Otolaryngology–Head and Neck Surgery

Objective. To perform a systematic literature review that evaluates the impact of proton pump inhibitor treatment of gastroesophageal reflux disease on sleep disturbance–related outcomes.

Data Sources. PubMed, Web of Science, and Cochrane databases were searched from 1989 (when omeprazole became available) to present; additional references gleaned from citations.

Review Methods. The search strategy identified all randomized placebo-controlled clinical trials published in English; both proton pump inhibitor use and outcome measures of sleep disturbance were reported for esophageal reflux disease patients. Using a preestablished systematic review protocol and data extraction format, 4 coauthors independently reviewed all articles.

Results. The original search identified 20 articles; 9 were not directly relevant, and 3 were not placebo controlled. Sample sizes varied from 15 to 642; mean age was 47.4 ± 4.56 years; mean body mass index was 29.4 ± 2.9; the proportion of women varied widely across studies. Esomeprazole was studied most frequently. More than 50% of publications permitted rescue antacids. Two studies reported polysomnography outcomes, without statistically significant improvement. All studies reported non-polysomnography outcomes; 7 identified statistically significant improvements demonstrating drug treatment superiority over placebo.

Conclusion. The existing evidence supports the use of proton pump inhibitors as a treatment for esophageal reflux disease to improve quality-of-life sleep disturbance–related outcomes. Given the wide variability in proton pump inhibitor treatments and sleep disturbance–related outcomes reported, however, study-specific results cannot be directly compared or aggregated. This conclusion appears robust not only for 7 of 8 studies included but also for the 3 highest quality studies.

Context. Perioperative antibiotics are widely used to improve the outcomes of endoscopic sinus surgery.

Objective. The aim of this study was to summarize the evidence on the effect of perioperative antibiotic prophylaxis on outcomes of endoscopic sinus surgery.

Data Sources and Review Methods. We searched electronic databases from inception through May 2011 for any relevant clinical trials or observational studies. Two reviewers working independently extracted study characteristics, quality, and the outcomes of interest. Random-effects meta-analysis was used to pool the relative risks (RRs) and the standardized mean differences (SMDs) across trials.

Results. We found 4 eligible trials with varying quality, of which 3 were included in the quantitative analysis. Antibiotic prophylaxis was associated with a nonsignificant reduction in the incidence of infections (relative risk, 0.76; 95% confidence interval [CI], 0.64 to 1.09), symptoms scores (SMD, −0.04; 95% CI, −0.46 to 0.38), and endoscopic scores (SMD, −0.09; 95% CI, 0.30 to 0.13). The heterogeneity associated with the analysis was significant only for the outcome of change in symptoms score (I-squared values, 0%, 70%, and 0% for the 3 outcomes, respectively).

Conclusions. Trial data available to date are unable to demonstrate a statistically significant reduction in infection, symptom scores, or endoscopic scores to support the routine use of postoperative prophylactic antibiotics following endoscopic sinus surgery. Our analysis was limited by the number of published trials related to this topic.

In this evidence-based case report, we address the following clinical question: What is the predictive value of serological testing for Borrelia for diagnosing neuroborreliosis in patients with sudden sensorineural hearing loss? We searched for relevant articles in PubMed, Embase, and Web of Science. We retrieved 49 unique publications and screened the title and abstract of these articles for relevance. We included 2 of 12 studies initially considered relevant to answer our question. These 2 studies reported a seroprevalence of antibodies against Borrelia of 16% in patients with sudden sensorineural hearing loss (SHL) as compared with 13.5% in the general population, but in neither patients with definite neuroborreliosis were they found. To date, there is no evidence regarding the added value of routine diagnostic serologic testing for Borrelia in diagnosing neuroborreliosis in patients with sudden SHL. Neuroborreliosis seems to be a rare cause of sudden SHL, and routine screening of patients for borrelia antibodies in serum should therefore not be recommended.

In 2011, the US federal government implemented an oversight program to encourage the adoption and meaningful use of electronic health records (EHRs). Otolaryngologists may receive as much as $44,000 under Medicare or $63,750 under Medicaid as part of this law. To receive this full benefit, otolaryngologists must acquire a certified EHR and demonstrate stage 1 meaningful use requirements by the end of 2012. Furthermore, the Office of the National Coordinator for Health IT intends to advance meaningful use requirements to stage 2 (estimated to go in effect in 2014) and stage 3 requirements. This commentary discusses updated recommendations from the Academy of Otolaryngology—Head and Neck Surgery Medical Informatics Committee for implementing meaningful use of EHRs, receiving incentive payments, and preparing for potential stage 2 and stage 3 requirements.

