Otolaryngology–Head and Neck Surgery

This guideline provides evidence-based recommendations on treating patients presenting with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia.

The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm.

For this guideline update, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology–head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology.

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include but are not limited to recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy.

The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation.

The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids in patients with dysphonia prior to visualization of the larynx.

The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia.

Differences from Prior Guideline

(1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply

(2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials

(3) Inclusion of a consumer advocate on the guideline update group

(4) Changes to 9 KASs from the original guideline

(5) New KAS 3 (escalation of care) and KAS 13 (outcomes)

(6) Addition of an algorithm outlining KASs for patients with dysphonia

The radiologic evaluation of patients with hearing loss includes computed tomography and magnetic resonance imaging (MRI) to highlight temporal bone and cochlear nerve anatomy. The central auditory pathways are often not studied for routine clinical evaluation. Diffusion tensor imaging (DTI) is an emerging MRI-based modality that can reveal microstructural changes in white matter. In this systematic review, we summarize the value of DTI in the detection of structural changes of the central auditory pathways in patients with sensorineural hearing loss.

PubMed, Embase, and Cochrane.

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement checklist for study design. All studies that included at least 1 sensorineural hearing loss patient with DTI outcome data were included.

After inclusion and exclusion criteria were met, 20 articles were analyzed. Patients with bilateral hearing loss comprised 60.8% of all subjects. Patients with unilateral or progressive hearing loss and tinnitus made up the remaining studies. The auditory cortex and inferior colliculus (IC) were the most commonly studied regions using DTI, and most cases were found to have changes in diffusion metrics, such as fractional anisotropy, compared to normal hearing controls. Detectable changes in other auditory regions were reported, but there was a higher degree of variability.

White matter changes based on DTI metrics can be seen in patients with sensorineural hearing loss, but studies are few in number with modest sample sizes. Further standardization of DTI using a prospective study design with larger sample sizes is needed.

The aim of this study was to determine the general outcomes and surgical success rates of anterior palatoplasty (AP) in patients with obstructive sleep apnea (OSA).

A systematic review of the literature and meta-analysis of published data were performed by searching the Cochrane, SAGE, MEDLINE, and Google Scholar databases, from January 1, 2007, to March 27, 2017, using relevant keywords.

The search scanned for studies with patients who had undergone AP (with or without tonsillectomy) as a single-stage, single-level surgical intervention for treatment of OSA. Two independent reviewers (M.B. and O.K.) inspected titles and abstracts of the studies according to established criteria. The full texts were then reviewed to extract the clinical and polysomnographic data. The primary outcome was the surgical success rate, defined as a reduction in the apnea-hypopnea index (AHI) of 50% or greater and an AHI of less than 20 postoperatively. The PRISMA statement was followed.

After systematic evaluation of potentially relevant articles, 14 studies were downloaded, and 6 studies, consisting of 170 patients, met the study criteria. A fixed effects model was used to analyze the data. The surgical success rate of AP was 60.6%. No serious complications were reported in the literature.

The results of the present meta-analysis support AP as a moderately effective surgical method for the treatment of OSA. Comparative and randomized controlled prospective studies showing long-term results, with pre- and postoperative data, should be conducted to demonstrate the exact outcomes and reliability of this surgical technique.

To evaluate whether an adjuvant therapy of leukotriene receptor antagonists (LTRAs) based on oral H1-antihistamines (H1) can increase efficacy of allergic rhinitis (AR) treatment.

The search involved databases of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials, from inception up to September 23, 2017. Randomized controlled trials (RCTs) that compared efficacy of LTRAs + H1 vs H1 alone were eligible.

Pooled comparative effects were measured using weighted mean difference (WMD) and 95% confidence interval (CI). Subgroup analysis comparing seasonal vs perennial AR was prespecified to explore the source of heterogeneity. The evidence quality of each outcome was assessed by the GRADE approach.

A total of 8 RCTs were included (n = 1886), and all measured outcomes used scaled scores. Compared with H1 alone, H1 + LTRAs were superior to improve overall daytime (WMD, –0.11; 95% CI, –0.19 to –0.03, high quality) and composite (WMD, –0.12; 95% CI, –0.23 to –0.01; low quality) nasal symptoms. Specifically, H1 + LTRAs had better efficacy against composite nasal rhinorrhea, sneezing, and daytime itching but not congestion. The effects were more pronounced in patients with perennial AR compared to those with seasonal AR. There were no significant differences in nighttime nasal symptoms and eye symptoms between the 2 groups.

The current evidence suggests that LTRAs + H1 can increase the therapeutic efficacy against daytime and composite nasal symptoms, including rhinorrhea, sneezing, and itching; however, it does not affect nighttime nasal symptoms and eye symptoms. The patients with perennial AR may benefit more from the combination therapy.

Studies have shown that the majority of cleft lip and palate (CLP) children have middle ear fluid present at the time of lip repair (3-4 months). Despite hearing loss, the majority of children do not undergo ventilation tube treatment if required until the time of palate repair (9-12 months). We aimed to examine the effectiveness and potential complications of early ventilation tube placement prior to palatoplasty in infants with cleft lip and palate.

Medline (1946-2015), Embase (1980-2015), and EBM Reviews (Cochrane Central Register of Controlled).

Data sources were searched for publications that described the results of early ventilation tube placement in children with CLP prior to cleft palate repair. Two independent reviewers appraised the selected studies.

Of 226 studies identified, 6 studies met the inclusion criteria. Early ventilation tube insertion in CLP gave similar speech and audiology outcomes to non-CLP children undergoing ventilation tube insertion and better outcomes than those children with CLP having later ventilation tube insertion at or after the time of palate closure. The main reported side effect was otorrhea, being higher for children with CLP having early ventilation tube insertion (67% vs 33%), with a reduction in otorrhea with increasing age. Larger studies with longer-term outcome reporting are required to fully address the study objectives.

Published data are limited but appear to support early insertion of ventilation tubes in children with CLP to restore middle ear function and maximize audiologic and speech outcomes.

The purpose of this study was to examine how biopsy modality affects the treatment course and outcomes of patients with cutaneous melanoma of the head and neck. Specifically, we investigated if partial biopsy techniques are associated with positive margins on definitive wide local excision (DWLE), the need for early reoperation to obtain adequate margins or sentinel lymph node biopsy, and survival.

Retrospective case series.

Tertiary care academic center.

Subjects (N = 170) included all patients who were surgically treated for primary cutaneous melanoma of the head and neck at the University of Missouri–Columbia between January 1, 2000, and December 31, 2015. For analysis, patients were divided into 4 groups based on biopsy modality: shave (n = 61), excisional (n = 62), punch (n = 33), and incisional (n = 14).

The shave biopsy group (P = .0324) and the punch biopsy group (P = .0479) were significantly more likely to have positive margins on DWLE. The shave biopsy group (P = .0042) and the punch biopsy group (P = .0479) were also significantly more likely to need early reoperation. The mean number of sentinel nodes and incidence of positive sentinel nodes detected on pathologic examination did not differ significantly across biopsy modality (P = .3600). Overall survival (P = .4605) and disease-free survival (P = .5011) did not differ significantly among the groups.

Patients diagnosed with shave and punch biopsy techniques are significantly more likely to have positive margins after DWLE and more frequently require early reoperation. Biopsy modality does not appear to influence the number of sentinel nodes detected, the incidence of detecting regional metastases in sentinel nodes, the overall survival, or the disease-free survival.

This study introduces a treatment algorithm based on staging neck dissection to identify patients with palatine tonsil squamous cell carcinoma who can be effectively treated with single-modality transoral robotic surgery while maintaining quality of life.

Retrospective case series.

Kaiser Permanente Southern California Medical Group from 2012 to 2017.

Patients with early-stage (T1/2) palatine tonsil squamous cell carcinoma with clinically and radiographically N0 necks underwent staging neck dissection. Those with pN2/3 disease or extracapsular extension on final pathology were triaged to definitive chemoradiation treatment. Patients with confirmed pN0/1 necks without extracapsular extension were treated definitively with transoral robotic surgery.

Nineteen patients with cN0 disease underwent selective neck dissection. All were p16 positive. Of these, 14 had pathologically confirmed N0/1 necks without extracapsular extension and were treated with primary surgical resection via transoral robotic surgery. Clear margins were obtained on all patients. There were no significant intra- or postoperative complications. No patients required gastrostomy tube or tracheostomy placement. Mean and median follow-up was 28 months with no recurrences to date.

Up-front staging neck dissection accurately triages low-risk patients, determining candidates for single-modality definitive treatment with transoral robotic surgery. This approach provides excellent survival outcomes and minimal morbidity and maintains quality of life among appropriately selected patients with palatine tonsil cancer.

18F-fluoro-deoxy-glucose positron emission tomography/computed tomography (FDG PET/CT) imaging is common in head and neck cancer and often identifies incidental findings that necessitate additional patient evaluations. Our goal was to assess the frequency and nature of these incidental imaging findings on FDG-PET/CT.

Retrospective cohort study.

Tertiary medical center.

All patients with head and neck cancer who had undergone FDG-PET/CT imaging between January 2014 and June 2015 at our institution were evaluated for incidental findings.

A total of 293 patients met criteria; more than one-third (n = 103) had at least 1 finding unrelated to their head and neck cancer, for a total of 134 incidental findings. Incidental findings within the head and neck (33.5% of all) excluding the thyroid were most common: 35% incidental findings were concerning for malignancy; of these, 25.5% were malignant with further workup. Recommendations were given by the head and neck radiologist on 72 (53.7%) findings: 74.5% of potentially malignant findings and 42.5% of benign findings had recommendations for follow-up. Significantly more patients with findings described as malignant were given recommendations for follow-up (P = .0004).

Incidental findings on FDG-PET/CT are present in more than one-third of patients with head and neck cancer. More than one-third of incidental findings were concerning for malignancy. This study illustrates how the incidental findings discovered on FDG PET/CT frequently necessitate additional evaluations unrelated to the index head and neck cancer. The impact of these additional assessments on the cost and quality of health care warrants future evaluation.

Evaluate clinicopathologic factors contributing to regional lymph node (LN) metastases in cutaneous head and neck melanoma (HNM).

Retrospective review of a national cancer database.

National Cancer Database (2004-2012).

National Cancer Database (NCDB) cases diagnosed between 2004 and 2012 were reviewed. Inclusion criteria were head and neck cutaneous site codes, melanoma histology codes, and clinically node-negative status. Independent, clinicopathologic factors associated with pathologic positive LN status were identified by multivariable logistic regression. Subset analysis was performed on thin melanoma cases of 0.75 to 1 mm tumor depth to determine factors predictive of LN involvement and survival.

Of 66,495 cases meeting inclusion criteria, 18,882 had nodes examined pathologically with 9.7% presenting with occult positive LN involvement. Mean (SD) age was 62.9 (16.13) years, and primary sites were scalp and neck (42.2%), face (40.2%), and external ear, lip, or eyelid (7.6%). Multivariable analysis found younger age; primary site of cutaneous scalp, neck, or face; increasing thickness; mitoses; ulceration; and vertical growth phase presence were independently associated with LN positivity (P < .001). Only 2% of 0.75- to 1.0-mm Breslow thickness cases had regional LN involvement, and age >70 was negatively associated with LN involvement (P = .002) in this subset.

This is the largest study examining factors predictive of occult LN involvement in patients with clinical node-negative cutaneous HNM who may benefit from sentinel LN biopsy. Primary sites of external ear, lip, or eyelid are less likely to present with occult nodal involvement, and older patients with T1a melanoma ≥0.76 mm are unlikely to present with regional node metastasis and may not require sentinel node guided management.

After radiation failure for early T-stage larynx cancer, national guidelines recommend salvage surgery. Total laryngectomy and conservation laryngeal surgery with an open or endoscopic approach are both used. Beyond single-institution studies, there is a lack of evidence concerning the outcomes of these procedures. We aim to study whether treatment with conservation laryngeal surgery is associated with poorer outcomes than treatment with total laryngectomy as salvage surgery after radiation failure for T1/T2 larynx cancers.

A retrospective study was conducted of adult squamous cell larynx cancer cases in the National Cancer Database diagnosed from 2004 to 2012.

Commission on Cancer cancer programs in the United States.

Demographic, facility, tumor, and survival variables were included in the analyses. Multivariate survival regressions as well as univariate Kaplan-Meier analyses were conducted.

Slightly more than 7% of patients receiving radiotherapy for T1/T2 larynx cancers later received salvage surgery. Salvage with partial laryngectomy was not associated with diminished survival as compared with total laryngectomy. However, positive surgical margins were associated with worse outcomes (hazard ratio, 1.782; P = .001), and a larger percentage of patients receiving partial laryngectomy had positive margins than those receiving total laryngectomy. Facility characteristics were not associated with differences in salvage surgery type or outcomes.

In recognition of the inherent selection bias, patients who experienced recurrences after radiation for T1/T2 larynx cancer and underwent conservation salvage laryngeal surgery demonstrated clinical outcomes similar to those of patients undergoing salvage total laryngectomy. Increased rates of positive surgical margins were observed among patients undergoing salvage conservation surgery.

Neurofibromatosis 2 (NF2) is a neuro-oncologic condition that presents with bilateral vestibular schwannomas of the cerebellopontine angle (CPA). Voice and swallowing impairment can occur from direct involvement or compression of the vagus nerve or as the result of surgical excision of CPA tumors. The objectives in this study are to (1) assess the prevalence of voice and swallowing impairments and (2) analyze the effects of vagal dysfunction in patients with NF2.

Cross-sectional.

Academic tertiary care center.

Patients at a neurofibromatosis center were mailed Voice Handicap Index and Sydney Swallow Questionnaire surveys. Stroboscopic, voice, and swallowing evaluations were performed for patients who elected to participate in screening exams.

There were high rates of self-assessed and objective voice and swallowing handicaps in this population. Fourteen of 40 (35%) patients had a self-assessed voice handicap, and 20 of 40 (50%) patients had a self-assessed swallow handicap. Vocal fold motion impairment (VFMI) was observed in 22 of 31 (71%) patients examined, with 27 of 62 (44%) possible vocal cords affected. Velopharyngeal insufficiency (45%) and piriform sinus pooling or residue (39%) were seen in a significant percentage of patients. There was a significant relationship between vocal cord motion impairment and CPA surgical intervention ipsilateral to the impairment (P = .002). The presence of VFMI was strongly associated with voice (P = .002) and swallowing (P = .01) impact on quality of life.

Speech and swallowing impairments are highly prevalent in patients with NF2, cause significant impact on quality of life, and are most commonly related to surgical interventions in the CPA region.

Vocal fold granulomas are benign lesions of the larynx commonly caused by gastroesophageal reflux, intubation, and phonotrauma. Current medical therapy includes inhaled corticosteroids to target inflammation that leads to granuloma formation. Particle sizes of commonly prescribed inhalers range over 1 to 4 µm. The study objective was to use computational fluid dynamics to investigate deposition patterns over a range of particle sizes of inhaled corticosteroids targeting the larynx and vocal fold granulomas.

Retrospective, case-specific computational study.

Tertiary academic center.

A 3-dimensional anatomically realistic computational model of a normal adult airway from mouth to trachea was constructed from 3 computed tomography scans. Virtual granulomas of varying sizes and positions along the vocal fold were incorporated into the base model. Assuming steady-state, inspiratory, turbulent airflow at 30 L/min, computational fluid dynamics was used to simulate respiratory transport and deposition of inhaled corticosteroid particles ranging over 1 to 20 µm.

Laryngeal deposition in the base model peaked for particle sizes 8 to 10 µm (2.8%-3.5%). Ideal sizes ranged over 6 to 10, 7 to 13, and 7 to 14 µm for small, medium, and large granuloma sizes, respectively. Glottic deposition was maximal at 10.8% for 9-µm-sized particles for the large posterior granuloma, 3 times the normal model (3.5%).

As the virtual granuloma size increased and the location became more posterior, glottic deposition and ideal particle size generally increased. This preliminary study suggests that inhalers with larger particle sizes, such as fluticasone propionate dry-powder inhaler, may improve laryngeal drug deposition. Most commercially available inhalers have smaller particles than suggested here.

Subglottic stenosis can be addressed with several different surgical techniques, but patient preferences for these treatment modalities are poorly understood. Economic methods are increasingly being used to understand how patients make decisions. The objective of this pilot study was to assess preferences in subglottic stenosis treatment using patient-centric stated preference techniques.

Discrete choice experiment (DCE).

Academic research facility.

A computer-based DCE was administered in a monitored setting to volunteers from the general population. Signs and symptoms of subglottic stenosis were described, and participants were asked to imagine they had subglottic stenosis. Hypothetical treatments were offered, with 5 systematically varied attributes: need for external incision, length of hospital stay, postoperative voice quality, likelihood of repeat procedures, and risk of complication. A conditional logistic model was used to assess the relative attribute importance.

In total, 162 participants were included. Attributes with the greatest impact on decision making included potential need for repeat procedures (importance 30.2%; P < .001), amount of operative risk (importance 28.1%; P < .001), and postoperative voice quality (importance 27.7%; P < .001), whereas presence of incision (importance 5.0%; P = .001) was less important, and hospital stay was not (importance 9.0%; P = .089). Based on aggregate responses for these attributes, the model demonstrated that most participants (80.4%) would prefer endoscopic surgery for subglottic stenosis as opposed to open tracheal resection (19.6%).

In this pilot population, most participants preferred voice-sparing, low-risk procedures as treatment for subglottic stenosis, consistent with an endoscopic approach, even if multiple procedures were required.

(1) To describe the relationships among the main instrumental features characterizing an acute unilateral vestibulopathy and (2) to clarify the role of the video head impulse test in predicting the development of chronic vestibular insufficiency.

Case series with chart review.

Tertiary referral center.

Sixty patients suffering from acute unilateral vestibulopathy were retrospectively analyzed: 30 who recovered spontaneously (group 1) and 30 who needed a vestibular rehabilitation program (group 2). The main outcome measures included Dizziness Handicap Inventory score, canal paresis, high-velocity vestibulo-oculomotor reflex gain, and catch-up saccade parameters. The tests were all performed between 4 and 8 weeks from the onset of symptoms.

The high-velocity vestibulo-oculomotor reflex gain correlated with the Dizziness Handicap Inventory score (P = .004), with the amplitude of covert and overt saccades (P < .001), and with the prevalence of overt saccades (P < .001). Patients in need for vestibular rehabilitation programs had a significantly lower gain (P < .001) and a higher prevalence and amplitude of overt saccades (P = .002 and P = .008, respectively). Conversely, we found no differences in terms of response to the caloric test (P = .359).

Lower values of high-velocity vestibulo-oculomotor reflex gain and a high prevalence of overt saccades are related to a worse prognosis after acute unilateral vestibulopathy. This is of great interest to clinicians in identifying which patients are less likely to recover and more likely to need a vestibular rehabilitation program.

(1) Evaluate changes in subjective symptoms in patients following transmastoid canal plugging for superior semicircular canal dehiscence (SSCD) syndrome. (2) Quantify changes in hearing in patients who have undergone transmastoid canal plugging for SSCD syndrome.

Case series with chart review.

Single tertiary care institution.

We retrospectively reviewed patients with SSCD who underwent repair with canal plugging via a transmastoid approach between January 2012 and January 2017. Symptom severity was assessed prospectively (autophony, sound/pressure-induced vertigo, disequilibrium, aural fullness, and pulsatile tinnitus) and after surgery. Pure-tone and speech audiometry were measured before and after surgery. Two-sided Wilcoxon rank-sum tests were used to evaluate changes in subjective symptoms and audiometric outcomes.

Seventeen patients (19 ears) met inclusion criteria. The superior canal was successfully plugged via the transmastoid approach in all cases. Patients reported a statistically significant improvement in autophony, vertigo, aural fullness, and pulsatile tinnitus (P < .01), without significant improvement in disequilibrium rating (P = .06). There were no changes noted in pure-tone average or word recognition score; however, there was a statistically significant improvement in air-bone gap at 250 Hz of 10.9 dB (P = .04) with 12.9-dB improvement in air conduction thresholds (P = .02) and no difference (0.9 dB, P = .9) in bone conduction thresholds.

In our study, patients with SSCD demonstrated excellent hearing outcomes and resolution of most otologic symptoms after surgical repair. Transmastoid canal plugging, which has been described to date only in smaller case series, is a safe and effective alternative to the traditional middle cranial fossa approach.

To evaluate (1) whether changes in serum prestin aid in early detection of cisplatin ototoxicity, (2) the role of diltiazem as an otoprotectant, and (3) whether prestin levels are sensitive to effects of diltiazem.

Experimental animal study.

Translational research laboratory.

Twenty female guinea pigs.

Two groups of 10 guinea pigs were used. The relationship between serum prestin levels and auditory brainstem response (ABR) thresholds was compared between the groups. All animals had baseline blood draws and ABR thresholds recorded prior to cisplatin administration. Intraperitoneal cisplatin bolus (8 mg/kg) was administered followed by 5 consecutive days of intratympanic (IT) diltiazem (2 mg/kg) or sham IT-saline injection. Serum prestin levels and ABR thresholds were measured at days 1, 2, 3, 7, and 14 postcisplatin.

In sham, IT-saline–treated animals, mean prestin levels were elevated above baseline on days 1 to 7. The prestin levels were significantly elevated from baseline on day 1 (P < .001), while significant ABR threshold elevations did not occur until day 2 (P = .028) for click-evoked ABRs and day 3 (P = .041) for tones. In diltiazem-treated animals, prestin levels were not elevated above baseline but ABR thresholds were elevated on days 1 to 3. However, the thresholds returned toward baseline on days 7 and 14.

Changes in serum prestin levels were detectable prior to shifts in ABR thresholds in a guinea pig cisplatin ototoxicity model. These changes did not occur in diltiazem-treated animals. Prestin may serve as a biomarker of cochlear injury that is sensitive to therapeutic interventions in cisplatin ototoxicity.

Ciprofloxacin, commonly given as eardrops, has been shown to adversely affect tympanic membrane fibroblasts. Dexamethasone potentiates this effect. A newly available eardrop contains ciprofloxacin and fluocinolone, a more potent steroid. We evaluated the cytotoxic effects of this preparation on mouse tympanic membrane fibroblasts.

Prospective, in vitro.

Academic laboratory.

In experiment 1, fibroblasts were exposed to 1:10 dilutions of commercially available 0.3% ofloxacin, 0.3% ciprofloxacin, 0.3% ciprofloxacin + 0.1% dexamethasone, 0.3% ciprofloxacin + 0.025% fluocinolone, or dilute hydrochloric acid (control), twice within 24 hours. In experiment 2, cells were also treated with the dilutions of the pure form of dexamethasone 0.1% or fluocinolone 0.025%, alone and in combination with ofloxacin or ciprofloxacin. Cells were exposed to the solutions for 2 hours each time and were placed back in growth media after the treatments. Cells were observed with phase-contrast microscope until the cytotoxicity assay was performed.

Survival of fibroblasts treated with ofloxacin was not different from the control. Fibroblasts treated with ciprofloxacin, ciprofloxacin + dexamethasone, or ciprofloxacin + fluocinolone had much lower survival (all P < .0001). Cells treated with ciprofloxacin + fluocinolone had lower survival than ciprofloxacin (P < .0001) and ciprofloxacin + dexamethasone (P = .0001). Steroids alone also decreased fibroblast survival compared to control (P < .0001). The combination of dexamethasone or fluocinolone with ciprofloxacin, but not ofloxacin, further decreased fibroblast survival (P < .0001). Phase-contrast images mirrored the cytotoxicity findings.

Tympanic membrane fibroblast cytotoxicity of ciprofloxacin is potentiated by corticosteroids. This effect may be deleterious when treating a healing perforation but beneficial when treating granulation tissue on the tympanic membrane.

The purpose is to determine the prevalence of electrocardiogram (ECG) abnormalities, including borderline and prolonged QT, among screened children with sensorineural hearing loss (SNHL) and to analyze their subsequent medical workup.

Institutional Review Board–approved case series with chart review.

Tertiary academic center.

Cases from 1996 to 2014 involving pediatric patients (N = 1994) with SNHL were analyzed. Abnormal ECGs were categorized as borderline/prolonged QT or other. A board-certified pediatric cardiologist retrospectively determined the clinical significance of ECG changes. For follow-up analysis, children with heart disease, known syndromes, or inaccessible records were excluded.

Among 772 children who had ECGs, 215 (27.8%) had abnormal results: 35 (4.5%) with QT abnormalities and 180 (23.3%) with other abnormalities. For children with QT abnormalities meeting inclusion criteria (n = 30), follow-up measures included cardiology referral (46.6%), repeat ECG by ear, nose, and throat (ENT) specialist (20%), clearance by ENT specialist with clinical correlation and/or comparison with old ECGs (20%), and pediatrician follow-up (6.7%). Documentation of further workup by ENT or referral was absent for 6.7%. For children with other ECG changes meeting inclusion criteria (n = 136), abnormalities were documented for 57 (41.9%); normal QT without other abnormality was documented for 18 (13.2%). The most common follow-up referrals were to pediatricians (16.9%) and cardiologists (10.3%). Among patients with clinically significant non-QT abnormalities mandating further evaluation (n = 122), 38 (31.1%) had documented follow-up in medical records.

There is a high prevalence of ECG abnormalities among children with congenital SNHL. If findings are confirmed by future studies, screening should be considered for congenital unilateral or bilateral SNHL, regardless of severity. We describe a standardized protocol for ECG screening/follow-up.

To determine the effectiveness of pediatric drug-induced sleep endoscopy (DISE)–directed surgery for children with infant obstructive sleep apnea (OSA) or OSA after adenotonsillectomy.

Case series with chart review.

Tertiary care pediatric hospital.

We included 56 children undergoing DISE from October 2013 to September 2015 who underwent subsequent surgery to address OSA. The primary outcome was successful response to DISE-directed surgery based on the postoperative obstructive Apnea-Hypopnea Index (oAHI). Wilcoxon matched-pairs signed-ranks tests were used to compare polysomnography variables before and after surgery, and regression was used to model response to surgery.

We evaluated 56 patients with a mean age of 5.9 ± 5.5 years (range, 0.1-17.4) and mean body mass index of 21.2 ± 7.9 kg/m² (percentile, 77 ± 30). The most commonly performed surgical procedures were adenoidectomy (48%, n = 27), supraglottoplasty (38%, n = 21), tonsillectomy (27%, n = 15), lingual tonsillectomy (13%, n = 7), nasal surgery (11%, n = 6), pharyngoplasty (7%, n = 4), and partial midline glossectomy (7%, n = 4). Mean oAHI improved from 14.9 ± 13.5 to 10.3 ± 16.2 events/hour, with 54% (30 of 56) of children with oAHI <5 and 16.1% (9 of 56) with oAHI <1. There was a significant improvement in oAHI (P = .001) and saturation nadir (P < .001) but not in time with end tidal carbon dioxide >50 mm Hg (P = .14). Multivariable modeling, controlling for age, race, body mass index, sex, and baseline polysomnography variables, revealed that white race predicted success of DISE-directed surgery.

Fifty-four percent of children with infant OSA or persistent OSA after adenotonsillectomy had oAHI <5 events per hour after DISE-directed surgery. Only white race was predictive of oAHI <5 events per hour.

We aim to explore the correlation between serum and tissue 2-methoxyestradiol (2-ME-2) levels and recurrence of juvenile-onset respiratory papillomatosis (JORRP).

Retrospective cohort studies.

Laboratory of Otolaryngology, Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University.

Sixty-four patients diagnosed with JORRP in our department from January 2007 to December 2012 were enrolled. Patients were divided into recurrence and nonrecurrence groups, with 32 patients in each group. ELISA detected the concentration of 2-ME-2 in serum and tissue samples collected during the first surgical procedure. Mann-Whitney analysis, receiver operating characteristic curves, logistic regression model, and Kaplan-Meier method were used for data processing.

There was no difference in the serum 2-ME-2 concentration between the groups (P = .237), while the tissue 2-ME-2 concentration of the recurrent group was significantly lower than that of the nonrecurrence group (P = .0001). When the area under the curve was 0.752, the cutoff value of tissue 2-ME-2 at 670.02 pg/mL yielded the highest predictive sensitivity (71.9%) and specificity (71.9%). Regrouped by this cutoff point, patients with a lower tissue 2-ME-2 level (n = 26) had shorter disease-free survival and a higher recurrence odds ratio than patients with a higher tissue 2-ME-2 level (n = 38; P = .0408, odds ratio = 7.667).

A low tissue 2-ME-2 level is associated with a higher recurrence rate of JORRP. Tissue 2-ME-2 may be an effective target for JORRP treatment and a convenient measure for recurrence monitoring.

Disparities in health and health care access are widely prevalent. However, disparities among patients with chronic rhinosinusitis (CRS) are poorly understood. We investigated if CRS severity at presentation according to socioeconomic factors.

Cross-sectional study.

Tertiary rhinology center.

Three hundred prospectively recruited patients presenting with CRS were included. Outcome variables included CRS symptomatology, as reflected by the 22-item Sinonasal Outcome Test (SNOT-22); general health status, as reflected by the EuroQol 5-dimensional visual analog scale (EQ-5D VAS); and CRS-related antibiotic and systemic corticosteroid use. Race/ethnicity, zip code income bracket, education level, and insurance status were used as predictor variables. Regression, controlling for clinical and demographic characteristics, was used to determine associations between predictor and outcome variables.

Mean SNOT-22 score was 33.8 (SD, 23.2), and mean EQ-5D VAS score was 74.2 (SD, 18.9). On multivariable analysis, presenting SNOT-22 and EQ-5D VAS scores were not associated with nonwhite patient race/ethnicity (P = .634 and P = .866), education (P = .106 and P = .586), or the percentage of households in zip code with incomes <$50,000 per year (P = .917 and P = .979, respectively). SNOT-22 scores did not differ by insurance type, but patients receiving Medicare reported worse general health status. Use of oral antibiotics or oral steroids for CRS was not associated with predictor variables.

Patients with CRS presented to a tertiary rhinology center with similar metrics for CRS severity and pre-presentation medical management regardless of race/ethnicity, education status, or zip code income level. Patients with Medicare had worse general health status. Further research should investigate potential disparities in diagnosis of CRS, specialist referral, and treatment outcomes.