Otolaryngology–Head and Neck Surgery

To assist otolaryngologists in counseling patients with hoarseness who would benefit from injection laryngoplasty on whether or not to perform the procedure in the office vs the operating room.

Cochrane library, CINAHL, PubMed, and EMBASE.

Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting standards of English-language articles that compared voice outcomes for in-office and in the operating room injection laryngoplasty. Two independent investigators assessed study eligibility, rated the quality using Methodological Index for Non-Randomized Studies (MINORS), and abstracted data for comparative analysis.

Of 689 initial studies, 4 observational, comparative studies met inclusion criteria, with follow-up of 2 weeks to 12 months postinjection. Laryngoplasty was most commonly performed for vocal fold immobility with varied injectable materials (micronized dermis, hyaluronic acid, and calcium hydroxyapatite). Follow-up ranged from 2 weeks to 12 months. Voice outcomes improved in all studies, with comparable improvement for patients injected in the office vs the operating room (P = .42 to P = .88). Meta-analysis of 3 studies showed no difference in Voice Handicap Index–10 voice outcomes by treatment setting (standardized mean difference −0.11, P = .441), with the 95% confidence interval (–0.405 to 0.176), making it unlikely that anything larger than a small or trivial difference was missed.

Our systematic review makes it unlikely that meaningful clinical differences exist in postprocedure voice outcomes for injection laryngoplasty in the office vs the operating room.

Various genome-wide association studies (GWASs) identified new head and neck cancer (HNC) susceptibility loci, although the evidence has not been systematically summarized. We performed a systematic review and meta-analyses of the GWASs to identify the most commonly reported genetic loci associated with a risk of HNC.

We searched the PubMed, ISI Web of Science, SCOPUS, and GWAS databases to retrieve eligible studies, in English or Italian, published until June 1, 2017.

Only GWASs reporting data on the association between single-nucleotide polymorphisms (SNPs) and HNC were included. The quality of included studies was evaluated using the Q-Genie tool. Random-effect meta-analyses were performed considering only SNPs with at least 1 significant result from the included articles, and pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Seven studies of case-control design were included in the review. Five studies on nasopharyngeal cancer (NPC) in Chinese, reporting on 27 different SNPs, were included in meta-analyses. Results show that 6 SNPs (rs2076483, rs2975042, rs9258122, rs29232, and rs9510787) had an increased pooled estimates for A risk alleles (OR [95% CI]: 1.55 [1.36-1.77], 1.90 [1.69-2.14], 1.47 [1.31-1.65], 1.52 [1.32-1.76], and 1.22 [1.13-1.31], respectively) while G risk allele of rs3129055 reported an OR of 1.49 (95% CI, 1.33-1.67).

Our systematic review identified 5 SNPs located on chromosome 6 (rs2076483, rs2975042, rs3129055, rs9258122, and rs29232) and 1 (rs9510787) on chromosome 13 as significantly associated with an increased risk of NPC in Chinese.

To define the learning curve for transoral endoscopic thyroidectomy via the vestibular approach (TOETVA).

Case series with planned data collection.

Tertiary care academic hospital.

Included patients were those who met the 2015 American Thyroid Association guidelines for lobectomy and our group’s previously documented indications for TOETVA. Operative time (incision to closure) was used as a surrogate for procedural proficiency and plotted as a function of case number to determine a learning curve. A simple moving average of operative time was then calculated, with the proficiency case defined as the case number where the slope of this curve changed. Demographic/characteristic data, outcomes, and complications were compared between the skill acquisition period (case 1 to proficiency case) and the proficiency period (remaining cases). A linear regression model was then used to calculate and compare the slopes of the skill acquisition and proficiency periods in the “operative time versus case number” plot.

Thirty cases were attempted, with a procedural success rate of 29 of 30 (94%) and no incidence of permanent mental nerve or recurrent laryngeal nerve injury. The proficiency case was case 11. There was a statistically significant difference between the skill acquisition and proficiency periods in slopes of the linear regressions (–16.7 vs –0.3, respectively; P < .001) and median operative times (191 vs 119 minutes, P < .001). There was no difference in demographics, procedural success rate, or complication rate between the periods.

The learning curve for TOETVA was 11 cases for the surgeon evaluated in this series.

To review our surgical experience and the impact of intraoperative parathyroid hormone (IOPTH) testing among patients with normocalcemic primary hyperparathyroidism.

Case series with chart review.

Academic referral hospital.

