Publications by authors named "Zachary G Schwam"

31 Publications

The Price of Otologic Procedures: Variation in Markup by Surgical Procedure and Geography in the United States.

Otol Neurotol 2021 Mar 26. Epub 2021 Mar 26.

Department of Otolaryngology, Icahn School of Medicine at Mount Sinai Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York.

Objective: To characterize and analyze variation in price markup of seven common otologic surgeries by procedure and geographic region.

Study Design: Retrospective Analysis of the Centers for Medicare and Medicaid Services database of 2017 Medicare Provider Utilization and Payment Public File.

Setting: Inpatient and outpatient centers delivering Medicare-reimbursed services.

Patients: Full sample of patients undergoing procedures with Medicare fee-for-service final action claims during 2017.

Interventions: Seven procedures (myringotomy, tympanoplasty, mastoidectomy, tympanomastoidectomy stapedotomy/stapedectomy, cochlear implant, bone-anchored hearing aid).

Main Outcome Measures: Markup ratio (MUR) is defined as the ratio of total charges to Medicare-allowable-costs; Variation in MUR was measured using coefficient of variation (CoV).

Results: Among all providers, the median MUR was 2.4 (interquartile range: 1.9-3.1). MUR varied significantly by procedure, from 2.3 for myringotomy to 8.7 for mastoidectomy (p < 0.01). MUR also varied significantly within procedure, with the least variation found in myringotomy (CoV = 0.46), and the greatest in cochlear implants (CoV = 0.92). Using the national average as baseline, MUR varied 71% between states, ranging from 1.75 to 6.24. Within the same state, significant variation was also noted, varying by 4% (CoV = 0.04) in Montana compared with 138% (CoV = 1.38) in Pennsylvania. MUR was not significantly correlated with patient comorbidity or Centers for Medicare and Medicaid Services risk scores.

Conclusions: There was significant variation in the price of otologic surgery across geographic regions and procedures. The MUR for otology is lower or comparable to that reported in other surgical fields.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAO.0000000000003151DOI Listing
March 2021

Outcomes in Revision Stapes Surgery.

Otolaryngol Head Neck Surg 2021 Feb 9:194599821991479. Epub 2021 Feb 9.

Department of Neurotology, Michigan Ear Institute, St John Providence Hospital, Michigan, USA.

Objectives: To compare audiometric outcomes and complication rates between primary and revision stapes surgical cases.

Study Design: Retrospective cohort study.

Setting: Large single-institution database.

Methods: Data on 809 patients (including 170 revisions) undergoing primary and revision stapes surgery were reviewed, with Pearson chi-square and multivariable logistic regression analysis performed.

Results: Rates of postoperative air-bone gap (ABG) closure to ≤10 dB were significantly worse in the revision group (40.2% vs 61.8%, < .001), as were those to ≤20 dB (78.1% vs 90.9%, < .001). The bone conduction pure tone average worsened by >10 dB in 7.1% of primary cases and 13.1% of revisions ( = .016). The mean postoperative ABG for revision cases was significantly higher at 15.5 dB as compared with 11.0 dB for primaries ( < .001), despite a slightly higher preoperative ABG for primary cases (30.6 vs 28.24 dB, = .010). In multivariate analysis, revision surgery had an odds ratio 0.41 ( < .001) in closing the ABG to ≤10 dB. Postoperative reparative granuloma (2.4% vs 0.2%, = .001) and hydrops (1.8% vs 0.2%, = .008) were higher in revision cases.

Conclusions: Revision stapes surgery was found to have less predictable and inferior results as compared with primary cases.

Level Of Evidence: 4 (retrospective observational research).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599821991479DOI Listing
February 2021

The utility of augmented reality in lateral skull base surgery: A preliminary report.

Am J Otolaryngol 2021 Jan 29;42(4):102942. Epub 2021 Jan 29.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology, United States of America.

Objective: To discuss the utility of augmented reality in lateral skull base surgery.

Patients: Those undergoing lateral skull base surgery at our institution.

Intervention(s): Cerebellopontine angle tumor resection using an augmented reality interface.

Main Outcome Measure(s): Ease of use, utility of, and future directions of augmented reality in lateral skull base surgery.

Results: Anecdotally we have found an augmented reality interface helpful in simulating cerebellopontine angle tumor resection as well as assisting in planning the incision and craniotomy.

Conclusions: Augmented reality has the potential to be a useful adjunct in lateral skull base surgery, but more study is needed with large series.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjoto.2021.102942DOI Listing
January 2021

Surgical Outcomes With Cochlear Implantation in Patients With Enlarged Cochlear Aperture: A Systematic Review.

Otol Neurotol 2021 Jan 22. Epub 2021 Jan 22.

Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York Harvard Medical School, Boston, MA Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York.

