Citations

Objectives/HypothesisApplication to otolaryngology–head and neck surgery residency is highly competitive, and the interview process strives to select qualified applicants with a high aptitude for the specialty. Commonly employed criteria for applicant selection have failed to show correlation with proficiency during residency training. We evaluate the correlation between the results of a surgical aptitude test administered to otolaryngology resident applicants and their performance during residency.Study DesignRetrospective study at an academic otolaryngology–head and neck surgery residency program.MethodsBetween 2007 and 2013, 224 resident applicants participated in a previously described surgical aptitude test administered at a microvascular surgical station. The composite score and attitudinal scores for 24 consecutive residents who matched at our institution were recorded, and their residency performance was analyzed by faculty survey on a five‐point scale. The composite and attitudinal scores were analyzed for correlation with residency performance score by regression analysis.ResultsTwenty‐four residents were evaluated for overall quality as a clinician by eight faculty members who were blinded to the results of surgical aptitude testing. The results of these surveys showed good inter‐rater reliability. Both the overall aptitude test scores and the subset attitudinal score showed reliability in predicting performance during residency training.ConclusionsThe goal of the residency selection process is to evaluate the candidate's potential for success in residency and beyond. The results of this study suggest that a simple‐to‐administer clinical skills test may have predictive value for success in residency and clinician quality.Level of Evidence4 Laryngoscope, 125:E57–E61, 2015

ObjectivesTo review the natural history of occult head and neck malignancy presenting with facial pain and evaluate the risk factors, diagnostic workup, and management of facial pain in the setting of occult malignancy.Study DesignRetrospective chart review.SettingTertiary care center.Subjects and MethodsAll patients presenting from 1980 to 2010 with facial pain and a delayed diagnosis of a head and neck cancer were reviewed.ResultsThirty‐eight patients were included. Onset of pain was rapid or sudden in 94.7%, intermittent in 84.2%, and sharp in 86.8%. Facial nerve weakness was present in 15.8%. Five patients had a history of locoregional skin cancer, and 14% had a history of malignancy. Average delay to diagnosis was 18.4 months. On average, the suspicious lesion was identified on the second scan (mean, 2.1; range, 1‐4 scans). Diagnosis was suggested by magnetic resonance imaging in 54.8% and computed tomography in 38.7% of patients. The most common pathology was squamous cell carcinoma (39.5%), and the predominant location was the parotid gland (28.9%). Surgical resection (66%) was the most common intervention. In patients who received treatment and had clinical follow‐up available for review, 97.0% (32/33) reported symptomatic improvement.ConclusionsIn our series, sudden‐onset, intermittent, sharp facial pain without resolution or improvement was associated with occult malignancy and should be considered in the differential diagnosis for facial pain. Based on the high incidence of early negative imaging, consideration should be given to repeat imaging when there is concern for malignancy. Therapeutic interventions often result in improvement of facial pain.

Objectives/HypothesisTo evaluate the utility of positron emission tomography (PET)/computed tomography (CT) for staging the neck in the preoperative setting by comparing it to both CT/magnetic resonance imaging (MRI) and pathologic staging.Study DesignRetrospective review.MethodsSeventy‐one patients with initial diagnosis of head and neck squamous cell carcinoma having preoperative MR or CT imaging and PET/CT with subsequent bilateral neck dissection as part of primary treatment (142 neck dissections). Comparison of cervical nodal metastases based on three separate staging systems: preoperative CT and/or MRI scan, preoperative PET/CT, and pathology.ResultsBoth CT/MRI scans and PET/CT scans statistically predicted pathologic outcomes (P = 0.0001, P = 0.0001, respectively) using Chi square analysis. There was a statistically significant improvement in the prediction of true pathologic disease using PET/CT compared to CT and/or MRI alone (P = 0.005). In a subgroup analysis including only the contralateral neck, this significance persisted (P = 0.013). McNemar's test revealed that subsequent detection of bilateral neck disease by PET/CT scan was significantly superior to MRI or CT alone (P = 0.023).ConclusionIn pathologically positive necks, PET/CT was statistically more reliable at identifying positive disease than CT or MRI alone. Furthermore, such a result is achieved without a statistically significant difference in false positivity between PET/CT and CT or MRI. This suggests that PET/CT positivity, despite negative clinical exam and CT/MRI findings, may be more likely to signify pathologic disease and require appropriate treatment.Level of Evidence4. Laryngoscope, 124:159–164, 2014