Normocalcemic hyperparathyroidism (NCHPT) patients were identified with normal-range blood ionized calcium and serum elevated parathyroid hormone. Patient demographics, intraoperative findings, IOPTH dynamics, and biochemical outcomes were compared with those of classic primary hyperparathyroidism (PHPT) patients.

Of the 2120 patients who underwent parathyroidectomy, 616 patients met the inclusion criteria: 119 (19.5%) patients had NCHPT, and 497 (80.5%) had classic PHPT. NCHPT patients had higher rates of multigland hyperplasia as compared with classic PHPT (12% vs 4%, P = .002) and smaller gland size (P < .001). Of 119 NCHPT patients, 114 (97%) achieved >50% drop in IOPTH intraoperatively, as opposed to 492 (99%) among 497 classic PHPT patients (P = .014). IOPTH drop >50% had an equivalent positive predictive value for long-term cure in both groups.

Surgeons treating NCHPT patients should suspect the presence of multigland disease and have a low threshold for converting to bilateral exploration depending on IOPTH decay dynamics.

Primary skull base lymphoma (PSBL) represents a rare manifestation of extranodal lymphoma. Presenting with nonspecific symptomatology and imaging findings, PSBL often masquerades as more common cranial base pathology and thus can present a diagnostic challenge. The objectives of this study were to characterize the manifestations and clinical outcomes of PSBL.

Case series and chart review.

Tertiary referral center.

Review of 48 patients with PSBL treated between 1994 and 2016.

The median age at diagnosis was 60 years. Diffuse large B-cell lymphoma comprised the most common subtype (56%). Presenting symptoms included diplopia (52%), trigeminal hypesthesia (38%), headache (29%), facial nerve weakness (25%), B-symptoms (fevers, night sweats, and/or weight loss) (25%), and hearing loss (21%). Discrete lesions commonly mimicked meningioma, schwannoma, and nasopharyngeal carcinoma. Diffuse lesions imitated neurosarcoidosis, granulomatosis with polyangiitis, and carcinomatosis meningitis. Only 26% of all initial clinical evaluations suspected lymphoma. The combination of restricted diffusion on diffusion-weighted imaging, an absence of flow voids or surrounding hyperostosis, bony erosion and/or marrow signal replacement, and heterogeneous contrast enhancement facilitated delineation between PSBL and common skull base pathology. Cerebrospinal fluid (CSF) analysis was diagnostic of lymphoma in 24% of cases. Lymphoma within CSF portended significantly worse overall survival (85% vs 18% at 3-years; P < .001).

A history significant for multiple cranial nerve palsies, B-symptoms, and imaging findings inconsistent with common skull base pathology should raise suspicion for PSBL. CSF analysis in the setting of PSBL can provide diagnostic and prognostic value for patients.

To evaluate the incidence and nature of complications associated with diagnostic and interventional sialendoscopies and to report intervention failures in a prospective setup.

Prospective observational study.

Academic tertiary care university hospital.

Patients who underwent diagnostic or interventional sialendoscopy between October 2015 and December 2016 were prospectively enrolled. Patient data, operation-related factors, treatment failures, and complications were recorded into a database and analyzed.

A total of 140 sialendoscopies were attempted or performed on 118 patients; 67 (48%) were for a parotid gland and 73 (52%) for a submandibular gland. The sialendoscopy was interventional in 81 cases (58%), diagnostic in 56 (40%), and not possible to perform in 3 (2.1%). A total of 21 complications were registered for 21 sialendoscopies (15%) and 21 patients (18%). The most common complication was infection, in 9 cases (6.4%). Other observed complications were salivary duct perforation (4 cases), prolonged glandular swelling (3 cases), transient lingual nerve analgesia (2 cases), basket entrapment (2 cases), and transient weakness in the marginal branch of the facial nerve (1 case). All complications were related to interventional procedures or papilla dilatation. Failure to treat occurred in 21 (15%) sialendoscopies: sialendoscopy itself was unsuccessful in 3 cases, and an intended intervention failed in 18 cases.

Complications in sialendoscopy are usually related to interventional procedures. The complications are mainly minor and temporary but lead to additional follow-up visits, further treatments, and sometimes hospitalization. Sialendoscopic procedures are safe but not free of complications.

(1) Compare efficacy of primary medical therapy vs primary surgical intervention in patients with esophageal foreign bodies (EFBs). (2) Investigate variables that may predict successful outcomes in patients treated for EFBs.

Case series with chart review.

Single-institution academic tertiary care medical center.

Adult patients (older than 18 years) seen at the University of Michigan Emergency Department (ED) over an 8-year period with the diagnosis of EFBs (January 1, 2003, to December 31, 2011; N = 250). Decision was made by ED physicians whether to treat patients with first-line medical therapy vs surgical intervention. Pertinent clinical and demographic data were extracted from medical records and summarized by descriptive statistics.

First-line treatment with surgical intervention (flexible or rigid esophagoscopy with foreign body removal) was much more likely to lead to resolution of symptoms than medical therapy (glucagon alone or in combination with other medical therapy) (98% vs 28%, P < .0001). When delivered within 12 hours of symptom onset, medical therapy was more likely to be successful (34% resolution vs 12% resolution, P < .01). There was no difference in complication rates for primary medical therapy vs surgical intervention (8% vs 8%).

Patients with EFBs are a commonly encountered consultation for both otolaryngologists and gastroenterologists. In these patients, first-line surgical intervention is superior to medical therapy and should not be avoided for a trial of medical therapy or concern for higher morbidity. Implementation of these findings has the ability to positively affect treatment patterns, outcomes, and patient quality of life.

To describe the incidence and determinants of survival of patients with squamous cell carcinoma of the soft palate (SCCSP) using the Surveillance, Epidemiology, and End Results (SEER) database.

Retrospective, population-based cohort study of patients.

SEER cancer registry.

Patients from the SEER cancer registry from 1973 to 2015 were used to analyze demographics and survival of SCCSP.

A total of 4366 cases were identified. The average overall survival (OS) and disease-specific survival (DSS) were 68.7 months and 161.3 months, respectively. Multivariate analysis revealed that male sex, stage, and treatment (hazard ratio [HR] = 0.690, P = .019; HR = 1.73, P < .001; HR = 0.64, P < .001, respectively) were independent determinants of better or worse DSS. Age, stage, and treatment (HR = 1.02, P < .001; HR = 1.49, P < .001; HR = 0.66, P < .001; HR = 0.48, P < .001, respectively) were independent determinants of better or worse OS. For stages I, II, and III, radiation alone and surgery alone have nearly equivalent OS. Patients with stage IV disease who underwent both surgery and radiation had a significantly higher median OS at 50.0 months.

Radiation alone and surgery alone both have nearly equivalent OS benefit for stages I to III, while surgery and radiation provide the most survival benefit for stage IV disease. The large discrepancy between OS and DSS can be due to significant comorbidities. Future studies should aim to address the determinants of quality-of-life variables that help direct treatment decisions and might indirectly affect survival.

Unplanned readmission within 30 days is a contributor to health care costs in the United States. The use of predictive modeling during hospitalization to identify patients at risk for readmission offers a novel approach to quality improvement and cost reduction.

Two-phase study including retrospective analysis of prospectively collected data followed by prospective longitudinal study.

Tertiary academic medical center.

Prospectively collected data for patients undergoing surgical treatment for head and neck cancer from January 2013 to January 2015 were used to build predictive models for readmission within 30 days of discharge using logistic regression, classification and regression tree (CART) analysis, and random forests. One model (logistic regression) was then placed prospectively into the discharge workflow from March 2016 to May 2016 to determine the model’s ability to predict which patients would be readmitted within 30 days.

In total, 174 admissions had descriptive data. Thirty-two were excluded due to incomplete data. Logistic regression, CART, and random forest predictive models were constructed using the remaining 142 admissions. When applied to 106 consecutive prospective head and neck oncology patients at the time of discharge, the logistic regression model predicted readmissions with a specificity of 94%, a sensitivity of 47%, a negative predictive value of 90%, and a positive predictive value of 62% (odds ratio, 14.9; 95% confidence interval, 4.02-55.45).

Prospectively collected head and neck cancer databases can be used to develop predictive models that can accurately predict which patients will be readmitted. This offers valuable support for quality improvement initiatives and readmission-related cost reduction in head and neck cancer care.

To conduct a multivariate analysis of a large cohort of oral cavity squamous cell carcinoma (OCSCC) cases for independent predictors of local recurrence (LR) and overall survival (OS), with emphasis on the relationship between (1) prognosis and (2) main specimen permanent margins and intraoperative tumor bed frozen margins.

Retrospective cohort study.

Tertiary academic head and neck cancer program.

This study included 426 patients treated with OCSCC resection between 2005 and 2014 at University of Iowa Hospitals and Clinics. Patients underwent excision of OCSCC with intraoperative tumor bed frozen margin sampling and main specimen permanent margin assessment. Multivariate analysis of the data set to predict LR and OS was performed.

Independent predictors of LR included nodal involvement, histologic grade, and main specimen permanent margin status. Specifically, the presence of a positive margin (odds ratio, 6.21; 95% CI, 3.3-11.9) or <1-mm/carcinoma in situ margin (odds ratio, 2.41; 95% CI, 1.19-4.87) on the main specimen was an independent predictor of LR, whereas intraoperative tumor bed margins were not predictive of LR on multivariate analysis. Similarly, independent predictors of OS on multivariate analysis included nodal involvement, extracapsular extension, and a positive main specimen margin. Tumor bed margins did not independently predict OS.

The main specimen margin is a strong independent predictor of LR and OS on multivariate analysis. Intraoperative tumor bed frozen margins do not independently predict prognosis. We conclude that emphasis should be placed on evaluating the main specimen margins when estimating prognosis after OCSCC resection.

To measure the association between race and head and neck cancer screening and education.

Nationally representative survey.

US National Center for Health Statistics.

Pooled data from the 2011-2014 National Health and Nutrition Examination Survey were used to examine disparities in head and neck cancer education and screening among US citizens aged ≥18 years. We measured the association between race and head and neck cancer education and screening, adjusting for age, sex, education, income, and health insurance. Subtype analyses were performed on ever smokers, a lifetime consumption of ≥100 cigarettes, and nonsmokers, a lifetime consumption of <100 cigarettes.

Among smokers, only 20.2% were educated about the benefits of giving up cigarette smoking; 27.7% had ever received an oral cancer screening examination in which a doctor or dentist pulls on the tongue; and 24.8% had ever had a screening examination in which a doctor or dentist feels the neck. As compared with white smokers, nonwhite smokers were significantly less likely to receive an oral cancer screening examination in which the tongue was pulled (black smokers: odds ratio, 0.44; 95% CI, 0.31-0.63). Although 72.2% of screenings of white participants were performed by dentists, black participants were more often screened by a physician (36.4%) as compared with any other race.

This study highlights socioeconomic disparities in head and neck cancer screening and education. We advocate increased patient screening and education by primary care physicians, especially for nonwhite patients and patients with relevant risk factors.

To provide an anatomic description of submandibular nodes at risk of being left undissected during neck dissection (ND) and to assess whether the Hayes Martin maneuver is a safe procedure in oncologic surgery of level IB nodes.

Prospective study.

Academic medical center.

We recruited 62 patients who were candidates for level IB ND. Perifacial nodes (PFNs) were identified and their characteristics noted. The Hayes Martin maneuver was simulated, and its oncologic safety was tested.

The study included 63 NDs. PFNs were identified in 84% of cases: their number ranged from 0 to 5, and their mean greatest diameter was 12.45 mm. Anterior PFNs were found to be in direct contact with the marginal mandibular nerve. In 59% of NDs, the Hayes Martin maneuver would have failed to remove all PFNs.

The PFNs were identified in 84% of cases and ranged in number from 0 to 5. In some cases, the distinction between retro- and preglandular nodes and PFNs is not useful. The Hayes Martin maneuver may not be oncologically sound for complete treatment of level IB nodes.

To determine the incidence of posttracheostomy tracheal stenosis and to investigate variables related to the patient, hospitalization, or operation that may affect stenosis rates.

A combined retrospective cohort and case-control study.

Tertiary care academic medical center.

A total of 1656 patients who underwent tracheostomy at a tertiary care medical center from January 2011 to November 2016 were reviewed for evidence of subsequent tracheal stenosis on airway endoscopy or computed tomography. Forty-three confirmed cases of posttracheostomy tracheal stenosis (PTTS) were compared with a subgroup of 319 controls. Factors including medical comorbidity, type and setting of tracheostomy, and hospitalization details were analyzed.

Five-year incidence of PTTS was 2.6%. Obesity was the sole demographic factor associated with stenosis. Hospitalization-related variables associated with stenosis included tracheostomy after 10 days of orotracheal intubation and endotracheal tube cuff pressure ≥30 mm H₂O. The surgical variables associated with higher rates of stenosis included percutaneous technique and insertion of an initial tracheostomy tube size >6. Bjork flap creation was negatively associated with stenosis. In multivariable analysis, obesity and insertion of tracheostomy tube size >6 were identified as risk factors.

Greater than 10 days of orotracheal intubation prior to tracheostomy and endotracheal tube cuff pressure ≥30 mm H₂O were associated with greater rates of subsequent tracheal stenosis. The only patient-related factor associated with tracheal stenosis was obesity. Surgical variables associated with increased rates of subsequent stenosis included placement of a tracheostomy tube size >6, use of percutaneous technique, and failure to create a Bjork flap.

