Otolaryngology–Head and Neck Surgery

To identify and appraise the evidence for an association between laryngomalacia (LM) and acid reflux through a systematic review of the existing literature.

MEDLINE, EMBASE, the Cochrane Library, Google Scholar, and collected additional publications cited in bibliographies.

Literature search by both authors with structured criteria to select studies evaluated for systematic review. The Oxford Centre for Evidence-Based Medicine (CEBM) guidelines were applied to assess study quality of evidence.

Twenty-seven studies, representing 1295 neonates with LM, were included. Levels of evidence varied from CEBM level 2a (n = 1) to 4 (n = 23). Although reflux definitions were diverse, overall reflux prevalence in this group was 59% (pooled odds ratio [OR] of 4 controlled studies = 1.15, P = .67). Further evidence supporting an association between reflux and LM included the ubiquity of acid reflux using dual-probe pH monitoring in children with LM (2 studies; n = 84), the increased prevalence of reflux in severe as compared with mild LM (3 studies; n = 237; pooled OR = 9.86, P < .0001), case series and reports of LM improvement with antireflux therapy (6 studies; n = 275), and histological evidence of reflux-related laryngeal inflammation in children with LM (2 studies; n = 18).

The literature shows a coexistence between acid reflux and LM, but the evidence for a causal association is limited. In view of the widespread use of antireflux treatment in LM, a randomized controlled trial of antireflux medication vs placebo appears justified.

To systematically review literature pertaining to head and neck lymphatic malformation treatment and to use individual-level data presented in qualifying case series to describe the reported efficacy, complications, and functional impact of surgery and sclerotherapy. The authors evaluated whether treatment modalities differ by lymphatic malformation stage.

The terms lymphangioendothelioma, lymphangioma, cystic hygroma, and malformation were used to perform an Ovid literature search yielding 6292 references. The authors excluded references that did not involve head and neck lymphatic malformation treatment, include at least 5 patients, follow patients 1 year, define treatment modality, and state complications.

The authors summarized data from 1205 patients reported in 41 articles. Individual-level data, in the 29 articles reporting these data, were pooled and tabulated.

The absence of within-study comparisons of treatment success, as well as the range of reporting methods, precluded a formal meta-analysis. Most reports were case series (37; 90%). The primary treatment modality was sclerotherapy in 17 (41%), surgery in 16 (39%), or surgery combined with other modalities in 9 (20%). Individual-level data were captured for 283 patients. No treatment modality clearly resulted in superior treatment outcome. Complications were more frequent in surgical series but were reported inconsistently in sclerotherapy studies.

There is evidence that lymphatic malformation treatment can be done effectively with surgery or sclerotherapy, but further study is necessary to determine which is superior. Standardized guidelines for reporting lymphatic malformation case series do not currently exist, making comparison of treatment outcomes of differing treatment modalities difficult.

Injury to the recurrent laryngeal nerve (RLN) remains a significant cause of morbidity during thyroid surgery. Intraoperative nerve monitoring (IONM) is being applied in many centers to facilitate nerve identification. The aim of this study was to elucidate normative human vagal and recurrent laryngeal nerve electromyograhic (EMG) parameters during standard IONM application.

A prospective IONM study conducted over an 8-month period. Internal review board (IRB) approval was obtained.

Department of Otolaryngology, Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear Infirmary, Boston.

All patients who were scheduled for routine thyroid, parathyroid, or neck exploration surgery were invited to participate. All patients had a preoperative and postoperative laryngeal examination to assess vocal cord function. Any patient with an abnormal preoperative laryngeal examination was excluded.

Fifty-eight patients participated in this study. The right and left RLN latencies were similar. The left vagus latency was greater than the right vagus but was not significant. The RLN latency was significantly less than the vagus nerve. The right vagus nerve amplitude was significantly greater than the left. There was no difference between male and female amplitudes for either the RLN or vagus nerve.

This study highlights the electrophysiological/EMG differences and similarities between the RLN and vagus nerve. Normative amplitude measurements for bilateral RLN and vagus nerve stimulation are presented. There are limited data available in the literature on normal RLN and vagal EMG signals generated during thyroid surgery.

To quantify the incidence of occult thyroid cancer encountered during neck dissection in patients with head and neck squamous cell carcinoma (HNSCC), to discuss the management of these patients, and to assess the need for further treatment of the incidentally discovered thyroid cancer.

