Novel mouse model for simulating microsurgical tumor excision with facial nerve preservation
Jae H. Lim, Glen M. Boyle, Benedict Panizza, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To determine the feasibility of using a mouse tumor model as a microsurgical training tool for otolaryngology-head and neck surgery (OHNS) trainees.
Study Design
Animal study.
Methods
We injected athymic nude mice with human cutaneous squamous cell carcinoma (A431 cell line) deep to the parotid region overlying the masseter muscle. We sacrificed the animals 1 to 3 weeks postinjection, once a visible tumor growth was confirmed. We then asked 10 OHNS trainees to excise the tumor with preservation of the facial nerves under a high-magnification dissecting microscope. The trainees graded the tasks in several areas of specific measures using a visual analogue scale (VAS) including 1) tumor texture, 2) surgical realism, 3) usefulness, and 4) difficulty of the task.
Results
Noticeable tumor growth occurred within 5 days following A431 cell injection and reached measureable size (0.5–1.5 cm) within 1 to 3 weeks. The tumor displaced the facial nerve laterally and medially, with few demonstrating infiltration of the nerve. VAS scores (± standard deviation) were 8.1 (±1.7), 7.7 (±2.5), 9.0 (±0.9) and 6.6 (±1.9) for tumor texture, surgical realism, usefulness, and the difficulty of the task, respectively.
Conclusions
We demonstrate a novel, reliable and cost-effective mouse model for simulating tumor extirpation microsurgery with preservation of important neural structures. OHNS trainees have found this simulation model to be realistic, useful, and appropriately challenging.
Level of Evidence
NA Laryngoscope, 2015
Endoscope-assisted transoral removal of a thyroglossal duct cyst using a frenotomy incision: A prospective clinical trial
Seung Hoon Woo, Jung Je Park, Jong Chul Hong, Soo-Geun Wang, Gi Cheol Park, Young Gyu Eun, Jin Pyeong Kim, Han-Sin Jeong, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Endoscope-assisted transoral removal of a thyroglossal duct cyst (TGDC) has been introduced to clinical practice. However, the technical feasibility, efficacy, and safety of this procedure have not been studied. Herein, we conducted a prospective clinical trial to evaluate endoscope-assisted transoral removal of a TGDC.
Study Design
Prospective cohort study.
Methods
Thirty patients were included. We performed endoscope-assisted transoral removal of TGDCs and evaluated the clinical results and complications over more than 2 years.
Results
Endoscope-assisted transoral resection was successful in all cases. However, transient morbidity was noted in one patient. The mean operation time was 67.33 ± 17.26 minutes. Surgery was not required for recurrence or revision during a follow-up.
Conclusions
Endoscope-assisted transoral resection of a TGDC is a potentially safe and effective procedure leading to excellent functional and cosmetic outcomes. Additionally, considering the embryological development of TGDCs, the transoral approach can open a new access route to these cysts.
Level of Evidence
2b. Laryngoscope, 2015
Adenosquamous carcinoma of the head and neck: Molecular analysis using CRTC-MAML FISH and survival comparison with paired conventional squamous cell carcinoma
Jason I. Kass, Steve C. Lee, Shira Abberbock, Raja R. Seethala, Umamaheswar Duvvuri, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Adenosquamous carcinoma (ASC) is a rare variant of head-and-neck squamous cell carcinoma (HNSCC) generally thought to be uniformly aggressive with poor prognosis. However, it remains unknown how overall survival compare with conventional HNSCC. Here we report for the first time that ASC does not necessarily indicate a worse prognosis than conventional HNSCC.
Study Design
Case-control retrospective study.
Methods
Forty-two primary tumors of the head and neck, treated with curative intent, were identified. Next, 2:1 matching of HNSCC was performed using the following matching criteria: gender, site, pathologic tumor stage, and pathologic node stage. Successful matching was performed for 32 of 42 tumors. Additionally, 20 samples were sent for break-apart FISH testing to evaluate for the presence of the CRTC1-MAML2 translocation.
Results
There was a 1.8:1 male to female ratio, with a mean age of 62 years (range 38–84). The layrnx was the most common site (26%), followed by oropharynx (24%), oral cavity (19%), and sinonasal (17%). Kaplan-Meier analysis of adenosquamous and matched HNSCC showed similar survival curves. Median survival times for ASC and HNSCC were 4 and 6 years, respectively. A random-effects Cox model with Gamma frailty revealed no statistical difference between the two groups (P = 0.25). All cases of ASC were negative for the CRTC1-MAML2 translocation.
Conclusion
This study directly compares primary ASC with HNSCC. No difference in overall survival was detected in contradistinction to the previously thought uniformly poor prognosis. We also highlight the importance of the CRTC1-MAML2 translocation in distinguishing ASC from mucoepidermoid carcinoma.
Level of Evidence
3b. Laryngoscope, 2015
Clinical analysis of drug-induced sleep endoscopy for the OSA patient
Dina Golbin, Brandon Musgrave, Eric Succar, Kathleen Yaremchuk, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To determine if the use of drug-induced sleep endoscopy (DISE) and transoral robotic surgery (TORS) for the treatment of obstructive sleep apnea (OSA) is associated with improved outcomes and acceptable complication rates when compared to uvulopalatopharyngoplasty (UPPP) with or without tonsillectomy (± T).
Methods
A retrospective cohort review was performed comparing 40 patients who had previously undergone UPPP ± T with 64 patients who had DISE, UPPP ± T, and possible TORS base-of-tongue resection and/or partial epiglottectomy. Apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), body mass index, sex, hospital length of stay, hospital charges, hospital readmissions, emergency department visits, and major complications were compared for both groups.
Results
The 40 patients who underwent UPPP ± T without DISE showed a significant reduction in AHI of −20.1 (P = 0.001) and a complication rate of 3% (P = 0.001). There was no significant change in ESS (−2.2; P = 0.734). The 64 patients who underwent DISE and subsequent procedures showed a significant reduction in AHI of −21.4 (P = 0.001) and a complication rate of 34.7% (P = 0.001). There was no significant difference in the ESS (+0.1; P = 0.734) or AHI (P = 0.092) between the two groups.
Conclusion
Patients who underwent UPPP ± T without DISE did not show a statistically significant difference in outcomes compared to the patients who underwent DISE with other procedures, including TORS. The TORS patients had increased total costs and length of stay that were statistically significant and had increased complications that were not statistically significant.
Level of Evidence
4. Laryngoscope, 2015
Recurrent laryngeal nerve reinnervation in children: Acoustic and endoscopic characteristics pre-intervention and post-intervention. A comparison of treatment options
Karen B. Zur, Linda M. Carroll, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To establish the benefit of ansa cervicalis-recurrent laryngeal nerve reinnervation (ANSA-RLN) for the management of dysphonia secondary to unilateral vocal cord paralysis (UVCP) in children. Children treated with ANSA-RLN for the management of dysphonia secondary to unilateral vocal fold immobility will have superior acoustic, perceptual, and stroboscopic outcomes compared to injection laryngoplasty and observation.
Study Design
Retrospective case-series chart review.
Methods
Laryngeal, perceptual, and acoustic analysis of dysphonia was performed in 33 children (age 2–16 years) diagnosed with UVCP. Comparison of pre-post function for treatment groups (no treatment, injection laryngoplasty, ANSA-RLN) with additional comparison between gestational ages, age at initial evaluation, and gender were examined. Perceptual measures included Pediatric Voice Handicap Index (pVHI) and Grade, Roughness, Breathiness, