Otolaryngology–Head and Neck Surgery

To provide an up-to-date review of the literature on the safety and efficacy of the endoscopic technique for cerebrospinal (CSF) leak repairs.

PubMed, Medline/Old Medline, and Cochrane Central databases.

Using the above outlined data sources, studies involving the endoscopic repair of CSF leaks were reviewed independently by 2 researchers. Studies included met the following criteria: full-text article written in the English language, at least 5 human patients undergoing purely endoscopic surgical repair of a CSF leak, and documented follow-up. Data extracted included leak etiology, presentation and location, the use of imaging, intrathecal fluorescein, and adjunctive measures as well as the success rate of the repair.

Fifty-five studies, involving 1778 fistulae repairs, were included for analysis. Spontaneous leaks were most prevalent, with the ethmoid roof and sphenoid the most common sites involved. The overall success rate of repair was high at 90% for primary and 97% for secondary repairs. A low complication rate of less than 0.03% was reported.

The endoscopic repair of CSF fistula is both safe and effective and should be considered the standard of care for most cases. Evidence supporting adjunctive measures such as lumbar drains and antibiotics remains limited despite their common use.

Fractures of the hyoid bone are rare occurrences. They are mainly caused by strangulation/asphyxiation injuries, trauma to the neck, and motor vehicle accidents (MVAs). As a result of their rarity, proper treatment guidelines are not in place for dealing with these injuries. In this study, a systematic literature review was conducted with the goal of identifying optimal management for patients with fracture of the hyoid bone.

MEDLINE and PubMed databases.

The MEDLINE and PubMed databases were searched for patients diagnosed with hyoid bone fracture. Further cases were obtained from the bibliographies of relevant articles. Full-text articles were obtained. Patient presentation, method of diagnosis, treatment regimen, and outcomes are discussed.

Forty-six cases were collected from 36 articles. No randomized controlled trials regarding treatment of hyoid fractures were found. The most common etiologies were MVA, assault, and neck trauma during athletic activities. Most common presenting symptoms included dysphagia, odynophagia, and pain upon neck rotation. Most frequent presenting signs included anterior neck tenderness and swelling. Five cases out of 46 had surgical repair of the fractured hyoid bone. In the remaining 41 cases, 26 were treated with conservative management, which included rest/observation, diet changes, and analgesia, while the other 15 cases required tracheotomy or surgical treatment for related injuries. All patients survived and had excellent outcomes with resolution of symptoms.

This review shows that direct surgical treatment of hyoid fractures was performed in only 10.9% of cases. Both conservative and surgical management yielded positive outcomes.

To report on airway endoscopic findings and gastrointestinal and atopic conditions in a large consecutive series of atypical croup.

Case series with chart review.

Tertiary pediatric referral center.

A surgical database was searched for all children who underwent full airway endoscopy to investigate atypical croup. The primary outcome measure was the prevalence of large airway lesions in patients with atypical croup undergoing endoscopy. Demographics, secondary diagnoses, and rate of positive findings were documented. Age and atopy were correlated using Spearman’s correlation coefficient, and multivariate analysis identified predictors of large airway lesions.

Eighty patients were identified over a period of 8 years (58 boys; mean [SD] age 4.8 [3.8] years; range, 46 days to 13.7 years). Of the 80 children, 31 had positive airway findings, with 33 large airway lesions demonstrated, including 10 subglottic stenosis, 7 laryngeal clefts, 6 subglottic hemangiomas, 4 tracheomalacia, and 3 laryngomalacia. Esophagitis was diagnosed in 36 children, 5 of whom had eosinophilic esophagitis. Thirty-five children had an atopic condition including asthma, allergic rhinitis, eosinophilic esophagitis, and food allergies. Age correlated with associated atopy (coefficient 0.4, P < .0001) and predicted the presence of any airway lesion (coefficient −0.0625, P < .001) and subglottic stenosis in particular (coefficient −0.0362, P = .001). Prior intubation predicted subglottic stenosis (coefficient 0.267, P = .011).

Thirty-nine percent of airway endoscopies demonstrated large airway lesions. When eosinophilic esophagitis was sought, it was confirmed in over 1:10 patients. The findings bolster the case for airway endoscopy coupled with allergy and gastrointestinal investigations.

To explore the relationship between food hypersensitivity and common upper aerodigestive disorders found in children younger than 2 years.

Case control study.

Tertiary pediatric gastroenterology/otolaryngology clinics.

Two-year retrospective chart review of a common cohort of children younger than 2 years with suspected cow’s milk protein allergy (CMPA). Patients were managed in both a tertiary pediatric gastroenterology and otolaryngology clinic and compared with a control study group.

One hundred ninety-one children with CMPA were reviewed. One hundred forty-one had aerodigestive complaints, with 101 having sufficient follow-up to participate in the study. Ninety-one percent of this final patient group demonstrated improved symptoms following dairy elimination. Twenty-five patients (27%) had associated otolaryngologic (ear, nose, and throat [ENT]) issues that had been refractory to maximal gastroesophageal reflux therapy. The most common associated upper aerodigestive conditions were persistent upper airway congestion (72%) and oropharyngeal dysphagia (80%). Sixty percent of ENT disease improved with elimination diet. Eosinophilic esophagitis was noted in 36% of the cohort who had mucosal biopsies performed. Otolaryngology intervention was much more common in the cohort of children with CMPA compared with controls (odds ratio, 33.78; 95% confidence interval, 7.55, 151.03).