Object The authors' objective was 2-fold: 1) to compare outcomes of microsurgical resection for vestibular schwannoma (VS) between patients aged 70 years or older and patients younger than 70 years and 2) to test the hypothesis that symptomatic tumors in elderly patients represent a more aggressive variant of VS than those in younger adults, resulting in increased morbidity and a higher rate of recurrence after subtotal resection (STR). Methods A retrospective matched cohort study was conducted. Patients aged 70 years or older who had undergone microsurgical resection of VS were matched to adult patients younger than 70 years; the matching was performed on the basis of surgical approach, completeness of resection, and tumor size. Associations between clinical, radiographic, and surgical data and postoperative outcome were analyzed using conditional logistic regression. Results Twenty patients aged 70 years or older (mean age ± SD 75.9 ± 5.3, range 70–86 years) were identified and matched to a cohort of younger adult patients (mean age ± SD 55.7 ± 13.8, range 25–69 years). The mean tumor size in both groups was approximately 3 cm. Overall, the elderly patients had a poorer preoperative American Society of Anesthesiology physical status score (p = 0.038), were more likely to report imbalance (OR 9.61, p = 0.016), and more commonly exhibited compromised balance and coordination (OR 9.61, p = 0.016) than patients in the younger cohort. There were no differences between the 2 cohorts in perioperative complications (p = 0.26) or facial nerve function (p > 0.5) at any time. The elderly patients were 13 times more likely to have long-term postoperative imbalance (OR 13.00, p = 0.013) than the younger patients. Overall, 9 tumors recurred among 32 patients undergoing STR; 6 of these patients underwent additional interventions (stereotactic radiosurgery in 5 patients and microsurgery in 1) and showed no evidence of tumor progression at the last follow-up. The median growth rate of the recurrent tumor in the 6 elderly patients was 4.8 mm/year (range 2.1–14.9 mm/year) and, in the 3 control patients, 2.2 mm/year (range 1.9–4.0 mm/year). Overall, the mortality data showed a trend toward statistical significance (p = 0.068) with a higher risk of death in the elderly. Conclusions As the number of elderly patients with VS increases, microsurgical resection will remain an important management option for these patients. Despite a poorer preoperative physical status in elderly patients, their morbidity profiles are similar to those in adult patients younger than 70 years. However, elderly patients may require longer convalescence due to prolonged postoperative imbalance. Not surprisingly, overall diminished functional reserve and advanced comorbidities may increase the mortality risk associated with surgical intervention in the elderly patients. Finally, there was a high risk of further tumor growth following STR in the elderly patients (6 [37.5%] of 16), underscoring the need for close postoperative radiological surveillance and consideration of early stereotactic radiosurgery for the tumor remnant following the STR.

Abstract To identify novel genetic loci influencing interindividual variation in red blood cell (RBC) traits in African-Americans, we conducted a genome-wide association study (GWAS) in 2315 individuals, divided into discovery (n = 1904) and replication (n = 411) cohorts. The traits included hemoglobin concentration (HGB), hematocrit (HCT), RBC count, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC). Patients were participants in the electronic MEdical Records and GEnomics (eMERGE) network and underwent genotyping of ~1.2 million single-nucleotide polymorphisms on the Illumina Human1M-Duo array. Association analyses were performed adjusting for age, sex, site, and population stratification. Three loci previously associated with resistance to malaria—HBB (11p15.4), HBA1/HBA2 (16p13.3), and G6PD (Xq28)—were associated (P ≤ 1 × 10−6) with RBC traits in the discovery cohort. The loci replicated in the replication cohort (P ≤ 0.02), and were significant at a genome-wide significance level (P < 5 × 10−8) in the combined cohort. The proportions of variance in RBC traits explained by significant variants at these loci were as follows: rs7120391 (near HBB) 1.3% of MCHC, rs9924561 (near HBA1/A2) 5.5% of MCV, 6.9% of MCH and 2.9% of MCHC, and rs1050828 (in G6PD) 2.4% of RBC count, 2.9% of MCV, and 1.4% of MCH, respectively. We were not able to replicate loci identified by a previous GWAS of RBC traits in a European ancestry cohort of similar sample size, suggesting that the genetic architecture of RBC traits differs by race. In conclusion, genetic variants that confer resistance to malaria are associated with RBC traits in African-Americans.