Objective: Evaluate surgical outcomes in patients with enlarged cochlear aperture (ECA) after cochlear implantation.

Databases Reviewed: PubMed, EMBASE, and Scopus.

Methods: A systematic review was performed using standardized methodology. Studies were included if they included subjects with ECA who underwent cochlear implantation. Exclusion criteria included non-English articles, abstracts, letters/commentaries, case reports, and reviews. Bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool.

Results: Out of 1,688 identified articles, 7 articles representing 23 subjects with ECA were included. Publication rates increased between the period of study from 2009 to 2018. Four studies were level 4 evidence and three studies were level 3 evidence. In total, 20 subjects underwent cochlear implantation. Cerebrospinal fluid gushers were encountered in the majority of cases that reported complications (16/17, 94.1%); one patient developed postoperative meningitis, and another experienced postimplantation facial nerve stimulation. No study provided measurements on cochlear aperture size or defined size criteria used to identify ECA. Four studies recognized X-linked deafness to be associated with ECA, and the most common mutation was in POU3F4 gene.

Conclusion: An association exists between ECA and cerebrospinal fluid gusher, underscoring the importance of reviewing preoperative imaging. Size criteria are not well defined, and there is a paucity of data with respect to normative measurements. Many cases of ECA may give a genetic link. Although level of evidence of current studies remains modest, ECA reports have increased and will likely continue to expand with advancements in imaging and genetic testing.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAO.0000000000003021DOI Listing
January 2021

Endoscopic Myringoplasty and Type I Tympanoplasty.

Otolaryngol Clin North Am 2021 Feb 2;54(1):75-88. Epub 2020 Nov 2.

Icahn School of Medicine of Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, 1 Gustave L. Levy Place, Box 1189, New York, NY 10029, USA.

Herein we provide a broad overview of the literature as it applies to endoscopic myringoplasty and type I tympanoplasty. Advantages and disadvantages of the endoscopic approach are reviewed for both the adult and pediatric populations and are compared with conventional microscopic techniques.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.otc.2020.09.010DOI Listing
February 2021

Microdrill in endoscopic stapes surgery: Is it safe?

Am J Otolaryngol 2020 Nov - Dec;41(6):102666. Epub 2020 Aug 12.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Purpose: To assess the safety of using a microdrill in endoscopic vs microscopic stapes surgery.

Materials And Methods: A retrospective review of 29 adult ears with otosclerosis who underwent either an endoscopic or microscopic approach to microdrill stapedotomy.

Primary Outcome: Determine if transcanal endoscopic stapes surgery with the microdrill is as safe as microscopic stapes surgery. Secondary outcome: Bone and air pure-tone averages, air-bone gap, speech discrimination, overall surgical cost, and operative time were measured and analyzed. Complications such as post-operative dysgeusia, vertigo, readmission, revision and hearing loss were noted.

Results: 29 patients with otosclerosis were retrospectively reviewed, in total 14 endoscopic and 15 microscopic approaches were included, all performed over one-year period. None of the endoscopic surgeries require conversion to the microscope. No statistically significant audiometric differences between the endoscopic vs microscopic approaches in air pure-tone averages and air-bone gap. There were 82.8% air-bone gap closure to <15 dB with no significant difference in the percent of such closures between the endoscopic (85.7%) and microscopic groups (80%, P = .68). Three prostheses were used: 4.25 mm (17.2%), 4.5 mm (58.6%) and the 4.75 mm (24.1%) smart/eclipse. Endoscopic median operative time was 51 min vs 42 min for microscopic approach (P =.004).

Conclusions: The endoscopic with microdrill approach is criticized to lack depth perception, especially when using a microdrill to perform in stapedotomies. Our study showcases that using the microdrill use produces minimal differences in outcomes, cost, and is a safe modality to stapes surgery in both approaches.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjoto.2020.102666DOI Listing
December 2020

Displacement of a Total Ossicular Replacement Prosthesis Following Ossicular Chain Reconstruction.

Ann Otol Rhinol Laryngol 2021 Apr 20;130(4):420-423. Epub 2020 Aug 20.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, USA.

Objective: Herein we describe the diagnosis and management of total ossicular replacement prosthesis (TORP) displacement following tympanoplasty with ossicular chain reconstruction (OCR).

Methods: Case report with literature review.

Results/case: A 40-year-old male with otorrhea and tympanic membrane perforation underwent a right revision tympanoplasty with OCR using a TORP with a tragal chondroperichondrial graft. On postoperative day (POD) 4, he developed vertigo and profound right-sided hearing loss. Temporal bone computed tomography showed the prosthesis in the vestibule. After a steroid taper with mild improvement in symptoms, the TORP was removed two weeks later and the patient continued to improve.