CMPA is difficult to diagnose because of limited accurate diagnostic tools, especially in young children. This study suggests a relationship between CMPA and otolaryngologic conditions in children younger than 2 years. Some patients in this study showed symptom improvement via an elimination diet. Early recognition of otolaryngologic manifestations of CMPA may help manage this condition in young children.

To determine the impact of age on disease-specific survival in differentiated thyroid cancer.

Retrospective analysis of a large population database.

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

The SEER database was examined to identify patients diagnosed with either papillary or follicular carcinoma of the thyroid between the years 1988 and 2003. Information obtained included patient age, sex, tumor type, size, extension, and nodal or distant metastases. Kaplan-Meier survival analyses were used to estimate disease-specific survival based on patient age range, and the log-rank test was used to assess for statistical differences between survival curves. A multivariate analysis was performed including the variables listed above to determine disease-specific hazard ratios of death for various age cutoffs.

A total of 42,209 patients were identified. Patients 45 years and older had significantly worse survival than younger patients (P < .0001). A significant decrease in disease-specific survival was first seen in patients aged 35 years and older, and survival continued to steadily decrease with each additional decade of age (P < .001). Patients aged 35 years and older were 14 times more likely to die from differentiated thyroid cancer than patients younger than 35 years.

Increasing age is associated with poorer survival in differentiated thyroid cancer. This relationship represents a continuum with an initial decrease in survival starting at age 35 years that continues to decline with further advancing age.

Patients considering surgery face many uncertainties and concerns. This investigation sought to develop an objective assessment tool for characterizing the areas of greatest concern among those considering thyroidectomy.

Prospective cohort design.

Tertiary-care otolaryngology practice.

Participants included individuals presenting with a thyroid nodule found to be of intermediate risk (15%-20%) of cancer based on fine-needle aspiration (FNA) biopsy and amendable to hemithyroidectomy.

As part of validating a clinical measure concerning perioperative concerns, patients presenting with thyroid nodules amendable to hemithyroidectomy were voluntarily recruited. Thirty individuals (6 men, 24 women) completed a novel 18-item questionnaire during their initial clinical visit and again 3 days later. Outcome measures included descriptive statistics and test-retest reliability.

Individual patients have both general and specific preoperative concerns. A wide range of responses was obtained across the entire spectrum of the survey. The questionnaire demonstrated fair-to-excellent test-retest reliability, with correlation values from 0.467 to 0.954. Between-rater reliability was consistent with intraclass correlation coefficient values of 0.52 to 0.86. No relationship between question order and patient response was identified. Women were found to be more concerned about scar appearance (P = .028), and men were conversely more concerned about resuming daily activities (P = .026).

Patients considering thyroidectomy have concerns that remain stable in the early preoperative period. This is the first study to evaluate preoperative patient concerns and preliminarily establishes the Western Surgical Concern Inventory–Thyroid as a means of ensuring adequate patient counseling and a method of evaluating preoperative patient education.

The purpose of this study is to determine if crawling wave elastography, a novel sonoelastography technique, can be used to provide quantitative measurements of thyroid tissue shear velocity (a measure of tissue stiffness) and distinguish between benign and malignant thyroid nodules.

Diagnostic test assessment.

Academic university.

Fresh thyroid specimens (n = 20) with 44 regions of interest were imaged ex vivo with crawling wave sonoelastography over a 9-month period in 2010 at a single institution. Using the sonoelastography technique, shear velocity estimations and contrast-to-noise ratios were calculated. The higher the shear velocity (SV) and contrast-to-noise ratio (CNR), the greater the tissue stiffness. Histological diagnosis was correlated with shear velocity and contrast-to-noise ratio values.

Both the shear velocity and contrast-to-noise values of papillary thyroid carcinoma (n = 10, CNR = 5.29, SV = 2.45 m/s) were significantly higher than benign nodules (n = 22, CNR = −0.41, SV = 1.90 m/s). There is a maximum sensitivity and specificity of 100% and 90.9%, respectively, for differentiating papillary thyroid carcinoma from benign nodules using contrast-to-noise ratio values. There is a maximum sensitivity and specificity of 83.3% and 72.7%, respectively, for differentiating papillary thyroid carcinoma from benign nodules using shear velocity values. Insufficient samples were obtained for comparison with other histological types.

Crawling wave sonoelastography can provide quantitative estimations of shear velocity, thereby depicting the elastic properties of thyroid nodules. The shear velocity and contrast-to-noise ratio can differentiate between benign thyroid nodules and papillary thyroid carcinoma with high specificity and sensitivity.

Tutoplast-processed fascia lata (TPFL) is a commercially available homograft that has been successfully used as graft tissue for rhinoplasty. The present study evaluates the histomorphological changes of TPFL in a rabbit rhinoplasty model.