Objective. To compare outcomes following osteocutaneous radial forearm and fibula free flap reconstruction of lateral mandibular defects.

Study Design. Retrospective case-controlled study.

Setting. Historical cohort study.

Subjects and Methods. All patients who underwent free flap reconstruction of lateral mandibular defects from 1999 to 2010 were included in this study. Patients were classified into 2 groups based on type of reconstruction: (1) osteocutaneous radial forearm (n = 73) and (2) fibula free flap reconstruction (n = 51). Patient characteristics, length of hospital stay, recipient and donor site complications, and long-term outcomes including postoperative diet were evaluated.

Results. Most patients were male (68%) and presented with advanced T-stage (71%) squamous cell carcinoma (94%) involving the alveolus (21%), retromolar trigone (23%), or oral tongue (21%). Median length of hospital stay was 8 days (range, 4-22 days). The recipient site complication rate approached 27% and included infection (n = 11), mandibular malunion (n = 9), exposed bone or mandibular plates (n = 9), and flap failure (n = 5). Most patients demonstrated little to no trismus following reconstruction (94%) and were able to resume a regular or edentulous diet (73%). No difference in complication rates or postoperative outcomes was seen between osteocutaneous radial forearm and fibula free flap groups (P > .05). One patient underwent dental implantation following osteocutaneous radial forearm free flap reconstruction. No patients from the fibula free flap group underwent dental implantation.

Conclusion. The osteocutaneous radial forearm and fibula free flap provide equivalent wound healing and functional outcomes in patients undergoing lateral mandibular defect reconstruction.

Objective. Solid silicone augmentation mentoplasty is a common procedure with consistent aesthetic results in properly selected patients. While many plastic surgeons employ the external approach, the intraoral method affords excellent aesthetic outcomes while avoiding an external scar. This is the largest series in the literature describing the midline intraoral incision approach with minimal disruption of soft tissues.

Study Design. Case series.

Setting. Academic medical center.

Subjects and Methods. One hundred twenty-five patients underwent chin augmentation with solid silicone implants between 2004 and 2010. Among these implants, 105 were placed transorally. Eighty-five patients were followed for at least 1 year. Demographic information, indications, patient satisfaction questionnaire results, and complications were recorded.

Results. All implants yielded satisfactory results with no displacement, infection, tissue reaction, lower lip incompetence, mental nerve injury, or intraoral implant contamination. Two cases of superficial mucosal irritation at the suture site were observed and resolved without consequence. Symmetry, projection, and overall balance of facial components were excellent. Although all patients were satisfied with the functional and aesthetic results, 20% stated they would like further augmentation. Patients were extremely satisfied with the lack of an external scar.

Conclusions. Based on our series, the intraoral technique with a midline incision avoiding disruption of the mentalis muscle is recommended for its ease, simplicity, patient satisfaction, low complication rate, and circumvention of an external scar. The external approach should be considered in cases that require a very large implant.

Objective. To investigate the prevalence of laryngopharyngeal reflux (LPR) symptoms in health checkup examinees and in patients with otitis media with effusion (OME) of undetermined etiology and the significance of age, body mass index (BMI), and pepsinogen (PG) concentration in middle ear effusions (MEEs).

Study Design. Cross-sectional study.

Setting. Health checkup and private clinics.

Subjects and Methods. A total of 410 subjects who had undergone a health checkup were asked to respond to the reflux symptom index (RSI) to identify the distribution of the RSI score, and the results were compared with 62 patients with OME by BMI and PG concentration in the MEEs.

Results. The RSI-positive (score >13) rate was 7.1% in the health checkup examinees. The highest rate was observed in men in their 40s, who had the highest average BMI. None of the men in their 80s were RSI positive. The RSI-positive rate in patients with OME was 21.0%. None of the male patients ≥70 years of age were RSI positive, whereas the average PG concentration was significantly higher in this group.

Conclusion. The prevalence of LPR symptoms evaluated by the RSI was significantly higher in OME patients than in the health checkup examinees; however, a similar pattern in which LPR symptoms were prominent in middle-aged men with a high BMI and much less in elderly men was observed. Middle-aged men with a high BMI might be diagnosed as having LPR disease based on the relevant symptoms. LPR findings would be more sensitive than symptoms in elderly men.

