Publications by authors named "Nicole Aaronson"

21 Publications

  • Page 1 of 1

Does perioperative ketorolac increase bleeding risk after intracapsular tonsillectomy?

Int J Pediatr Otorhinolaryngol 2021 Aug 21;147:110781. Epub 2021 May 21.

Division of Pediatric Otolaryngology, Nemours/Alfred I. DuPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA; Department of Otolaryngology-Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, 19107, USA.

Importance: Conflicting evidence exists regarding the post-tonsillectomy bleed risk associated with perioperative ketorolac use in the pediatric population. Surgical technique for tonsillectomy can further confound this risk.

Objective: The primary objective was to retrospectively quantify the post-tonsillectomy bleed rate after single-dose administration of ketorolac in pediatric patients following intracapsular tonsillectomy. The secondary objective was to determine if age, sex, body mass index, medical comorbidities, and indication for surgery increased post-tonsillectomy bleed risk.

Design: Retrospective cohort study of 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018.

Setting: This study was completed at a tertiary-care pediatric referral center.

Participants: 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018 at a single tertiary-care children's hospital.

Exposures: Patients were divided into two cohorts: 1458 patients (75.9%) received ketorolac (K+), and 462 (24.1%) did not (NK). Age, sex, body mass index, comorbidities, and indication for surgery also were evaluated for association with post-tonsillectomy bleed risk.

Main Outcome(s) And Measure(s): Primary study outcome for both cohorts was post-tonsillectomy hemorrhage requiring operative intervention.

Results: 1920 study participants were included with an average age of 6.5 years; 51.5% of participants were males; and, 63.9% were white. Overall, the postoperative bleeding rate was 1.5%. However, there was no significant difference when comparing bleeding rates for the ketorolac group and the non-keterolac group (1.4%-1.7%; P = .82) Age, chronic tonsillitis, higher body mass index Z-scores, attention-deficit/hyperactivity disorder, and behavioral diagnoses were statistically significant risk factors for post-tonsillectomy hemorrhage.

Conclusions And Relevance: Single-dose postoperative ketorolac does not appear to be associated with increased risk of post-tonsillectomy bleed in pediatric patients undergoing intracapsular tonsillectomy. Providers should not avoid using ketorolac in patients undergoing intracapsular tonsillectomy due to concerns over bleeding risk.
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http://dx.doi.org/10.1016/j.ijporl.2021.110781DOI Listing
August 2021

Comparing telehealth with office-based visits for common pediatric otolaryngology complaints.

Int J Pediatr Otorhinolaryngol 2021 Jun 19;145:110712. Epub 2021 Apr 19.

Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd., Wilmington, DE, 19803, USA; Department of Otolaryngology - Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, 19107, USA. Electronic address:

Objective: The objective of this study was to evaluate the feasibility of telehealth visits and compare office-based visits for pediatric patients undergoing evaluation of recurrent acute otitis media or sleep-disordered breathing.

Methods: A retrospective cohort study compared telehealth patients with matched controls seen in the office. The feasibility of a thorough patient evaluation in a single telehealth visit without a follow-up office visit was assessed. Both groups were also compared for completeness of physical exam, management, follow-up recommendations, and correlation of physical exam findings with intraoperative findings.

Results: 100 children [mean age (SD) = 20.7 (15.6) months] with a chief complaint of recurrent acute otitis media and 128 children [5.4 (3.2) years] with a chief complaint of sleep-disordered breathing were evaluated. Recommendations for surgery, additional studies, or routine follow-up were similar between telehealth and office-based groups. Physical exam feasibility was significantly different for the nasal cavity, oropharynx, and middle ear (P < .001). Patients who underwent office-based consultation were much more likely to have findings of middle ear fluid at the time of tympanostomy tube placement (79.3% vs 39.3%, P = .002). There was no significant difference between preoperative and intraoperative tonsil size discrepancies (P = .749).

Conclusion: Telehealth can be used successfully for the evaluation of pediatric patients with sleep-disordered breathing; however, reliance on history alone may result in unnecessary tympanostomy tube placement in patients with recurrent acute otitis media. Physical examination of the oropharynx, nasal cavity, and middle ear via telehealth presents a unique challenge in pediatric otolaryngology.
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http://dx.doi.org/10.1016/j.ijporl.2021.110712DOI Listing
June 2021

Comparative evaluation of one-handed versus two-handed mask holding techniques in children during inhalational induction of anesthesia: A randomized crossover study.

