Laryngeal manifestations of cranial nerve IX/X compression at the brainstem

Objective

We report an association between lower cranial nerve (CN IX/X) vascular compression at the brainstem with laryngeal symptoms utilizing a stepwise algorithm that systematically evaluates and eliminates all other common etiologies. Our experiences with retromastoid craniectomy with lower cranial nerve (LCN) decompression versus non‐neurosurgical treatments are detailed.

Study Design

Retrospective chart review at a tertiary care academic medical center with follow‐up telephone survey.

Methods

Baseline demographics, clinical characteristics, quality‐of‐life surveys, and treatment outcomes were recorded for patients with laryngeal symptoms associated with LCN compression at the brainstem.

Results

Forty‐nine patients demonstrated LCN compression at the brainstem on imaging and presented with chief complaints of dysphonia (25 of 49, 51%), chronic cough (19 of 49, 39%), dysphoric breathing (3 of 49, 6%), and dysphagia (2 of 49, 4%). Poor initial scores were noted for Voice‐Related Quality of Life (V‐RQOL), Reflux Symptom Index, and Glottal Closure Index. Twenty‐four patients underwent LCN decompression, of which 21 of 24 (88%) reported partial, near‐complete, or complete improvement. Major perioperative complications occurred in four of 24 patients (17%). Patients who had undergone decompression were more likely to obtain complete/near‐complete symptom resolution (10 of 24 patients, 42%) compared to those undergoing conservative treatments (2 of 25 patients, 8%) (P = 0.02). V‐RQOL scores improved more in surgical patients [mean change score, 33.0 (standard deviation [SD], 31.2) than nonsurgical patients (mean change score 9.6, SD 20.9) (P = 0.03) (mean follow‐up 3.0 years, SD 2.0).

Conclusion

Lower cranial nerve compression at the brainstem should be considered when all other etiologies are excluded. Retromastoid craniectomy with LCN decompression demonstrates an acceptable safety profile.

Level of Evidence

4. Laryngoscope, 1–7, 2018

http://bit.ly/2Tb5eZV

Lingual tonsil lymphatic tissue regrowth in patients undergoing transoral robotic surgery

Objectives/Hypothesis

To evaluate a possible regrowth of lingual tonsil lymphatic tissue in patients submitted to lingual tonsil resection with transoral robotic surgery (TORS).

Study Design

Retrospective Study.

Methods

Medical records of patients surgically treated by means of TORS to remove excessive lymphatic tissue of the lingual tonsil were retrospectively reviewed. Postoperative endoscopic data after long‐term follow‐up were analyzed to investigate possible lymphatic tissue regrowth. Preoperative and postoperative lingual tonsil lymphatic tissue were classified according to the standardized Friedman's grading scale ranging from 0 to 4.

Results

Sixty‐eight patients (41 male and 27 female; mean age = 51.3 years) were considered suitable for the study analysis. Clinical regrowth was observed in six (8.8%) patients: four (5.9%) and two (2.9%) patients with grade 2 and 3 lymphatic hypertrophy, respectively. No correlation between the grade of regrowth, the time interval from surgery, and the volume of lymphatic tissue removed was found.

Conclusions

The lymphatic tissue regrowth after TORS resection appears to be very low.

Level of Evidence

4 Laryngoscope, 2018

http://bit.ly/2CvIgXH

Ultrasonographic Criteria to Define the Lower Limits of Neck Node Levels 2 and 3

Objective

To find ultrasonographic landmarks to define the lower limits of neck node levels 2 and 3.