Objectives. Control of perioperative infection can increase the success rate of organ transplant. The incidence, clinical features, and optimal management of chronic otitis media (COM) in solid organ transplant recipients have not been adequately evaluated. We therefore assessed the incidence and clinical course of COM in solid-organ transplant recipients.

Design. Case series with chart review.

Setting. Tertiary referral center.

Subjects and Methods. We reviewed the medical records of 3278 patients who underwent solid organ transplantations between February 1995 and December 2007 to identify those diagnosed with COM before and after transplant. We analyzed the long-term clinical course and management of COM in these patients.

Results. Of 3278 solid organ transplant recipients, 65 (2.0%) were diagnosed with pretransplant COM with a perforated ear drum, including 31 liver, 28 renal, and 6 heart transplant recipients. The primary symptom was otorrhea, followed by hearing disturbance, otalgia, and tinnitus. Middle ear swab culture showed bacterial growth in 17 of the 40 patients (42.5%) with suppurative COM. Of these 40 patients, 14 underwent tympanomastoid surgery (operation group) and 26 were prescribed antibiotics (medication group). The remaining 25 patients, with dry perforated ear drums and well-pneumatized mastoids, were observed without treatment (observation group). After transplantation, the incidence of otorrhea was significantly lower in the operation group (11.1%) than in either the medication (26.9%) or observation (26.7%) group (P = .040, .048, respectively).

Conclusions. Precise diagnosis and proper surgical intervention for COM may reduce the rate of otorrhea and exacerbation of COM in solid organ transplant recipients.

Objective. No study has done a comparative analysis of radiologic imaging findings between primary nasopharyngeal lymphoma (PNL) and nasopharyngeal carcinoma (NPC). The purpose of this study was to analyze computed tomography (CT) and magnetic resonance (MR) images and to evaluate the maximum standardized uptake value (SUV max) of positron emission tomography (PET)/CT between PNL and NPC, knowing the imaging features that distinguish PNL from NPC.

Study Design. Cross-sectional study.

Setting. University tertiary care facility.

Subjects and Methods. The authors analyzed the features on CT, MR imaging, and PET/CT of 16 patients diagnosed with PNL and 32 patients diagnosed with NPC histopathologically.

Results. Patients with PNL had a larger tumor volume and showed symmetry of tumor shape than did patients with NPC. Patients with PNL also had higher tumor homogeneity than NPC patients on CT, T2-weighted, and postcontrast MR images. All PNL patients showed a high degree of enhancement without invasion to the adjacent deep structure. The involvement of the Waldeyer ring was significantly higher in PNL patients. Cervical and retropharyngeal lymphadenopathy and PET/CT SUV max showed no significant difference between PNL and NPC.

Conclusions. If the images present a bulky, symmetric nasopharyngeal mass with marked homogeneity, a high degree of enhancement, and a higher Waldeyer ring involvement combined with no invasion into the deep structure, PNL should be considered over NPC.

Objective. Transforming growth factor β1 (TGFβ1) promotes tumor growth and metastasis in the later stage of cancer development. In this study, we explored whether TGFβ1 polymorphisms were associated with increased risk of nasopharyngeal carcinoma (NPC) in a Chinese population.

Design. Case-control study.

Setting. Hospitals of the Department of Otorhinolaryngology–Head and Neck Surgery.

Subjects and Methods. Two single nucleotide polymorphisms of TGFβ1 gene promoter -509C/T (rs1800469) and 869T/C (Leu 10 Pro, rs1800470) at exon 1 were analyzed in 522 NPC patients and 712 age- and sex-matched controls in a Chinese population, using polymerase chain reaction–restriction fragment length polymorphism (PCR-RFLP) analysis. Functional relevance of the polymorphism was determined by biochemical assays.

Results. The -509T allele carriers were associated with a significantly reduced risk of NPC as compared with the noncarriers (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.53-0.89 and OR, 0.50; 95% CI, 0.31-0.67, respectively). Moreover, -509C-containing TGFβ1 promoter drove an ~1.7-fold increase in reporter expression, compared with the -509T-containing counterpart in both CNE-1 and CNE-2 cell lines. The TGFβ1 -509 CC genotype carriers had a higher TGFβ1 mRNA level than the TGFβ1 -509TT genotype carriers did (P < .01). However, no significant association was observed between the 869T/C polymorphism and risk of NPC.

Conclusion. These findings indicate that the -509C/T polymorphism in TGFβ1 may play a vital role in mediating individual susceptibility to NPC.