Unexplained chronic cough (UCC) is a perplexing condition treated with neuromodulators. Although previous literature describes the effectiveness of neuromodulators, there is little on the development of tachyphylaxis or dependence to neuromodulators over time. Our objective is to capture the experience of a large cohort of patients with UCC over an extended period, looking for these 2 phenomena.

Case series with chart review.

Tertiary care hospital.

We performed a retrospective review of patients diagnosed with UCC from 2010 to 2014. Patient outcomes were measured through percentage improvement scores. Treatment failures were attributed to no benefit, intolerable side effects, or tachyphylaxis. Tachyphylaxis was defined as the need for higher doses of medication following diminishing therapeutic benefit, while dependence was defined as a failure to stop therapy following attempted de-escalation or resurgence following drug cessation.

Sixty-eight patients were included in the study. Tachyphylaxis was observed among 35% of patients while dependence was observed among 27% of successfully treated patients, together effecting >50% of the cohort. Sixty-eight percent of patients ultimately experienced successful treatment with neuromodulators, demonstrating strikingly distinct responses to different neuromodulator drug classes.

Tachyphylaxis and dependence occur frequently during UCC treatment and have a major impact on treatment outcomes. Patients sometimes demonstrate distinct responses to different neuromodulator classes. The majority of patients will experience successful treatment for their cough, although several trials may be required.

The purpose of this study is to describe the demographics of children undergoing inpatient management of epistaxis and recognize the clinical circumstances that may necessitate embolization or ligation for epistaxis management.

Cross-sectional analysis of a national database.

A review of data reported by hospitals in the United States to the Healthcare Cost and Utilization Project Kids’ Inpatient Database with a diagnosis of epistaxis was conducted (International Classification of Diseases, Ninth Revision [ICD-9] code 784.7). The database provides new data every 3 years. The most recent databases, 2006, 2009, and 2012, were reviewed.

A total of 11,366 patients with a diagnosis of epistaxis were identified. The average age was 12 years, and most patients were male (60%). Of the patients who underwent intervention for epistaxis, 704 underwent packing, 119 underwent ligation, and 98 underwent embolization. Transfusion of blood or platelets was highest in the patients undergoing packing only (38%, P < .0001). The lowest average length of stay was for the ligation group with a mean (SD) of 6.95 (14.02) days. Embolization and ligation most frequently occurred in the setting of an urban teaching hospital (95.63% and 73.28%, respectively). For patients who underwent embolization with epistaxis as a secondary diagnosis, benign neoplasm of nasopharynx (58.3%) was the most common primary diagnosis. In those patients who underwent ligation, nasal bone fracture (28.5%) was the most common primary diagnosis.

This study highlights that 11,366 patients were treated for epistaxis during 2006, 2009, and 2012, and most patients were treated conservatively.

The absence of a centralized health system has limited epidemiologic research surrounding vestibular schwannoma (VS) in the United States. The Rochester Epidemiology Project (REP) comprises a unique medical consortium that covers a complete population of all ages in a well-defined geographic region over the past half-century. The objective of this study was to characterize the incidence of sporadic VS over this extended period.

Population-based study.

Olmsted County, Minnesota.

Review of all VSs diagnosed between January 1, 1966, and December 31, 2016, was conducted with the REP medical records linkage system.

A total of 153 incident cases of VS were identified. The incidence of VS significantly increased over the past half-century from 1.5 per 100,000 person-years during the first decade to 4.2 in the last decade (P < .001). Incidence increased with age (P < .001): those aged ≥70 years exhibited the highest incidence rate at 18.3 per 100,000 person-years in the last decade. Age at diagnosis significantly increased from a median of 52 years in the first decade to 62 years in the last (P < .001). Despite presenting with fewer symptoms and smaller tumors, the time delay between symptom onset and diagnosis significantly decreased over the past 5 decades (all P < .05). Almost 1 in 4 patients was diagnosed incidentally in the last decade.

The incidence of VS increased significantly over the past half-century to a rate greater than previously reported. Patients’ ease of access to medical care in Olmsted County and the comprehensive REP system likely contributed to this elevated detection rate of VS.

Chronic otitis media can cause cholesteatomas or tympanosclerosis; however, the pathophysiology of such conditions is not completely known. The aim was to identify a bacterial genome that might be present in tympanosclerotic plaques and cholesteatomas using sequence analysis of the gene responsible for the transcription of 16 ribosomal RNA (rRNA).

Metagenomics analysis of the samples.

Samples were collected and evaluated at tertiary care centers.