Methods

Data were collected prospectively between February 2014 and January 2015. In total, 103 patients were recruited (50 men and 53 women), and the mean age was 50.9 years (range: 18–89). At the lower level of the hyoid, we classified ultrasonographic findings as hyoid type (HT)1 when the internal and external carotid arteries were visualized separately, HT2 when the internal and external carotid arteries joined together, and HT3 when the common carotid artery was visualized. At the lower border of the cricoid cartilage, we classified ultrasonographic findings as cricoid type (CT)1 when the omohyoid reached the medial half of the common carotid artery, CT2 when the omohyoid reached the lateral half of the common carotid artery, CT3 when the omohyoid reached the medial half of the internal jugular vein, and CT4 when the omohyoid reached the lateral half of the internal jugular vein.

Results

At the lower border of the hyoid, HT1 was most commonly observed in 59.2%, whereas HT2 and HT3 were observed in 31.3% and 9.7%, respectively. At the lower border of the cricoid cartilage, CT3 was most commonly observed in 52.9%, whereas CT2, CT4, and CT1 were observed in 20.4%, 14.1%, and 12.6%, respectively.

Conclusion

HT1 and CT3 can be suggested ultrasonographic landmarks for the lower limits of levels 2 and 3, respectively.

Level of Evidence

2. Laryngoscope, 2018

http://bit.ly/2T7GilI

Subacute acrolein exposure to rat larynx in vivo

Objectives/Hypothesis

Inhaled pollutants can contact vocal fold tissue and induce detrimental voice changes. Acrolein is a pollutant in cigarette smoke and can also be inhaled during the combustion of fossil fuels, animal fats, and plastics in the environment. However, the vocal fold pathological changes induced by acrolein and the underlying inflammatory pathways are not well understood. These biologic data are needed to understand why voice problems may result from pollutant exposure.

Study Design

In vivo prospective design with experimental and control groups.

Methods

Sprague‐Dawley male rats (N = 36) were exposed to acrolein (3 ppm) or filtered air (control) through a whole‐body exposure system for 5 hours/day, for 5 days/week, over 4 weeks. Histopathological changes, presence of edema, expression of proinflammatory cytokines and markers, and the phosphorylation of nuclear factor kappa‐light‐chain‐enhancer of activated B cells (NF‐κB) were investigated.

Results

Histological evaluation and quantification demonstrated that subacute acrolein exposure induced significant vocal fold edema. Acrolein exposure also induced epithelial sloughing and cell death. Quantitative polymerase chain reaction showed a significant upregulation of genes encoding interferon regulatory factor and chitinase‐3‐like protein 3. Western blot revealed a 76.8% increase in phosphorylation of NF‐κB P65 after subacute acrolein exposure.

Conclusions

These findings suggest that 4‐week exposures to 3 ppm acrolein induce vocal fold inflammation manifested as edema, related to the activation of NF‐κB signaling. The edema may underlie the voice changes reported in speakers exposed to pollutants.

Level of Evidence

NA Laryngoscope, 2018

http://bit.ly/2Cye3HB

Adult epiglottitis: Trends and predictors of mortality in over 30 thousand cases from 2007 to 2014

Objectives

To characterize trends of adult epiglottitis presenting to the emergency department (ED) and analyze mortality.

Methods

We utilized the National Emergency Department Sample to characterize adult epiglottitis from 2007 to 2014 and used provided weights to obtain nationally representative data (all presented data are weighted). Univariate and multivariate analyses were conducted to determine predictors of mortality.

Results

A total of 33,549 cases were identified (weighted). Over the study period, the average patient age increased significantly from 47 to 51 (R² > 0.5), with an overall mean age of 49. A total of 11.8% of patients were coded as having obstruction, and 68.3% of cases were admitted to the hospital. Across all years, < 1% received laryngoscopic or airway procedures in the ED. Utilization of both X‐ray and computed tomography was <10%. Over the 8 years, there were an average of 42 deaths per year (1.01% overall mortality). No clinical factors, except obstruction, were significant on univariate analysis (P < 0.05). Multivariate analysis indicated that patient age, degree of hospital urbanization, and smoking status also were nonsignificant.