Objective. Total laryngectomy (TL) can be offered for management of chronic aspiration, radionecrosis, and/or airway compromise after head and neck cancer (HNC) treatment. The objective of this study was to evaluate functional outcomes after TL in disease-free HNC survivors.

Design. Retrospective case series with chart review.

Setting. The University of Texas MD Anderson Cancer Center.

Patients. Twenty-three disease-free HNC survivors who underwent TL for laryngopharyngeal dysfunction.

Intervention. TL ± pharyngectomy.

Main Outcome Measures. Post-TL swallowing-related (diet, gastrostomy dependence, and pneumonia rates) and communication outcomes.

Results. All patients who underwent TL for dysfunction were previously treated with radiotherapy (12/23, 52%) or chemoradiotherapy (11/23, 48%). Preoperative complications included aspiration (22/23, 96%), pneumonia (16/23, 70%), tracheostomy (9/23, 39%), and stricture (7/23, 30%); 17 patients (74%) required enteral/parenteral nutrition, and 13 of 23 (57%) were nothing per oral (NPO). Rates of pneumonia, NPO status, and feeding tube dependence significantly decreased after TL (P < .001). At last follow-up after TL, all patients tolerated oral intake, but 4 (17%) required supplemental enteral nutrition. Continued smoking after radiotherapy and a preoperative history of recurrent pneumonia were significantly (P < .05) associated with final tube dependence and/or diet level. Sixteen patients (70%) underwent tracheoesophageal (TE) puncture, and 57% (13 of 23) communicated using TE voice after TL.

Conclusion. Salvage TL may improve health status by significantly decreasing the rate of pneumonia and improve quality of life by restoring oral intake in patients with refractory laryngopharyngeal dysfunction after HNC treatment. TE voice restoration may enhance functional outcomes in select patients treated with elective TL for dysfunction.

Objective. Determine if completion lymph node dissection (CLND) is associated with improved survival in sentinel lymph node (SLN)–positive cutaneous melanoma of the head and neck (CMHN) patients.

Study Design. Retrospective analysis of large population database.

Setting. Surveillance, Epidemiology and End Results (SEER) database/multiple settings.

Subjects and Methods. Using the SEER database, the authors identified patients with SLN-positive CMHN. Clinicopathologic data and 5-year disease-specific survival (DSS) were examined for patients who underwent sentinel lymph node biopsy (SLNB) alone vs SLNB + CLND.

Results. Among 350 SLN-positive patients, 210 (60%) had SLNB + CLND, and 140 (40%) had SLNB only. Patients in the SLNB-only group were significantly older (median age 62 vs 53 years, P < .0001). The cohort as a whole did not significantly benefit from CLND; however, CLND was associated with improved DSS for a subgroup of patients age <60 years with nonulcerated tumors ≤2 mm thick (P = .03). Relative to SLNB alone, CLND did not improve survival for patients age ≥60 years or those with thicker (>2 mm) or ulcerated tumors.

Conclusions. Compared with SLNB alone, CLND does not seem to be associated with improved survival for most patients with SLN-positive CMHN. CLND likely improves survival for patients age <60 years with thin (≤2 mm) nonulcerated tumors and when there is a low risk of identifying positive non-SLNs.

Objective. Assess the impact of surgical margin CO2 laser photocoagulation (LPC) on disease local control in patients submitted to endoscopic surgery for early glottic cancer in comparison with subjects treated with laser cordectomy without borders LPC.

Study Design. Historical cohort study.

Setting. Regional referral cancer center.

Subjects and Methods. A total 281 patients with early glottic cancer (T1a, T1b, T2) were treated with endoscopic laser cordectomy according to the European Laryngological Society Classification between 1999 and 2006. Among the patients, 123 (treated between 2003 and 2006) were submitted to postresection LPC of surgical margins (group 1), whereas 158 (operated between 1999 and 2002) underwent laser cordectomy without margin LPC (group 2). Median follow-up was 51 months (range, 36-101 months).

Results. Local recurrence was found in 43 of 281 (15.30%) subjects (18 with T1a, 13 with T1b, 12 with T2). A significant difference in recurrence rate was found among patients treated with margin LPC in comparison with group 2 (P = .022). In particular, a lower recurrence rate in LPC patients was noticed in case of close (≤1 mm), nondefinable, and positive margins with infiltration of the superficial border. No significant difference was noticed in the case of negative edges (>1 mm) or involvement of either deep margin or both superficial and deep edges.