Case series with chart review.

University-based tertiary care hospital.

The authors retrospectively reviewed 2538 neck dissections performed at their institution over a 15-year period. Twenty-nine patients had an incidental pathologic finding of thyroid cancer at surgery. The authors reviewed demographics, diagnoses, histopathology, initial and subsequent management, and outcome.

Well-differentiated thyroid cancer (WDC) was found in every case in this cohort. Fifteen patients died during the period of the study (2.4-year follow-up), with 14 patients still alive (4.3-year follow-up). Seven patients, all of whom are still alive, received further treatment for their thyroid cancer: 2 with completion thyroidectomy, 2 with I-131 ablation, and 3 with both. There was no clinical evidence of recurrence of thyroid cancer in any of the patients who died, and none died as a result of thyroid cancer. In addition, none of the patients still alive have biopsy-proven evidence of thyroid cancer recurrence.

None of the patients in this cohort died as a result of their thyroid disease, and none of the patients had evidence of recurrence of their WDC during the follow-up period. The results suggest that further management of occult WDC discovered in patients receiving neck dissections for HNSCC is not necessary.

To investigate the efficacy of fibrin sealant (FS) for reducing postoperative drainage in patients who underwent total thyroidectomy (TT) with bilateral central neck dissection (CND) for papillary thyroid cancer.

Prospective randomized trial.

Tertiary care institution.

Seventy-eight patients with papillary thyroid cancer were enrolled and randomized to either the FS application group (FS+, 38 patients) or no FS application group (FS–, 40 patients). In both groups, postoperative drainage amounts were measured by a negative suction system until the criterion of drain removal was met. Drainage amounts as well as the time to drain removal, postoperative complications, and chemical profile assay of drain fluids between the 2 groups were performed.

Drainage amounts at the initial 24 hours as well as total amounts of the FS+ group tended to be lower than those of the FS– group; however, they were not statistically different (at initial 24 hours, 64.3 ± 17.5 mL vs 73.0 ± 18.0 mL, P = .06; total amounts, 93.5 ± 30.7 mL vs 105.7 ± 31.2 mL, P = .05). The FS application did not shorten the time to drain removal even when different criteria for drain removal were applied (criteria of <20 mL/d or <30 mL/d). When chemistry profiles of collected drain fluids were analyzed in patient subgroups, the level of triglycerides in the FS+ group was significantly lower than in the FS– group.

Fibrin sealant has no additional advantage in terms of drainage reduction and early discharge despite the additional medical cost.

(1) To show that extracellular matrix deposition in 3-dimensional culture of human septal chondrocytes cultured in a rotary bioreactor is comparable to the deposition achieved under static culture conditions. (2) To demonstrate that the biomechanical properties of human septal chondrocytes cultured in a bioreactor are enhanced with time and are analogous to beads cultured under static culture.

Prospective, basic science.

Research laboratory.

Human septal chondrocytes from 9 donors were expanded in monolayer and seeded in alginate beads. The beads were cultured in a rotary bioreactor for 21 days in media supplemented with growth factors and human serum, using static culture as the control. Biochemical and biomechanical properties of the beads were measured.

Glycosaminoglycan (GAG) accumulation significantly increased during 2 measured time intervals, 0 to 21 days and 10 to 21 days (P < .01). No significant difference was seen between the static and bioreactor conditions. Substantial type II collagen production was demonstrated in the beads terminated at day 21 of culture in both conditions. In addition, the biomechanical properties of the beads were significantly improved at 21 days in comparison to beads from day 0.

Human septal chondrocytes cultured in alginate beads exhibit significant matrix deposition and improved biomechanical properties after 21 days. Alginate bead diameter and stiffness positively correlated with GAG and type II collagen accretion. Matrix production in beads is supported by the use of a rotary bioreactor.

To describe the feasibility and initial results of the implementation of a continuous quality improvement project using the newly available Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS), in a small cohort of otolaryngology–head and neck surgery practices.

Prospective observational study using a newly validated health care consumer survey.

Two community-based and 2 university-based otolaryngology–head and neck surgery outpatient clinic practices.