Prospective study using a rabbit model.

Animal laboratory of the Asan Medical Center.

The study used 15 New Zealand White rabbits. Each rabbit was implanted with a TPFL (experimental group) and autologous fascia lata (control group) graft of equal size into the nasal dorsum. Rabbits were killed at 1, 3, and 6 months, and the grafts were removed and microscopically assessed for fibroblast proliferation, neovascularization, inflammation, and thickness.

For TPFL grafts, the degree of inflammation significantly decreased between 1 and 3 months (P = .041). The degree of fibroblast proliferation continually increased over time. There was a mild degree of neovascularization for the TPFL graft at 1 month. The degree of neovascularization increased between 3 and 6 months (P = .041). For the degree of inflammation, fibroblast proliferation, and neovascularization, there was no significant difference between TPFL and autologous fascia lata at 6 months. Mean thickness analysis showed that there was no significant thickness reduction in both TPFL and autologous fascia lata grafts at 6 months.

The TPFL grafts showed negligible resorption rates and favorable tissue reactions in the rabbit rhinoplasty model.

To determine the prevalence of unverifiable (“ghost”) publications in applications to an otolaryngology residency program through the Electronic Residency Application Service (ERAS), correlate with applicant characteristics, and determine if incidence changed after the addition of PubMed (PMID) numbers in 2008.

Cross-sectional study of residency applications before and after inclusion of PMID numbers at an academic otolaryngology program.

Applications for 2007 and 2008 were reviewed. Publications were verified against Medline, Google Scholar, PubMed, ISI Web of Science, and Google. Ghost publications were defined as journals, books, abstracts, or posters that could not be verified as presented, published, or including the applicant author.

In total, 489 applications were reviewed: 243 before PMID numbers were requested and 246 after. Of 2300 listed publications, 125 (5%) were not actual publications and 460 (20%) were in pending status. Forty-five percent (775/1715) could not be verified: 660 of 953 (69%) abstracts/posters, 18 of 47 (38%) chapters, and 97 of 715 (14%) journal articles. Abstracts/posters and book chapters were hardest to verify. The proportion of overall reported publications that could be verified was lower following the addition of PMID to the ERAS application (P = .0003), and the proportion of verifiable journal articles was unchanged from 86.0% to 86.9% (P = .62). Unlike previous findings, gender and medical school ranking were not associated with ghost publications.

A substantial number of publications, especially book chapters and posters/abstracts, listed on otolaryngology residency applications could not be verified. The addition of the PMID to applications did not reduce the number of ghost journal publications.

The purpose of this study was to assess the association between the Otolaryngology Training Examination (OTE) and the passage rate of first-time examinees on the American Board of Otolaryngology (ABOto) Written Qualifying Examination (WQE).

Historical cohort study.

De-identified database containing information on examinees who took the WQE in 2007 to 2011 and the OTE in 2005 to 2011.

One thousand three hundred nine otolaryngology residents took the WQE for the first time in 2007 to 2011 and the OTE in their final and penultimate years of training in 2005 to 2011. Data were analyzed using 1-way frequencies and table analysis. Logistic regression was used to model the relationship between the pass/fail WQE result and the OTE percentile score in the final and penultimate years of training. Data transformation was used to analyze WQE passage as a function of OTE scores by deciles and quartiles.

There is a significant relationship between OTE score and passage of the WQE on the first attempt. The probability of passing the WQE on the first attempt is 97% if the resident scores in the upper 3 quartiles of the OTE in the final and penultimate years of training compared with 70% if the examinee scores in the bottom quartile both years.

Residents who score in the bottom quartile in both their final and penultimate years of training are at significantly higher risk of failing the WQE on the first attempt. Remediation efforts should be focused on these individuals.

Understand (1) significance between minimum, mean, and maximum case numbers for otolaryngology resident surgical procedures; (2) weaknesses of Accreditation Council for Graduate Medical Education (ACGME) resident case log system contributing to inaccurate data/case inflation; and (3) when excessive case load may transform education into service.

Cross-sectional survey using a national database.

Academic otolaryngology residency programs.

Review of otolaryngology resident national data reports from ACGME resident case log system performed from 2004 to 2010. Minimum, mean, standard deviation, and maximum values for total number of resident surgeon cases and for specific surgical procedures were compared. Case unbundling, resident data entry habits, and tracked vs untracked Current Procedural Terminology (CPT) codes were reviewed.

Mean total number of resident surgeon cases remained constant (1699.5 ± 424.2 to 1772.2 ± 517). Minimum total number of cases ranged from 730 to 811 (approaching 2 standard deviations below the mean). Zero was reported as the minimum case number for some procedures. Maximum for total number of cases increased (3559 to 4857) and surpassed the mean by 4 to 5 standard deviations. Some procedures have maximums greater than 11 standard deviations above the mean. The authors identified untracked CPT codes and variations in resident case log documentation habits.

Large differences between the minimum, mean, and maximum resident surgeon case numbers exist. Establishing minimum case number requirements for otolaryngology residents should be considered. Educational benefit derived from excessive case load is unclear. Critical examination of the ACGME resident case log system and resident documentation habits is needed to improve accuracy of reporting.