Conclusion: TORP displacement into the vestibule is a very rare complication following OCR. Conservative management with high dose steroids may improve symptoms, however further middle ear exploration and surgical management may be warranted depending on the depth of displacement into the inner ear as well as symptom severity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0003489420953587DOI Listing
April 2021

Enlarged Cochlear Aperture as a Risk Factor for Cerebrospinal Fluid Gusher During Cochlear Implant Surgery.

Ear Nose Throat J 2020 Aug 13:145561320947631. Epub 2020 Aug 13.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0145561320947631DOI Listing
August 2020

Staying ahead of the curve: Early lessons from a New York City Otolaryngology Department's organizational response to the coronavirus pandemic.

Laryngoscope Investig Otolaryngol 2020 Jun 19;5(3):401-403. Epub 2020 May 19.

Department of Otolaryngology-Head and Neck Surgery Icahn School of Medicine at Mount Sinai New York New York USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lio2.400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276712PMC
June 2020

The National Landscape of Acute Mastoiditis: Analysis of the Nationwide Readmissions Database.

Otol Neurotol 2020 09;41(8):1084-1093

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai.

Objective: To determine risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility in patients with acute mastoiditis. Trends in treatment and complication rates were also examined.

Study Design: Retrospective cohort study.

Setting: Nationwide Readmissions Database (2013, 2014).

Patients: Pediatric and adult patients in the Nationwide Readmissions Database with a primary diagnosis of acute mastoiditis.

Interventions: Medical treatment, surgical intervention.

Outcome Measures: Rates of and risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility. Procedure and complication rates were also examined.

Results: Four thousand two hundred ninety-five pediatric and adult admissions for acute mastoiditis were analyzed. The overall rates of readmission, prolonged length of stay, and discharge to a rehabilitation facility were 17.0, 10.4, and 10.2%, respectively. Children 4 to 17 years of age had the highest rates of intracranial complications, and children ≤3 years were most likely to undergo operative intervention. Any procedure was performed in 31.2% of cases, and undergoing myringotomy or mastoidectomy was associated with lower rates of readmission but higher rates of prolonged length of stay. Those with intracranial complications and subperiosteal abscesses had the highest surgical intervention rates.

Conclusions: Readmission, prolonged length of stay, and discharge to a rehabilitation facility are common in patients with acute mastoiditis with various sociodemographic and disease-related risk factors. While once a primarily surgical disease, a minority of patients in our cohort underwent procedures. Undergoing a surgical procedure was protective against readmission but a risk factor for prolonged length of stay.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAO.0000000000002745DOI Listing
September 2020

Nuances in transcanal endoscopic surgical technique for glomus tympanicum tumors.

Am J Otolaryngol 2020 Sep - Oct;41(5):102562. Epub 2020 May 27.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.

Objective: To describe the utility and nuances of transcanal endoscopic surgery (TCES) on glomus tympanicum tumors from a single surgeon's experience.

Patients/intervention: Twelve patients, eight female and four males, diagnosed pre-operatively with glomus tympanicum tumors. They all underwent endoscopic resection by a single surgeon.

Main Outcome Measures: Feasibility of endoscopic resection of glomus tympanicum tumors without conversion to a microscopic approach. Secondary outcomes include tumor stage, pre and post-operative audiometry, vertigo, sensorineural hearing loss (SNHL) and integrity of the facial nerve, ossicles, chorda tympani and tympanic membrane.

Results: Twelve patients underwent TCES, eight patient's pathology results were glomus tympanicum, ranging from Glasscock-Jackson grade I-III. Due to loss in follow up, 6/8 patients had complete audiometric data, which were analyzed. Average pre-operative air-bone-gap (ABG) was 5.41 compared to post-operative ABG of 5.08 (p > 0.89). No patients resulted in any, post-operative vertigo, tinnitus, SNHL, facial nerve injury or chorda tympani nerve injury. Two patients had intentional tympanic membrane perforations secondary to tumor adherence to the membrane. They were repaired with tragal perichondrium graft. No patients have had any recurrences.

Conclusions: Endoscopic resection of glomus tympanicum tumors is a feasible and effective, alternative visualization modality for the neurotologist. Surgical pearls are described herein.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjoto.2020.102562DOI Listing
November 2020

COVID-19 sampling from the middle ear and mastoid: A case report.

Am J Otolaryngol 2020 Sep - Oct;41(5):102577. Epub 2020 Jun 2.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjoto.2020.102577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264918PMC
September 2020

Thirty-Day Readmission and Prolonged Length of Stay in Malignant Otitis Externa.

Laryngoscope 2020 09 22;130(9):2220-2228. Epub 2019 Nov 22.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.

Objectives: To determine independent risk factors for 30-day readmission, prolonged length of stay (PLOS), and discharge to a rehabilitation facility for those with malignant otitis externa.

