Publications by authors named "James L Netterville"

82 Publications

Impact of COVID-19 on presentation, staging, and treatment of head and neck mucosal squamous cell carcinoma.

Am J Otolaryngol 2021 Oct 8;43(1):103263. Epub 2021 Oct 8.

Department of Otolaryngology Head and Neck Surgery, Vanderbilt University Medical Center, 7th floor 1215 21st Ave S, Nashville, TN 37232, USA.

Objectives: During the COVID-19 pandemic, maintenance of safe and timely oncologic care has been challenging. The goal of this study is to compare presenting symptoms, staging, and treatment of head and neck mucosal squamous cell carcinoma during the pandemic with an analogous timeframe one year prior.

Materials And Methods: Retrospective cohort study at a single tertiary academic center of new adult patients evaluated in a head and neck surgical oncology clinic from March -July 2019 (pre-pandemic control) and March - July 2020 (COVID-19 pandemic).

Results: During the pandemic, the proportion of patients with newly diagnosed malignancies increased by 5%, while the overall number of new patients decreased (n = 575) compared to the control year (n = 776). For patients with mucosal squamous cell carcinoma (SCC), median time from referral to initial clinic visit decreased from 11 days (2019) to 8 days (2020) (p = 0.0031). There was no significant difference in total number (p = 0.914) or duration (p = 0.872) of symptoms. During the pandemic, patients were more likely to present with regional nodal metastases (adjusted odds ratio (OR) 2.846, 95% CI 1.072-3.219, p = 0.028) and more advanced clinical nodal (N) staging (p = 0.011). No significant difference was seen for clinical tumor (T) (p = 0.502) or metastasis (M) staging (p = 0.278). No significant difference in pathologic T (p = 0.665), or N staging (p = 0.907) was found between the two periods.

Conclusion: Head and neck mucosal SCC patients presented with more advanced clinical nodal disease during the early months of the COVID-19 pandemic despite no change in presenting symptoms.
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http://dx.doi.org/10.1016/j.amjoto.2021.103263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8500684PMC
October 2021

Organ-Preserving Treatment Strategy for Extra-Axial Chordoma Metastatic to the Larynx Causing Airway Compromise.

Ear Nose Throat J 2021 Jul 31:1455613211037639. Epub 2021 Jul 31.

Department of Otolaryngology-Head and Neck Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA.

Chordomas are rare, malignant bone tumors that arise from embryological remnants of the notochord, typically affecting the skull base, mobile spine, and sacrum with uncommon metastasis to the larynx. Patients with metastasis to the larynx may present with slowly progressive dysphonia and dyspnea. Here, we report an organ-preservation treatment strategy for a patient with widely metastatic extra-axial chordoma presenting with airway compromise who was found to have a new metastasis to the cricoid cartilage.
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http://dx.doi.org/10.1177/01455613211037639DOI Listing
July 2021

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis.

Ann Otol Rhinol Laryngol 2021 Oct 25;130(10):1116-1124. Epub 2021 Feb 25.

Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, CA, USA.

Objectives: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients.

Methods: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence.

Results: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression.

Conclusions: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.
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http://dx.doi.org/10.1177/0003489421995283DOI Listing
October 2021

Community health worker-based hearing screening on a mobile platform: A scalable protocol piloted in Haiti.

Laryngoscope Investig Otolaryngol 2020 Apr 12;5(2):305-312. Epub 2020 Feb 12.

Department of Otolaryngology Vanderbilt University Medical Center Nashville Tennessee.

Objective: To establish the feasibility of a systematic, community health worker (CHW)-based hearing screening program that gathers Health Insurance Portability and Accountability Act-compliant electronic data (otoscopic images of tympanic membrane and audiometric evaluation) on a smartphone in an effort to streamline treatment options in resource-limited communities.

Methods: This is a cross-sectional study in which four schools were screened in Port-au-Prince, Haiti, during in April 2018. A total of 122 subjects (61% female) aged 5-17 years underwent an initial brief audiometric screen followed by a more comprehensive air conduction audiometric evaluation if they failed their initial screen. Participants with more than 35-dB loss in any frequency on their comprehensive audiometric evaluation received endoscopic otoscopy.

Results: Seventy-five percent of subjects (91/122) passed their initial screen. Of those who failed, 9% (4/44 ears) had a severe or profound hearing loss on comprehensive evaluation. Abnormal otoscopic findings (11/36 ears, 31%) included are cerumen impaction (n = 6), myringosclerosis (n = 3), tympanic membrane perforation (n = 1), and tympanic membrane retraction (n = 1). The average duration of the initial testing was 100 seconds (SD = 74 seconds), whereas the duration of comprehensive testing was 394 seconds (SD = 175 seconds). Extrapolating from these data, we estimate that a group of seven trained CHWs could gather formal audiologic and otologic data points for 100 children per hour using this protocol.

Conclusions: A systematic approach that utilizes local resources (CHWs) and existing infrastructure (cell phones and the Internet) can significantly reduce the burden of hearing healthcare specialists while simultaneously facilitating early diagnosis and management of disabling hearing loss in low-resourced settings.

Level Of Evidence: Level 4.
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http://dx.doi.org/10.1002/lio2.361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178457PMC
April 2020

Ultrasound Training for Head and Neck Surgeons in Rural Kenya: A Feasibility Study.

J Surg Educ 2020 Jul - Aug;77(4):866-872. Epub 2020 Mar 4.

Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Objective: To determine the feasibility of training otolaryngologists to perform head and neck ultrasound in low- and middle-income countries over a short timeframe.

Design: Prospective cohort evaluating an ultrasound training course for otolaryngologists in low- and middle-income countries.