Determine the frequency of, the characteristics predictive of, and potential associated survival benefit from sentinel lymph node biopsy in a population of patients with desmoplastic melanoma of the head and neck.

Analysis of a national database.

The 17-registry Surveillance, Epidemiology, and End Results (SEER) database.

Using the SEER database, the authors identified patients diagnosed with cutaneous desmoplastic melanoma of the head and neck between 2003 and 2007. Nodal metastasis and impact of sentinel lymph node biopsy on survival were determined.

The authors identified 467 cases of desmoplastic melanoma. Although most were locally advanced (median Breslow depth 3.5 mm), few had regional lymph node metastases (3.4%) or distant spread (3.2%) at the time of initial management. Of 165 patients who had sentinel lymph node biopsy, 5% had positive regional lymph nodes. Breslow depth, ulceration, age, and sex were not predictive of positive sentinel lymph node biopsy. Patients who had sentinel lymph node biopsy did not have different cause-specific survival from those who did not undergo sentinel lymph node biopsy.

Positive sentinel lymph node biopsies are rare in patients with desmoplastic melanoma of the head and neck. The low (5%) incidence of positive sentinel lymph node biopsy, coupled with the absence of identifiable survival benefit from its use, supports a more selective application of sentinel lymph node biopsy to this group of patients.

Nodal metastasis from oral tongue squamous cell carcinoma follows a predictable pattern. Isolated level IV involvement, termed skip metastases, is described. This study attempts to identify the incidence of skip metastasis.

Case series with chart review.

Tertiary academic hospital.

Fifty-two consecutive patients with T1 to T4 N0 stage who underwent excision of the primary tumor with neck dissection (levels I-IV).

Retrospective study. The incidence of isolated level III or IV involvement pathologically and isolated nodal recurrence in levels III and IV was analyzed.

Pathologically, isolated level III involvement occurred in 2 (3.8%) patients. Isolated level IV occurred in 1 (1.9%) patient. Mean follow-up was 24 months. Two patients had recurrence in the primary site; 1 had recurrence in neck level II. None had recurrence in level III or IV.

Skip metastasis is rare in T1 and T2 oral tongue squamous cell carcinoma. Inclusion of level IV is not mandatory in selective neck dissection for clinically and radiologically negative neck disease in early tumors (T1 and T2).

Determine if preoperative radiation therapy (RT) decreases the lymph node (LN) yield found at the time of neck dissection.

Cross-sectional analysis of Surveillance, Epidemiology, and End Results (SEER) database.

The SEER database was queried for patients presenting between 1998 and 2002 with tonsil, oropharynx, hypopharynx, and laryngeal primary lesions. Tabulation was made by LNs examined, type of neck dissection performed, and timing of RT. Data from 2441 patients were retrieved. Descriptive statistics were used.

One hundred sixty-one patients with RT preoperatively had a median of 20 LNs sampled (0-72). In total, 647 patients receiving no RT had a median of 27 LNs examined (0-88), and 1643 patients receiving RT postoperatively had a median of 29 (0-89). Mann-Whitney P = .02 was derived for RT preoperatively compared with no RT/RT postoperatively.

In the head and neck, preoperative RT contributes to lower neck dissection LN yield.

There is a lack of consensus regarding the causes of the differences in the higher incidence of and the mortality from head and neck squamous cell carcinoma (HNSCC) in African Americans (AA) versus Caucasian Americans (CA). We examined a comprehensive array of risk factors influencing health and disease in an access-to-care, racially diverse, primary HNSCC cohort.

Cross-sectional study.

Primary care academic health care system.

The cohort of 673 patients comprised 391 CA and 282 AA (42%). Risk variables included demographic, histopathology, and clinical/epidemiologic factors. Tumor DNA was interrogated for loss and gain of 113 genes with known involvement in HNSCC/cancer. Logistic regression for univariate analysis was followed by multivariate modeling with determination of model predictability (c-index).

Of the 39 univariate differences between AA and CA, multivariate modeling (c-index = 0.81) retained 7 differences (P < .05). AA were less likely to be married and more likely to have tumor lymphocytic response, undergo radiation treatment, and smoke. Insurance type was a significant predictor of race. AA were more likely to have Medicaid, Medicare, and other HMO types. AA tumors were more likely to have loss of CDKN2A and gain of SCYA3 versus CA.

Multivariate modeling indicated significant differences between AA and CA HNSCC for histopathology, treatment, smoking, marital status, type of insurance, and tumor gene copy number alterations. Our data reiterate that for HNSCC, as in the case of other complex diseases, tumor genetics or biology is only one of many potential contributors to differences among racial groups.

To investigate common treatment approaches of general otolaryngologists for adult dysphonic patients without obvious laryngeal anatomic abnormalities.

Cross-sectional survey.

General otolaryngology community.

One thousand randomly chosen American Academy of Otolaryngology—Head and Neck Surgery general otolaryngologists were mailed a survey.