Methods: Retrospective cohort study of patients hospitalized with malignant otitis externa (International Classification of Diseases, 9th edition, code 380.14) in the Nationwide Readmissions Database (2013-2014). Overall and disease-specific complication and mortality data were analyzed using chi-squared and multivariate analysis.

Results: There were 1267 cases of malignant otitis externa extracted. A PLOS of ≥8 days (90th percentile) was found in 14.2% (n = 180) of patients, and 13.7% (n = 174) were discharged to a facility. Patients were readmitted within 30 days at a rate of 12.5% (n = 159). The overall rates of uncomplicated and complicated diabetes were found to be 42.1% and 17.8%, respectively. Factors independently associated with PLOS included undergoing a surgical procedure (odds ratio [OR] 2.08, P < .001), and having central nervous system complications (OR 3.21, P < .001). Independent risk factors for disposition to a facility included nutritional deficiency (OR 1.91, P = .029), PLOS (OR 4.61, P < .001), and age 65-79 years (OR 6.57, P = .001). Readmission was independently linked to PLOS (OR 3.14, P < .001). Diabetes was not an independent risk factor for any outcome.

Conclusions: Thirty-day readmission, PLOS, and ultimate discharge to a rehabilitation facility were common and closely intertwined. Despite the classic association between diabetes and malignant otitis externa, diabetes was not an independent risk factor for any of our outcomes.

Level Of Evidence: 4 Laryngoscope, 130:2220-2228, 2020.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.28409DOI Listing
September 2020

Accuracy of a Modern Intraoperative Navigation System for Temporal Bone Surgery in a Cadaveric Model.

Otolaryngol Head Neck Surg 2019 11 24;161(5):842-845. Epub 2019 Sep 24.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objectives: To determine the accuracy of a modern navigation system in temporal bone surgery. While routine in other specialties, navigation has had limited use in the temporal bone due to issues of accuracy, perceived impracticality, and value.

Study Design: Prospective observational study.

Setting: Temporal bone laboratory.

Subjects And Methods: Eighteen cadaveric specimens were dissected after rigid fiducials were implanted and computed tomography scans were obtained. Target registration and target localization errors were then measured at various points.

Results: The mean overall target registration error was 0.48 ± 0.29 mm. The mean target localization error was 0.54 mm at the sinodural angle, 0.48 mm at the lateral semicircular canal, 0.55 mm at the round window, 0.39 mm at the oval window, and 0.52 mm at the second genu of the facial nerve.

Conclusion: A modern navigation system demonstrated submillimeter accuracy for all points of interest. Its use in clinical as well as training settings has yet to be fully elucidated.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599819864292DOI Listing
November 2019

National 30-day readmission and prolonged length of stay after vestibular schwannoma surgery: Analysis of the Nationwide Readmissions Database.

Am J Otolaryngol 2019 Nov - Dec;40(6):102290. Epub 2019 Sep 10.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology, United States of America; Audiology, Hearing, and Balance Center, Mount Sinai Health System, United States of America; Ear Institute, Mount Sinai Health System, United States of America. Electronic address:

Purpose: To determine the risk factors for unanticipated readmission, prolonged index admission, and discharge to a facility after vestibular schwannoma surgery.

Materials And Methods: Retrospective cohort study of those undergoing surgery for vestibular schwannoma in the Nationwide Readmissions Database (2013-2014). Main outcome measures included readmission rate, length of stay, discharge destination.

Results: There were 4585 cases identified. The overall unanticipated readmission rate was 8.1%, and 9.1% had a prolonged length of stay (PLOS) of ≥7 days. Mean and median LOS were 4.63 and 4.00 days, respectively, and >90% of patients were discharged after 7 days. Disposition to a facility occurred in 6.7% of cases. Teaching hospitals were protective against unintended readmission (odds ratio [OR] 0.44, p < .001). Major functional loss was associated with PLOS (OR 12.55, p < .001). High volume centers were associated with decreased risk of PLOS (OR 0.46, p < .001) and facility discharge (OR 0.68, p < .001). The most common readmission diagnoses included "other nervous system complications" (n = 128), cerebrospinal fluid leak (n = 71), "other postoperative infection" (n = 61), and meningitis (n = 59).

Conclusions: Unanticipated readmission and prolonged LOS following vestibular schwannoma surgery are common, with varied sociodemographic, hospital, and patient factors independently associated with each. Further studies are needed to investigate targeted interventions aimed at minimizing readmission and prolonged LOS using the factors outlined above.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjoto.2019.102290DOI Listing
April 2020

The utility of intraoperative navigation of the temporal bone for otolaryngology resident training.

Laryngoscope 2020 05 5;130(5):E368-E371. Epub 2019 Aug 5.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, U.S.A.

Objectives: To determine whether image guidance improves dissection quality among residents in the temporal bone lab and to gauge their reactions to its use.