Setting: Surgical training camp for otolaryngologists in semirural Kenya.

Methods: Participants were prospectively recruited to participate in an ultrasound training course during a 2-week surgical training camp. They performed baseline ultrasound exams (9-item test, 5-point scale) with no assistance, followed by didactic sessions teaching ultrasound techniques. Participating surgeons then performed head and neck ultrasound exams on patients in clinic or in the operating room with direct supervision. Postcourse ultrasounds were performed, and the results of these tests were compared to baseline exams.

Results: Eight surgeons were enrolled out of a total of 13 (62%). Three were attending surgeons (37.5%), 1 enrollee was a head and neck surgery fellow, and 4 were senior residents (50%). Six of 8 surgeons were from Kenya. The mean precourse test score was 25 (range 21-30) compared to a mean postcourse test score of 40 (range 37-45, p < 0.005). All participants significantly improved their scores, with a mean improvement of 16 points (range 10-23).

Discussion: Otolaryngologists are uniquely equipped to learn head and neck ultrasound given their familiarity with the anatomy and pathology in this region. Training physicians without prior experience can be done even over short timeframes. Early training should focus on ultrasound, with later stages of training focusing on pathology.
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http://dx.doi.org/10.1016/j.jsurg.2020.02.005DOI Listing
June 2021

Transcervical sonography and human papillomavirus 16 E6 antibodies are sensitive for the detection of oropharyngeal cancer.

Cancer 2020 06 4;126(11):2658-2665. Epub 2020 Mar 4.

Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Human papillomavirus 16 (HPV-16) E6 seropositivity is a promising early marker of human papillomavirus-driven oropharyngeal cancer (HPV-OPC), yet more sensitive imaging modalities are needed before screening is considered. The objective of this study was to determine the sensitivity of transcervical sonography (TCS) for detecting clinically apparent HPV-OPC in comparison with computed tomography (CT) and positron emission tomography (PET)/CT.

Methods: Fifty-one patients with known or suspected HPV-OPC without prior treatment underwent oropharyngeal TCS and blood collection (for HPV multiplex serology testing). Eight standard sonographic images were collected; primary-site tumors were measured in 3 dimensions if identified. Each patient underwent a full diagnostic workup as part of standard clinical care. The pathologic details, HPV status, final staging, and imaging findings were abstracted from the medical record. The sensitivity of each imaging modality was compared with the final clinical diagnosis (the gold standard).

Results: Twenty-four base of tongue cancers (47%), 22 tonsillar cancers (43%), and 2 unknown primary cancers (4%) were diagnosed; 3 patients (6%) had no tumors. All p16-tested patients were positive (n = 47). Primary-site tumors were correctly identified in 90.2% (95% confidence interval [CI], 78.6%-96.7%) with TCS, in 69.4% (95% CI, 54.6%-81.7%) with CT, and in 83.3% (95% CI, 68.6%-93.0%) with PET/CT. TCS identified tumors in 10 of 14 cases missed by CT and recognized the absence of tumors in 3 cases for which CT or PET/CT was falsely positive. The smallest sonographically identified primary-site tumor was 0.5 cm in its greatest dimension; the average size was 2.3 cm. Among p16-positive patients, 76.1% (95% CI, 61.2%-87.4%) were seropositive for HPV-16 E6.

Conclusions: TCS and HPV-16 E6 antibodies are sensitive for the diagnosis of HPV-OPC.
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http://dx.doi.org/10.1002/cncr.32799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7829679PMC
June 2020

Risk Factors and Outcomes of Postoperative Recurrent Well-Differentiated Thyroid Cancer: A Single Institution's 15-Year Experience.

Otolaryngol Head Neck Surg 2020 Apr 18;162(4):469-475. Epub 2020 Feb 18.

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objective: Identify risk factors and outcomes of recurrent well-differentiated thyroid cancer.

Study Design: Retrospective case-control analysis.

Setting: Tertiary care academic center in Nashville, Tennessee.

Subjects And Methods: This single-center analysis reviews 478 patients who underwent initial surgical management of well-differentiated thyroid carcinoma between 2002 and 2017. Patients were dichotomized with or without recurrent well-differentiated thyroid cancer. Demographic and clinicopathologic risk factors were carefully reviewed. Univariate, multiple regression, and survival analyses were used to evaluate predictors of recurrence.

Results: Thirty-eight patients (7.9%) who received initial surgical intervention for well-differentiated thyroid carcinoma at our institution recurred, with an average time to recurrence of 24 months. Male sex, tumor size, multifocality, extrathyroidal extension, lymphovascular invasion, number of positive lymph nodes, and low lymph node yield were all significantly associated with locoregional recurrence ( < .05). Multiple regression analysis showed that extrathyroidal extension, number of positive lymph nodes, and low lymph node yield were independent factors predictive of posttreatment recurrence ( < .05). Metastatic lymph node ratio, the ratio of positive lymph nodes extracted to lymph node yield, of ≥0.3 is associated with increased risk of recurrence ( < .001) and decreased 5-year recurrence free survival ( < .001).

Conclusion: Extrathyroidal extension, number of positive lymph nodes, and low lymph node yield are independent clinicopathologic risk factors for postoperative recurrence of well-differentiated thyroid cancer. Metastatic lymph node ratio is uncommonly used but can be an important prognosticator of recurrence. Patients with metastatic lymph node ratio ≥0.3 should be counseled on their increased risk of recurrence and should undergo close surveillance following surgery.
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http://dx.doi.org/10.1177/0194599820904923DOI Listing
April 2020

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

JAMA Otolaryngol Head Neck Surg 2020 01;146(1):20-29

Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research.

Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease.

Design, Setting, And Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook.

Main Outcomes And Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications.

Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk.

Conclusions And Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.
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http://dx.doi.org/10.1001/jamaoto.2019.3022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824232PMC
January 2020

Teacher Prescreening for Hearing Loss in the Developing World.

Ear Nose Throat J 2021 Jun 13;100(3_suppl):259S-262S. Epub 2019 Oct 13.

Department of Otolaryngology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.

The goal of this prospective cohort study was to characterize the ability of teachers to identify schoolchildren at risk of hearing loss in order to maximize hearing screening efficiency in low-resource settings. At 4 semirural schools in Malindi, Kenya, preselected schoolchildren perceived as hearing impaired were compared to children thought to have normal hearing using portable audiometry. Eight of 127 children (54% male) failed hearing screening, all of who were identified by schoolteachers as having a high risk of hearing loss. Thus, for every 5 children prescreened by schoolteachers, an average of 1 child would be identified as having hearing loss. Overall, teacher prescreening had a 100% hearing loss identification rate and a 20% referral rate. In conclusion, in resource-limited settings, where universal hearing screening is challenging, teachers can effectively identify children with hearing loss for early intervention.
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http://dx.doi.org/10.1177/0145561319880388DOI Listing
June 2021

Head and Neck Ultrasound in Otolaryngology Surgical Missions.

Ear Nose Throat J 2019 Oct-Nov;98(9):535-536. Epub 2019 Sep 25.

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

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http://dx.doi.org/10.1177/0145561319864553DOI Listing
April 2020

Color Doppler Ultrasonography for Monitoring a Free Flap Anastomosis During a Head and Neck Surgical Camp.

Ear Nose Throat J 2021 Mar 23;100(3):160-161. Epub 2019 Sep 23.

Department of Otolaryngology-Head and Neck Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA.

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http://dx.doi.org/10.1177/0145561319864556DOI Listing
March 2021

Community health workers obtain similar results using cell-phone based hearing screening tools compared to otolaryngologists in low resourced settings.

Int J Pediatr Otorhinolaryngol 2019 Dec 5;127:109670. Epub 2019 Sep 5.

Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, USA.

Objective: To establish community health workers as reliable hearing screening operators in a technology-based pre-surgical hearing screening program in a low and middle-income country (LMIC).

Methods: This is a cross sectional study that evaluated community health worker driven hearing screening that took place in semi-rural Malindi, Kenya during an annual two-week otolaryngology surgical training mission in October 2017. At five separate locations (four schools) near Malindi, Kenya, children between the ages of 2-16 underwent hearing screening using screening audiometry (Android-based HearX Group). Children were screened by a community health worker who underwent a short training course, a senior otolaryngology resident, or both. Hearing screening results were compared to determine the reliability and concordance between independent, blinded community health worker and otolaryngology resident testing.

Results: One hundred and four participants (53% males) underwent hearing screening. Hearing screening pass rate was 93%. Community health workers obtained a similar result to otolaryngology residents 96% of the time (McNemar test: p = 0.16, OR 0.96, 95% CI 0.9-1.0).

Conclusion: Community health workers can obtain reliable results using a technology-based, pre-surgical hearing screening platform when compared to otolaryngology residents. This finding has profound implications in low-resourced settings where hearing healthcare specialists (audiologists and otolaryngologists) are limited and can ultimately improve the surgical yield of patients presenting to local otolaryngologists in these settings.
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http://dx.doi.org/10.1016/j.ijporl.2019.109670DOI Listing
December 2019

Pediatric hearing screening in low-resource settings: Incorporation of video-otoscopy and an electronic medical record.

Int J Pediatr Otorhinolaryngol 2019 Nov 10;126:109633. Epub 2019 Aug 10.

Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.

Objective: To develop a sustainable, comprehensive, intervention-based approach to pediatric hearing care in low- and middle income countries (LMICs) where global hearing loss is most heavily concentrated.

Methods: Community health workers (CHWs) in Kilifi county, Kenya were trained to conduct hearing screening and video-otoscopy via a unified, smartphone-based platform using mobile electronic medical record (EMR) generation for children diagnosed with hearing loss or other pathology. Among at-risk students pre-selected by their teachers, the frequency of hearing loss and pathology in children with and without hearing loss was measured.

Results: Of the 155 screened, 16 (10%) children were found to have hearing loss. 12 (5.9%) children with normal hearing had the following pathology: perforation (N = 5 ears), effusion (N = 9), retraction (N = 6), and infections (N = 7). CHWs were also adept at EMR creation without significant delay in workflow. Out of all those screened, 28 (18%) children were found to have hearing loss or other pathology and were referred to follow up. All 28 of 28 children referred were successfully entered into the EMR.

Conclusions: CHWs with little to no prior medical experience can provide a much needed public health service - hearing screening in LMICs where access to health care is limited. The incorporation of video-otoscopy provides a more comprehensive approach to hearing care by not only helping identify etiologies of existing hearing disability but also conditions that predispose to future hearing loss. It can easily be performed in conjunction with hearing screenings via the use of a unified, mobile platform. The addition of EMR supports follow-up and allows remote consultation.
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http://dx.doi.org/10.1016/j.ijporl.2019.109633DOI Listing
November 2019

Early onset oral tongue squamous cell carcinoma: Associated factors and patient outcomes.

Head Neck 2019 06 11;41(6):1952-1960. Epub 2019 Jan 11.

Vanderbilt University Medical Center, Department of Otolaryngology, Nashville, Tennessee, USA.

Background: Incidence of oral tongue squamous cell carcinoma (OTC) is rising among those under age 50 years. The etiology is unknown.