Conclusions. Surgical margin LPC increases disease local control in the case of close and superficial margin positivity. In such cases, no further treatment (surgical revision or radiotherapy) seems to be required in LPC patients. In case of deep border involvement, surgical revision or radiotherapy should be performed.

Objective. To evaluate the short-term outcomes of using cross-linked porcine collagen for vocal fold augmentation.

Study Design. Case series with planned data collection.

Setting. Tertiary referral hospital.

Subjects and Methods. Twenty consecutive patients of unilateral vocal fold paralysis (UVFP) were recruited, including 10 males and 10 females. All the subjects received videolaryngostroboscopic (VLS) evaluation for the glottic closure pattern, perceptual grading using the GRB scale (grade, roughness, breathiness), acoustic analysis, maximal phonation time (MPT), and Voice Handicap Index (VHI) questionnaire. Purified telopeptide-free, glutaraldehyde cross-linked porcine collagen was injected under local anesthesia with fiberscopic guidance.

Results. Treatment outcomes were evaluated 3 months after the injection. Fifteen (75%) of 20 patients reported complete resolution of symptoms, whereas the other 5 (25%) patients had substantial improvements. The median score of perceptual analysis of voice quality showed significant improvements from G2/R2/B2 to G1/R1/B0 (P < .001). Glottic closure pattern under stroboscopy had improved from “predominantly open” before the procedure to a “half-open and half-close” pattern after the procedure (P < .001). Acoustic analysis demonstrated significant improvements of jitter and normalized noise energy (P < .05). Maximal phonation time revealed a significant improvement from 7.5 ± 3.2 seconds to 13.1 ± 3.9 seconds (P < .01). The VHI had also decreased from 53 ± 25 points to 27 ± 20 points (P < .01). No patients had serious adverse events during the follow-up period.

Conclusion. This case series demonstrated that porcine collagen may be a suitable material for temporary vocal fold augmentation.

Objective. Postoperative external auditory canal (EAC) stenosis is the most common complication after congenital aural atresia (CAA) surgery. The authors applied an ear mold or hearing aid as an EAC stent following surgery and analyzed the impact on postoperative EAC stenosis.

Study Design. Historical cohort study.

Setting. A tertiary hospital.

Subjects and Methods. Ninety-six patients who underwent canaloplasty between 1996 and 2010 were included in this study. To discover factors contributing to postoperative EAC stenosis, clinical parameters, including age, sex, Marx grading, Schuknecht classification, Jahrsdoerfer score, surgical approach, triamcinolone injection, and use of stenting with an ear mold or hearing aid, were reviewed and analyzed. Each stent was used for at least 6 months postoperatively. Pure-tone audiometry was performed preoperatively and 3, 6, and 12 months after canaloplasty.

Results. Postoperative EAC stenosis was the most common postoperative complication, occurring in 8 (8.2%) cases with a mean time interval of 4.1 months. For patients who did not use an ear mold or a hearing aid during the postoperative follow-up period, the relative risk for the development of postoperative EAC stenosis was 5.125 (95% confidence interval, 1.428-18.400; P = .023). Other factors did not show an association with postoperative stenosis. Preoperative air-bone gap (ABG) was 49.00 dB, and closure of the ABG within 30 dB was obtained in 56.9%, 58.1%, and 48.7% of patients at the 3-, 6-, and 12-month follow-up, respectively.

Conclusion. Stenting with an ear mold or hearing aid might be a useful method for preventing postoperative EAC stenosis in CAA patients.

Objective. To evaluate the inner ear effects of canal wall down (CWD) mastoidectomy without ossiculoplasty in the treatment of chronic otitis media (COM) with regard to sensorineural hearing loss (SNHL) and reported tinnitus and dizziness-related disability.

Setting. Tertiary care academic medical center.

Subjects and Methods. Prospective study of 86 patients treated by CWD mastoidectomy without ossiculoplasty for COM with or without cholesteatoma. Standard patient workup included preoperative audiogram and completion of 2 surveys: Dizziness Handicap Inventory (DHI) and Tinnitus Handicap Inventory (THI). Patients underwent repeat audiogram, DHI, and THI surveys at 4 to 6 months postoperatively. Preoperative and postoperative data were analyzed.

Results. No significant SNHL occurred after CWD mastoidectomy. Thirteen patients (13/34 [38%]) had DHI improvement greater than 18 points, indicating a significant improvement in dizziness-related disability. Three patients developed new-onset postoperative dizziness complaints. Twenty patients (20/43 [46.5%]) had THI improvement greater than 7 points, indicating a significant improvement in tinnitus-related disability. Five patients developed new-onset postoperative tinnitus complaints. The odds ratio for improving DHI and THI scores after surgery was 6.6 (1.8 to 25.0) and 4.2 (95% confidence interval, 1.45% to 12.2%), respectively.