Conclusions

Epiglottitis is still a significant pathology seen in EDs, is stable over the study period, and carries a mortality risk. There is an exceptionally low rate of documented clinical interventions in the ED, especially compared with inpatient studies of epiglottis. This suggests a lack of recognition of the need and utilization of critical airway interventions early in the patient encounter. Future research is needed to characterize the reasons for the low rate of early airway visualization and intervention of epiglottitis in the ED.

Level of Evidence

4. Laryngoscope, 2018

http://bit.ly/2T8oC9D

What makes a great Surgeon?

http://bit.ly/2CwURde

Revision surgery following minimally invasive image‐guided cochlear implantation

Minimally invasive image‐guided cochlear implantation (CI) research continues to progress. We previously performed the procedure in nine patients. Herein, we describe the first revision operation for device failure following minimally invasive image‐guided CI. It was possible to reuse the original drill channel, obviating the need to convert to a wide‐field mastoidectomy. Revision surgery, if required, can therefore be performed safely after minimally invasive image‐guided CI.

Level of Evidence

NA. Laryngoscope, 2018

http://bit.ly/2T6E2LB

Diagnosis of a maxillary sinus fungus ball without intralesional hyperdensity on computed tomography

Objectives/Hypothesis

Maxillary sinus fungus ball (MSFB) is the most common type of noninvasive fungal rhinosinusitis. Surgical removal of the ball achieves good outcomes. Making a rapid and accurate diagnosis is important to avoid unnecessary medical therapy. Intralesional hyperdensity (IH) on computed tomography (CT) is reportedly a good indicator. The aim of this study was to evaluate the diagnostic features of MSFB without IH on preoperative CT images.

Study Design

Retrospective database review.

Methods

Two hundred fifty‐eight patients with histopathological evidence of a sinus fungal ball were retrospectively investigated. Forty‐seven of 222 patients with MSFB did not show IH on preoperative CT images and were enrolled in the MSFB group. Forty‐one patients with unilateral nonfungal chronic rhinosinusitis were enrolled in a control group. CT features previously reported to have diagnostic significance were evaluated.

Results

Sclerosis of the lateral sinus wall, erosion of the inner sinus wall, and irregular surface of the material were significantly more common in the MSFB group than in the control group. In the subgroup of patients with total opacification in the maxillary sinus, the sensitivity, specificity, and positive and negative predictive values for erosion of the inner sinus wall were more than 90%. In the subgroup with partial opacification, the sensitivity, specificity, and positive predictive value of an irregular surface of the material were more than 80%.

Conclusions

We have devised an algorithm to help diagnose MSFB without IH on preoperative CT images. Use of this algorithm would improve the diagnostic accuracy and ensure appropriate treatment.

Level of Evidence

4 Laryngoscope, 2018

http://bit.ly/2Cye3r5

Otologic considerations in a full face transplant recipient

Facial transplantation provides a functional and aesthetic solution to severe facial disfigurement previously unresolved by conventional reconstruction. Few facial allografts have been ear containing; hence, there is limited knowledge of the postoperative otologic considerations. We describe the case of a 44‐year‐old man who underwent transplantation of the total face, eyelids, ears, scalp, and skeletal subunits in 2015 after an extensive thermal injury. We detail the patient's transition from osseointegrated prosthetic ears to an ear‐containing facial allograft, and describe the unique surgical approach and challenges encountered. Subsequent bilateral revision meatoplasties were performed, which provided relief from stenosis of the external auditory meatus. Laryngoscope, 2018

http://bit.ly/2T6E2v5

Critical care resources utilized in high‐risk adenotonsillectomy patients

Objective

Children at high risk for respiratory complication after adenotonsillectomy are often admitted to a pediatric intensive care unit (PICU) postoperatively. Although many patients receive care in such units, it is unknown how many utilize critical care resources.