Fourteen board-certified otolaryngology, head and neck surgeons from 4 practice sites voluntarily participated in this project. All adult patients scheduled for surgery during a 12-month period were asked to complete the S-CAHPS survey through an electronic data capture (EDC) system 7 to 28 days after surgery. The surgeons were not directly involved in administration or collection of survey data.

Three sites successfully implemented the S-CAHPS project. A 39.9% response rate was achieved for the cohort of surgical patients entered into the EDC system. While most patients rated their surgeons very high (mean of 9.5 or greater out of 10), subanalysis revealed there is variability among sites and surgeons in communication practices. From these data, a potential surgeon Quality Improvement report was developed that highlights priority areas to improve surgeon-patient rapport.

The S-CAHPS survey can be successfully implemented in most otolaryngology practices, and our initial work holds promise for how the survey can be best deployed and analyzed for the betterment of both the surgeon and the patient.

This study examined swallowing apnea duration (SAD) and respiratory phase patterns as a function of taste, tastes combined with barium, age, and genetic taste group.

Prospective group design.

University medical center.

Eighty healthy adult women were identified as nontasters and supertasters and equally comprised 2 age groups: 18 to 35 years (n = 40) and 60+ years (n = 40). The KayPentax Swallowing Signals Lab was used to acquire SAD and respiratory phase patterns via nasal cannula during randomized 5-mL swallows of water, 1.0 M sucrose (sweet), 1.0 M sodium chloride (salty), and 0.032 M caffeine (bitter) alone and mixed with barium. The SAD and respiratory patterns were analyzed in a linear mixed model and a binary logistic regression generalized estimating equation model, respectively.

A significant main effect of age was found (P = .007). Older women demonstrated longer SAD than younger women. There were no significant effects of taste or genetic taste group on SAD. There was a significant interaction between barium and supertaster status; SAD was shorter in supertasters when barium was included. There were no significant differences in respiratory patterns between age groups, genetic taste groups, or among taste stimuli.

Advanced age elicited longer SAD, a robust finding in repeated investigations from multiple laboratories. Main tastes did not affect SAD or respiratory phase patterns. Genetic taste group altered SAD when barium was combined with the taste. That is, taste + barium shortened SAD in supertasters. This finding may affect clinical management of dysphagia patients and warrants further investigation.

To examine whether the implementation of a multidisciplinary percutaneous tracheostomy team decreases complications, improves efficiency in patient care, and reduces length of stay and cost in patients undergoing percutaneous tracheostomy.

Case series with planned data collection.

Urban, academic, tertiary care medical center.

Patients who underwent a percutaneous tracheostomy in 2004 and 2008, before and after the formation of a multidisciplinary percutaneous tracheostomy team, were included in the study. Data for the study were retrieved from a tracheostomy database. Measured outcomes include complications, efficiency, length of stay, and cost.

Complications such as airway bleeding and physiological disturbances decreased significantly in 2008 as compared with 2004. The percentage of patients who received a tracheostomy within 2 days increased from 42.3% to 92% (2004 vs 2008), showing improvement in efficiency of care. There was no significant difference between the groups in terms of infection rate, length of stay, or mortality. However, in a subanalysis, the length of stay was found to be decreased in patients whose primary diagnosis was a neurological disorder. Finally, despite the necessity of a hospital-based subsidy, the team approach yielded substantial financial benefit to the medical center.

Airway bleeding, physiological disturbances, and efficiency of care improved after the institution of a multidisciplinary percutaneous tracheostomy team approach and may have a favorable impact on health care costs.

The role of ¹⁸F-fluorodeocyglucose positron emission tomography (PET)/computed tomography (CT) in only PET/CT–positive lymph nodes (LNs) is not well elucidated yet. This study was conducted to evaluate the diagnostic value of only PET/CT–positive LNs without correlating positive findings on conventional imaging modalities (CT, magnetic resonance imaging [MRI], and ultrasound [US]) in patients with head and neck squamous cell carcinoma (HNSCC).

Case series with chart review.

Hallym University School of Medicine.

From January 2006 to September 2009, 114 patients with HNSCC who underwent CT, MRI, US, and PET/CT before definitive surgery with neck dissection were reviewed. All imaging tests were interpreted on imaging-based nodal classification and were compared with histopathological findings.