Sixty-five tympanosclerotic plaques and 37 cholesteatomas were evaluated. The polymerase chain reaction (PCR) was performed using primers designed for the amplification of the gene responsible for the transcription of bacterial 16 rRNA. The PCR-positive samples were sequenced via Sanger method, and 46 selected samples were analyzed with next-generation sequencing (NGS).

Sanger sequencing revealed the presence of bacterial genomes in a total of 18 of the 102 samples tested. Sequencing of these genomes indicated the presence of Alloiococcus otitis, Staphylococcus aureus, Achromobacter xylosoxidans, Escherichia coli, Staphylococcus sciuri, Staphylococcus caprae, Parvimonas spp., and Bacillus sp. in the tested samples. The NGS showed 1 or more different bacterial genomes in 44 (95.7%) of the 46 samples tested. Predominately, genome of Clostridiales (27 samples), Staphylococcaceae (24 samples), Peptoniphilaceae (12 samples), and Turicella otitidis (9 samples) were identified.

The middle ear is inhabited by a diverse microbial community than that previously known. With the use of molecular biology, it has become easier to identify the bacterial genomes and improve our understanding of the role of middle ear microbiota in the pathogenesis of chronic inflammatory ear diseases.

To determine whether alginate exposure to the round window of the mouse causes any measurable ototoxicity.

Prospective animal study.

Basic science laboratory affiliated with a tertiary care university medical center.

After Institutional Animal Care and Use Committee approval, 5 adult mice were obtained and underwent bullostomy and round window niche application of alginate. Auditory brainstem response (ABR) tests were completed at baseline prior to the procedure and also 5, 14, and 30 days postprocedure. Results were compared. At termination of procedure, the mice were sacrificed with harvest of the cochleae, which were viewed under histologic section.

There were no significant increases in ABR thresholds in any of the test animals at all test periods after alginate exposure compared to baseline. There were also no observable behavioral changes after the procedure to indicate vestibular dysfunction. Cochlear sectioning revealed no evidence of histologic damage.

Exposure of alginate to the round window does not cause any obvious ototoxicity in the mouse model. Further clinical trials will be needed to elucidate the effect of alginate in the human middle ear.

The degree of pneumatization of the temporal bone has implications in the pathophysiology and surgical considerations of many temporal bone disorders. This study aims to identify common pneumatization patterns in the petrous apex, mastoid, and infralabyrinthine compartments of the temporal bone. Variables associated with temporal bone pneumatization were also identified.

Case series with chart review.

Single tertiary hospital.

In total, 299 high-resolution computed tomography scans of the temporal bone performed on patients between 2013 and 2016 were reviewed. Only normal temporal bone scans in patients aged 13 years and older were included. Previously published grading systems were used to classify pneumatization patterns in the petrous apex, mastoid, and infralabyrinthine region.

The most common pneumatization pattern in the petrous apex was group 2 (less than half of the petrous apex medial to the labyrinth is pneumatized), that in the mastoid was group 4 (hyperpneumatization), and that in the infralabyrinthine region was type B (limited pneumatization), at 54.8%, 55.4%, and 76.0% of patients, respectively. Patients with increased pneumatization of 1 temporal bone compartment tended to have increased pneumatization of the same compartment on the contralateral side and the other compartments on the ipsilateral side (P < .05). Younger age (P < .001) and male sex (P = .001) were associated with increased pneumatization in the petrous apex and infralabyrinthine compartments.

The degree of temporal bone pneumatization varies among the different compartments. Age and sex have a significant association with the degree of pneumatization of the petrous apex and infralabyrinthine compartment.

(1) To describe the presentation, management, and outcomes associated with pediatric esophageal food impaction (EFI) at a single tertiary care institution. (2) To identify the key clinical features of pediatric EFI that are associated with a diagnosis of eosinophilic esophagitis (EoE).

Case series with chart review.

Tertiary care children’s hospital.

Thirty-five children <18 years of age presenting with EFI between November 1, 2006, and October 31, 2013, were included. Presenting symptoms, medical history, biopsy results, endoscopic findings, and underlying etiology were examined. Fisher exact test, t tests, and logistic regression were used to compare between patients with and without EoE.

Thirty-five patients had isolated EFI and were included in the study. EoE accounted for 74% (n = 26) of pediatric EFI, with the remaining cases being attributed to neurologic impairment (n = 5, 15%), prior surgeries (n = 1, 3%), reflux esophagitis (n = 1, 3%), or unknown etiologies (n = 2, 6%). EFI was the initial manifestation of EoE in 81% (n = 21) of patients. The most common presenting symptoms were dysphagia (n = 34), choking (n = 26), and vomiting (n = 23). Linear furrowing was the only endoscopic finding that was significantly associated with EoE (P < .001).

Most esophageal food impactions in the pediatric population are associated with an underlying diagnosis of EoE and are often the initial manifestation of the disease. EoE must be considered in all pediatric patients with EFI; esophageal biopsies should be strongly considered in these patients at the time of endoscopic management of the EFI.

Tonsillectomy is a common operation; however, there are controversial opinions regarding the posttonsillectomy diet. The aim of this study was to compare the effects of cold/liquid diet vs regular diet on posttonsillectomy pain and bleeding.

Prospective randomized controlled trial.

Tertiary referral center.

In total, 194 children who underwent tonsillectomy (with or without adenoidectomy) were randomly allocated into 2 groups. A total of 100 patients were allocated in the cold/liquid diet, and 94 patients were allocated in the regular diet group. Pain score was recorded for the first 7 days, and rate of hemorrhage was recorded for 10 days after surgery.

The participants’ age range was 3 to 17 years. The mean pain score level in the regular diet group after breakfast, lunch, and dinner was not statistically significant in comparison with the cold/liquid diet group. One patient in the regular diet group was admitted to the hospital due to secondary bleeding, but it stopped without any intervention.

Most otolaryngologists believe in dietary restrictions following tonsillectomy. However, there is much controversy regarding posttonsillectomy dietary advice in the literature. In addition, only a few randomized clinical trials have focused on this subject. We found that there was no difference between regular diet and cold/liquid diet in terms of posttonsillectomy pain and bleeding. Hence, we do not recommend a limited posttonsillectomy diet.

To describe how deductible health plans affect parental decision making for common pediatric otolaryngology operations.

A cross-sectional survey study.

Tertiary care pediatric hospital.

Caregivers of patients aged <18 years were surveyed to assess factors in decision making related to common otolaryngologic surgical procedures, including outpatient tympanostomy tubes and adenotonsillectomy, between July 2015 and June 2016. Children in foster care and those who underwent nonelective surgery were excluded. Decision-making factors were statistically analyzed with univariate and multivariate ordinal logistic regression.

A total of 155 caregivers completed the survey. The median age of the patient at the time of the surgery was 3 years. Surgical procedures included tympanostomy tube placement (51%), adenotonsillectomy (37%), tympanostomy tube placement with adenotonsillectomy (10%), and other (2%). The mean ± SD annual deductible per child was $1870 ± $140, and the mean maximum out-of-pocket expense was $3833 ± $235. The odds of having the deductible or out-of-pocket expense affect surgical decision making was greater for those covered under a high-deductible health plan (odds ratio = 2.27; 95% CI, 1.25-4.12; P = .007).

High-deductible health plans and out-of-pocket expenses can influence parental decision making for common otolaryngology operations, such as tympanostomy tube placement and adenotonsillectomy. Future studies are needed to determine if such policies affect access to care in the pediatric population.

We sought to determine whether chronic rhinosinusitis (CRS) symptom severity, endoscopic exam findings, and acute exacerbation of CRS (AECRS) frequency—all important and distinct clinical manifestations of CRS—would be predictive of each other and, therefore, inform when further assessment of each other metric should be pursued.

Cross-sectional cohort study.

Tertiary academic rhinology clinic.

In total, 241 patients with CRS were prospectively recruited and completed the 22-item Sinonasal Outcome Test (SNOT-22) to reflect CRS symptom severity. AECRS frequency was assessed using the number of sinus infections as well as CRS-related antibiotics and CRS-related oral corticosteroids used in the past 3 months. An endoscopy score was calculated for each patient.

SNOT-22 score and AECRS were predictive of each other while AECRS and endoscopy score were not predictive of each other. SNOT-22 score could be used to predict having had, in the past 3 months, at least 1 sinus infection (area under the curve [AUC] = 0.727; P < .001), at least 1 CRS-related antibiotic used (AUC = 0.691; P < .001), or at least 1 CRS-related oral corticosteroid course used (AUC = 0.655; P < .001). Having a SNOT-22 score ≥30 could be predicted by reporting at least 1 sinus infection (AUC = 0.634; P < .001), CRS-related antibiotics (AUC = 0.614; P < .001), or CRS-related oral corticosteroids (AUC = 0.616; P < .001) in the past 3 months. These relationships held for patients with and without nasal polyps.

The predictive power of CRS outcome measures reflecting symptomatology, AECRS frequency, and endoscopic findings may be of clinical utility in situations where time or resources are limited to perform an ideally full assessment of patients with CRS.