Paediatr Anaesth 2021 03 18;31(3):338-345. Epub 2021 Jan 18.

Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.

Background: We aimed to evaluate if two-handed mask airway is superior to one-handed mask airway during inhalational induction of anesthesia in children.

Methods: A randomized, two period, crossover study was performed on 60 children aged 1-8 years, with obstructive sleep apnea due to adenotonsillar hypertrophy, scheduled for adenotonsillectomy. Children were assigned to two study sequences and one control sequence of 20 subjects each. A control sequence was added to evaluate the effect of anesthetic depth. Sequence 1: One-handed followed by two-handed airway, 30 seconds each; Sequence 2: two-handed followed by one-handed airway, 30 seconds each and Sequence 3: two-handed airway, for 60 seconds. The work of breathing indices, phase angle, and labored breathing index were recorded using respiratory inductance plethysmography. Additional outcome measures were tidal volume, minute ventilation, and respiratory rate. A straight comparison and a crossover analysis was performed.

Results: The initial comparison revealed that one-handed airway had greater phase angle (mean diff. 17.4; 95% confidence interval [CI] 1.07-33.68; P = .034), greater labored breathing index (mean diff. 0.56; 95% CI 0.16-1.04; P = .004),lower minute ventilation (mean diff. -1567; 95% CI -2695 to -5.4; P = .004),and lower tidal volume (mean diff. -39; 95% CI -2.7 to -5.4; P = .02) than two-handed airway. On crossover analysis, within-subject difference in the phase angle was greater during one-handed than two-handed airway (34.3; 95% CI 8.46-60.14; P = .01) as was labored breathing index (mean diff. 1.2; 95% CI 0.39-2.00; P < .0046).Minute ventilation was lower during one-handed than two-handed airway (mean diff. -3359; 95% CI -4363 to -2355, P < 0.0001) as was tidal volume(mean diff. -78; 95% CI -110.4 to -45.8; P < .0001).

Conclusion: In children with obstructive sleep apnea due to adenotonsillar hypertrophy, two-handed airway provides superior airway patency that was not influenced by the anesthetic depth.
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http://dx.doi.org/10.1111/pan.14111DOI Listing
March 2021

Improving Attendance and Patient Experiences During the Expansion of a Telehealth-Based Pediatric Otolaryngology Practice.

Otolaryngol Head Neck Surg 2021 05 20;164(5):952-958. Epub 2020 Oct 20.

Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.

Objective: To determine the rates and primary causes of missed appointments (MAs) for telehealth visits and present remedies for improvement.

Methods: This cross-sectional survey was conducted at a tertiary care pediatric otolaryngology practice during expansion of telehealth-based visits. A review of questionnaire responses was performed for 103 consecutive patients with MAs over 50 business days from March 20, 2020, to May 29, 2020. Families were asked a brief survey regarding the cause of the MA and assisted with technical support and rescheduling. MA rates and causes were analyzed.

Results: The overall MA rate during the initiation of telehealth services was significantly increased at 12.4% as compared with clinic-based visits of a similar duration before COVID of 5.2% ( < .001). Technical issues were the most common causes of MAs (51.3%). Of the caregivers, 23.8% forgot or reported cancellation of the appointment. Five percent of patients were non-English speaking and scheduled without translator support. Minorities and patients with public insurance represented 53.6% and 61.9% of MAs, respectively.

Discussion: Technical difficulties were the most commonly reported cause of missed telehealth appointments. Optimization of applications by providing patient reminders, determining need for translator assistance, and reducing required upload/download speeds may significantly reduce rates of MAs and conversions to other communication.

Implications For Practice: Clear, concise education materials on the technical aspects of telehealth, platform optimization, and robust technical and administrative support may be necessary to reduced missed telehealth appointments and support large-scale telehealth operations. An assessment of institutional capacity is critical when considering telehealth expansion.
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http://dx.doi.org/10.1177/0194599820965917DOI Listing
May 2021

Interstate variation within a five-state health system: Polysomnography prior to tonsillectomy in trisomy 21 patients.

Int J Pediatr Otorhinolaryngol 2020 Nov 29;138:110336. Epub 2020 Aug 29.