Methods: A total of 395 cases of OTC diagnosed and/or treated at Vanderbilt University Medical Center between 2000 and 2017 were identified. Of those, 113 (28.6%) were early onset (age < 50 years). Logistic regression was used to identify factors associated with early onset OTC. Cox proportional hazards models evaluated survival and recurrence.

Results: Compared to typical onset patients, patients with early onset OTC were more likely to receive multimodality treatment (surgery and radiation; adjusted odds ratio [aOR], 2.7; 95% confidence interval [CI], 1.2-6.3) and report a history of snuff use (aOR, 5.4; 95% CI, 1.8-15.8) and were less likely to report a history of cigarette use (aOR, 0.5; 95% CI, 0.2-0.9). Early onset patients had better overall survival (adjusted hazard ratio, 0.6).

Conclusions: This is the largest study to evaluate factors associated with early onset OTC and the first to report an association with snuff.
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http://dx.doi.org/10.1002/hed.25650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7010313PMC
June 2019

Association Between Red Blood Cell Distribution Width and Outcomes of Open Airway Reconstruction Surgery in Adults.

JAMA Otolaryngol Head Neck Surg 2019 03;145(3):210-215

Surgical Outcomes Center for Kids, Vanderbilt University Medical Center. Nashville, Tennessee.

Importance: Airway reconstruction for adults with laryngotracheal stenosis (LTS) is directed toward improving airway caliber to mitigate the patient's dyspnea and achieve prosthesis-free breathing (ie, without tracheostomy, intraluminal stent, or T-tube). Despite the importance of preoperative risk stratification to minimize postoperative complications, consensus on an objective predictive algorithm for open airway reconstruction is lacking.

Objective: To determine whether the ability to achieve a prosthesis-free airway in adults after open airway reconstruction is associated with red blood cell distribution width (RDW) at the time of surgery.

Design, Setting, And Participants: Case series study investigating 92 consecutive patients 18 years and older with laryngotracheal stenosis who underwent open airway reconstruction at a US tertiary care hospital from January 1, 2006, to January 1, 2017.

Main Outcomes And Measures: The main outcome was a prosthesis-free airway (absence of tracheostomy, intraluminal stent, or T-tubes) at last follow-up. Multivariate logistic regression modeling was used to identify independent factors associated with this outcome.

Results: Of the 92 patients who met inclusion criteria, the median (interquartile range) age was 44 (33.0-60.3) years; 50 (53%) were female, and 82 (89%) were white. In all, 74 patients (80%) were prosthesis free at the last follow-up (mean, 833 days; 95% CI, 10-4229 days). In multivariate analyses, airway decannulation was significantly correlated with reduced RDW (odds ratio [OR], 0.40; 95% CI, 0.19-0.84) and the absence of posterior glottic stenosis (OR, 0.12; 95% CI, 0.04-0.37).

Conclusions And Relevance: These data suggest that surgical success in open airway reconstruction is significantly associated with RDW and whether the patient had posterior glottic stenosis. The RDW is a routine laboratory parameter that may provide some insight to the preoperative probability of prosthesis removal, facilitate risk stratification, promote informed patient decision making, and optimize health care resource management.
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http://dx.doi.org/10.1001/jamaoto.2018.3793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439750PMC
March 2019

Survival Outcomes in T4aN0M0 Mandibular Gingival Squamous Cell Carcinoma Treated with Surgery Alone.

Otolaryngol Head Neck Surg 2019 05 1;160(5):870-875. Epub 2019 Jan 1.

1 Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objectives: To measure disease-free, disease-specific, and overall survival among patients with T4aN0M0 mandibular gingival squamous cell carcinoma who were treated with surgery alone.

Study Design: Case series with chart review.

Setting: Tertiary care center.

Subjects And Methods: A retrospective chart review was performed of all adult patients treated surgically with an oral cavity composite resection between January 2005 and March 2017. Among other data, patient preoperative characteristics were recorded (eg, age, sex, smoking history, alcohol use, and clinical stage); operative notes were reviewed to determine tumor subsite involvement, reconstruction method, and intraoperative surgical complications; and pathology reports were evaluated for various pathologic findings. Survival outcomes were determined with Kaplan-Meier analysis.

Results: The mean follow-up was 18.5 months (range, 0.1-100). The 1- and 5-year disease-free survival rates were 90.5% and 84.5%, respectively, while the 1- and 5-year disease-specific survival rates were 87.8% and 81.9%. The 1- and 5-year overall survival rates were 86.4% and 80.6%.

Conclusions: Patients with T4aN0M0 squamous cell carcinoma of the mandibular gingiva treated with surgery alone have a 5-year overall survival of 80.6%. Treatment with surgery alone obviates morbidities associated with adjuvant therapy while upholding survival outcomes.
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http://dx.doi.org/10.1177/0194599818821892DOI Listing
May 2019

Temporoparietal frey syndrome: An uncommon variant of a common syndrome.

Laryngoscope 2019 09 20;129(9):2071-2075. Epub 2018 Dec 20.

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.

Objectives/hypothesis: To describe a previously unreported variant of Frey syndrome. Gustatory sweating is a common complication of parotidectomy and typically directly overlies the surgical site or parotid bed. In some instances, the sweating may occur beyond the parotid bed or involve tissue that was undisturbed during the procedure.

Study Design: Retrospective case series.

Methods: All cases of temporoparietal Frey syndrome in a single surgeon's experience were reviewed.

