Endoscopic image-guided removal of metallic intravascular foreign body of the skull base.
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Embolization, Therapeutic↗
Biomedical subjects
Eric A Mair
Publications and source records attributed to Eric A Mair.
Two babies, one heart, and no airway.
The medical literature on conjoined twins is replete with descriptions of the complexity of surgical separations. However, airway management, although quite challenging, is neglected in literature. We present experience with conjoined twins united anteriorly at the thorax and abdomen sharing one six-chambered heart. Laryngoscopy and intubation recommendations, bronchoscopy techniques, and tracheotomy strategies are outlined for the face-to-face twins. Difficult, unique case report at tertiary care medical center. Conjoined thoraco-omphalopagus twins were successfully intubated at birth using the rigid Seldinger-assisted videotelescopic intubation (SAVI) technique. Flexible airway endoscopy allows for timely management of ventilator-dependent conjoined twins. Tracheotomy was later performed with the twins in the upright position with heads slightly rotated. Meticulous attention to detail, monitoring and vigilance are mandatory. Successful management of conjoined twins relies on close communication and cooperation of all members of the multidisciplinary team. Conjoined thoraco-omphalopagus twins united anteriorly require a challenging airway management strategy. A three-dimensional perspective is utilized for intubation and tracheotomy. The SAVI technique is helpful for difficult intubations in the emergent twin airways.
Adult↗
Acoustical analysis of snoring: can the probability of success be predicted?
PURPOSE: Palatal flutter snoring is the most common form of snoring. However, other types of snoring do exist. Does identifying palatal snoring beforehand translate into improved subjective treatment success with palatal stiffening procedures? METHODS: Fifty-three patients presenting with snoring were evaluated with a commercially available device. The proportion (%) and magnitude of palatal flutter (dB) were quantified. Patients then underwent a palatal stiffening procedure and subjective success/failure was assessed. RESULTS: Overall subjective treatment success was 85% (45 of 53). The percent palatal flutter was the most predictive of success (area under ROC = 0.8556, 95% CI = .7428-.9683). Patients exceeding 68% palatal flutter had a 95% (39 of 41) success rate (P = 0.001, Fisher's exact) and an adjusted odds ratio of treatment success of 25.2 (95% CI = 3.22-196, P = 0.002). CONCLUSION: Palatal stiffening treatments are successful in the majority of patients. However, identifying patients with predominant palatal flutter snoring significantly increases the probability of subjective treatment success. EBM RATING: B-2b.
Acoustics↗
Coblation lingual tonsillectomy.
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Catheter Ablation↗
Avian flu: what the otolaryngologist needs to know.
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Animals↗
Home versus laboratory sleep studies.
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Humans↗
Submucosal minimally invasive lingual excision: an effective, novel surgery for pediatric tongue base reduction.
OBJECTIVES: The aim of this study was to develop an effective single intraoral, minimally invasive technique to reduce the enlarged tongue base in children with obstructive macroglossia. METHODS: We present the anatomic dissection of fresh cadavers and a representative case series of children who underwent submucosal minimally invasive lingual excision (SMILE) with a plasma-mediated radiofrequency device (coblation) under intraoral ultrasonic and endoscopic guidance. Multiple anatomic dissections determined the relative location of the hypoglossal nerve and lingual neurovascular bundle in relation to removable tongue base musculature. A pediatric case series demonstrates the straightforward SMILE technique. RESULTS: Laboratory anatomic dissection and clinical lingual ultrasonography revealed the surgical safety borders for SMILE. The surgical safety and efficacy of SMILE is demonstrated by preoperative and postoperative clinical examinations and polysomnograms in children with obstructive macroglossia (such as Beckwith-Wiedemann and Down syndromes and tongue vascular malformation). Coblation submucosally removes excessive tongue base tissue through a small anterior tongue incision. SMILE was performed without excessive pain, bleeding, edema, infection, or tongue dysfunction. CONCLUSIONS: SMILE is an effective novel operation that incorporates coblation with ultrasonography and endoscopic guidance for children who need tongue base reduction. Anatomic dissection and clinical cases demonstrate the potential for aggressive yet relatively safe tissue removal by this minimally invasive technique. SMILE also has significant potential for adults with obstructive sleep apnea due to a large tongue base.
Adolescent↗
Pediatric functional endoscopic sinus surgery: frequently asked questions.
Pediatric endoscopic sinus surgery is a controversial procedure that has evolved considerably over the past 2 decades. We present a current review of the literature regarding the treatment of children with refractory sinusitis with a focus on the use of endoscopic sinus surgery. Preoperative evaluation, surgical technique, postoperative care, and unusual applications are discussed.
Adenoidectomy↗
Does obstructive sleep apnea affect aerobic fitness?