Conclusion. In this study, CWD mastoidectomy without ossiculoplasty in the treatment of COM did not cause significant SNHL. In addition, using the DHI and THI measures, patient-perceived disability from dizziness and tinnitus, respectively, was shown to decrease after mastoid surgery.

Objective. Cisplatin is a commonly used chemotherapeutic agent. One of its major dose-limiting side effects is ototoxicity. No treatment has yet been approved for this condition. The objective of this study was to determine the potential protective effect of a systemic administration of erdosteine against cisplatin-induced ototoxicity.

Study Design. A prospective controlled trial conducted in an animal model.

Setting. Animal care research facilities of The Montreal Children’s Hospital Research Institute.

Subjects and Methods. A total of 27 guinea pigs were assigned to 4 groups, each receiving a different concentration of intraperitoneal erdosteine: group 1 (control group; n = 9) did not receive erdosteine, group 2 (n = 6) received 100 mg/kg/d, group 3 (n = 6) received 200 mg/kg/d, and group 4 (n = 6) received 500 mg/kg/d. The animals in the experimental groups received the erdosteine injection daily for 4 days. All of the animals received 12 mg/kg of intraperitoneal cisplatin. Auditory brainstem response threshold shifts were measured at 4 frequencies (8, 16, 20, and 25 kHz) for all groups. Scanning electron microscopy and outer hair cell counts were performed to assess the protective effect of erdosteine.

Results. Significant protection was observed in groups 3 and 4 at 25 kHz. These findings are supported by outer hair cell counts by scanning electron microscopy.

Conclusion. A systemic administration of erdosteine appears to provide an otoprotective effect at high frequencies for cisplatin-induced ototoxicity.

Objective. To determine the role of intraoperative electrocochleography to optimize the fitting of the floating mass transducer of the Vibrant Soundbridge on the round window membrane in patients with conductive and mixed hearing loss.

Study Design. Prospective cohort study.

Setting. Tertiary referral center, Otolaryngology Department, University of Verona, Verona, Italy.

Subjects and Methods. Twenty-six adult patients suffering from chronic otitis media with moderate to severe conductive and mixed hearing loss, all with previous unsuccessful functional surgery, underwent round window vibroplasty. Thirteen subjects had intraoperative compound cochlear action potentials measured to assess vibroplasty coupling during and after surgery. In these patients, surgery was modified according to electrocochleographic feedback. The other 13 had vibroplasty without electrocochleography monitoring.

Results. The average preoperative air conduction and bone conduction thresholds (0.5-4 kHz) were not statistically significantly different between the 2 cohorts (P > .05). Compound action potential recordings indicated specific surgical modalities to optimize coupling of the floating mass transducer with the round window membrane. The average postoperative Vibrant Soundbridge–aided air conduction threshold improvements (0.5-4 kHz) were 54.6 ± 8.9 and 41.7 ± 11.1 dB HL, respectively, in the monitored and unmonitored cohorts (P = .0032).

Conclusion. Improved round window vibroplasty outcomes are observed when the surgeon is promptly informed of the compound action potential changes induced by the floating mass transducer round window membrane vibroplasty and alters surgery accordingly. The key point for optimal coupling is a floating mass transducer in full contact with the round window membrane, free to vibrate without any contact with the surrounding bony structures and mobile footplate.

Objective. Basic fibroblast growth factor (bFGF) promotes the regeneration of denervated nerves. The aim of this study was to evaluate the regeneration-facilitating effects of novel facial nerve decompression surgery using bFGF in a gelatin hydrogel in patients with severe Bell palsy.

Study Design. Prospective clinical study.

Setting. Tertiary referral center.

Subjects and Methods. Twenty patients with Bell palsy after more than 2 weeks following the onset of severe paralysis were treated with the new procedure. The facial nerve was decompressed between tympanic and mastoid segments via the mastoid. A bFGF-impregnated biodegradable gelatin hydrogel was placed around the exposed nerve. Regeneration of the facial nerve was evaluated by the House-Brackmann (H-B) grading system. The outcomes were compared with the authors’ previous study, which reported outcomes of the patients who underwent conventional decompression surgery (n = 58) or conservative treatment (n = 43).