The response rate was 27.8%. Mean years in practice was 19.5. The most common treatments were proton pump inhibitor (PPI), referral to speech pathology, and stroboscopy. Muscle tension dysphonia, vocal fold nodules, and dysphonia of uncertain etiology were the most common reasons for voice therapy referral. Various forms of supraglottic compression and tender extralaryngeal muscles were identified as findings of muscle tension dysphonia. Response to once-daily PPI, laryngeal signs, and throat symptoms were the most common determinants for laryngopharyngeal reflux. When patients failed initial treatment, 58.2% refer for voice therapy, 46.9% obtain stroboscopy, and 33.3% extend or increase duration of PPI treatment.

Varied treatment approaches to adult dysphonic patients were identified. How practice patterns vary from best practice guidelines, affect patient outcome, and influence health care costs needs examination.

To analyze the grade of reflux and the behavior of the cricopharyngeal muscle (CPM) in patients with gastroesophageal reflux (GER) by means of electromyographic (EMG) analysis of CPM.

Prospective clinical study.

Istanbul Training and Research Hospital.

Motor unit potential (MUP) recordings and kinesiological recordings of CPM were performed using a concentric needle electrode during dry material swallowing and 3-, 5-, and 10-mL water swallowing. Twenty-four patients with GER were compared with 21 healthy volunteers.

GER was mild in 15 patients and moderate-to-severe in 9 patients. MUP recordings were normal in both groups during the preswallowing/postswallowing periods. Kinesiological investigations revealed that the number of patients who did not show a preswallow EMG burst had a positive correlation with the severity of reflux and the amount of liquid swallowed. Rebound bursts were observed in the patient and the control groups. Duration of preswallow and rebound bursts was similar in all groups. Duration of swallowing was shorter in mild GER patients compared with healthy volunteers and moderate-to-severe GER patients. Piecemeal deglutition during 10-mL liquid swallowing was higher in moderate-to-severe GER patients. We also found a positive correlation between the number of swallows and the severity of reflux.

Needle EMG of the upper esophageal sphincter was normal in GER patients. Kinesiological evaluations showed increased piecemeal deglutition and number of swallows that correlated positively with the severity of GER.

To investigate the hypothesis that prophylactic triamcinolone modulates acute vocal fold inflammatory and profibrotic signaling during acute phonotrauma.

In vivo rabbit phonation model.

Academic medical center.

Forty New Zealand white breeder rabbits were randomly assigned to 1 of 4 groups: control (no intervention), no treatment (30 minutes of raised intensity phonation), sham treatment (bilateral intralaryngeal triamcinolone acetonide injection at 0 µg/25 µL followed by 30 minutes of raised intensity phonation), or steroid treatment (bilateral intralaryngeal triamcinolone acetonide injection at 400 µg/25 µL followed by 30 minutes of raised intensity phonation). Quantitative polymerase chain reaction (qPCR) was used to investigate gene expression levels of cyclooxygenase-2 (COX-2), interleukin (IL)–1β, and transforming growth factor (TGF)–β1.

Results revealed a significant main effect for COX-2 (P = .002). Post hoc testing revealed that rabbits receiving no treatment (15.10) had higher COX-2 gene expression than control (5.90; P < .001). There were no significant differences in COX-2 expression between treatment groups. Results revealed a significant main effect for IL-1β (P < .001). Post hoc testing revealed that rabbits receiving no treatment (14.70) had higher IL-1β gene expression than control (6.30) (P = .001). There were no significant differences in IL-1β gene expression between treatment groups. There were no significant differences in TGF-β1 gene expression (P = .525) between treatment and control groups.

Given conflicting evidence, further studies are necessary to investigate vocal fold steroid injections prior to and following the induction of phonotrauma. Prophylactic administration of triamcinolone immediately prior to acute phonotrauma resulted in no significant changes in COX-2, IL-1β, and TGF-β1 gene transcript levels.

The purpose of this study was to compare the efficacy of the treatment of tinnitus with a phase-shifting pure tone to that of the same tone treatment without phase shifting.

A double-blind crossover randomized controlled trial.

This study was conducted at the University Medical Center Groningen.

Twenty-two patients with predominantly tonal tinnitus underwent both intervention and control treatments. Each treatment consisted of three 30-minute sessions in 1 week. The control treatment was identical to the intervention treatment, except that the stimulus was a pure tone without phase shifting. Questionnaires, tinnitus loudness match, and annoyance and loudness ratings were used to measure treatment effects.

Pure-tone treatment and phase-shift treatment had no significant effect on tinnitus according to questionnaires (Tinnitus Handicap Index, Tinnitus Reaction Questionnaire, Hospital Anxiety and Depression Scale, and Maastricht Questionnaire), audiological matching procedures, and loudness and annoyance ratings of tinnitus. Furthermore, phase-shift treatment showed no additional significant improvement in comparison with pure-tone treatment. Changes in questionnaire scores due to pure-tone and the phase-shift treatment were correlated.

On average across the group, both treatments failed to demonstrate a significant effect. Both treatments were beneficial for some patients. However, a positive effect was not demonstrated that could be attributed to the periodic shifting of the phase of the stimulus tone.

To establish clinically derived indications for performing canal wall-up or canal wall-down surgery when treating children with cholesteatoma.