OBJECTIVES: We sought to determine whether patients with obstructive sleep apnea (OSA) had an objective change in aerobic fitness during cycle ergometry compared to a normal population. The most accurate test of aerobic fitness is measurement of maximum oxygen consumption (VO2max) with cycle ergometry. METHODS: We performed a retrospective cohort analysis (247 patients with OSA) of VO2max from annual cycle ergometry tests compared to a large control group (normative data from 1.4 million US Air Force tests) in a tertiary care setting. RESULTS: Overall, individuals with OSA had increased VO2max when compared to the normalized US Air Force data (p < .001). Patients with an apnea-hypopnea index of greater than 20 demonstrated a decreased VO2max as compared to normalized values (p < .001). No differences in VO2max were observed after either medical or surgical therapy for OSA. CONCLUSIONS: Overall, in a US Air Force population, OSA does not predict a decrease in aerobic fitness as measured by cycle ergometry. However, patients with an apnea-hypopnea index of greater than 20 have a statistically significant decrease in aerobic fitness compared to the normal population. This study demonstrates the effects of OSA on aerobic fitness. Further correlation of fitness testing results with OSA severity and treatment is needed.
Adolescent↗
Validations of a portable home sleep study with twelve-lead polysomnography: comparisons and insights into a variable gold standard.
OBJECTIVES: Accurate and timely diagnosis for patients with obstructive sleep apnea (OSA) is imperative. Unfortunately, growing interest in this diagnosis has resulted in increased requests and waiting times for polysomnography (PSG), as well as a potential delay in diagnosis and treatment. This study evaluated the accuracy and viability of utilizing SNAP (SNAP Laboratories, LLC, Wheeling, Illinois), a portable home sleep test, as an alternative to traditional PSG in diagnosing OSA. METHODS: This prospective clinical trial included 59 patients evaluated at our institution's sleep laboratory. Concurrent PSG and SNAP testing was performed for 1 night on each patient. Independent, blinded readers at our institution and at an outside-accredited institution read the PSG data, and 2 independent, blinded readers interpreted the SNAP data at SNAP laboratories. The apnea-hypopnea index (AHI) was used to compare the 2 testing modalities. The correlation coefficient, receiver operating characteristic curve analysis, and the Bland-Altman curves, as well as sensitivity, specificity, inter-reader variability, positive predictive value, and negative predictive value, were used to compare SNAP and PSG. RESULTS: There is a definitive, statistically sound correlation between the AHIs determined from both PSG and SNAP. This relationship holds true for all measures of comparison, while displaying a concerning, weaker correlation between the different PSG interpretations. CONCLUSIONS: There is a convincing correlation between the study-determined AHIs of both PSG and SNAP. This finding supports SNAP as a suitable alternative to PSG in identifying OSA, while accentuating the inherent variation present in a PSG-derived AHI. This test expands the diagnostic and therapeutic prowess of the practicing otolaryngologist by offering an alternative OSA testing modality that is associated with not only less expense, decreased waiting time, and increased convenience, but also statistically proven accuracy.
Adult↗
Neonatal suppurative submandibular sialadenitis: case report and literature review.
Acute submandibular sialadenitis is rare in the neonatal period and appears to be associated with prematurity. We describe a case of a premature neonate who developed suppurative submandibular sialadenitis from a hypervirulent strain of methicillin-resistant Staphylococcus aureus. The etiology, diagnosis, and treatment of this condition are discussed.
Anti-Bacterial Agents↗
West Nile virus: a primer for the otolaryngologist.
BACKGROUND: Since recognition in the United States with a 1999 New York City epidemic, West Nile virus has enduringly migrated westward, leaving few states unaffected. Infection rates are rising at an alarming rate, doubling every year since introduction, with more than 9800 cases in 2003 alone and more than 260 deaths. Patients may present with myriad symptoms including a maculopapular rash that affects the face and trunk and diffuse lymphadenopathy, both of which may result in the initial consultation of the otolaryngologist. We review the clinical history of West Nile virus and its epidemiology, laboratory findings, and variable clinical presentation, with an emphasis on otolaryngologic manifestations. STUDY DESIGN AND SETTING COMPREHENSIVE: review of the literature over the past 50 years with an emphasis on what the present-day otolaryngologist needs to know concerning West Nile virus. Clinical manifestations of the head and neck such as encephalitis, meningitis, maculopapular rash, lymphadenopathy and dysphagia are discussed. RESULTS: To date, there are no articles in the otolaryngology literature discussing West Nile virus. These patients may present initially to multiple providers in diverse specialties because of multifarious initial signs and symptoms. The otolaryngologist must be educated on this quickly growing affliction and practice with a high index of suspicion. CONCLUSIONS: In this article we describe the clinical manifestations of West Nile virus, with an emphasis on the otolaryngologic manifestations. The otolaryngologist must become educated about this entity to facilitate preventative measures, adequately treat, and assist other providers in hopeful control and potential eradication of this infectious threat.