Results: Seven patients were found to have temporoparietal Frey syndrome. Three patients had concomitant first bite syndrome. Three patients had some form of reconstruction at time of surgery. The mean time to onset of symptoms was 11.5 months, with a range of 7 to 21 months. Four patients did not require any treatment for their symptoms, but two patients required intradermal Botox injections for symptomatic relief.

Discussion: This study describes a previously unreported variant of Frey syndrome with symptoms occurring distal to the parotid gland. This likely develops either by regeneration of severed postganglionic fibers into sympathetic targets distally along the course of the auriculotemporal nerve or by regeneration into fibers of the sympathetic plexus traveling along the superficial temporal artery.

Level Of Evidence: Laryngoscope, 129:2071-2075, 2019.
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http://dx.doi.org/10.1002/lary.27632DOI Listing
September 2019

Early onset oral tongue cancer in the United States: A literature review.

Oral Oncol 2018 12 14;87:1-7. Epub 2018 Oct 14.

Vanderbilt University Medical Center, Department of Otolaryngology, 1215 21st Ave S, Nashville, TN 37232, USA; Vanderbilt University Medical Center, 2525 West End Ave, Suite 300, Nashville, TN, 37203, USA. Electronic address:

The incidence of early onset oral tongue squamous cell carcinoma (OTC) has been increasing in the United States, and no clear etiology has been identified. Studies on this topic have generally been small and presented varied results. The goal of this review is to analyze and synthesize the literature regarding early onset OTC risk factors, outcomes, and molecular analyses within the US. To date, studies suggest that early onset OTC patients tend to have less heavy cigarette use than typical onset patients, but there may be an association between early onset OTC and smokeless tobacco (chewing tobacco and snuff) use. Early onset OTC is associated with similar or possibly improved survival compared to typical onset OTC. There has been no evidence to support a significant role for human papillomavirus in development of early onset OTC. Further research with larger cohorts of these patients is needed to better characterize this disease entity.
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http://dx.doi.org/10.1016/j.oraloncology.2018.10.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7039330PMC
December 2018

Expanding the Capacity of Otolaryngologists in Kenya through Mobile Technology.

OTO Open 2018 Jan-Mar;2(1):2473974X18766824. Epub 2018 Mar 26.

Vanderbilt University Medical Center, Department of Otolaryngology, Nashville, Tennessee, USA.

Objective: To determine if reliable, objective audiologic data can be obtained by nonotolaryngology and nonaudiology practitioners using novel mobile technology in an effort to expand the capacity for early identification and treatment of disabling hearing loss in the developing world.

Study Design: Cross-sectional, proof-of-concept pilot study.

Setting: Screenings took place during an annual 2-week otolaryngology surgical mission in October 2016 in semirural Malindi, Kenya.

Subject And Methods: Eighty-seven patients (174 total ears) were included from 2 deaf schools (n = 12 and 9), a nondeaf school (n = 9), a tuberculosis ward (n = 8), and a walk-in otology clinic at a local hospital (n = 49). An automated, tablet-based, language-independent, clinically validated, play audiometry system and wireless otoscopic endoscopy via an iPhone or laptop platform was administered by Kenyan community health workers (CHWs) and nursing staff.

Results: Various degrees of hearing loss and otologic pathology were identified, including 1 child presumed to be deaf who was found to have unilaterally normal hearing. Other pathology included 2 active perforations, 2 healed perforations, 2 middle ear effusions, and 1 cholesteatoma. CHWs and nursing staff demonstrated proficiency performing audiograms and endoscopy. Patients screened in a deaf school were more likely to complete an unreliable audiogram than patients screened in other settings ( < .01).

Conclusion: This study demonstrates the feasibility of a non-otolaryngology-based hearing screening program. This may become an important tool in reducing the impact of hearing loss and otologic pathology in areas bereft of otolaryngologists and audiologists by allowing CHWs to gather important patient data prior to otolaryngologic evaluation.
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http://dx.doi.org/10.1177/2473974X18766824DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239030PMC
March 2018

Pathologic Fibroblasts in Idiopathic Subglottic Stenosis Amplify Local Inflammatory Signals.

Otolaryngol Head Neck Surg 2019 01 16;160(1):107-115. Epub 2018 Oct 16.

1 Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA.

Objective: To characterize the phenotype and function of fibroblasts derived from airway scar in idiopathic subglottic stenosis (iSGS) and to explore scar fibroblast response to interleukin 17A (IL-17A).

Study Design: Basic science.

Setting: Laboratory.

Subjects And Methods: Primary fibroblast cell lines from iSGS subjects, idiopathic pulmonary fibrosis subjects, and normal control airways were utilized for analysis. Protein, molecular, and flow cytometric techniques were applied in vitro to assess the phenotype and functional response of disease fibroblasts to IL-17A.

Results: Mechanistically, IL-17A drives iSGS scar fibroblast proliferation ( P < .01), synergizes with transforming growth factor ß1 to promote extracellular matrix production (collagen and fibronectin; P = .04), and directly stimulates scar fibroblasts to produce chemokines (chemokine ligand 2) and cytokines (IL-6 and granulocyte-macrophage colony-stimulating factor) critical to the recruitment and differentiation of myeloid cells ( P < .01). Glucocorticoids abrogated IL-17A-dependent iSGS scar fibroblast production of granulocyte-macrophage colony-stimulating factor ( P = .02).

Conclusion: IL-17A directly drives iSGS scar fibroblast proliferation, synergizes with transforming growth factor ß1 to promote extracellular matrix production, and amplifies local inflammatory signaling. Glucocorticoids appear to partially abrogate fibroblast-dependent inflammatory signaling. These results offer mechanistic support for future translational study of clinical reagents for manipulation of the IL-17A pathway in iSGS patients.
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http://dx.doi.org/10.1177/0194599818803584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6389372PMC
January 2019

Treatment options in idiopathic subglottic stenosis: protocol for a prospective international multicentre pragmatic trial.