Methods: Prospective cohort study of nine otolaryngology residents who dissected cadaveric temporal bones with and without image guidance in the temporal bone laboratory. Quality of dissection was measured with the Welling scale. A survey was administered assessing their interactions with the navigation system.

Results: There was no significant difference in quality of dissection for the majority of structures or number of major errors with use of image guidance. Dissection quality of the tegmen (4.67 vs. 5.67, P = .034) and sinodural angle (0.83 vs. 1.56, P = .005) was superior in the non-navigation specimens. The majority of residents reported increased confidence with locating several critical anatomic structures and found the system intuitive to use. Nearly all thought it would be helpful in revision cases or for aural atresia.

Conclusion: Image guidance did not improve quality of temporal bone dissection or number of major errors in this cohort of residents, but the majority found it intuitive and increased confidence in finding several structures. Navigation systems may play an important adjunctive role in resident education and further work is required to determine its optimal use.

Level Of Evidence: NA Laryngoscope, 130:E368-E371, 2020.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.28219DOI Listing
May 2020

Angiolymphoid hyperplasia with eosinophilia of the external ear.

Am J Otolaryngol 2019 May - Jun;40(3):453-455. Epub 2019 Mar 12.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, USA; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology, USA; Audiology, Hearing, and Balance Center, Mount Sinai Health System, USA; Ear Institute, Mount Sinai Health System, USA.

Herein we present the rare case of angiolymphoid hyperplasia with eosinophilia of the external ear treated by surgical resection and full-thickness skin graft. Current diagnosis and management options are reviewed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjoto.2019.03.007DOI Listing
October 2019

Purely intracranial vagal schwannoma: A case report of a rare lesion.

Am J Otolaryngol 2019 May - Jun;40(3):443-444. Epub 2019 Feb 18.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology, United States of America; Audiology, Hearing, and Balance Center, Mount Sinai Health System, United States of America; Ear Institute, Mount Sinai Health System, United States of America. Electronic address:

We present a rare intracranial vagal schwannoma along with its preoperative, intraoperative, and postoperative course.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjoto.2019.02.011DOI Listing
October 2019

Endoscopic resection of a chorda tympani schwannoma: A novel approach for an exceedingly rare entity.

Laryngoscope 2019 05 12;129(5):1188-1190. Epub 2018 Sep 12.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.

We present a novel approach for a rare chorda tympani schwannoma. A case report as well as special considerations in all phases of care are reviewed. Laryngoscope, 129:1188-1190, 2019.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.27482DOI Listing
May 2019

Thirty-day morbidity and mortality following otologic/neurotologic surgery: Analysis of the national surgical quality improvement program.

Laryngoscope 2018 06 22;128(6):1431-1437. Epub 2017 Sep 22.

Department of Surgery, Section of Otolaryngology, Yale School of Medicine, New Haven, Connecticut, U.S.A.

Objectives/hypothesis: To determine the rate and timing of, as well as risk factors for, postoperative morbidity and mortality following otologic and neurotologic surgery.

Study Design: Retrospective cohort study.

Methods: A total of 1,381 patients were identified in the American College of Surgeons National Surgical Quality Improvement Program for the years 2005 to 2010. Simple summary statistics, χ , and multivariable logistic regression were performed.

Results: Lateral skull base/neurotologic tumor resection (LSB) was done in 35.9%, and middle ear/mastoid procedures (MEM) were performed in 63.5%. The overall adverse event rate was 10.4%, although it was significantly higher for LSB (24.2%) and lower for MEM (2.6%). The overall mortality rate was 1.4%. Complications occurred postdischarge in 40.4% of cases. The outpatient setting (odds ratio [OR]: 0.31, 95% confidence interval [CI]: 0.15-0.65) and undergoing MEM (OR: 0.23, 95% CI: 0.12-0.47) were associated with lower risk of experiencing a complication. Impaired functional status (OR: 10.45, 95% CI: 3.65-29.89) was associated with postoperative mortality. An open wound preoperatively was associated with multiple causes of postoperative morbidity.

Conclusions: Patients undergoing approaches to the skull base and neurotologic tumor resections had the higher adverse event rate. Open wounds were predictive of several postoperative complications, and poor functional status was associated with mortality. Patients with significant comorbidities should be evaluated early on in their postoperative course to prevent readmission as well as major morbidity and mortality.

Level Of Evidence: 2b. Laryngoscope, 128:1431-1437, 2018.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.26848DOI Listing
June 2018

The 50 Most Cited Articles in Facial Plastic Surgery.

Aesthetic Plast Surg 2017 Oct 20;41(5):1202-1207. Epub 2017 Jun 20.

Section of Otolaryngology, Yale School of Medicine, New Haven, CT, USA.