Methods

A review was conducted to audit intensive care needs of postadenotonsillectomy patients admitted to the PICU at a tertiary, academic, pediatric hospital between July 2013, and March 2017. Demographic information, ICU indication, polysomnogram results, and comorbidities were collected. Patients were defined as needing ICU resources based on supplemental oxygen requirements greater than 2 L between 2 to 24 hours postoperatively, more than two desaturation events in a 2‐hour period, or more than hourly nursing intervention. Factors associated with utilization of ICU resources were assessed.

Results

One hundred and ten patients were admitted to the PICU after adenotonsillectomy. Median age was 4.2 years, median body mass index was 90.8 percentile, and median apnea hypopnea index (AHI) was 34.3. Twenty patients (18.2%) utilized ICU resources by criteria defined. Of these patients, 14 were known to need such resources by 2 hours postoperatively (70%, negative predictive value 93.8%). Neither AHI nor obesity status was correlated with need for resources; however, resource need was associated with young age, gastrostomy tube status, and neuromuscular disorders (P = 0.048, P = 0.002 and 0.013, respectively).

Conclusion

Most high‐risk adenotonsillectomy patients do not utilize critical care resources despite their increased perioperative risk. Patients with respiratory complications are frequently identifiable within the first 2 hours of surgery.

Level of Evidence

4. Laryngoscope, 2018

http://bit.ly/2Cy3zrX

Risk and outcomes for second primary human papillomavirus–related and –unrelated head and neck malignancy

Objectives/Hypothesis

To 1) examine the characteristics of patients who develop second primary malignancies (SPMs) from an index human papillomavirus (HPV)‐related head and neck squamous cell carcinoma (HNSCC) and HPV‐unrelated HNSCC and to 2) compare overall survival between those with HPV‐related and HPV‐unrelated index HNSCC among patients who develop SPM.

Study Design

Retrospective cohort analysis.

Methods

A retrospective study was conducted of 113,259 patients who were diagnosed with HNSCC from 2000 to 2014. SPM was defined as the first subsequent primary cancer occurring at least 2 months after index cancer diagnosis, and HPV‐relatedness was based on whether patients' index HNSCC was potentially HPV‐related or HPV‐unrelated. Multivariable Fine and Gray (FG) competing‐risks regression models were used to estimate factors associated with risk of SPM by HPV‐relatedness. Among patients with SPM, an adjusted Cox proportional hazards (PH) regression model was used to assess the association between HPV‐relatedness and survival.

Results

Approximately 13,900 patients (12.3%) developed SPM. In the FG model, patients with HPV‐unrelated HNSCC had a 15% higher risk of developing SPM (adjusted hazard ratio: 1.15, 95% confidence interval: 1.10‐1.20) than those with potentially HPV‐related HNSCC, but the same characteristics were associated with SPM development. In the Cox PH model, patients with SPM whose index HNSCC was HPV‐unrelated had higher risk of death than those whose index HNSCC was potentially HPV‐related (adjusted hazard ratio: 1.06; 95% confidence interval: 1.02‐1.11).

Conclusions

Patients with HPV‐unrelated HNSCC have a higher risk of SPM development than do those with HPV‐related HNSCC. Effective secondary disease‐prevention strategies should be established to improve long‐term patient outcomes.

Level of Evidence

NA Laryngoscope, 2018

http://bit.ly/2Tb89BP

Is greater antibiotic therapy prior to ESS associated with differences in surgical outcomes in CRS?

Objective

Antibiotics have been a mainstay of chronic rhinosinusitis therapy; however, data suggest that antibiotics may also result in several adverse unintended consequences. We aimed to evaluate if greater antibiotic use prior to sinus surgery was associated with differences in surgical outcomes.

Methods

Adult CRS patients enrolled in a prospective, multi‐institutional, observational cohort study were asked to recall systemic antibiotic use in the 90 days prior to endoscopic sinus surgery (ESS). Antibiotic use was examined in relation to demographics, disease characteristics, and outcomes.

