). Four hours after surgery, PONV was seen in 52% of the packing group and 46% of the control group (P =0.54). While PONV was seen in 34% of the packing group 8 hours after surgery, only 28% of the control group experienced PONV (P =0.51). PONV was not seen in either group at 24 hours after surgery. No significant differences in PONV were seen between groups. Septorhinoplasty surgeries had the highest incidence of PONV followed by functional endoscopic sinus surgery then septoplasty.

Conclusions: Use of perioperative pharyngeal packing in patients undergoing nasal surgery has no effect on

PONV.

Reviewer's Comments: While much of what we do in medicine makes intuitive sense, the dawn of the era of

evidence-based medicine practice has prompted us to critically evaluate clinical efficacy. Pharyngeal packing, while making intuitive sense, has been shown in multiple studies, including this one, to not have a significant impact in reducing PONV. Given the potential risks of pharyngeal packing including potential dislodgment, throat pain, and postoperative aphthous stomatitis, its use for the purpose of reducing PONV warrants reconsideration. (Reviewer-Tang Ho, MD).

Keywords: Postoperative Nausea & Vomiting, Pharyngeal Packing, Nasal Surgery


Managing Vertigo in Pilots Can Become a Medicolegal Issue

A Pilot With an Intravestibular Schwannoma: To Fly or Not to Fly?

Gordts F, Van Der Veken P, et al:


This case report discusses a rare intralabyrinthine schwannoma and potential medical-legal consequences of vertigo in a commercial pilot.

Background: Vertigo can be a disabling symptom because one never knows when an attack can occur. This

can be especially problematic for some professions, such as pilots, where down time is not possible.

Objective: To report a rare intravestibular schwannoma and discuss management in a professional pilot. Case Report: A 32-year-old male presented with unilateral tinnitus and fluctuating hearing loss. After the patient

presented, an initial 1.5 Tesla MRI revealed a possible intralabyrinthine lesion. A second 3.0 Tesla scan with gadolinium enhancement revealed an enhancing lesion within the vestibule confirming a likely schwannoma.

Results: At the time the lesion was discovered, the patient did not have vertigo. After discovery of the schwannoma, the patient was allowed to fly with restrictions that included periodic MRI and flight only as the copilot. After 16 months, the patient self-reported a vertigo episode and was grounded.

Conclusions: Intravestibular schwannoma is a rare tumor that can produce Ménière-like symptoms of tinnitus, fluctuating hearing loss, and episodic vertigo. Management of vertigo in pilots can become a difficult medical/legal issue.

Reviewer's Comments: This was an interesting case for a couple of reasons. First, this intravestibular schwannoma would probably have been classified as Ménière disease a few years ago, when this small tumor would have been missed by imaging modalities available at most institutions. This is something we should consider when making the diagnosis of Ménière disease, and these types of tumors will likely become more prevalent as 3.0 Tesla MRI becomes more available. The second issue raised by this report is the legal issue of when someone who has episodic attacks of vertigo should be allowed to transport the public. Episodic vertigo may impair a pilot’s ability to fly, but diagnosis depends almost entirely on self-reporting of symptoms. Those who stand to lose their job have a strong motivation to hide their symptoms. Another issue raised by such cases is whether these patients can return to flying after treatment, and if so, what should be considered treatment and how long do they need to wait after treatment? (Reviewer-Benjamin T. Crane, MD).

Keywords: Vertigo, Vestibular Loss, Schwannoma, Pilots


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