Objectives/HypothesisTo describe the natural history of primary inner ear schwannomas (PIES) and evaluate management outcomes and relationship between PIES location, clinical presentation, and time to diagnosis.Study DesignRetrospective chart review and systematic review of the literature.MethodsVestibular schwannoma confined to or arising from the inner ear were included. PIES classification was based on anatomic subsite(s) involved. Detailed clinical history and outcomes were recorded.ResultsIn a systematic review (1933–2011), including 14 patients from the authors' institution (1999–2009), a total of 72 studies comprising 234 patients were evaluated. Mean follow‐up was 32.8 ± 39.1 months (range, 0–183 months). The cochlea was the most commonly involved subsite (51%). Hearing loss was the most frequent presenting symptom (99%). Vertigo and abnormal balance were more common among tumors involving the vestibular system (P < .01). Average delay between symptom onset and diagnosis was 7.0 ± 8.0 years (median, 5 years; range, 0–40 years). Recent onset hearing loss was more likely to elicit an earlier diagnosis (P = .01). The majority of patients were observed without treatment (53%). Tumor progression was seen in 52% of patients.Conclusions PIES are rare tumors and most commonly involve the cochlea. Tumor location is often associated with clinical presentation and correlates with delay between symptom onset and diagnosis. A watch‐and‐scan approach is the management strategy of choice in the absence of intractable vertigo or extensive tumor growth. The majority of patients report stable or improved symptoms over time, regardless of treatment. Laryngoscope, 123:1957–1966, 2013

SummaryBackgroundThe optimal methadone dosing regimen for children undergoing spinal surgery is uncertain because of sparse pediatric pharmacokinetic data and a paucity of analgesic effect data. The minimum effective analgesic concentration of methadone in opioid naïve adults is 58 mcg·L−1.MethodsAdolescents aged 12–19 years undergoing idiopathic scoliosis correction were administered 0.25 mg·kg−1 racemic methadone IV prior to surgical incision. Arterial blood samples for methadone assay were obtained at 0 min, 5 min, 10 min, 15 min, 20 min, 40 min, 1 h, 2 h, 4 h, 5 h, 6 h, 8 h, 10 h, 12 h, 24 h, and 48 h. Compartment analysis was undertaken using nonlinear mixed effects models. Parameter estimates were standardized to a 70‐kg person using allometric models.ResultsA three‐compartment linear disposition model best described observed time–concentration profiles. Population parameter estimates (between‐subjects variability) were central volume (V1) 19.1 (126%) L 70 kg−1, peripheral volumes of distribution V2 65.5 (60%) L 70 kg−1, V3 485 (23%) L 70 kg−1, clearance (CL) 9.3 (11%) L·h−1·70 kg−1, and inter‐compartment clearances Q2 282 (95%) L·h−1 70 kg−1, Q3 139 (42%) L·h−1 70 kg−1. The terminal elimination half‐life was 44.4 h. The mean observed methadone concentration was <58 mcg·L−1 by the first hour after administration.ConclusionsCurrent pharmacokinetic parameter estimates in adolescents are similar to those reported in adults. Methadone undergoes rapid redistribution after bolus administration. This may result in plasma concentrations that provide inadequate analgesia postoperatively. We would suggest following the bolus (0.25 mg.kg‐1) with an infusion (0.1–0.15 mg·kg−1·h−1 for 4 h) during spinal surgery to ensure adequate plasma concentrations for 24 h.