Only PET/CT–positive LNs were found at 48 nodal levels in 33 patients. Thirteen of 48 (27%) nodal levels were true-positive (TP), and 35 of 48 (73%) were false-positive (FP). Fourteen nodal levels were included on N+ necks, and 34 were included on N0 necks. In N0 necks, the FP rate was significantly higher than the TP rate (28 vs 6, P = .034). Eleven only PET/CT–positive nodal levels in 10 patients were found on the contralateral neck side, and FP was significantly more prevalent than TP (8 vs 3, P = .041). No significant difference was observed for mean standardized uptake value and LN sizes between TP and FP.

Only PET/CT–positive LNs can frequently be found and do not predict LN metastasis, because a high percentage of results were FP. Our results suggest that only PET/CT–positive LNs should be considered negative, especially in N0 and contralateral necks.

To report the long-term significance of sentinel lymph node (SLN) biopsy on prognosis, determine false-negative SLN occurrences, and determine risk factors for death and recurrence in a large series of patients with head and neck melanoma.

Case series with tumor registry review.

Academic tertiary care medical center.

A database review was performed of all patients who underwent SLN biopsy for head and neck melanoma from 1994 to 2009. End points assessed were SLN status, recurrence, false-negative SLN results, and survival comparing SLN-positive and SLN-negative patients and different locations. Survival curves and multivariate analyses were performed.

SLN biopsy was performed in 365 patients. SLNs were identified in 98.6% of patients with a mean of 3.7 nodes removed from 1.6 nodal basins per patient. Median follow-up was 8 years. The SLN was positive in 40 (11%) patients. SLN–positive patients had significantly thicker melanomas, higher recurrence (P < .0001), and a significant decrease in overall survival compared with SLN-negative patients (P < .002). Scalp melanoma patients had significantly thicker melanomas and an elevated risk of SLN positivity, recurrence, and death compared with other sites. Seventeen of 365 SLN-negative patients developed regional nodal disease for a false-omission rate of 5.2% and a negative predictive value of a negative SLN to be 94.8%. Risks for false negative-SLN occurrences included thick melanomas and scalp melanomas.

SLN biopsy is accurate in head and neck melanoma and provides significant prognostic data. Scalp melanoma patients present with thicker tumors with an increase in SLN positivity and false-negative SLN occurrences.

The optimal type of neck dissection in head and neck squamous cell carcinoma (SCC) with clinical cervical metastases has not been determined. The following study was performed to determine the rate of regional control with selective neck dissection (SND) in these patients.

Case series with planned data collection.

Single institution, cancer center.

Patients with cervical lymph node metastases from mucosal cancers of the head and neck who were treated with SND from 2000 to 2010 were selected. Demographics, tumor characteristics, extent of neck dissection, adjuvant treatments, locoregional control, and survival were recorded. Recurrence in the neck and disease-specific survival (DSS) were primary and secondary end points.

One hundred eight patients underwent SND. Sixty-nine (64%) were male. Median age was 62 (20-89) years. The most common primary site was the oral cavity (71.3%). Ninety-five (88%) received adjuvant treatment. Median follow-up was 21 months. Six patients (5.5%) had isolated recurrence in the dissected neck. Patients with N2C disease had poorer neck recurrence-free survival. At the end of study, 64 (59.3%) patients had no evidence of disease, and 23 (21.3%) had died of disease. Two-year DSS was 76.9%. Number of positive nodes (P = .026) and positive surgical margins (P = .001), among others, were predictors of poorer DSS.

In a highly selected group of patients with cervical lymph node metastases from head and neck SCC, selective neck dissection is effective in controlling the disease in the neck when performed in the setting of a multimodality treatment, including adjuvant radiotherapy or radiochemotherapy.

To compare operative time and hemostasis of fiber-enabled CO₂ laser (FECL) energy to that of the electrocautery (EC) technique for oral tongue resection, to compare return to oral intake and preoperative weight after FECL and EC resection, and to compare histologic changes in adjacent tissue after FECL and EC resection.

Prospective animal study.

Research laboratory.

The CO₂ laser fiber and the Bovie cautery were each used to resect the anterior tongue in 15 adult rats. Fixative perfusion and killing were performed on postoperative day 0 (n = 10), 3 (n = 10), or 7 (n = 10). Body weight, food intake, and water intake were recorded daily for 3- and 7-day survival rats. After preparation for histologic analysis, the tongue tissue was graded with a mucosal wound-healing scale (MWHS).