BMJ Open 2018 04 10;8(4):e022243. Epub 2018 Apr 10.

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Introduction: Idiopathic subglottic stenosis (iSGS) is an unexplained progressive obstruction of the upper airway that occurs almost exclusively in adult, Caucasian women. The disease is characterised by mucosal inflammation and localised fibrosis resulting in life-threatening blockage of the upper airway. Because of high recurrence rates, patients with iSGS will frequently require multiple procedures following their initial diagnosis. Both the disease and its therapies profoundly affect patients' ability to breathe, communicate and swallow. A variety of treatments have been advanced to manage this condition. However, comparative data on effectiveness and side effects of the unique approaches have never been systematically evaluated. This study will create an international, multi-institutional prospective cohort of patients with iSGS. It will compare three surgical approaches to determine how well the most commonly used treatments in iSGS 'work' and what quality of life (QOL) trade-offs are associated with each approach.

Methods And Analysis: A prospective pragmatic trial comparing the 'Standard of Care' for iSGS at multiple international institutions. Patients with a diagnosis of iSGS without clinical or laboratory evidence of vasculitis or a history of endotracheal intubation 2 years prior to symptom onset will be included in the study. Prospective evaluation of disease recurrence requiring operative intervention, validated patient-reported outcome (PRO) measures as well as patient-generated health data (mobile peak flow recordings and daily steps taken) will be longitudinally tracked for 36 months. The primary endpoint is treatment effectiveness defined as time to recurrent operative procedure. Secondary endpoints relate to treatment side effects and include PRO measures in voice, swallowing, breathing and global QOL as well as patient-generated health data.

Ethics And Dissemination: This protocol was approved by the local IRB Committee of the Vanderbilt University Medical Center in July 2015. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and directly to patient with iSGS via social media-based support groups.

Trial Registration Number: NCT02481817.
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http://dx.doi.org/10.1136/bmjopen-2018-022243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898326PMC
April 2018

Free dermal fat graft reconstruction of the head and neck: An alternate reconstructive option.

Am J Otolaryngol 2017 May - Jun;38(3):291-296. Epub 2017 Jan 27.

Vanderbilt University Medical Center, Department of Otolaryngology - Head and Neck Surgery, Nashville, TN, United States.

Objectives: Ablative procedures of the head and neck often result in significant facial and cervical irregularities and cosmetic asymmetry. The deformity resulting from ablative procedures of the head and neck is a significant source of cosmetic morbidity and postoperative dissatisfaction. Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from primary closure to free tissue transfer. The free dermal fat graft (FDFG) is one such option and has been used to repair volume defects of varying sizes after common head and neck procedures such as parotidectomy. However, its use is largely undocumented in the literature. We seek to further illustrate the FDFG as an alternate method of reconstruction of head and neck defects.

Study Design: Non-randomized retrospective analysis.

Methods: The medical records of all patients who underwent primary autologous abdominal FDFG reconstruction of head and neck defects by a single surgeon at Vanderbilt University Medical Center from January 1997 to August 2010 were reviewed. All patients were called in order to assess their post-operative cosmetic satisfaction.

Results: Sixty-two patients were analyzed. Only three patients were found to have post-operative complications directly related to the FDFG. No complications were found at the donor site. Based on a telephone survey, the majority of patients were satisfied post-operatively with their cosmetic outcomes in the primary site and donor site.

Conclusions: From our experience the FDFG is a cosmetically and functionally advantageous option for reconstruction of ablative procedures of the head and neck.
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http://dx.doi.org/10.1016/j.amjoto.2017.01.026DOI Listing
April 2018

Head and neck surgical subspecialty training in Africa: Sustainable models to improve cancer care in developing countries.

Head Neck 2017 03 23;39(3):605-611. Epub 2016 Nov 23.

Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Head and Neck Cancer Center, Baltimore, Maryland.

Background: Cancer poses a health crisis in the developing world where surgery is the mainstay of treatment for head and neck cancers. However, a shortage of surgeons with appropriate skills exists. How do we train head and neck surgeons in developing countries and avoid a brain drain? The ideal model provides appropriate affordable training leading to establishment of head and neck cancer centers that teach and train others.

Methods: Different head and neck surgery training models are presented based on the personal experiences of the authors. Surgical exposure of head and neck fellows in Cape Town and (potentially) in Nairobi is benchmarked against programs in the United States.

Results: Surgical exposure in Cape Town is equivalent to that in the United States, but more appropriate to a developing world setting.

Conclusion: Training can be achieved in a number of ways, which may be complimentary. Fellowship training is possible in developing countries. © 2016 Wiley Periodicals, Inc. Head Neck 39: 605-611, 2017.
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http://dx.doi.org/10.1002/hed.24591DOI Listing
March 2017

Idiopathic subglottic stenosis is associated with activation of the inflammatory IL-17A/IL-23 axis.

Laryngoscope 2016 11 14;126(11):E356-E361. Epub 2016 Jun 14.

Department of Medicine, Division of Infectious Disease, Vanderbilt University, Nashville, Tennessee.

Objectives/hypothesis: Idiopathic subglottic stenosis (iSGS) is a rare and devastating extrathoracic obstruction involving the lower laryngeal and upper tracheal airway. It arises without known antecedent injury or associated disease process. Persistent mucosal inflammation and a localized fibrotic response are hallmarks of the disease. Despite the initial clinical description of iSGS more than 40 year ago, there have been no substantive investigations into the pathogenesis of this enigmatic and progressive airway obstruction. In these studies, we present the initial characterization of the molecular pathogenesis underlying the fibrosing phenotype of iSGS.