Division of Pediatric Otolaryngology, Nemours/Alfred I. DuPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, 19803, USA; Department of Otolaryngology - Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address:

Objectives: Since 2011, the American Academy of Otolaryngology - Head and Neck Surgery Clinical Practice Guidelines have recommended polysomnography (PSG) prior to tonsillectomy in children with Down syndrome (DS). The purpose of this study was to determine adherence to guidelines recommending polysomnography before tonsillectomy for children with DS and sleep-disordered breathing among pediatric otolaryngologists.

Methods: A one-year quality assurance retrospective review was conducted at four hospitals within one pediatric health system to identify children with a diagnosis of DS who underwent a tonsillectomy with or without adenoidectomy from January 1, 2018, to December 31, 2018. De-identified data related to age, sex, BMI, procedure type, and preoperative PSG were collected and examined.

Results: The rate of PSG prior to tonsillectomy was 90.4% (66 of 73) among patients with DS. 51.6% of PSG studies were performed within 90 days before surgery, and 92.2% (59 of 64) of PSG studies were performed within one year before surgery. 33% of patients who did not undergo PSG also were obese or under age two years. The most common reason for not obtaining a PSG prior to tonsillectomy was that either the provider or parent felt the patient would not tolerate it. There was no variance from guidelines by age, sex, and procedure type.

Conclusions: Polysomnography for children with DS prior to tonsillectomy is achieved greater than 90% of the time in a multistate pediatric health system. Broader assessment across the nation and future studies regarding the timing of PSG before tonsillectomy are warranted.
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http://dx.doi.org/10.1016/j.ijporl.2020.110336DOI Listing
November 2020

Bilateral Posterior Neck Masses in an 8-Year-Old Boy: A Case of Pediatric Tularemia of the Head and Neck.

Ear Nose Throat J 2021 Nov 8;100(9):631-633. Epub 2020 May 8.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA.

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http://dx.doi.org/10.1177/0145561320923830DOI Listing
November 2021

Quality of Patient Education Sections on Otitis Media Across Different Website Platforms.

Ann Otol Rhinol Laryngol 2020 Jun 24;129(6):591-598. Epub 2020 Jan 24.

Department of Surgery, Section of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.

Objective: To determine the quality, content, and readability of patient education materials pertaining to otitis media across several popular online platforms focused on otolaryngology and pediatric primary care education.

Methods: Online patient materials related to otitis media and directed toward parents were collected from the American Association for Family Practice (AAFP), ENT-Health section of the American Academy of Otolaryngology-Head and Neck Surgery, Healthychildren.org from the American Academy of Pediatrics, KidsHealth from Nemours, WebMD, and Wikipedia. Materials were analyzed for quality, content, and readability. The DISCERN instrument was used to score quality. A unique content score was generated based on the information provided on each website and on the medical and surgical management of otitis media. Readability scores were calculated using the Flesch-Kincaid Grade Level, Flesch Reading Ease Score, Gunning-Fog Index, Simple Measure of Gobbledygook, Coleman-Liau Index, and Automated Readability Index.

Results: Overall, content was well-balanced. Information from AAFP and Healthychildren.org was focused more on medical management than other sources. The average DISCERN scores showed all sources to be of good quality with minimal shortcomings. The AAFP and KidsHealth websites had some readability scores around the 8th-grade reading level, the National Institute of Health's upper limit recommended for public health information; however, most websites were above this recommended reading level.

Conclusion: Patient education materials related to otitis media on academic and certain popular internet sites are good sources to obtain high-quality information on the topic. Patient educational background, prior knowledge and understanding of otitis media, and physician-patient partnership goals should be taken into account when referring patients to online materials.
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http://dx.doi.org/10.1177/0003489420902183DOI Listing
June 2020

Parental health literacy in pediatric otolaryngology: A pilot study.

Int J Pediatr Otorhinolaryngol 2019 Oct 28;125:87-91. Epub 2019 Jun 28.

Johns Hopkins University Departments of Otolaryngology and Health Policy & Management, Baltimore, MD, USA. Electronic address:

Objectives: Pediatric otolaryngology bears the highest frequency of elective surgical cases in children, but little is known regarding the health literacy of these children's parents. In a questionnaire-based pilot study, we assessed parental health literacy in our pediatric otolaryngology clinic and evaluated its relation to personal demographics. We also evaluated postoperative and diagnosis-based leaflets for readability using validated measures.

Methods: Parents completed the Short Assessment of Health Literacy-English (SAHL-E) and were defined as low (0-14) or high (>14) literacy based on mean scores.