A higher incidence of intraoperative bleeding and shorter operative times were noted in the EC group. No statistically significant difference in postoperative food or water intake between the EC and FECL groups was noted. The FECL group returned to baseline weight by postoperative day 6. MWHS scores were lower in the EC group by postoperative day 3 and lower in the FECL group by postoperative day 7.

Both EC and FECL are effective for resection of the tongue in rats. EC has the advantage of shorter operative time and lower MWHS scores by postoperative day 3; FECL has the advantages of less intraoperative bleeding, faster return to baseline body weight, and lower MWHS score by postoperative day 7.

During tracheal resection with primary anastomosis, cartilaginous reinforcing sutures may be placed outside of the primary anastomosis with the goal of preventing early dehiscence. The direct effect of such reinforcing sutures on anastomotic strength has not been previously investigated. The goal of this study was to determine if the addition of cartilaginous reinforcing sutures adds to tracheal anastomosis stability.

Prospective cadaver study.

This research was conducted at an anatomy lab at Indiana University School of Medicine.

Twelve cadaver tracheas were harvested. Each trachea was bifurcated, with 1 segment of each trachea transected and anastomosed using circumferential sutures and the remaining tracheal segment undergoing the same procedure with the addition of cartilaginous reinforcing sutures. Segments (proximal versus distal) were alternated to control for potential anatomic-based strength differences. The force necessary for anastomotic rupture was measured, and a Wilcoxon signed-rank test was used to compare means.

Analysis demonstrated the mean anastomotic rupture point for tracheas with reinforcing sutures was 297 N (95% confidence interval = 241.1-352.9), while the mean for trials without reinforcing sutures was 173 N (95% confidence interval = 142.63-203.37; P = .0054). The point of rupture occurred at the anastomosis in 1 case with reinforcing sutures and in 8 of 11 cases without reinforcing sutures.

Cartilaginous reinforcing sutures were found to provide a higher force requirement for tracheal anastomotic rupture when compared with anastomoses without these sutures. This improved stability in tracheal anastomosis may result in a decreased risk of early tracheal rupture after anastomosis.

The presence of regional metastases in patients with head and neck squamous cell carcinoma (HNSCC) is a common and adverse event associated with poor prognosis. The authors’ recent work on human HNSCC tissues underlies Snail’s role as a molecular prognostic marker for HNSCC. Snail positivity is significantly predictive of poorly differentiated, lymphovascular invasive, and regionally metastatic tumors. Here, the authors investigate the capacity of Snail to drive epithelial-mesenchymal transition (EMT) in human oral epithelial cell lines and its ability to confer drug resistance.

Snail was overexpressed in HNSCC and oral epithelial cell lines. Anchorage independent growth assays, wound healing assays, invasion and migration assays, spheroid modeling, and cell survival assays were performed.

Academic tertiary medical center.

Snail overexpressing HNSCC (OSC, Tu212, Tu686) and oral epithelial cell lines (HOK 16-B, OKF-6) were evaluated using assays for wound healing, invasion and migration, 3-dimensional growth, Western blot, and immunofluorescence.

The overexpression of Snail in human HNSCC and oral epithelial cell lines drives EMT. The transfection of Snail confers the expression of a mesenchymal molecular signature, including downregulation of the epithelial adherens, such as E-cadherin and β-catenin, and induction of mesenchymal markers. Snail-overexpressing cell lines demonstrate rapid growth in Anchorage-independent growth assays, a decreased capacity to form tight spheroids, an increased resistance to erlotinib, and an increased capacity for invasion.

Snail controls the mesenchymal phenotype and drives erlotinib resistance in HNSCC cells. Snail may prove to be a useful marker in predicting epidermal growth factor receptor inhibitor responsiveness.

To evaluate clinician perception of voice quality, patient self-reported psychosocial impact of dysphonia, and glottic closure in patients who have undergone resection of the recurrent laryngeal nerve (RLN) and immediate operative reconstruction during thyroid surgery.

Prospective observational study.

Single tertiary care hospital.

Nine patients underwent immediate operative reconstruction of the RLN by the senior author from 2002 to present. Outcome measures included (1) perceptual voice ratings assessed using the GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale, (2) psychosocial impact of dysphonia assessed using the Voice Handicap Index (VHI), and (3) assessment of glottic closure from laryngeal videostroboscopy.