Case series with chart review.

Tertiary care academic pediatric otolaryngology practice.

Retrospective review of 420 children who underwent 700 procedures for cholesteatoma between 1996 and 2010.

The canal wall was preserved in 89.5% of cases. Common reasons for removing the canal wall were to provide access to the disease, extensive erosion of key structures, and the desire to avoid further surgery. The mean pure-tone average (PTA) for the canal wall-up group was 30 dB, whereas the canal wall-down group had a mean PTA of 45 dB. A matched-pairs analysis demonstrated that the better performance of the canal wall-up group was independent of preoperative hearing levels. Furthermore, although the presence of the stapes did influence hearing results, the canal wall-up procedure yielded better results even when the condition of the stapes was taken into account. The number needed to treat with canal wall-up to prevent 1 case of hearing loss (ie, mean threshold >30 dB) would be around 6. The need for revision surgery was higher in the canal wall-up group (51%) compared with the canal wall-down group (21%).

In the setting of adequate follow-up and open access to surgical resources, most children with cholesteatoma can be managed with an intact canal wall technique. The authors believe that the better audiometric outcomes and easier postoperative care outweigh the need for revision surgery in this group.

To report the prevalence of anatomic variants on computed tomography (CT) in congenital aural atresia (CAA) and external auditory canal stenosis (EACS). Anatomic variants included inferiorly displaced/obstructing tegmen mastoideum, malleus-incus complex (MIC) directly lateral to stapes, facial nerve obstruction of oval window (OW) or middle ear, and incudostapedial joint (ISJ) angle.

Cross-sectional study.

Tertiary care children’s hospital.

An anatomic analysis of 130 CT scans (98 children, 32 bilateral) of CAA/EACS, performed by a blinded neuroradiologist. Both Jahrsdoerfer’s and new/modified anatomic considerations were graded in 32 atresiaplasty and 66 nonsurgical patients. Surgical data were analyzed for anatomic correlations related to surgical findings.

Prevalence of anatomic variants was as follows: 13% of the ears had mild inferior displacement of tegmen, 4% had a significantly obstructing tegmen, and 24% had MIC directly lateral to stapes. The facial nerve obstructed access to OW in 41% and middle ear in 21%. Six atresiaplasty patients were reported to have a large MIC obstructing stapes access with increased intraoperative difficulty in viewing and assessing the integrity and mobility of the ISJ and stapes. Five of these 6 (83%) were noted on CT scan. The mean ISJ angle was 101° (range, 51°-155°).

A large obstructing MIC increases difficulty of atresiaplasty. Awareness of the presence of these anatomic variants is an aid in teaching temporal bone anatomy and may possibly influence the decision regarding atresiaplasty.

To establish the efficacy of proton pump inhibitors (PPI) in the treatment of adenoid hypertrophy in children.

Randomized controlled double-blinded clinical trial.

Forty children, aged 2 to 12 years, with adenoid hypertrophy fulfilling the inclusion and exclusion criteria.

Patients were randomly allocated into 2 groups: one to be treated with oral Losec MUPS for a period of 2 months (treatment group) and the other to be given a low-dose vitamin C tablet for the same period (control group). The patients were reviewed on 2 occasions during the 2-month study period, during which endoscopy was performed to examine the adenoid glands to assess their size and the larynx to assess signs of reflux disease. Examination of tonsillar size was also performed.

There was a significant reduction in adenoid size in the treatment group, but the control group also demonstrated a significant reduction in adenoid size. Comparison between the 2 groups in terms of adenoid grade change between the first and second visits did not reveal any significant statistical difference.

The results of this study do not demonstrate any efficacy of PPIs for adenoid hypertrophy in children, and these drugs should not be used for this purpose.

To evaluate changes in infantile hemangioma tissue before and after propranolol therapy, using gray-scale and color Doppler ultrasound imaging.

Case series with chart review.

Tertiary pediatric hospital.

Medical records and image studies of head and neck infantile hemangioma patients treated with propranolol, identified in a quality improvement database, were reviewed. Patients with imaging before and at least 4 weeks following the initiation of treatment were included. Data collected included sex, age, location, and concurrent treatment. Student t tests were used to evaluate change in cutaneous lesion area, volume, and vessel density. Logistic regression was used to compare lesion area, volume, and vessel density.

Of the 177 patients identified, 19 met inclusion criteria. Fourteen of 19 were female, and 5 of 19 were older than 1 year. Mean lesion area change with treatment was 13.0 cm² (range, −2.8 to 28.9 cm², P = .05). Measured volume change was a mean of 10.3 cm³ (range, 1.5-19.2 cm³, P = .01). Mean vessel density change was 4.4 vessels per cm² (range, 2.5-6.3 vessels per cm², P < .01). Treatment decreased clinically determined hemangioma area proportionately less than gray-scale and color Doppler ultrasound measured lesion volume. Gray-scale and color Doppler ultrasound measured treatment response did not differ with sex, lesion location, or age at propranolol initiation.

Gray-scale and color Doppler ultrasound imaging of propranolol-treated infantile hemangiomas detected a significant reduction in lesion volume and vessel density. Patient age at propranolol treatment and concomitant corticosteroid use did not affect lesion volume change.