Results: Fifty parents participated (mean SAHL-E score, 17.6), and all scored >14, indicating proficient health literacy. No differences existed in mean or median scores based on demographics. Continued education after high school was associated with higher scores (P = 0.003) and was the only significant variable in multivariable linear regression. All leaflets were at or below the recommended reading level for public health information.

Conclusions: Parents generally had high health literacy.
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http://dx.doi.org/10.1016/j.ijporl.2019.06.029DOI Listing
October 2019

Health literacy in pediatric otolaryngology: A scoping review.

Int J Pediatr Otorhinolaryngol 2018 Oct 11;113:252-259. Epub 2018 Aug 11.

Departments of Otolaryngology and Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA.

Objective: To review research on status and outcomes of health literacy in pediatric otolaryngology and identify opportunities for quality improvement.

Methods: We performed a scoping review, adhering to methodologic standards. A combination of MeSH terms and keywords related to health literacy in otolaryngology was used to conduct a search. Relevant studies were identified using PubMed, Ovid MEDLINE, and Google Scholar databases. Studies were selected for inclusion by two authors if they addressed the domains of pediatric otolaryngology as well as health literacy. Data were abstracted from each study on the number of participants, the setting, the study design, the outcome measure, the intervention used, and the overall theme. Authors identified prominent overarching themes and grouped studies accordingly. Results were then tabulated for further review and to discern implications for future practice and research.

Results: Of 1046 articles identified, 20 articles were included. Studies fell into three major themes: readability of patient materials, patient recall after informed consent, and optimal patient education. Prominent findings included the following: 1. Much of the printed and electronic educational material in otolaryngology is above the recommended reading level for public health information; 2. Parents do not easily recall information provided verbally or in written form; and 3. Adding visual and multimodal components improves the success of parental education.

Conclusion: Health literacy in pediatric otolaryngology may influence comprehension of educational materials and adequacy of informed consent. Future research may address whether patient health literacy affects clinical outcomes.
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http://dx.doi.org/10.1016/j.ijporl.2018.08.013DOI Listing
October 2018

Quality, Readability, and Trends for Websites on Ankyloglossia.

Ann Otol Rhinol Laryngol 2018 Jul 18;127(7):439-444. Epub 2018 May 18.

2 Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA.

Objective: This study evaluates the quality and readability of websites on ankyloglossia, tongue tie, and frenulectomy.

Methods: Google was queried with six search terms: tongue tie, tongue tie and breastfeeding, tongue tie and frenulectomy, ankyloglossia, ankyloglossia and breastfeeding, and ankyloglossia and frenulectomy. Website quality was assessed using the DISCERN instrument. Readability was evaluated using the Flesch-Kincaid Reading Grade Level, Flesch Reading Ease Score, and Fry readability formula. Correlations were calculated. Search terms were analyzed for frequency using Google Trends and the NCBI database.

Results: Of the maximum of 80, average DISCERN score for the websites was 65.7 (SD = 9.1, median = 65). Mean score for the Flesch-Kincaid Reading Grade Level was 11.6 (SD = 3.0, median = 10.7). Two websites (10%) were in the optimal range of 6 to 8. Google Trends shows tongue tie searches increasing in frequency, although the NCBI database showed a decreased in tongue tie articles.

Conclusions: Most of the websites on ankyloglossia were of good quality; however, a majority were above the recommended reading level for public health information. Parents increasingly seek information on ankyloglossia online, while fewer investigators are publishing articles on this topic.
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http://dx.doi.org/10.1177/0003489418776343DOI Listing
July 2018

Can telemetry data obviate the need for sleep studies in Pierre Robin Sequence?

Int J Pediatr Otorhinolaryngol 2017 Sep 14;100:238-241. Epub 2017 Jul 14.

Children's Hospital of Pittsburgh of UPMC, Department of Otolaryngology, University of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 7th Floor, Pittsburgh, PA 15224, United States.

Objective: This study looks to correlate telemetry data gathered on patients with Pierre Robin Sequence (PRS) with sleep study data. Strong correlation might allow obstructive sleep apnea (OSA) to be reasonably predicted without the need for sleep study.