Methods: Utilizing 20 human iSGS and healthy control specimens, we applied histologic, immunohistochemical, molecular, and immunologic techniques.

Results: We demonstrate significant activation of the canonical IL-23/IL-17A pathway in the tracheal mucosa of iSGS patients, as well as identify γδ T cells as the primary cellular source of IL-17A.

Conclusion: Our results suggest that aberrant mucosal immune activation is a component in of the pathogenesis of iSGS. Most critically, our work offers new targets for future therapeutic intervention.

Level Of Evidence: NA Laryngoscope, 126:E356-E361, 2016.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5077677PMC
http://dx.doi.org/10.1002/lary.26098DOI Listing
November 2016

Molecular analysis of idiopathic subglottic stenosis for Mycobacterium species.

Laryngoscope 2017 01 14;127(1):179-185. Epub 2016 Jun 14.

Department of Medicine, Division of Infectious Disease, Vanderbilt University, Nashville, Tennessee.

Objectives/hypothesis: Idiopathic subglottic stenosis (iSGS) is an unexplained obstruction involving the lower laryngeal and upper tracheal airway. Persistent mucosal inflammation is a hallmark of the disease. Epithelial microbiota dysbiosis is found in other chronic inflammatory mucosal diseases; however, the relationship between tracheal microbiota composition and iSGS is unknown. Given the critical role for host defense at mucosal barriers, we analyzed tissue specimens from iSGS patients for the presence of microbial pathogens.

Methods: Utilizing 30 human iSGS, 20 intubation-related tracheal stenosis (iLTS), and 20 healthy control specimens, we applied molecular, immunohistochemical, electron microscopic, immunologic, and Sanger-sequencing techniques.

Results: With unbiased culture-independent nucleic acid, protein, and immunologic approaches, we demonstrate that Mycobacterium species are uniquely associated with iSGS. Phylogenetic analysis of the mycobacterial virulence factor rpoB suggests that, rather than Mycobacterium tuberculosis, a variant member of the Mycobacterium tuberculosis complex or a closely related novel mycobacterium is present in iSGS specimens.

Conclusion: These studies identify a novel pathogenic role for established large airway bacteria and provide new targets for future therapeutic intervention.

Level Of Evidence: NA Laryngoscope, 127:179-185, 2017.
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http://dx.doi.org/10.1002/lary.26097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5156582PMC
January 2017

Head and Neck Paragangliomas: An Update on Evaluation and Management.

Otolaryngol Head Neck Surg 2016 Apr 9;154(4):597-605. Epub 2016 Feb 9.

Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA.

Objective: Head and neck paragangliomas are a group of slow-growing hypervascular tumors associated with the paraganglion system. The approach to evaluate and treat these lesions has evolved over the last 2 decades. While radical surgery had been the traditional approach, improvements in diagnostic imaging as well as radiation therapy techniques have led to an emphasis on observation and nonsurgical therapy in many patients. This article reviews the contemporary approach to the workup and management of head and neck paragangliomas.

Data Source: Articles were identified from PubMed.

Review Methods: PubMed searches with the following keywords were performed: carotid body paraganglioma management, vagal paraganglioma management, jugulotympanic paraganglioma management, imaging of head and neck paragangliomas, head and neck paraganglioma embolization, paraganglioma radiation, head and neck paraganglioma management, observation of head and neck paragangliomas, bilateral carotid body paragangliomas, and genetics of paragangliomas. Review and original research articles available in the English language and published during or after 2009 were selected on the basis of their clinical relevance and scientific strength. Certain articles published prior to 2009 were also included if they provided background information that was relevant.

Conclusions/implications For Practice: Workup and treatment of head and neck paragangliomas are changing. With more now known regarding the longitudinal behavior of these tumors, observation and nonsurgical therapy are indicated in many instances. For patients where surgery is the most appropriate option, improved diagnostic and perioperative techniques are allowing patients to tolerate resection, often with reduced morbidity.
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http://dx.doi.org/10.1177/0194599815627667DOI Listing
April 2016

Dysphagia Following Airway Reconstruction in Adults.

JAMA Otolaryngol Head Neck Surg 2016 Jan;142(1):20-4

Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: Patients who undergo open airway reconstruction procedures are likely to experience some degree of postoperative dysphagia symptoms and delayed return to oral intake.

Objective: To review the duration of postoperative dysphagia symptoms and outcomes in a group of adult patients.

Design, Setting, And Participants: Retrospective review of the medical records of adult patients undergoing laryngotracheoplasty, posterior cricoid split laryngoplasty, tracheal resection, and cricotracheal resection in a tertiary hospital between July 2009 and September 2014.

Exposures: Laryngotracheoplasty, posterior cricoid split laryngoplasty, tracheal resection, and cricotracheal resection.

Main Outcomes And Measures: Demographic characteristics, etiology of airway stenosis, surgical procedure, stent type, and duration of dysphagia symptoms.