Humans↗
Seldinger-assisted videotelescopic intubation (SAVI): a common sense approach to the difficult pediatric airway.
OBJECTIVES: To describe the Seldinger-assisted videotelescopic intubation (SAVI) technique, a complementary method for aiding in difficult pediatric intubations that uses common equipment available to the practicing otolaryngologist. STUDY DESIGN: Technique description. METHODS: Detailed description of technique for use of a pediatric laryngoscope with video-assisted endotracheal tube (ETT) covered rigid tracheoscopy controlled intubation in difficult pediatric airways. RESULTS: In our practice, SAVI is vital in establishing a secure airway in the difficult-to-intubate child. After insertion of a laryngoscope, an appropriate sized endotracheal tube is delivered through the glottis under direct video-visualization from a rigid telescope using a variation of the well-established Seldinger technique. The telescope serves as the stable ETT stylet that also provides panoramic visualization. The ETT slides over the telescope to provide a secure airway directly visible to all in the operating room. Benefits of the SAVI technique to previously described video-assisted intubations with flexible or specially designed endoscope devices include decreased cost, employment of previously existing endoscopy skills, the benefit of rigid delivery of the endotracheal tube as well as innate versatility to a multitude of clinical situations. CONCLUSIONS: The SAVI technique offers an additional practical clinical solution to the difficult pediatric airway. Although ultimately establishing the airway depends on the skills of the operator, the SAVI technique has saved multiple lives by using common equipment through a common-sense approach. EBM RATING: D.
Child↗
Total nasopharyngeal stenosis: treatment with laser excision, nasopharyngeal obturators, and topical mitomycin-c.
OBJECTIVE: Severe nasopharyngeal stenosis after uvulopalatopharyngoplasty (UPPP) is a dreaded complication. Very little has been written about successful treatment because attempts at correction frequently fail. Severe stenosis of the nasopharynx drastically worsens speech, swallowing, and obstructive sleep apnea (OSA). We present our successful experience with severe stenosis focusing on a simple functional repair using topical mitomycin-c as well as differing daytime and nighttime palatal obturators. METHODS: Three adults with total or near-total nasopharyngeal stenosis secondary to UPPP were referred to our institution after multiple failed attempts at repair. Each presented with significant OSA on polysomnogram (PSG), with excessive daytime somnolence and voice and swallowing complaints. Under general anesthesia, a CO2 laser is used to create an opening in the nasopharynx. Removable and adjustable palatal obturators are fashioned to keep the nasopharynx open with a daytime insert piece with a small obturator hole for diminished velopharyngeal insufficiency and a nighttime piece without an insert to maximize recumbent airflow. Obturators are removed 6 months later with topical application of mitomycin-c as a fibroblast inhibitor. All patients were followed clinically for at least 1 year and received posttreatment PSG. RESULTS: All patients experienced resolution of their stenoses. Swallowing and voice complaints resolved. Either OSA was eliminated or any residual OSA was successfully treated with nasal continuous positive airway pressure. Serial videoendoscopic images throughout the treatment phase demonstrate the effectiveness of this new technique. CONCLUSIONS: Severe nasopharyngeal stenosis is a rare but devastating complication of UPPP. We introduce a simple technique that uses functional palatal obturators and topical mitomycin-c and describe our success with this treatment algorithm.
Adult↗
Does increased electrocautery during adenoidectomy lead to neck pain?
OBJECTIVES: The objective was to assess the impact of electrocautery on complications in adenoidectomy. We sought to quantify cautery-related temperature changes in prevertebral fascia that may occur during the procedure, retrospectively evaluate the incidence of cautery-related complications, and prospectively assess the role of cautery in postoperative neck pain. METHODS: Three consecutive related trials were performed. Initially, adenoidectomy was performed on 20 fresh cadavers, using a thermister to evaluate temperature changes in the prevertebral fascia after electrocautery (30 watts over a 30-second period). Next, retrospective analysis of adenoidectomy complications in 1206 children over a 5-year period was performed. Based on these findings, a prospective study of the incidence of neck pain following adenoidectomy was performed in a cohort of 276 children. Adenoidectomy technique, wattage, and duration of electrocautery were recorded for each child. Children with significant neck pain were evaluated with MRI. RESULTS: Peak thermister readings averaged 74 degrees C, for a mean change of 51.8 degrees C. Complications observed in retrospective analysis included neck pain (3), Grisel's syndrome (1), prolonged velopharyngeal insufficiency (1), retropharyngeal edema (1), and severe nasopharyngeal stenosis (1). The incidence of neck pain in the prospective study was 12% (33 pts), and was independent of adenoidectomy technique, cautery wattage, or duration of cautery use. MRIs revealed edema without abscess. CONCLUSIONS: Cautery can result in substantial temperature changes in the surgical adenoid bed. Despite this, the incidence of complications, specifically neck pain, associated with adenoidectomy is low, although underreported. Complications appear to be independent of adenoidectomy technique and cautery use.