Results. The complete recovery (H-B grade 1) rate of the novel surgery (75.0%) was significantly better than the rate of conventional surgery (44.8%) and conservative treatment (23.3%). Every patient in the novel decompression surgery group improved to H-B grade 2 or better even when undergone between 31 and 99 days after onset.

Conclusion. Advantages of this decompression surgery are low risk of complications and long effective period after onset of the paralysis. To the authors’ knowledge, this is the first clinical report of the efficacy of bFGF using a new drug delivery system in patients with severe Bell palsy.

Objective. (1) Characterize risk factors for subsequent tonsillectomy in pediatric patients undergoing primary adenoidectomy for upper airway obstruction. (2) Compare rates of subsequent tonsillectomy between adenoidectomy patients with and without upper airway obstruction.

Study Design. Historical cohort study with a nested case-control study. Cohort data were analyzed using Kaplan-Meier plots and a multiple regression model. Case-control data were analyzed using logistic regression.

Subjects and Methods. Patients undergoing adenoidectomy without tonsillectomy at the University of Missouri between 1995 and 2010 were identified using billing records and selected chart review. A nested case-control study with detailed chart review was conducted to determine predictors of subsequent tonsillectomy in patients with upper airway obstruction.

Results. Of 1291 patients identified in the historical cohort, 7.8% later underwent tonsillectomy. Age younger than 3 years (P = .027), female sex (P < .0001), and upper airway obstruction (P = .001) were found to be significant predictors of subsequent tonsillectomy. In the nested case-control study, potential predictors investigated included adenoidectomy indications, symptoms, smoke exposure, weight, comorbidities, and tonsil size at the time of adenoidectomy. Of these, only tonsil size was significant, with an increased odds of future tonsillectomy of 2.5 (P = .01) for each unit increase in tonsil size.

Conclusion. Patients undergoing adenoidectomy for upper airway obstruction are likely to be at an increased risk of subsequent tonsillectomy when compared with those with other indications. Within this subgroup of patients with upper airway obstruction, young age, female sex, and large tonsil size may further increase the risk of subsequent tonsillectomy.

Objective. To understand the epidemiologic antibiotic treatment patterns and the potential impact of race and insurance status on the medical management of acute otitis media (AOM).

Study Design. Cross-sectional analysis of a national database.

Setting. National ambulatory care setting.

Methods. Cases of isolated AOM in children ≤16.0 years were extracted from the National Ambulatory Medical Care Survey (2006-2008). The frequency and type of antibiotic prescribed were extracted. A multivariate logistic regression model incorporating age, sex, race, ethnicity, and insurance type was used to determine the influence of these demographic variables on antibiotic prescribing patterns.

Results. A total of 15.8 ± 1.5 million cases of AOM were studied (mean age, 3.6 ± 0.3 years; 55.1% ± 2.9% male). Of the children, 15.0% ± 2.8% were Hispanic and 10.4% ± 3.1% were black. Medicaid/State Children’s Health Insurance Program and private insurance covered 30.6% ± 4.4% and 69.4% ± 4.4% of children, respectively. Overall, 83.1% ± 2.2% of children received an antibiotic prescription. The most commonly prescribed antibiotics were amoxicillin (6.5 ± 0.9 million), beta-lactamase inhibitors (2.6 ± 0.4 million), and third-generation cephalosporins (2.3 ± 0.4 million prescriptions). On multivariate analysis, insurance status, ethnicity, race, age, and sex did not influence the likelihood of an antibiotic being prescribed during the visit (P = .884, .909, .849, .102, and .931 respectively).

Conclusions. Most children receiving medical treatment for AOM receive an antibiotic prescription during their visit. Ethnicity, race, and insurance type do not significantly influence antibiotic prescribing rates for AOM, and nearly all patients have medical insurance.

Objective. Environmental tobacco smoke exposure in children increases the incidence of upper respiratory infections, chronic sinusitis, and chronic otitis media. This study investigated the effects of ex vivo and in vitro smoke exposure on dynamic ciliary beat frequency (CBF) in pediatric adenoid explants.

Study Design. Blinded and controlled prospective study.

Setting. Tertiary care pediatric hospital.

Subjects and Methods. Fifty-five children undergoing adenoidectomy for obstructive sleep apnea and adenotonsillar hypertrophy were enrolled in this study. Adenoids were surgically removed using currettage. Hair was collected for nicotine analysis. Tissue was sectioned into 1-mm strips and allowed to equilibrate in DMEM/F12 with 2% fetal bovine serum for 24 hours. Cilia-bearing explant tissues were treated with either DMEM/F12 media, 5% cigarette smoke extract (CSE), or 10% CSE for 24 hours. Cilia were then stimulated using either isoproterenol (10⁻⁹ M) or methacholine (10⁻⁶M), and CBF was serially recorded using the Sisson-Ammons Video Analysis (SAVA) software.