Results: Thirty-eight patients (14 men, 24 women; mean [SD; range] age, 48 [14.4; 20-80] years) fitting the inclusion criteria were identified. Twenty-four (63%) patients had laryngotracheal stenosis secondary to prolonged intubation, with 3 (8%), 5 (13%), and 6 (16%) cases being due to autoimmune, idiopathic, or other etiology, respectively. Twenty-five (66%) patients underwent tracheal or cricotracheal resection, and 13 (34%) underwent laryngotracheoplasty or posterior cricoid split laryngoplasty. Of the 17 patients with stents placed, 6 (35%) patients had a suprastomal stent sewn at the top with a polypropylene suture using a horizontal mattress technique, 6 (35%) patients had a suprastomal stent capped with an extended Silastic thoracic T-tube segment, and 5 (29%) patients had either a T-tube or hood bronchial stent. Eight of 17 patients used a nasogastric feeding tube while the stent was in place (up to 5 weeks). All patients returned to their preoperative diet. The mean (SD) duration of dysphagia symptoms in all patients (both those without a stent and following stent removal) was 8 (27.2) days (median, 1.5 days). The mean (SD) duration of dysphagia symptoms in patients who did not have a stent placed was 4.8 (5.3) days (median, 4 days).

Conclusions And Relevance: In this study of adults who underwent open airway reconstruction, all returned to their preoperative diet, but those without stents had a shorter duration of dysphagia symptoms than those with stents. Approximately half as many patients with a stent had a prolonged course with dysphagia symptoms compared with those without a stent.
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http://dx.doi.org/10.1001/jamaoto.2015.2562DOI Listing
January 2016

Disease homogeneity and treatment heterogeneity in idiopathic subglottic stenosis.

Laryngoscope 2016 06 4;126(6):1390-6. Epub 2015 Nov 4.

Vanderbilt University Medical Center Dept. of Otolaryngology and Pulmonology, Nashville, Tennessee.

Objectives/hypothesis: Idiopathic subglottic stenosis (iSGS) is a rare and potentially life-threatening disease marked by recurrent and progressive airway obstruction frequently requiring repeated surgery to stabilize the airway. Unknown etiology and low disease prevalence have limited the ability to characterize the natural history of iSGS and resulted in variability in surgical management. It is uncertain how this variation relates to clinical outcomes.

Study Design: Medical record abstraction.

Methods: Utilizing an international, multi-institutional collaborative, we collected retrospective data on patient characteristics, treatment, and clinical outcomes. We investigated variation between and within open and endoscopic treatment approaches and assessed therapeutic outcomes; specifically, disease recurrence and need for tracheostomy at last follow-up.

Results: Strikingly, 479 iSGS patients across 10 participating centers were nearly exclusively female (98%, 95% confidence interval [CI], 96.1-99.6), Caucasian (95%, 95% CI, 92.2-98.8), and otherwise healthy (mean age-adjusted Charlson Comorbidity Index 1.5; 95% CI, 1.44-1.69). The patients presented at a mean age of 50 years (95% CI, 48.8-51.1). A total of 80.2% were managed endoscopically, whereas 19.8% underwent open reconstruction. Endoscopic surgery had a significantly higher rate of disease recurrence than the open approach (chi(2) = 4.09, P = 0.043). Tracheostomy was avoided in 97% of patients irrespective of surgical approach (95% CI, 94.5-99.8). Interestingly, there were outliers in rates of disease recurrence between centers using similar treatment approaches.

Conclusion: Idiopathic subglottic stenosis patients are surprisingly homogeneous. The heterogeneity of treatment approaches and the observed outliers in disease recurrence rates between centers raises the potential for improved clinical outcomes through a detailed understanding of the processes of care.

Level Of Evidence: 4. Laryngoscope, 126:1390-1396, 2016.
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http://dx.doi.org/10.1002/lary.25708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6198250PMC
June 2016

The Natural History and Management of Petrous Apex Cholesterol Granulomas.

Otol Neurotol 2015 Dec;36(10):1714-9

*Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee †Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota ‡Vanderbilt University School of Medicine, Nashville, Tennessee §Department of Neurosurgery, Mayo Clinic School of Medicine, Rochester, Minnesota, U.S.A.

Objective: To evaluate the clinical and radiographic characteristics of cholesterol granulomas of the petrous apex, as well as the outcomes of operative and conservative management.

Study Design: Retrospective chart review.

Setting: Two independent tertiary academic referral centers.

Patients: Adult and pediatric patients with cholesterol granulomas of the petrous apex were identified from the experience of two separate centers. Patients were included after radiographic diagnosis and clinical evaluation. All patients with less than 6 months of follow-up and those with iatrogenic postoperative cholesterol granulomas were excluded.

Intervention: Demographic information, presenting symptoms, imaging characteristics, treatment strategies, and outcomes were recorded.

Main Outcome Measures: Patients were evaluated on the basis of symptom and radiographic evolution during time, with or without operative intervention.

Results: Ninety petrous apex cholesterol granulomas were analyzed (57.8% females, 55.6% right-sided). The average age at presentation was 43.1 years (median 42.0, range 8.0-77.0 years). The most common presenting symptom was headache (56.7%), and the average lesion size in the greatest dimension was 2.1 cm (median 1.7, range 0.7-5.0 cm). During a mean follow-up of 46.0 months, no cases of spontaneous rupture or carotid injury occurred. Twenty-three patients (25.6%) ultimately underwent surgical management, most commonly for intractable headache, and only 47.8% of these patients experienced durable symptom improvement by their last postoperative follow-up.

Conclusion: Many cholesterol granulomas of the petrous apex remain stable during time and can be safely managed with primary observation. Surgery should be reserved for lesions that are causing, or threatening, neurologic dysfunction because of mass effect or erosion of critical structures such as the otic capsule. Cranial neuropathy associated with cholesterol granuloma may improve after operative management; however, symptoms such as headache and dizziness are less likely to benefit from surgery. As a general guideline, in the presence of a radiologically stable cholesterol granuloma in the petrous apex, alternative etiologies for headache and dizziness should be considered and treated before offering surgical intervention.
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http://dx.doi.org/10.1097/MAO.0000000000000862DOI Listing
December 2015
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