Adenoidectomy↗
Endoscopic surgery of the anterior skull base.
OBJECTIVES/HYPOTHESIS: Traditional surgical approaches to the anterior skull base often involve craniotomy, facial incisions, disruption of skeletal framework, tracheotomy, and an extended hospital stay. As experience with endoscopic sinus surgery has grown, the techniques and equipment have been found to be adaptable to treatment of lesions of the anterior and central skull base. A minimally invasive endoscopic approach theoretically offers the advantages of avoiding facial incisions, osteotomies, and tracheotomy; surgery should be less painful, recovery quicker, and hospital stays should be shorter. The study attempted to assess endoscopic approaches to the anterior and central skull base for its ability to achieve those goals. STUDY DESIGN: Retrospective review of 72 cases performed at a single institution from November 1996 to July 2003. A subgroup of 15 patients who underwent endoscopic approach to their pituitary tumors was compared with a similar group of 15 patients who underwent traditional open trans-sphenoidal surgery for their pituitary tumors. METHODS: Patient records were analyzed and information tabulated for age, sex, disease, location of lesion, operative time, use of image-guided surgical systems, blood loss, length of intensive care unit stay, duration of operative pain, length of postoperative hospitalization, complications, and completeness of resection. RESULTS: Of the cases, 86.1% were performed exclusively endoscopically, and 13.9% used a combination of endoscopic and open techniques. An image-guided surgical system was used in 83% of cases. Hospital length of stay was 2.3 days for the exclusively endoscopic group as opposed to 8 days for the combined group. With the patients with pituitary tumors, operative times were similar between the two groups (255.13 vs. 245.73 min), blood loss was less in the endoscopic group (125.33 vs. 243.33 mL), pain duration was shorter in the endoscopic group (10 of 15 patients pain free on postoperative day 1 vs. 2 of 15 patients pain free in the open group), and intensive care unit stay and hospital length of stay were both shorter in the endoscopic group. Complication rates and completeness of resection was similar in both groups, although the open group had a higher rate of complications related to the approach to the sella. CONCLUSION: The study demonstrated the safety and efficacy of judicious endoscopic approaches to anterior skull base lesions. An outcomes assessment in pituitary surgery demonstrates advantages of an endoscopic approach in appropriate cases.
Adolescent↗
Potential applications of the da Vinci minimally invasive surgical robotic system in otolaryngology.
Anatomic constraints and instrumentation design characteristics have limited the exploitation of endoscopic surgery in otolaryngology. The move toward less invasive and less morbid procedures has paved the way for the development and application of robotic and computer-assisted systems in surgery. Surgical robotics allows for the use of new instrumentation in our field. We review the operative advantages, limitations, and possible surgical applications of the da Vinci Surgical System in otolaryngology. In the laboratory setting, we explored the setup and use of the da Vinci system in porcine and cadaveric head and neck airway models; the setup was configuredfor optimal airway surgery. Endoscopic cautery, manipulation, and suturing of supraglottic tissues were performed in both the porcine and cadaveric models. We found that the da Vinci system provided the advantages of the lower morbidity associated with endoscopic surgery, more freedom of movement, and three-dimensional open surgical viewing. We also observed that the system has several limitations to use in otolaryngology.
Animals↗
Injection snoreplasty: investigation of alternative sclerotherapy agents.
OBJECTIVE: Palatal sclerotherapy with sodium tetradecyl sulfate ("injection snoreplasty") was recently introduced as a safe and effective treatment for primary snoring. However, multiple other sclerotherapy agents also have excellent safety records and documented efficacy in the head and neck. Widely available and inexpensive agents were evaluated as potential palatal sclerosing agents for the treatment of snoring. STUDY DESIGN AND SETTING: A described canine palatal flutter model was used to evaluate the palatal stiffening efficacy of ethanol, doxycycline, and hypertonic saline in comparison to 3% sodium tetradecyl sulfate (STS) and a negative control (normal saline). Based on the animal study results, a human pilot study with ethanol was performed with subjective and objective data. RESULTS: Ethanol was found to be equally effective as 3% STS in the canine model. Doxycycline was effective but less so, and hypertonic saline was comparatively ineffective. Palatal injection in human patients with 50% ethanol was found to produce equivalent subjective and objective snoring efficacy and equivalent pain and recovery time compared with 3% STS. However, there was a higher rate of transient palatal fistula with ethanol. CONCLUSIONS AND SIGNIFICANCE: Injection snoreplasty with 50% ethanol is equally efficacious compared with 3% STS. There could be a higher fistula rate with the use of ethanol, although this complication has been self-limited and transient in every case.
Animals↗