The RLN was reconstructed with primary anastomosis (4), free nerve graft (3), or vagus-RLN anastomosis (2). Seven patients had voice samples and videostroboscopy examinations obtained at a minimum of 9 months from surgery. Six were judged to have slight disturbance of voice based on overall Grade scoring (G = 1). Five rated their voice as normal or mild on the VHI instrument (score range 8-29). Laryngeal analysis revealed the immobile vocal fold in the median, physiologic phonating position with preserved bulk, recovered tension, and glottic closure during phonation. Three patients less than 9 months from surgery had an expected severe self-reported rating of dysphonia.

Primary anastomosis, free nerve grafting, and vagus-RLN anastomosis are viable options for RLN reconstruction. Patients who undergo resection and immediate reconstruction of the RLN are able to regain self-perceived functional voices.

To compare 3-D segmented volumetric analysis of vestibular schwannomas (VS) with traditional linear tumor measurement on serial magnetic resonance imaging (MRI) studies to assess volume and growth rates.

Case series with retrospective chart review.

Tertiary care medical center.

This analysis identified 24 VS patients clinically followed with serial gadolinium enhanced images. Maximum linear dimensions (MLD) were obtained from gadolinium-contrasted T1 sequences from 3 serial MRI scans per RECIST guidelines. MLD was cubed (MLD³) and orthogonal analysis (OA) was carried out to provide volumetric estimates for comparison with segmented data. Segmented volumetric analysis (SVA) was performed with semi-automated 3-D conformal procedure. Tumor volume, percentage change in volume, and interval percentage change were compared using paired 2-tailed t tests.

The average interval between MRIs was 2.6 years. Volume estimates differed significantly between SVA and OA and MLD³ at all intervals. Linear growth measurements averaged 0.5 mm/y (5.4%). Volumetric growth was 50 mm³/y (22.8%) with SVA, 110 mm³/y (19.6%) with OA, and 210 mm³/y (14.4%) with MLD³ estimates. Differences between MLD and both MLD³ and SVA were significant, but significance between MLD³ and SVA was only identified in interval analysis. Progression was identified in 75% more patients with SVA than OA, MLD³, or MLD.

VS assume complex configurations. Linear measurements inaccurately estimate tumor volume and growth compared with segmented analysis. SVA is a useful clinical tool that accurately assesses tumor volume. Use of outcomes such as tumor volume and percentage of volume change may be more sensitive in assessing tumor progression compared with linear measurements.

To understand the audiologic and vestibular toxicities associated with adoptive cell immunotherapy (ACI) targeting pigment-pathway antigens on melanoma and to investigate the use of intratympanic steroid injections in the treatment of these toxicities.

Prospective nonrandomized study.

Tertiary clinical research center.

Thirty-two patients with progressive metastatic melanoma who failed conventional therapy underwent ACI with T cells genetically modified to target MART-1 (n = 18) or gp100 (n = 14). All patients received serial audiometric testing. Vestibular testing was performed on patients with vestibular complaints. Patients with significant deficits received intratympanic steroid injections.

Of 32 patients, 15 had no hearing change, 9 had mild hearing loss, and 8 had moderate hearing loss following treatment. Ten patients received intratympanic steroid injections for mild (n = 2) or moderate (n = 7) hearing loss or for significant imbalance (n = 1). Of those with mild hearing loss (n = 9), all but 1 recovered to pretreatment hearing levels. Four of 8 patients with moderate hearing loss recovered to baseline hearing levels, and 4 had partial recovery. All 7 patients with posttreatment vestibular complaints had demonstrable vestibular dysfunction. Three of these patients demonstrated recovery to normal vestibular function. The number of modified T cells infused for therapy correlated with the degree of audiovestibular deficit.

Adoptive cell immunotherapy targeting pigment-pathway cell proteins, a novel therapy for melanoma, can induce hearing loss and vestibular dysfunction. The presumed mechanism of autoimmune attack on normal melanocytes in the cochlear stria vascularis and in the vestibular organs demonstrates the importance of melanocytes in normal inner ear function.

Jugular bulb abnormalities (JBA), including high-riding jugular bulb (HRJB) and jugular bulb diverticulum (JBD), can erode into the inner ear. In this study, the authors investigate the prevalence and consequences of JBA and their erosion into inner ear structures using temporal bone histopathology and computed tomography (CT).