To add to the existing knowledge of endoscopic surgery for fronto-ethmoidal mucoceles and to determine factors that influence the outcomes of endoscopic surgery.

Case series with chart review.

University adult tertiary care institution.

A database of patients treated surgically for mucoceles of the paranasal sinus has been kept by the senior author since 1995. It was used to identify those who have had endoscopic surgery for fronto-ethmoidal mucoceles from 1995 to 2010. All adult patients with 6 months or more of follow-up were included. The database was reviewed and assessed for variables that may affect outcome after surgery.

Forty patients underwent 44 endoscopic procedures for treatment of fronto-ethmoidal mucoceles and the complications of surgery. The mean age was 46.3 years, and mean follow-up time was 74.9 months. Two patients had a history of head trauma. A total of 28 Draf IIa procedures, 13 Draf IIb, and 3 Draf III procedures were performed. Three patients had combined open approaches. Two patients had bilateral surgery, and 2 patients required revision surgery: 1 for restenosis after a Draf IIa procedure (1/28) and 1 for disease recurrence. Stenosis was found in a further 3 patients who had Draf IIb surgery (3/13).

The current series represents one of the largest for the endoscopic management of fronto-ethmoidal mucoceles. Endoscopic approaches are suitable for most mucoceles. The most common complication, restenosis of the frontal recess, was more likely following Draf IIb procedures (23%) than Draf IIa (3.6%) procedures.

Nitric oxide (NO) is produced in the respiratory tract with a major contribution coming from paranasal sinuses and the nose. The pathophysiological role of NO in the airways has been debated. The aims of this study were to measure fraction of exhaled NO (FENO), a validated marker of airway inflammation, in patients affected by nasal polyposis with and without asthma; to assess the importance of FENO measurement in detecting subclinical involvement of lower airways in patients with clinical rhinosinusal symptoms; and to clarify the impact of endoscopic surgical removal of polyps on airway inflammation.

The study was conducted at the O.R.L. Clinic and Clinical Pharmacology Unit, University Hospital Agostino Gemelli, Rome, Italy.

Prospective study.

Concentrations of FENO were measured with the NIOX system (Aerocrine, Stockholm, Sweden) by using a single-breath online method, according to the American Thoracic Society guidelines.

Compared with those in healthy subjects (15 [11-19] ppb, n = 15; P < .0001), FENO values were elevated in patients with nasal polyposis (41 [21-77] ppb, n = 43). There was no significant difference in FENO concentrations between asthmatic and nonasthmatic patients with nasal polyposis (P = .73). Concentrations of FENO in patients with nasal polyposis were decreased after surgery (64.2 [30.0-132.7] ppb vs 56.0 [26.4-73.8] ppb, respectively; P = .03).

The fraction of exhaled NO is elevated in the inflammatory process involving both the rhinosinusal district and lower airways, supporting the one-airway disease hypothesis.

Chronic sinusitis is the most prevalent chronic disease in the United States in adults aged 18 to 44 years, with approximately 250,000 operations performed annually. Although often successful, sinus surgery fails in greater than 15% of patients. Adhesion formation is a common complication and cause for subsequent revision surgery. Here, the authors evaluate a sprayable chitosan/starch-based sinus sealant and demonstrate its ability to reduce adhesion formation both in vitro and in 2 animal models.

Randomized, controlled, animal trials.

Academic medical center (fibroblast experiments) and animal laboratories (sheep and rabbit studies).

This sinus sealant was applied to human cultured fibroblasts obtained from surgically removed polyps to examine its ability to inhibit fibroblast migration and proliferation. The sinus sealant was applied to New Zealand White rabbits (n = 20) in an established cecal-sidewall abrasion model and to sheep (n = 10) in a sinus surgical adhesion model to examine its ability to reduce adhesion formation.

This sinus sealant inhibited migration and proliferation of human cultured fibroblasts and reduced the total adhesion score from 4.9 to 0.3 for a total reduction of 94% (95th percentile confidence interval [CI], 78%, 100%; P < .001) in a well-established rabbit cecal-sidewall model commonly used for adhesion testing. Moreover, this sealant reduced adhesion formation from 80% to 10% for a total reduction of 70% (95th percentile CI, 57%, 93%; P = .003) in a sheep sinus adhesion surgical model.

This chitosan-based sealant demonstrates promise for reducing adhesion formation in sinus surgery.

Describe the incidence, risk factors, and outcomes of postoperative vagal palsy in patients undergoing surgical excision of cerebellopontine angle (CPA) tumors.

Case series with chart review.

Academic tertiary care center.

One hundred eighty-one consecutive patients undergoing surgical excision of CPA pathology from January 1, 2008, to December 31, 2010, at Johns Hopkins Hospital. Postoperative unilateral vagal palsy was identified by laryngoscopy or videofluoroscopy, and clinical variables were collected from medical records.

