Category Archives: Otolaryngology

PUBLISHED: Transcervical Vocal Fold Injection (In-Office)

Transcervical Vocal Fold Injection (In-Office)
Seth M. Cohen, MD, MPHC. Scott Brown, MD
Duke University Medical Center

Vocal fold injection (VFI) is a treatment modality applicable to various laryngeal diseases and is successfully used as an alternative to laryngeal framework surgery. The indications for in-office VFI include vocal fold paralysis, paresis, atrophy, and scarring along with their sequelae. This video is a detailed demonstration of office-based VFI in a patient with unilateral vocal fold paralysis (UVFP), which is the most common neurologic disorder affecting the larynx.

PUBLISHED: Local Tissue Advancement: Reconstructing Superior Helical Rim Defect and Exposed Ear Cartilage After Mohs Surgery

Local Tissue Advancement: Reconstructing Superior Helical Rim Defect and Exposed Ear Cartilage After Mohs Surgery
Cheryl Yu, MD1Derek Sheen, MD2Katherine M. Yu, MD1Sarah Debs, MD1Peter Kwak, MD1Kevin J. Quinn, MD3Thomas Lee, MD, FACS1
1Virginia Commonwealth University Medical Center
2University of Texas Southwestern Medical Center
3Mass Eye and Ear/Harvard Medical School

Reconstruction of external ear defects often poses various challenges due to the complex anatomy of the ear and its significant role in overall facial aesthetics. The location of the defect independently impacts the repair as various locations present distinct, additional factors to consider during planning. Specifically, defects of the superior auricle complicate the reconstructive process, due to the role of the helical root and superior rim in providing mechanical support for facial accessories such as glasses or hearing aids. The approach to reconstruction must be systematic while also being individually tailored in order to appropriately restore both optimal cosmesis and function.

The featured case involves the reconstruction of a full-thickness superior helix and auricular defect in a patient who wears eyeglasses with a cochlear implant on the same side. The discussion highlights the complexity of superior auricular reconstruction as well as the various surgical options used and challenges encountered.

PUBLISHED: Neuronavigation and Endoscopy as Adjunctive Tools in Orbital Floor Implant Revision: Surgical Management of Infected, Misplaced Orbital Floor Implant with Chronic Eyelid Fistula and Sinusitis

Neuronavigation and Endoscopy as Adjunctive Tools in Orbital Floor Implant Revision: Surgical Management of Infected, Misplaced Orbital Floor Implant with Chronic Eyelid Fistula and Sinusitis
Derek Sheen, MD1Cheryl Yu, MD2Sarah Debs, MD2Katherine M. Yu, MD2Alyssa N. Calder, MD2Kevin J. Quinn, MD3Dimitrios Sismanis, MD4Thomas Lee, MD, FACS2
1University of Texas Southwestern Medical Center
2Virginia Commonwealth University Medical Center
3Mass Eye and Ear/Harvard Medical School
4Virginia Oculofacial Surgeons

Orbital floor fractures represent common sequelae of facial trauma that may result in significant functional and aesthetic consequences. This article presents a comprehensive overview of the management of a revision case involving an orbital floor fracture, focusing on complications related to extruded, infected orbital hardware. In addition, common mistakes that involve improper placement of orbital floor implant, poor implant sizing, and lack of adequate implant fixation are discussed.

The featured case involves delayed wound healing and a sino-orbital cutaneous fistula (SOCF) due to infected orbital hardware from a previous orbital floor fracture repair. The discussion centers on preoperative planning, including the choice of surgical approach (transconjunctival with lateral canthotomy) and implant material. Intraoperative neuronavigation was utilized as an adjunctive tool to confirm the position of the newly placed orbital implant. This case provides valuable insight on preventable complications for this procedure, nuances in surgical approach, and uncommon challenges faced by providers who perform operative facial trauma repair.

PUBLISHED: Mastoidectomy

Mastoidectomy
David M. Kaylie, MD, MS1Adam A. Karkoutli2C. Scott Brown, MD1
1Duke University Medical Center
2Louisiana State University Health Sciences Center – New Orleans

Mastoidectomy involves the removal of bone and air cells contained within the mastoid portion of the temporal bone. Common indications for this procedure include acute mastoiditis, chronic mastoiditis, cholesteatoma, and the presence of tympanic retraction pockets. Mastoidectomy may also be performed as part of other otologic procedures (e.g. cochlear implantation, lateral skull base tumors, labyrinthectomy, etc.) in order to gain access to the middle ear cavity, petrous apex, and cerebellopontine angle.

The procedure involves dissecting within the confines of the mastoid cavity, which include the tegmen superiorly, the sigmoid sinus posteriorly, the bony ear canal anteriorly, and the labyrinth medially. Mastoidectomy is traditionally classified as: simple (cortical/Schwartze), radical, and modified radical/Bondy’s mastoidectomy. The procedure can also be classified based on the preservation of the posterior canal wall: canal wall up (CWU) or canal wall down (CWD).