Methods: Charts from forty-six infants with PRS who presented to our children's hospital between 2005 and 2015 and received a polysomnogram (PSG) prior to surgical intervention were retrospectively reviewed. Correlations and scatterplots were used to compare average daily oxygen nadir, overall oxygen nadir, and average number of daily desaturations from telemetry data with apnea-hypopnea index (AHI) and oxygen nadir on sleep study. Results were also categorized into groups of AHI ≥ or <10 and oxygen nadir ≥ or <80% for chi-squared analysis.

Results: Our data did not show significant correlations between telemetry data and sleep study data. Patients with O2 nadir below 80% on telemetry were not more likely to have an O2 nadir below 80% on sleep study. Patients with an average O2 nadir below 80% did show some correlation with having an AHI greater than 10 on sleep study but this relationship did not reach significance. Of 22 patients who did not have any desaturations on telemetry below 80%, 16 (73%) had an AHI >10 on sleep study.

Conclusions: In the workup of infants with PRS, the index of suspicion is high for OSA. In our series, telemetry data was not useful in ruling out severe OSA. Thus our data do not support forgoing sleep study in patients with PRS and concern for OSA despite normal telemetry patterns.
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http://dx.doi.org/10.1016/j.ijporl.2017.07.015DOI Listing
September 2017

Quality and readability of websites for patient information on tonsillectomy and sleep apnea.

Int J Pediatr Otorhinolaryngol 2017 Jul 23;98:1-3. Epub 2017 Apr 23.

Children's Hospital of Pittsburgh of UPMC, Department of Otolaryngology, University of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 7th Floor, Pittsburgh, PA 15224, United States. Electronic address:

Objectives: Tonsillectomy is a common treatment for obstructive sleep apnea (OSA). The Internet allows patients direct access to medical information. Since information on the Internet is largely unregulated, quality and readability are variable. This study evaluates the quality and readability of the most likely visited websites presenting information on sleep apnea and tonsillectomy.

Methods: The three most popular search engines (Google, Bing, Yahoo) were queried with the phrase "sleep apnea AND tonsillectomy." The DISCERN instrument was used to assess quality of information. Readability was evaluated using the Flesch-Kincaid Reading Grade Level (FKGL) and Flesch Reading Ease Score (FRES).

Results: Out of the maximum of 80, the average DISCERN quality score for the websites was 55.1 (SD- 12.3, Median- 60.5). The mean score for FRES was 42.3 (SD- 15.9, Median- 45.5), which falls in the range defined as difficult. No website was above the optimal score of 65. The mean score for the FKGL was US grade-level of 10.7 (SD- 1.6, Median- 11.6). Only 4(27%) websites were in the optimal range of 6-8. There was very weak correlation between FRES and DISCERN (r = 0.07) and FKGL and DISCERN (r = 0.21).

Conclusions: Tonsillectomy is one of the most common surgeries in the US. However, the internet information readily available to patients varies in quality. Additionally, much of the information is above the recommended grade level for comprehension by the public. By being aware of what information patients are reading online, physicians can better explain treatments and address misunderstandings. Physicians may consider using similar methods to test the readability for their own resources for patient education.
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http://dx.doi.org/10.1016/j.ijporl.2017.04.031DOI Listing
July 2017

A population based analysis of the implementation of pediatric facemasks in girls youth lacrosse.

Int J Pediatr Otorhinolaryngol 2017 Feb 29;93:141-144. Epub 2016 Dec 29.

Department of Otolaryngology - Head & Neck Surgery, Yale New Haven Hospital, New Haven, CT, USA.

Objective: To determine the incidence, relative risk reduction, odds ratio and absolute risk reduction of head and ear injuries associated with the implementation of pediatric facial eye guards in lacrosse events.

Study Design: Cross Sectional Review of a National Database.

Study Location: National Emergency Injury Survelliance System.

Methods: Our group retrospectively reviewed a nationwide sampling estimate of 809 patients who presented to emergency rooms with head and ear injuries during lacrosse events. The database was queried for lacerations, fractures, hemorrhages, abrasions and punctures associated with the face and ear. Incidence, relative risk, odds ratio and absolute risk reductions were calculated both five years before and five years after the introduction of the facial mask guard in 2006 to determine benefit.