Postoperative unilateral vagal palsy was identified in 19 of 181 (10%) patients. Vocal fold motion impairment (VFMI) in combination with pharyngeal palsy was more common than VFMI or pharyngeal palsy alone. Those with vagal palsy had a larger mean tumor size (30 mm) than those without vagal palsy (20 mm, P = .0002) and a significantly longer mean hospital stay (9 vs 5 days, P < .0001). Vagal palsy was not associated with tumor pathology, prior treatment (stereotactic radiation or prior surgery), or surgical approach (suboccipital craniotomy vs translabyrinthine approach). Significant rates of aspiration were observed in patients with vagal palsy (67%).

Voice and swallowing function can be affected by surgical excision of pathology of the CPA. Tumor size is an independent risk factor for postoperative vagal palsy, which in turn has important consequences for prolonged hospital stay, aspiration, and voice and swallowing impairment.

The infratemporal fossa (ITF) has historically been one of the most difficult regions of the skull base to access surgically. Available open approaches are complex, are associated with high morbidity, and do not always afford optimal visualization. Endoscopic access to the ITF improves visualization for management of many sinonasal and lateral skull base lesions involving this region. The purpose of this study is to evaluate a graduated multiangle approach for endoscopic access to this area using a cadaveric model.

Cadaveric study at an academic medical center.

Endoscopic dissection was performed on a total of 10 sides of 5 fresh cadaveric heads. Four different approaches to the ITF were studied: ipsilateral endonasal, endoscopically assisted Caldwell-Luc, contralateral endonasal via septotomy, and endoscopically assisted Gillies transtemporal. High-quality endoscopic pictures and high-definition videos of each technique were obtained in order to document the differences in access achieved with each approach.

The combination of the 4 different endoscopic techniques allowed complete access to all areas of the ITF. The endoscopically assisted Caldwell-Luc improved anteroposterior access, the contralateral septotomy approach resulted in excellent far lateral access, and the endoscopically assisted Gillies approach allowed posterosuperior visualization and instrumentation.

Endoscopic access to the ITF can be accomplished by each of the 4 methods described. A multiangle, graduated approach can provide surgeons the ability to customize surgical access depending on the location of a specific lesion within the ITF.

To share our experiences treating patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) with titratable thermoplastic (TPD) and custom-made mandibular advancement devices (MAD) and to compare these devices in terms of objective improvement and cure and treatment success (improvement/cure plus adherence at 6 months).

Case series with planned data collection.

Tertiary care center.

Patients with OSAHS who failed or refused both continuous positive airway pressure (CPAP) and surgery had a titratable oral appliance fitted. Patients were offered an office-fitted TPD or a custom-made dentist-fitted device. Assessment included pretreatment and appliance-titration polysomnography (PSG). Improvement was defined as ≥50% apnea-hypopnea index (AHI) reduction plus posttreatment AHI <20, and cure was defined as AHI <5. Patients were contacted at 1 and 6 months regarding treatment adherence.

A total of 180 patients (123 TPD, 57 custom) with complete PSG data were reviewed. Improvement/cure were significantly better with the custom device overall (91.2%/71.9% vs 77.2%/52.0%, P = .024/.012). Adherence data at 1 and 6 months were obtained from 128/180 and 119/180 patients, respectively. Using an intention-to-treat analysis, those lost to follow-up were considered nonadherent. Adherence at 1/6 months was 64.9%/50.9% for custom versus 53.7%/32.5% for TPD (P = .156/.018), yielding treatment success rates (with initial improvement/cure) of 49.1%/40.4% for custom versus 27.6%/17.1% for TPD (P = .005/<.001) at 6 months.

Custom-fit devices achieve higher rates of objective improvement and cure of OSAHS than TPD at the time of titration-PSG. TPDs have a high acceptance rate, low cost, and reasonable initial improvement and cure rates of 77.2% and 52.0%, respectively, but significantly poorer 6-month compliance.

Although adenotonsillectomy is the accepted treatment for obstructive sleep apnea (OSA) in the pediatric population, tonsillectomy has not been widely adopted in adults, and its success in this group has not been well reported. Despite the lack of current evidence, there may be an important role for tonsillectomy in selected adult cases, and further study is required. This is a pilot study from a larger group of subjects currently enrolled and awaiting surgery and repeat polysomnography.

Retrospective series with chart review.

Tertiary referral teaching hospitals.

Thirteen consecutive eligible subjects with tonsillar hypertrophy and OSA were identified after treatment. These patients had undergone pre- and postoperative polysomnography for assessment of the severity of sleep-disordered breathing. Post hoc analysis of key parameters was performed by Wilcoxon signed rank and paired t tests. Tonsillectomy was performed on all subjects, using the diathermy dissection technique. Nasal surgery was performed simultaneously in 11 subjects for symptomatic nasal blockage unresponsive to medical treatment.

There was a statistically significant improvement in the severity of OSA after surgery. The total Respiratory Disturbance Index (RDI) was significantly decreased from median values of 31.7 to 5.5 (P = .0002). The RDI in rapid eye movement and non–rapid eye movement sleep and the arousal index were also significantly decreased.

In selected adult subjects, tonsillectomy with intercurrent nasal surgery should be considered an effective treatment for OSA and may reduce the requirement for continuous positive airway pressure, oral appliances, or further therapeutic intervention.