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  1. T or F?  In fixation of NOE fractures, when placing a transnasal wire for fixating the medial canthus, if the wire is placed too anteriorly it can lead to worsened telecanthus
    True.

    • Proper position of transnasal wire:
    • AP position of transnasal wire
    • NOE fractures often result in a lateral splaying of the medial canthi, resulting in telecanthus. This can often be corrected by placement of a transnasal wire.  When confronted with a NOE fracture requiring a transnasal wire, it is important to place the wire fixation in its proper posterior position. The upper illustration represents a wire that has been placed anteriorly, resulting in a further lateral splaying of the bone supporting the medial canthus, and a worsening of the telecanthus.  The lower illustration represents the proper posterior placement of the transnasal wire with a proper reduction of the bone attached to the medial canthus.
    • Image Upload

    • Horizontal position of transnasal wire
    • As much as the AP projection of the medial canthi is important, the horizontal position of the canthi is also very important.  In many cases the lateral canthi appear to be cephalad to a horizontal line through the medial canthi, while the eyelids are open. With the eyelids closed and in a more relaxed position, the lateral canthi fall into more of a horizontal position with the medial canthi. A surgeon should attempt to position the medial canthi into a relative horizontal line with the uninjured canthi.

    Image Upload
  2. What is the most common etiology of otogenic temporal bone cerebrospinal fluid (CSF) leaks?
    Spontaneous idiopathic

    • The rate of spontaneous CSF otogenic effusion has increased over the past 25 years as the incidence of infections and iatrogenic trauma resulting in CSF otorrhea have decreased.  Son et al. reviewed their series of 45 patients with temporal bone CSF leaks, 33 of which were spontaneous.  The origin of spontaneous CSF effusion may be related to congenital anatomical defects such as enlarging microscopic arachnoid granulations ectopically present on aerated portions of the skull base.  These granulations cause cortical erosion and perforation of the dura mater over time.  A higher body mass index (BMI) has been suggested to be associated with spontaneous CSF effusion.  Many of these patients will also demonstrate an empty sella on MRI, which is characteristic of idiopathic intracranial hypertension. 
    • Spontaneous Cerebrospinal fluid effusion of the temporal bone: Repair, audiological outcomes, and obesitySon HJ, Karkas A, Buchanan P, Giurintano JP, Theodosopoulos P, Pensak ML, Samy RN. . Laryngoscope. 2014 May;124(5):1204-8.
  3. T or F?    The Bárány test is also known as caloric testing.
    True
  4. T or F?    When treating early laryngeal cancers, the use of cryotherapy along with standard laser techniques results in a statistically significant increase in survival.
    • False.  Cryotherapy does not improve survival in these patients. 
    • The Use of Cryotherapy for Papilloma and Early Laryngeal CancersLong-term ResultsMichael S. Benninger,  Adeeb Derakhshan,  Claudio F. MilsteinStudy
    • Design: Retrospective chart review.
    • Objective: To determine the efficacy of adjuvant cryotherapy in the treatment of early glottic cancer and laryngeal papillomatosis.
    • Summary of Background Data: The use of cryotherapy in conjunction with traditional modalities has recently been proposed to improve voice outcomes in patients with early laryngeal cancer as compared to pretreatment conditions. This study investigates its utility in improving oncological outcomes and decreasing recurrences of laryngeal papillomatosis.
    • Methods: Patients with either early glottic cancer or laryngeal papillomatosis that received cryotherapy as part of their surgical regimen were investigated. All patients were seen at a large tertiary care center within a 10-year window. Demographic data were collected and all postoperative notes were reviewed. Recurrences of the laryngeal cancer were noted, as was the duration of time between successive papillomatosis operations.
    • Results: The charts of 54 glottic cancer and 29 papillomatosis patients that received cryotherapy were reviewed. One patient from the papillomatosis cohort was excluded from statistical analysis due to lack of follow-up. Overall, 16 (30%) of the laryngeal cancer patient experienced a malignant recurrence. The overall 5-year survival of these patients was 98% and the 5-year disease-free survival was 74%. The use of adjuvant cryotherapy in the treatment of laryngeal papillomatosis extended the duration of time between surgeries by an average of 79 days (P = .23).
    • Conclusion: The use of adjuvant cryotherapy in the treatment of early glottic cancer does not improve the rate of carcinoma recurrences. Additionally, cryotherapy does not result in a statistically significant increase in the duration of disease-free period for laryngeal papillomatosis patients, although the observed increase may be clinically important.
  5. Which of the following is NOT true concerning the use of octreotide in patients with chyle fistula? 
    A.   It is useful for low output fistulae
    B.   It is not useful for high output fistulae
    C.   Most fistulae close within 1 week of starting octreotide
    D.   Side effects are minimal
    • Answer:  B.   It is not useful for high output fistulae 
    • Actually according to the following study, octreotide works equally well on low and high output fistalas, closing most within one week with minimal side effects.

    • A prospective study on the role of Octreotide in management of chyle fistula neck
    • Avani Jain MD, Shashank Nath Singh MD,Pawan Singhal MD, Man Prakash Sharma MD and Mohnish Grover MD
    • The Laryngoscope Volume 125, Issue 7, pages 1624-1627, July 2015


    • Objective:   To study the effectiveness of octreotide in managing chyle fistula neck and its effect on duration of hospitalization.
    • Study Design:   Prospective study.
    • Methods:   A total of 19 patients with chyle fistula following neck dissection over a period of 10 years were included in the study. All the patients first underwent conservative management of the chyle leak, including suction drainage, pressure dressings, bed rest, and nutritional modifications. In all of the cases, chyle leak persisted despite conservative management. Octreotide was started in a dose of 100 µg subcutaneously every 8 hours for 5 days in cases with low-output leaks and for 7 days in cases with high-output leaks. In all of the cases, the duration of chyle leak after starting treatment with octreotide and the duration of hospitalization was recorded.
    • Results:   Chyle leak stopped in all the cases using octreotide. The mean duration of hospitalization was 13.8 days.
    • Conclusion:   Chyle leak stopped within 5 days of starting octreotide in the low-output cases and within 7 days in the high-output cases. This permitted early resumption of a regular oral diet and reduced morbidity associated with chyle fistula. The rapid response and minimal side effect profile make octreotide a promising addition to the medical management of a chyle fistula.

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