Bibliometric analysis is a common method to determine the most influential articles in medical specialties, as it is an objective measure of peer recognition of scientific work. This study is the first bibliometric analysis of the literature in facial plastic surgery, to determine the most cited papers in the field. Bibliometric analysis was performed using the Science Citation Index from the Institute for Scientific Information, accessed through the Web of Science™. Filter terms relevant to the field of facial plastic surgery were used to identify the 50 most cited journal articles between 1900 and 2016. The median number of citations was 150 (range 116-1091). The articles spanned a wide range of topics in the field, with the most common topics being free flap reconstruction (n = 10), nasal surgery (n = 9), and rhytidectomy (n = 6). The majority of these articles (n = 29) presented findings supported by level IV or V evidence. This analysis provides an overview of the most cited articles in facial plastic surgery, many of which introduced some of the most fundamental principles and techniques in the field. These landmark articles represent important educational points that should be reviewed by all clinicians and trainees in this field. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00266-017-0908-xDOI Listing
October 2017

Comparing 30-Day Morbidity and Mortality in Pediatric and Adult Otologic Surgery.

Otolaryngol Head Neck Surg 2017 11 2;157(5):830-836. Epub 2017 May 2.

2 Yale School of Medicine, Department of Surgery, Section of Otolaryngology, New Haven, Connecticut, USA.

Objective To determine differences in timing and rate of postoperative adverse events among pediatric and adult populations undergoing specific otologic procedures. Study Design Administrative database study. Setting Multi-institutional database. Subjects and Methods The National Surgical Quality Improvement Program (NSQIP) and NSQIP-Pediatric (NSQIP-P) were used to extract data from 819 adults (years 2005-2010) and 7020 children (years 2012-2014) undergoing tympanoplasty and (tympano)mastoidectomy, respectively. Simple summary statistics, χ, and multivariable logistic regression analyses were performed. Results There were no significant differences in overall adverse event rates between adults (2.9%) and children (2.3%) ( P = .233). Adults experienced infectious complications more frequently than did children (0.4% vs 0.0%, P = .002). Postdischarge complications accounted for 83.7% of all complications. Children treated by pediatric otolaryngologists had higher readmission rates (odds ratio [OR], 2.80; 95% confidence interval [CI], 1.20-3.60; P = .002). Tympanomastoidectomy was associated with higher odds of reoperation (OR, 1.02; 95% CI, 1.01-1.03; P < .001), as was undergoing a concurrent procedure that did not include myringotomy (OR, 3.38; 95% CI, 1.47-7.79; P = .004). Conclusion Both adult and pediatric otologic surgery are safe, with patients experiencing similarly low complication rates. Most adverse events occur after discharge.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599817704376DOI Listing
November 2017

Survival Outcomes for Combined Modality Therapy for Sinonasal Undifferentiated Carcinoma.

Otolaryngol Head Neck Surg 2017 01 5;156(1):132-136. Epub 2016 Oct 5.

1 Otolaryngology Section, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA.

Objective Sinonasal undifferentiated carcinoma is a rare and aggressive malignancy of the nasal cavity and paranasal sinuses. Multi-institutional studies examining outcomes of combined modality treatment versus other treatment modalities have not been performed. The objective of our study was to present outcomes for multimodality therapy through use of the National Cancer Database. Study Design Retrospective cohort study. Setting National Cancer Database. Methods A total of 435 cases of SNUC diagnosed between 2004 and 2012 were identified. Kaplan-Meier analyses were performed to find 5-year cumulative survival rates. Multivariate Cox regression evaluated overall survival based on treatment when adjusting for other prognostic factors (age, primary site, sex, race, comorbidity, insurance, and TNM stage). Within the surgery + chemoradiotherapy group, survival analysis was also performed to compare outcomes for induction and adjuvant chemotherapy. Results The cumulative 5-year survival rate was 41.5%, and 36.1% of patients received surgery with chemoradiotherapy. In multivariate analysis, surgery + chemoradiotherapy was associated with significantly improved overall survival versus surgery + radiotherapy and radiotherapy but not significantly different from chemoradiotherapy. Within the surgery + chemoradiotherapy group, induction and adjuvant chemotherapy groups did not have associated differences in survival. Conclusion Combined modality therapy (chemoradiotherapy or surgery + chemoradiotherapy) is associated with improved survival outcomes versus other treatment modalities in patients with sinonasal undifferentiated carcinoma.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0194599816670146DOI Listing
January 2017

Patient knowledge and expectations in endoscopic sinus surgery.

Int Forum Allergy Rhinol 2016 09 30;6(9):921-5. Epub 2016 Mar 30.

Section of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, CT.

Background: The potential for patient misconceptions about endoscopic sinus surgery (ESS) has implications for the informed consent process. An understanding of patients' baseline knowledge and sources of information regarding ESS would improve surgeons' ability to counsel patients preoperatively and provide effective educational materials.