To produce alternate cell sources for tissue regeneration, human nasal septal cartilage–derived progenitor cells (NSPs) were tested to identify whether these cells meet the criteria of cartilage progenitor cells. We also evaluated the effects of prolonged cultivation on the characteristics of NSPs.

In vitro study.

Academic research laboratory.

NSPs were isolated from discarded human nasal septal cartilage. NSPs were cultured for 10 passages. The expression of septal progenitor cell surface markers was assessed by fluorescence-activated cell sorting. Cell proliferation was measured with a cell-counting kit. Cytokine secretion was analyzed with multiplex immunoassays. Chondrogenic differentiation of NSPs without differentiation induction was analyzed with type II collagen immunohistochemistry. Cartilage-specific protein expression was evaluated by Western blotting. Under osteo- and adipodifferentiation media, 2 lineage differentiation potentials were evaluated by histology and gene expression analysis.

Surface epitope analysis revealed that NSPs are positive for mesenchymal stem cells markers and negative for hematopoietic cell markers. Cultured NSPs showed sufficient cell expansion and chondrogenic potential, as demonstrated by immunostaining and expression of cartilage-specific protein. IL-6, IL-8, and transforming growth factor ß were secreted by over 200 pg/mL. The osteo- and adipodifferentiation potentials of NSPs were identified by histology and specific gene expression. The aforementioned characteristics were not influenced by prolonged cultivation.

NSPs represent an initial step toward creating a cell source from surgically discarded tissue that may prove useful in cartilage regeneration.

To objectively compare the nasal decongestion potency of lidocaine/phenylephrine when delivered with a nasal nebulizer and a nasal spray before a rigid nasoendoscopic examination.

Open-label randomized controlled trial.

Multicenter study.

This prospective clinical trial involved 106 participants with untreated chronic rhinitis. Fifty-three participants had 400 μL of lidocaine/phenylephrine administered into the right nostril with a nasal nebulizer, while the remaining 53 participants had 400 μL administered with a nasal spray. The control was the left nostril. Nasal resistance at 150-Pa fixed pressure was evaluated with an active anterior rhinomanometry at 5, 10, 15, and 30 minutes postintervention. Pain score was assessed subjectively by applying pressure to the inferior turbinate 30 minutes after intervention.

There was an overall reduction in nasal resistance of the right nostril when lidocaine/phenylephrine was administered with the nasal nebulizer in comparison with the nasal spray. However, a statistically significant difference in nasal resistance was seen only at 5 minutes (P = .047), 15 minutes (P = .016), and 30 minutes (P = .036). The examining endoscopist further supported the degree of nasal decongestion via subjective assessment of the nasal cavity (P = .001). Pain scores obtained after the intervention showed a significant decrease in pain threshold when the nasal nebulizer was used instead of the nasal spray (P = .040).

This study suggests that the delivery of lidocaine/phenylephrine to the nasal cavity by the nasal nebulizer provides better decongestive and analgesic potency as compared with the delivery by nasal sprays.

To evaluate the impact of the treatment of persistent pediatric obstructive sleep apnea (OSA) on quality of life (QOL) with patient-reported outcomes tools and to compare parent- and self-reported Pediatric Quality of Life Inventory (PedsQL) scores.

Prospective case series.

Multidisciplinary upper airway center at a tertiary pediatric institution.

Children with persistent OSA referred to our multidisciplinary upper airway center from 2014 to 2016. Patients and their families completed validated questionnaires for QOL, including the Family Impact Questionnaire, the Obstructive Sleep Apnea–18, the PedsQL, and the Epworth Sleepiness Scale for Children and Adolescents. They completed the same surveys after treatment.

Twenty-three children (7 females) and their families were included in the study. Patients had a mean age of 12.7 years. Pretreatment, the mean obstructive apnea-hypopnea index was 15.0 events/hour (95% CI, 8.7-21.3); after treatment, the mean was 3.9 events/hour (P = .003). The mean PedsQL score for children improved from 60.5 to 74.2 (P = .04). The PedsQL score for parents did not significantly improve (61.6 to 63.8, P = .39). There was a significant though weak association between OSA severity (R² = 0.25, P = .03) and PedsQL scores. The Family Impact Questionnaire negative subscore and Epworth Sleepiness Scale for Children and Adolescents scores did not change with treatment.

For children treated for persistent OSA, we found that self-reported QOL significantly improved after treatment; however, parent-reported QOL did not significantly change. It is unclear if parents underestimate or patients overestimate QOL after treatment. We suggest that patient-reported outcomes be obtained when feasible.