Cross-sectional study of temporal bone histopathology and radiology.

Academic medical center.

In total, 1579 temporal bone specimens and 100 CT of the temporal bones (200 ears) were examined for JBA and any associated dehiscence of inner ear structures. Temporal bone specimens were examined for histological consequences of inner ear erosion. Jugular bulb dimensions were measured on axial CT scans and compared across groups. Accompanying demographic and clinical information were reviewed.

High jugular bulbs were noted in 8.2% (130/1579) of temporal bone specimens and in 8.5% (17/200) of temporal bone CT. The prevalence of JBA increases during the first 4 decades of life and stabilizes thereafter. High-riding jugular bulbs eroded inner ear structures such as the vestibular aqueduct, vertical facial nerve, or posterior semicircular canal in 2.8% (44/1579) of cases histologically and 1.5% (3/200) radiologically. In most, jugular bulb–mediated inner ear dehiscence was clinically and radiologically silent.

Jugular bulb abnormalities are common. They are present in 10% to 15% individuals and are primarily acquired by the fourth decade of life. In 1% to 3% of cases, the HRJB erodes into the inner ear and most frequently involves the vestibular aqueduct.

To determine changes in cortical neural networks as defined by resting-state functional connectivity magnetic resonance imaging during voluntary modulation of tinnitus with orofacial maneuvers.

Cross-sectional study.

Academic medical center.

Participants were scanned during the maneuver and also at baseline to serve as their own control. The authors chose, a priori, 58 seed regions to evaluate previously described cortical neural networks by computing temporal correlations between all seed region pairs. Seed regions whose correlations significantly differed between rest and maneuver (P < .05, uncorrected) entered into a second-stage analysis of computing the correlation coefficient between the seed region and time courses in each of the remaining brain voxels. A threshold-free cluster enhancement permutation analysis evaluated the distribution of these correlation coefficients after transformation to Fisher z scores and registration to a surface-based reconstruction using Freesurfer.

The median age for the 16 subjects was 54 years (range, 27-72 years), and all had subjective, unilateral or bilateral, nonpulsatile tinnitus for 6 months or longer. In 9 subjects who could voluntarily increase the loudness of their tinnitus, there were no significant differences in functional connectivity in any cortical networks. A separate analysis evaluated results from 3 patients who decreased the loudness of their tinnitus. Four subjects were excluded because of excessive motion in the scanner.

The absence of significant differences in functional connectivity due to voluntary orofacial maneuvers that increased tinnitus loudness failed to confirm prior reports of altered cerebral blood flows during somatomotor behaviors.

To compare cognitive performance between children with cochlear implants (CI) and normal-hearing peers; provide information about correlations between cognitive performance, basic academic achievement, and medical/audiological and social background variables; and assess the predictor quality of these variables for cognition.

Cross-sectional study with comparison group, diagnostic test assessment.

Data were collected in the authors’ clinic (children with CI) and in Austrian schools (normal-hearing children).

Forty children with CI (of the initial 65 children eligible for this study), aged 7 to 11 years, and 40 normal-hearing children, matched by age and sex, were tested with (a) the Culture Fair Intelligence Test (CFIT); (b) the Number Sequences subtest of the Heidelberger Rechentest 1-4 (HRT); (c) Comprehension, (d) Coding, (e) Digit Span, and (f) Vocabulary subtests of HAWIK III (German WISC III); (g) the Corsi Block Tapping Test; (h) the Arithmetic Operations subtests of the HRT; and (i) Salzburger Lese–Screening (SLS, reading). In addition, medical, audiological, social, and educational data from children with CI were collected.

The children with CI equaled normal-hearing children in (a), (d), (e), (g), (h), and (i) and performed significantly worse in (b), (c) and (f). Background variables correlate significantly with cognitive skills and academic achievement. Medical/audiological variables explain 44.3% of the variance in CFT1 (CFIT, younger children). Social variables explain 55% of CFT1 and 24.5% of the Corsi test.

This study augments the knowledge about cognitive skills and academic skills of children with CI. Cognitive performance is dependent on the early feasibility to hear and the social/educational background of the family.