Results: Of the 809 women's lacrosse injuries, 199 were localized to the facial region and 56 to the ear. After the implementation of the facial mask mandate, there was a significant decrease in the total incidence and relative risk of facial lacerations (P = 0.01, RR = 0.08 vs 0.01) and facial abrasions (P = 0.02, RR = 0.28 vs 0.12) respectively. Furthermore, there was a significant decrease in the odds of obtaining a facial laceration (OR: 0.16 95% CI:0.07-0.37), facial fractures (OR: 0.01, 95% CI:0.03-0.35) and abrasion (OR: 0.11, 95% CI:0.08-0.18) with facemask use. Unfortunately, there was no difference in total incidence, relative risk or odds of obtaining ear injury.

Conclusion: It appears that the implementation of the mandate for female athletes to utilize the facemask starting in 2006 has provided a reduction in specific facial injuries. Further discussion should be continued in order to reduce further risk to the remaining head and neck region including the ears and neck with additional protective equipment.
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http://dx.doi.org/10.1016/j.ijporl.2016.12.040DOI Listing
February 2017

Epiglottitis: It Hasn't Gone Away.

Anesthesiology 2016 06;124(6):1404-7

From the Departments of Anesthesiology (J.L.L., M.R.R.), Otolaryngology (N.L.A., T.S., E.D.B.), and Radiology and Biomedical Imaging (T.R.G.), Yale University School of Medicine, New Haven, Connecticut.

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http://dx.doi.org/10.1097/ALN.0000000000001125DOI Listing
June 2016

An Unusual Morphology of a Pleomorphic Adenoma.

Conn Med 2015 Jan;79(1):27-9

We present a case of a deep lobe parotid pleomorphic adenoma extending into the parapharyngeal space via an unusual morphology. This is a single patient case report of an unusual morphology with an associated review of the literature. The patient successfully underwent right parotidectomy during which it was seen that the tumor was extending above rather than through the stylomandibular tunnel, an unusual morphology for a pleomorphic adenoma. Despite the classic teaching that deep lobe parotid tumors reach the parapharyngeal space by traveling through, or below, the stylomandibular tunnel, it is possible for tumors to occur outside this tunnel. Recognition that this unusual growth path, although rare, can occur is important when designing an appropriate surgical resection.
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January 2015

Fetal rhabdomyoma of the tongue in a newborn.

Ear Nose Throat J 2015 Jul;94(7):266-8

Section of Otolaryngology, Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.

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http://dx.doi.org/10.1177/014556131509400708DOI Listing
July 2015

Carotid stent extrusion following carotid blowout.

Auris Nasus Larynx 2015 Apr 8;42(2):176-8. Epub 2015 Jan 8.

Section of Otolaryngology, Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.

Objective: We describe an unusual foreign body, a carotid stent extruded into the upper airway, and discuss the predisposing factors.

Methods: This is a single patient case report with review of the literature.

Results: Our patient is a 59 year old female treated for T3N2aM0 (stage IVa) left tonsil squamous cell carcinoma who experienced a carotid blowout treated by carotid stent placement with subsequent carotid coiling and vessel takedown. Approximately ten months later, she coughed and expelled approximately 3cm of tubular stent-appearing material into her airway causing acute stridor and dysphagia. CT angiography (CTA) showed the distal and proximal stent in proper position without evidence of extravasation. The stent was extracted transorally showing the distal end of the carotid to be patent and covered by fibrin within its lumen. Review of the literature shows that such stent extrusions, although rare, do occur.

Conclusion: Carotid stents are a valuable tool in cases of carotid blowout. However, long-term data on patient prognosis is lacking. The foreign body response triggered by stent placement can cause dislodgement. The potential for stent extrusion is greatest in patients who have preexisting ulceration or who have undergone radiation, both common in head and neck cancer patients.
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http://dx.doi.org/10.1016/j.anl.2014.10.016DOI Listing
April 2015

Correction of the deviated septum: from ancient Egypt to the endoscopic era.

Int Forum Allergy Rhinol 2014 Nov 18;4(11):931-6. Epub 2014 Aug 18.

Section of Otolaryngology, Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT.

Background: Obstructed nasal breathing can occur due to deviation of the nasal septum. When the external nose appears grossly normal and cosmesis is not the focus, septoplasty has been the procedure used to straighten the septum with the goal of improving nasal airflow. Septoplasty has evolved over time.

Methods: A historical literature review was conducted to look for primary source journal articles and medical conferences proccedings addressing the evolution of the septoplasty procedure.