Results

Data were collected for 271 study participants followed for a mean of 14.9 [± 5.1] months across four institutions, with a mean preoperative antibiotic use of 27.8 [± 22.7] days out of the 90 preceding ESS. After ESS, significant improvement (P < 0.001) was reported for patient‐reported outcome measures and endoscopy scores for the overall cohort. No bivariate correlation between preoperative antibiotic use and degree of benefit in objective clinical measures (endoscopy, Brief Smell Identification Test) was seen. Increased preoperative antibiotic use was associated with less improvement in 22‐item SinoNasal Outcome Test (SNOT‐22) and its rhinologic subdomain after ESS. Prevalence of achieving a minimal clinically important difference in overall SNOT‐22 symptom scores was lower in those using more preoperative antibiotics, although statistical significance was not reached when adjusting for independent covariates in multivariate modeling.

Conclusion

Higher amounts of previous antibiotic use do not appear to be associated with better ESS outcomes. Specific recommendations for antibiotic use as part of CRS‐appropriate medical therapy prior to ESS require further study, particularly given concerns for antibiotic overuse and implications for improving outcomes in the modern healthcare era.

Level of Evidence

2C. Laryngoscope, 2018

http://bit.ly/2CvI0YN

Morbidity after pediatric tonsillotomy versus tonsillectomy: A population‐based cohort study

Objectives/Hypothesis

To compare and evaluate morbidity following pediatric tonsillectomy (TE) and tonsillotomy (TT) performed due to tonsil‐related upper airway obstruction.

Study Design

Retrospective population‐based cohort study based on data from the Swedish National Patient Register (NPR).

Methods

All patients aged 1 to 12 years who were registered in the NPR between January 1, 2007 and December 31, 2015, and who underwent an isolated tonsil surgery (± adenoidectomy) for the sole indication of upper airway obstruction were included. Postoperative morbidity within 30 days of surgery, including readmission due to hemorrhage and return to theater (RTT), was evaluated and compared between the two groups. A forward stepwise multivariable logistic regression analysis was used to identify independent predictors of postoperative morbidity.

Results

In total, 35,060 patients were included in the study, 23,447 of whom underwent TT and 11,613 of whom underwent TE. Readmission due to postoperative hemorrhage, RTT, readmission due to any reason, and contact with healthcare were all less common after TT than after TE. Readmission due to postoperative hemorrhage was significantly more common after TE (2.5%) than after TT (0.6%) (odds ratio: 3.91, 95% confidence interval: 3.20‐4.77).

Conclusions

This study showed that TT is associated with a statistically significantly lower risk of postoperative complications than TE when performed in children to correct tonsil‐related upper airway obstruction. Statistically significant differences were found for all outcome variables, namely, readmission to hospital due to bleeding, RTT, readmission due to any reason, and postoperative contact with healthcare for any reason.

Level of Evidence

2b Laryngoscope, 2018

http://bit.ly/2T6ji6L

Patient‐reported versus physiologic swallowing outcomes in patients with head and neck cancer after chemoradiation

Objective

The primary objective of this project was to retrospectively investigate the relationship between patient‐reported and physiologic swallowing measures after chemoradiation therapy for head neck cancer (HNC).

Methods

Adult patients who underwent chemoradiation therapy for HNC and presented for videofluoroscopic swallow study were reviewed retrospectively. Surgically treated patients were excluded. Patient perception of swallowing‐related outcomes was assessed via the MD Anderson Dysphagia Inventory (MDADI) on the same day that physiologic measures of swallow function were obtained. Using vidoefluoroscopic data, the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale yielded measures of safety (DIGEST‐S: penetration/aspiration) and efficiency (DIGEST‐E: residue). Statistical analysis for correlation coefficients was performed.