Dendritic cells are professional antigen presenting cells, capable of initiating Th1 or Th2 responses, and have been implicated in the pathogenesis of a number of diseases, including sinusitis. Vitamin D₃ is a steroid hormone that acts on dendritic cells in a manner similar to corticosteroids. Investigators examined whether children with allergic fungal rhinosinusitis (AFRS) or chronic rhinosinusitis with nasal polyposis (CRSwNP) were vitamin D₃ deficient and the relationship of vitamin D₃ deficiency to dendritic cell infiltrate in the sinus mucosa.

Tertiary care university hospital.

Retrospective, controlled study using samples collected from pediatric patients seen from August 2009 to July 2011.

Plasma levels of 25-hydroxy vitamin D₃ were measured by enzyme-linked immunosorbent assay in children (≤18 years old) with AFRS, CRSwNP, or CRS without nasal polyposis (CRSsNP) and in controls undergoing surgery for adenotonsillar hypertrophy. Vitamin D₃ levels were confirmed using clinical diagnostic methods for those with CRSwNP or AFRS. Tissue samples were immunohistochemically stained for the dendritic cell marker CD209 and the costimulatory molecules CD80 and CD86.

There was no difference in mean vitamin D₃ levels between control and CRSsNP, whereas mean CRSwNP and AFRS levels were both well below the minimum recommended level of 30 ng/mL and significantly lower than control and CRSsNP levels. CD209⁺ dendritic cells inversely correlated with vitamin D₃ but not costimulatory molecule expression.

These studies identify that children with CRSwNP or AFRS are vitamin D₃ deficient, which may be linked to increased dendritic cell infiltrate. These results suggest a role for vitamin D₃ as a key player in the immunopathology of pediatric CRSwNP.

To conduct the first prospective randomized controlled trial assessing and comparing the safety and efficacy of endoscopic dacryocystorhinostomy (DCR) with double posteriorly based nasal and lacrimal flaps to conventional endoscopic DCR in adult patients with acquired complete nasolacrimal obstruction.

A prospective randomized controlled study.

General hospital.

Seventy-four adult patients with a total of 80 procedures were recruited to undergo endoscopic DCR. They were prospectively equally randomized into 2 groups: endoscopic DCR with flaps (group I) and conventional endoscopic DCR (group II). Regular follow-up settings were done to document the patient’s subjective improvement, judge ostium patency on irrigation, and record any complications.

Endoscopic DCR with flaps had a higher (92.1%) but nonsignificant difference in success rate when compared with conventional endoscopic DCR (87.4%). There was no significant difference between the 2 techniques in operative time, adverse events, and tolerability of the technique to be done under local anesthesia with minimal sedation. Group I demonstrated a significantly lower number of debridement sessions than did group II.

Endoscopic DCR with double posteriorly based nasal and lacrimal flaps provides a viable alternative to conventional endoscopic DCR in managing acquired nasolacrimal duct obstructions in adults. It has a comparable success rate, operative time, and safety profile, with a suggestion of a better healing profile in terms of mucosal recovery, wound healing, and less need for debridement sessions.

To evaluate the apurinic/apyrimidinic endonuclease 1 (APE1) expression in sinonasal squamous cell carcinomas (SCC) and to examine the correlation between APE1 expression patterns and various clinicopathological factors associated with sinonasal SCC that include SCC with inverted papilloma (SCCwIP) and SCC alone.

Case-control study.

Chungnam National University Hospital.

The expressions of APE1 were analyzed by means of immunohistochemistry in 30 sinonasal SCC, including 14 SCC patients associated with IP and 16 patients with SCC alone. A total of 19 patients who had been diagnosed with chronic rhinosinusitis with nasal polyposis and who required endoscopic sinus surgery were used as the control group. The degrees of APE1 expression were analyzed with respect to the following clinicopathologic variables: age, sex, T stage, histologic differentiation, distant metastasis, and recurrence.

Cytoplasmic staining of APE1 was significantly higher in SCC compared with SCCwIP (68.75% vs 14.29%). Cytoplasmic staining of APE1 was significantly associated with T stage (P = .044) in SCC and histologic grade (P = .0025) in sinonasal SCC. Nuclear staining of APE1 was significantly associated with distant metastasis (P = .022) in SCC.

These results suggest that the nuclear and cytoplasmic expression of APE1 may be related to tumor invasiveness and prognosis in sinonasal SCC. The suppression of APE1 expression can potentially be a new target for future sinonasal SCC therapies.