Results: Early techniques involved forcible fractures and splinting. Submucous resection was the first major advancement in surgical technique. Once the complications resulting from this technique were observed, it was subsequently revised with attempts to better address the caudal septal deviation. Attention was then turned to better incorporating the role surrounding support structures, such as the upper lateral cartilages. The premaxilla-maxilla approach attempted to address the overall nasal structure to best improve nasal breathing. The advent of endoscopic technique has been the most recent shift in surgical technique with improved visualization allowing for targeted septoplasty and reoperation on complicated cases including pituitary and skull base surgery.

Conclusion: This paper discusses the evolution of septoplasty techniques over time from the initial undertakings of the ancient Egyptians to the modern-day septoplasty. While the principles behind septoplasty have remained much the same, experience has allowed for refinement of surgical technique. No doubt new instrumentations and innovations will further help to tailor the practice of septoplasty to the anatomy and functional needs of each individual patient.
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http://dx.doi.org/10.1002/alr.21371DOI Listing
November 2014

Warthin's tumor with superimposed mycobacterium tuberculosis infection.

Conn Med 2014 Feb;78(2):85-9

We report a case of atypical mycobacterium infection in a Warthin's tumor which occurred in a 79-year-old man. The patient had along history of a left parotid mass that underwent rapid growth, became painful, and fistulized. The patient underwent left parotidectomy and neck dissection which showed a Warthin's tumor with areas of necrotizing granulomas. Subsequent culture showed the growth of acid fast bacilli. Consideration of an underlying mycobacterium infection, although rare, is important due to the public health concerns and other treatment needs that such a diagnosis raises.
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February 2014

Quantification of benign lesion regression as a function of 532-nm pulsed potassium titanyl phosphate laser parameter selection.

Laryngoscope 2011 Mar 4;121(3):590-5. Epub 2011 Feb 4.

Department of Otolaryngology, New York University Medical Center, New York, New York, USA.

Objectives/hypothesis: Although the potassium titanyl phosphate (KTP) laser is versatile, the variability in laser parameters for laryngeal pathologies and the lack of clinical efficacy data remain problematic. We provide preliminary data regarding these parameters for benign lesion regression. In addition, we describe a novel method for the quantification of the effects of the KTP laser on vocal fold (VF) lesions.

Study Design: Retrospective chart review.

Methods: Images were captured from examinations before and after in-office KTP treatment in patients with a range of benign lesions. Laser settings were noted for each patient. Imaging software was then used to calculate a ratio of lesion area to VF length. Ten percent of images were requantified to determine inter-rater reliability.

Results: Thirty-two patients underwent 47 procedures for lesions including hemorrhagic polyp, nonhemorrhagic polyp, vocal process granuloma, Reinke's edema, cyst/pseudocyst, leukoplakia, and squamous cell carcinoma in situ. No statistically significant differences were observed with regard to the laser parameters used as a function of lesion type. Regardless, by 1 month following treatment, all lesions had significantly decreased in size, except nonhemorrhagic polyps. Similar data were obtained at 2-month follow-up. We then compared the pre-KTP lesion size with the smallest lesion size quantified during the 1-year follow-up period. All lesions were significantly smaller, with the exception of Reinke's edema. Inter-rater reliability was quite good.

Conclusions: KTP laser effectively reduced VF lesion size, irrespective of the laser parameters used. In addition, our quantification method for lesion size appeared to be both viable and reliable.
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March 2011

Outcome of carotid endarterectomy for acute neurological deficit.

Vasc Endovascular Surg 2009 Aug-Sep;43(4):364-9. Epub 2009 Jul 23.

Division of Vascular and Endovascular Surgery, New York University School of Medicine, New York, NY 10016, USA.

We reviewed our experience with urgent carotid intervention in the setting of acute neurological deficits. Between June 1992 and August 2008, a total of 3145 carotid endarterectomies (CEA) were performed. Twenty-seven patients (<1.0%) were categorized as urgent. The mean age was 74.1 years (range 56-93 years) with 16 (60%) men, and 11 (40%) women, Symptoms included extremity weakness or paralysis (n=13), amaurosis fugax (n=6), speech difficulty (n=2), and syncope, (n=3). Three patients exhibited a combination of these symptoms. Three open thrombectomy were performed. Regional anesthesia was used in 13 patients (52%). Seventeen patients (67%), required shunt placement. At 30-days, 2 patient (7%) suffered a stroke, and 1 (4%) died. Urgent CEA can be performed safely. A stroke rate of 7% is acceptable in those who may otherwise suffer a dismal outcome without intervention.
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October 2009
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