PUBLISHED: Cochlear Implant

Cochlear Implant
C. Scott Brown, MDCalhoun D. Cunningham III, MD
Duke University Medical Center

For patients who present with bilateral severe-to-profound sensorineural hearing loss who have little-to-no benefit from conventional hearing aids, cochlear implants can restore hearing by directly stimulating the cochlear nerve.

This video demonstrates the placement of a cochlear implant. A standard mastoidectomy and facial recess approach is performed to visualize the round window niche and membrane. The round window membrane is opened, and the cochlear implant electrode is carefully inserted into the scala tympani. After several weeks, the patient returns for implant activation with a dedicated team of audiologists.

PUBLISHED: Hypoglossal Nerve Stimulator

Hypoglossal Nerve Stimulator
Russel Kahmke, MD1Adam Honeybrook, MBBS1Clayton Wyland2C. Scott Brown, MD1
1 Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center
2 Lake Erie College of Osteopathic Medicine

Obstructive sleep apnea (OSA) is a common condition with several effective treatment strategies centered around relieving airway obstruction. The gold standard for OSA treatment remains continuous positive airway pressure (CPAP), but other options exist.

A recent therapy developed within the past decade utilizes hypoglossal nerve stimulation (HGNS) through a surgically implanted device. As the patient inspires, the device sends an electrical impulse similar to a cardiac pacemaker. The impulse activates targeted branches of the hypoglossal nerve, leading to stimulation of muscles that protrude the tongue and open the airway posteriorly. This mechanism has been shown to reduce airway obstruction by activating these muscles during inspiration.

Along with detailing the chronological order of events, this case outlines various complex anatomical structures that are identified in order to safely and effectively implant the hypoglossal nerve stimulator.

PUBLISHED: Anterior Skull Base Resection of Esthesioneuroblastoma (Endoscopic)

Anterior Skull Base Resection of Esthesioneuroblastoma (Endoscopic)
David W. Jang, MD¹; Ali R. Zomorodi, MD¹; Feras Ackall, MD¹; Josef Madrigal, BS²; C. Scott Brown, MD¹
¹Duke University Medical Center
²David Geffen School of Medicine at the University of California, Los Angeles

First described by Berger in 1924, esthesioneuroblastoma (ENB) remains a rare sinonasal tumor believed to originate from specialized sensory olfactory cells. To date, the literature includes 1,000 recorded cases of ENB. Patients with ENB often present with non-specific symptoms, most often chronic nasal obstruction or epistaxis. Careful examination may reveal a pink or brown polyploid mass in the nasal cavity. Overall, ENB may demonstrate various growth patterns ranging from slow, indolent progression to aggressive invasion with widespread metastasis.

Current literature indicates that ENB should be treated with a combination of surgical resection and postoperative radiation therapy with or without chemotherapy. However, significant controversy remains regarding the appropriate surgical approach. This video demonstrates a transnasal endoscopic approach, which has gained significant popularity over the previous two decades compared to classic “open” approaches. Although this approach demonstrates improved perioperative outcomes while still achieving oncologic margins, further work is required to evaluate long-term survival.

PUBLISHED: Laser Stapedotomy for Otosclerosis

Laser Stapedotomy for Otosclerosis
C. Scott Brown, MD; Calhoun D. Cunningham III, MD
Duke University Medical Center

Otosclerosis can lead to progressive conductive hearing loss, significantly affecting quality of life. For patients who choose surgery, the tympanic membrane is elevated, and the middle ear space is explored. If the surgeon confirms that the stapes is fixed in the oval window, either a stapedotomy or stapedectomy can be performed.

In the stapedotomy, the surgeon removes the stapes superstructure, creates a fenestration in the footplate, and places a prosthesis from the incus through the fenestration into the vestibule. In this instance, the patient was able to regain nearly all of the hearing that had been lost as a result of stapes fixation.

PUBLISHED: Endolymphatic Sac Decompression

Endolymphatic Sac Decompression
C. Scott Brown, MD; Calhoun D. Cunningham III, MD
Duke University Medical Center

Endolymphatic sac (ELS) decompression can be performed for patients with Meniere’s disease who have failed conservative treatment such as dietary changes and medical therapy. The full pathophysiological mechanisms that result in Meniere’s disease are not entirely understood. The variation in techniques for performing ELS decompression support this; there is no concrete data to justify one approach over another. Regardless, in the correct patient, ELS decompression can significantly alleviate the patient’s symptoms. To do so, a mastoidectomy is performed to expose the bony labyrinth as well as the bone overlying the sigmoid sinus. Decompression of the sac can be accomplished by removing overlying bone, incising the dura, or stenting the dura open.

PUBLISHED: Transmastoid Repair of Superior Semicircular Canal Dehiscence

Transmastoid Repair of Superior Semicircular Canal Dehiscence
C. Scott Brown, MD; David M. Kaylie, MD, MS
Duke University Medical Center

Superior semicircular canal dehiscence (SSCD) is associated with conductive hearing loss, autophony, and pressure/sound induced vertigo. Patients who are symptomatic may elect to undergo surgical intervention.

Here, Dr. Kaylie demonstrates the transmastoid approach to repairing SSCD. This approach affords the opportunity for an outpatient procedure to expose and plug the canal around the defect.