Methods: A prospective patient survey was performed at 2 independent tertiary care medical centers. Patients who were offered ESS as part of routine rhinology care were queried about expectations, knowledge, and sources of information regarding ESS before preoperative counseling.

Results: Of the 30 patients who completed the survey, 70% of patients reported doing research on ESS before the visit. The most common sources of information were friends and family (40%), YouTube (30.0%), and WebMD (26.7%). The most important factors researched included risks (95%), benefits (85%), and recovery related issues (70%). Patients in the younger group used healthcare and physician rating websites whereas none of the patients older than the median age of 44 years reported using them (33.3% vs 0%, p = 0.028). The older group more often relied upon healthcare providers than the younger group (71.5% vs 18.8%, p = 0.011). A range of responses were noted regarding early postoperative symptoms and recovery time.

Conclusion: This study identified a varied understanding of ESS including significant misconceptions about risks, anesthesia, and need for ongoing therapy, among others. Patients obtain their information from a variety of sources including peers, other doctors, and the Internet. Awareness of the gaps in patient knowledge and the sources of information will improve preoperative counseling.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/alr.21763DOI Listing
September 2016

Comparison of intranasal fluticasone spray, budesonide atomizer, and budesonide respules in patients with chronic rhinosinusitis with polyposis after endoscopic sinus surgery.

Int Forum Allergy Rhinol 2016 Mar 17;6(3):233-7. Epub 2015 Dec 17.

Section of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, CT.

Background: Nasal steroids are a critical part of the management of patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) after endoscopic sinus surgery (ESS). Increasingly, practitioners are using budesonide respules delivered to the sinonasal cavities, which is an off-label use, in lieu of traditional nasal steroids. There has been little research comparing budesonide with traditional nasal steroids and the most effective delivery method of budesonide.

Methods: A randomized controlled trial was performed on patients after ESS for CRSwNP in a tertiary care center. Patients were randomized into 1 of 3 groups: group A received fluticasone nasal spray twice daily; group B received budesonide respules via a mucosal atomization device (MAD) twice daily; and group C received budesonide respules instilled via the vertex-to-floor (VF) position twice daily. Primary endpoints were 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy scores at 6 months.

Results: Thirty-two patients were enrolled in the study, 23 of whom completed the 6-month trial. There were no significant differences among groups A, B, and C with respect to age, gender, asthma, aspirin sensitivity, or previous ESS. Group B had a statistically significant greater reduction in SNOT-22 and Lund-Kennedy scores at the primary endpoint of 6 months compared to groups A and C. Group C had the next greatest reduction, which was statistically significant, followed by group A.

Conclusion: Patients treated with budesonide after ESS for CRSwNP had greater improvement in SNOT-22 and Lund-Kennedy scores compared to fluticasone at 6 months. The data supports the use of budesonide respules, particularly with a MAD, over fluticasone for CRSwNP patients after ESS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/alr.21688DOI Listing
March 2016

Applications of 3-Dimensional Printing in Facial Plastic Surgery.

J Oral Maxillofac Surg 2016 Mar 28;74(3):427-8. Epub 2015 Oct 28.

Chief Resident, Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.joms.2015.10.016DOI Listing
March 2016

Improved prognosis for patients with oral cavity squamous cell carcinoma: Analysis of the National Cancer Database 1998-2006.

Oral Oncol 2016 Jan 6;52:45-51. Epub 2015 Nov 6.

Yale University School of Medicine, Department of Surgery, Section of Otolaryngology, 333 Cedar Street, PO Box 208041, New Haven, CT 06520, USA. Electronic address:

Background: Improvements in prognosis have been reported for oral cavity squamous cell carcinoma (OCSCC) in international cohorts. We sought to quantify improvement in survival of OCSCC and to determine factors associated with survival in the United States using a large administrative database.

Methods: Retrospective cohort study of 13,655 patients with OCSCC in the National Cancer Database diagnosed during time periods 1998-2003 and 2004-2006. Statistical methods included chi-square and Cox regression.

Results: Patients with early (Stages I and II) and late stage (Stages III and IV) disease had improvements of 36.2% and 16.0% in three-year overall survival, respectively. Receipt of adjuvant chemoradiation increased from 8.3% to 36.4% for late stage disease, while receipt of adjuvant therapy in early stage disease remained stable. Patients with early stage disease increased from 64.1% for years 1998-2003 to 67.4% during 2004-2006 (p<.001). Being diagnosed between 2004 and 2006 was associated with decreased mortality in early and late stage disease (HR 0.67 and 0.87, p<.001, respectively). Other treatment factors associated with improved survival for patients of all stages included treatment in a high-volume center (HR 0.91, p=.002) and undergoing neck dissection (HR 0.90, p=.001).