Results. Children with hair nicotine levels ≥1 ng/mg consistent with secondhand smoke exposure display blunted dynamic CBF response ex vivo. Explants incubated with CSE in vitro demonstrate significant impairment of isoproterenol and methacholine-induced CBF.

Conclusion. CBF of adenoid explants increases when stimulated with isoproterenol and methacholine. Ex vivo and in vitro smoke exposure blunted ciliostimulation of CBF in adenoid explants. Smoke exposure impairs ciliary function in the pediatric airway and could potentially contribute to disorders such as chronic rhinosinusitis and chronic otitis media.

Objective. The Draf III procedure is an advanced surgical option for frontal sinus disease refractory to endoscopic frontal sinusotomy and is used to expose the anterior limit of resection of the skull base during endoscopic management of anterior skull base tumors. Our objective was to evaluate outcomes of a strategy using mucosal grafts to decrease postoperative closure.

Study Design. Prospective cohort.

Setting. Tertiary care facility.

Subjects and Methods. Patients requiring a Draf III procedure were prospectively enrolled in the study. Demographics, reason for the procedure, percentage graft viability, and complications were recorded. The primary outcome measure was anterior-posterior (AP) diameter at 3 months.

Results. Mucosal grafting was performed during 29 Draf III procedures from 2008 to 2011. Twenty-seven patients (average age, 58 years) were available for measurement at 3 months (average postoperative follow-up, 15.4 months; range, 3–30 months). Reasons for the procedure included tumor (n = 14), chronic rhinosinusitis (CRS) with frontal ostium stenosis (n = 12), and trauma (n = 1). Average intraoperative AP diameter was 11.7 mm. All patients met the definition of success (<50% reduction in diameter), maintaining a patent combined frontal sinus ostium for the duration of follow-up (average diameter 10.8 mm at 3 months). Nine patients with CRS and frontal ostium stenosis had openings similar to the entire cohort (>1-year follow-up; average, 19.3 months) with significant symptom reduction (SNOT-22 preop 62.3 ± 20.8 vs 3 months 27.8 ± 14.8 and 1 year 21.4 ± 13.6; P < .0001).

Conclusion. Cicatricial stenosis and osteoneogenesis are common following the Draf III procedure. This study indicates that the use of mucosal grafts may assist with postoperative stenosis and should be considered a routine strategy for preventing closure.

Objective. The aim of this study was to investigate the prevalence of biofilms and the effects of medical treatment modalities in chronic rhinosinusitis (CRS) patients without nasal polyps.

Study Design. Randomized controlled trial.

Settings. Tertiary referral hospital.

Subjects and Methods. The authors randomly divided 32 adult patients with CRS without nasal polyps into 2 groups. In the first group (n = 16), oral clarithromycin was administered 500 mg/bid for 2 weeks and then 250 mg/d for the following 6 weeks. In the second group (n = 16), an 8-week course of 200-mcg/d topical mometasone furoate was added to the clarithromycin regimen, identical to the first group. The pre- and posttreatment nasal tissue samples were evaluated by scanning electron microscopy for biofilm prevalence and graded from 0 to 3 according to density and extension.

Results. Biofilms were detected in 24 of 32 patients (75%) before the treatment (grades 1-3). Biofilms were detected in 14 of 32 patients (43.8%) after the treatment (grades 1-2). When each group was evaluated independently, there was a significant improvement after the treatment in both groups I and II. When the biofilm grades of group I were compared to those of group II, there was no significant difference both in the pre- and posttreatment evaluation.

Conclusion. The prevalence of biofilms in CRS without polyps was 75% in our study. Regression of biofilms to 43% was observed under medical treatment. Adding nasal steroids to macrolides gave no further benefit.

Lee DH, Lim SC. Sinonasal Sarcoidosis [published online ahead of print December 27, 2011]. Otolaryngol Head Neck Surg. doi: 10.1177/0194599811433277.

Fujii, Y, Itakura, M. Antiemetic Efficacy of Low-Dose Midazolam in Patients Undergoing Thyroidectomy. Otolaryngol Head Neck Surg. 2011;144:206-209. (Original doi: 10.1177/0194599810391728)