Results

Thirty patients met the inclusion criteria. The oropharynx was the most commonly affected site (70.0%), followed by the larynx (16.7%). The median radiation dose was 72 grays (Gy), and participants were assessed a mean of 4.6 (range 0–12) years following completion of treatment. There was no correlation between the MDADI and the DIGEST‐E score (Pearson rho = −0.045, P = 0.812), DIGEST‐S score (Pearson rho = 0.075, P = 0.695), or summary DIGEST grade (Pearson rho = 0.046, P = 0.810). MDADI scores did not change significantly with increasing time since radiation (P = 0.375), whereas the DIGEST‐E scores, DIGEST‐S score, and summary DIGEST grades worsened over time (P = 0.007, P = 0.002, and P = 0.0005, respectively).

Conclusion

Assessment of swallowing physiology showed that function worsened after chemoradiation therapy, but this did not correlate with patient‐reported quality‐of‐life measures. Reduced patient awareness of swallow dysfunction years after completion of chemoradiation has implications for management of dysphagia in the face of physiologic decline.

Level of Evidence

4. Laryngoscope, 2018

http://bit.ly/2CwUQGc

A separation of innate and learned vocal behaviors defines the symptomatology of spasmodic dysphonia

Objective

Spasmodic dysphonia (SD) is a neurological disorder characterized by involuntary spasms in the laryngeal muscles. It is thought to selectively affect speaking; other vocal behaviors remain intact. However, the patients' own perspective on their symptoms is largely missing, leading to partial understanding of the full spectrum of voice alterations in SD.

Methods

A cohort of 178 SD patients rated their symptoms on the visual analog scale based on the level of effort required for speaking, singing, shouting, whispering, crying, laughing, and yawning. Statistical differences between the effort for speaking and the effort for other vocal behaviors were assessed using nonparametric Wilcoxon rank‐sum tests within the overall SD cohort as well as within different subgroups of SD.

Results

Speech production was found to be the most impaired behavior, ranking as the most effortful type of voice production in all SD patients. In addition, singing required nearly similar effort as speaking, ranking as the second most altered vocal behavior. Shouting showed a range of variability in its alterations, being especially difficult to produce for patients with adductor form, co‐occurring voice tremor, late onset of disorder, and familial history of dystonia. Other vocal behaviors, such as crying, laughing, whispering, and yawning, were within the normal ranges across all SD patients.

Conclusion

Our findings widen the symptomatology of SD, which has predominantly been focused on selective speech impairments. We suggest that a separation of SD symptoms is rooted in selective aberrations of the neural circuitry controlling learned but not innate vocal behaviors.

Level of Evidence

4. Laryngoscope, 2018

http://bit.ly/2T6jd2X

Observations from a pediatric dysphagia clinic: Characteristics of children at risk of aspiration pneumonia

Objectives

The clinical variables that are predictive of aspiration pneumonia are not clear in the pediatric population. This study was conducted in order to identify the demographic, clinical, and radiological risk factors for the development of aspiration pneumonia in children referred to the dysphagia clinic.

Methods

A retrospective analysis of medical records of 88 children referred to the dysphagia clinic who had undergone videofluroscopic swallow study (VFSS).

Results

Oropharyngeal dysphagia was found in 61.3% (54 of 88). Incidence of aspiration pneumonia was 39.8% (35 of 88).

Conclusion

Respiratory symptoms such as cough, choking, excessive secretions, and pharyngeal dysmotility other than aspiration in VFSS were not predictors of pneumonia. Infants and children with laryngotracheal anomalies, demonstrable aspiration in VFSS, and major cardiac illness are at risk of presenting with aspiration pneumonia. Whether gastroesophageal reflux disease (GERD) or esophageal dysmotility are causative of aspiration in the rest of the population needs to be investigated by future prospective studies.

Level of Evidence

3b. Laryngoscope, 2018

http://bit.ly/2CvI22N

Patient opinions regarding surgeon presence, trainee participation, and overlapping surgery

Objectives

To explore patient opinions and underlying values regarding overlapping surgery (OS) scenarios, specifically evaluating the effect of attending surgeon presence and availability, as well as trainee participation on patient comfort level and willingness to consent.