Conclusions: Three-year overall survival has increased dramatically for OCSCC patients. Advanced stage patients have been increasingly treated with chemoradiotherapy, while treatment of early stage patients has remained relatively unchanged. While other factors such as negative surgical margins and undergoing neck dissection may be partly responsible for improvements in early stage patients, further study is needed to understand the observed survival improvements.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.oraloncology.2015.10.012DOI Listing
January 2016

Refusal of postoperative radiotherapy and its association with survival in head and neck cancer.

Radiother Oncol 2015 Nov 24;117(2):343-50. Epub 2015 Oct 24.

Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, USA.

Background And Purpose: Administering postoperative radiotherapy (PORT) is associated with improved survival and slower disease progression in select head and neck cancer patients. Predictive factors for PORT refusal have not been described in this population.

Materials And Methods: Retrospective analysis of 6127 head and neck cancer patients who received or refused PORT in the National Cancer Database (2003-2006) was performed. Statistical analysis included Chi-square, multivariable logistic regression, Kaplan-Meier, and Cox proportional hazards analysis.

Results: In total, 247 patients (4.0%) refused PORT. Three-year overall survival was 62.8% versus 53.4% for those who received and refused PORT, respectively. PORT refusers were more likely to have negative nodes than those who underwent PORT (37.4% versus 20.1%, p<.001). In multivariate analysis, predictive factors for refusing PORT included living far from the treatment facility (OR 1.92), having negative nodes (OR 2.14), and Charlson score of ⩾ 2 (OR 2.14) (all p ⩽.001). PORT refusal was associated with increased mortality (hazard ratio 1.20, p=.044).

Conclusions: A significant proportion of head and neck cancer patients refused PORT; this was associated with compromised overall survival. Predictive factors for PORT refusal included socioeconomic, demographic, and pathologic variables. Elucidating root causes of refusal may lead to interventions that improve long-term outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.radonc.2015.10.013DOI Listing
November 2015

National treatment patterns in patients presenting with Stage IVC head and neck cancer: analysis of the National Cancer Database.

Cancer Med 2015 Dec 16;4(12):1828-35. Epub 2015 Oct 16.

Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut.

Head and neck cancer patients presenting with distant metastases are generally considered incurable. Treatment patterns and survival by primary disease site and therapy have not been described. Retrospective cohort analysis of 2525 patients in the National Cancer Database (2003-2006). Kaplan-Meier and Cox proportional hazards analyses were performed. Combined locoregional and systemic therapy was the most common treatment regimen (39.2%), followed by no treatment (23.9%), locoregional (19.0%), and systemic treatment (17.8%). Multivariate analysis demonstrated decreased survival was associated with age 65-79 years hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.14-1.80), Medicaid/uninsured status (HR 1.27, 95% CI 1.13-1.42), Medicare/other government insurance (HR 1.21, 95% 1.07-1.38), treatment at a nonacademic/research program (HR 1.17, 95% CI 1.07-1.27), and Charlson comorbidity score of 1 (HR 1.33, 95% 1.19-1.48). Compared to systemic therapy alone, receiving locoregional and systemic therapy was associated with decreased risk of death (HR 0.73, 95% CI 0.65-0.83). Only 14.6% and 0.6% of patients were recorded as receiving palliative therapy or being enrolled in a clinical trial, respectively. Significant treatment diversity exists in distantly metastatic head and neck cancer. Those who received combination locoregional and systemic therapy were more likely to have improved overall survival, but important factors in treatment selection are unknown. A small proportion of patients was found to receive either palliative therapy or was enrolled in a clinical trial, although these data likely underestimate the true proportions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cam4.546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123708PMC
December 2015

Severe epistaxis due to aberrant vasculature in a patient with STAT-1 mutation.

Head Neck 2016 Mar 7;38(3):E68-70. Epub 2015 Oct 7.

Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut.

Background: Signal transducer and activator 1 (STAT-1) mutations are rare and have been implicated in combined immunodeficiency, enhanced tumorigenesis, and vascular defects.

Methods: A 60-year-old woman with a novel STAT-1 mutation and resulting immunodeficiency, squamous cell carcinoma, and vascular disease presented with profuse epistaxis secondary to rupture of an aberrant artery that she developed in part because of this mutation. After unsuccessful posterior packing, embolization was initiated but subsequently aborted because of a bovine origin carotid artery and a history of multiple carotid dissections.

Results: After repeat posterior packing, hemostasis was achieved. No additional episodes of epistaxis occurred in the subsequent 13 months.

Conclusion: Vascular anomalies can present challenges in epistaxis management. In patients with conditions known to cause vascular anomalies, it is critical to obtain vascular imaging before intervention.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.24165DOI Listing
March 2016