Study Design

Mixed methods.

Methods

Forty adults participated in semi‐structured interviews. Interviews included vignettes involving three scenarios of OS (1: attending present; 2: attending absent for wound closure; 3: attending absent and unavailable for wound closure, with covering attending), visual analog scale ratings of participants' comfort with scenarios, and cognitive debriefing. Themes and subthemes were identified using hierarchical coding of transcripts, and quantitative and qualitative analyses were conducted.

Results

Quantitative analysis revealed anticipated decreases in comfort with decreasing attending presence/availability (mean comfort level 94% vs. 78% vs. 63% for scenarios 1 vs. 2 vs. 3, P < 0.005), although many patients reported improved comfort with scenario 3 if meeting the covering attending. Participants demonstrated a preference for less trainee involvement (P < 0.005, scenario 1) and greater trainee experience (P < 0.05, all scenarios). However, not all individuals were uncomfortable with attending absence or trainee independence. Themes important for decision making included trust in the surgeon, surgeon experience, trainee involvement, disease severity, cost, and wait time.

Conclusion

Patients varied highly in their willingness to consent to OS scenarios. In settings of trainee independence and covering surgeons, many patients desired meeting these members of the treatment team, which improved comfort for some. For some patients, tradeoffs and incentives of timeliness, cost, and convenience modified their willingness to have OS.

Level of Evidence

4. Laryngoscope, 2018

http://bit.ly/2T6d32M

Carotid body tumor with hidden internal carotid artery aneurysm

Abstract

Background

The most common head and neck paraganglioma is the carotid body paraganglioma. Treatment of carotid body tumors is primarily surgical, and uncontrolled growth leads to cranial nerve deficits and more morbid resection.

Methods

A 60‐year‐old man was referred for evaluation of carotid body tumor, and workup revealed an internal carotid artery (ICA) aneurysm within the known mass.

Results

Interventional Radiology performed angiogram and stenting across aneurysm with interval dramatic reduction in size of mass, and surgery was avoided altogether.

Conclusions

Surgical resection is indicated for carotid body paragangliomas when the patient can tolerate the surgery and when the tumor was not very advanced. This patient had a small tumor that initially appeared easily resectable. Failure to detect the ICA aneurysm before resection may have resulted in devastating vascular injury and possible stroke or death. Identification of underlying vascular pathology is essential for safe treatment and should be prioritized, especially considering this case.

http://bit.ly/2rResPa

Simulation‐Guided Tracheotomy in a Patient With Fibrodysplasia Ossificans Progressiva

Fibrodysplasia ossificans progressiva (FOP) is a rare disorder that causes heterotopic bone formation leading to chest wall and spinal deformities. This case describes an 11‐year‐old female with FOP who presented in respiratory failure necessitating two emergent fiberoptic nasotracheal intubations. The patient had severe trismus, rotary flexion of the neck, and distortion of the airway. A three‐dimensional printed model based off of a computed tomography reconstruction was created for an in situ simulation before the true procedure. The surgery and trach change were both uneventful. We propose that with careful preoperative planning, tracheotomy can be an appropriate option for FOP patients. Laryngoscope, 2018

http://bit.ly/2ShPqo5

Case Report and Literature Review of a Pathologic Mandibular Fracture from Metastatic Esophageal Adenocarcinoma

Distant metastasis to the jaws, including the maxilla or mandible, is very rare. Although the mandible is the preferred sight of these rare metastases, it is extremely rare for oral cavity malignancies to present as pathological mandibular fractures. Here, we present a case of esophageal adenocarcinoma metastasizing to the mandible, and the first reported case presenting with a pathological mandibular fracture secondary to esophageal adenocarcinoma. We also review the 9 other reported cases of metastatic esophageal adenocarcinoma to either the maxilla or mandible.

http://bit.ly/2ELBM9w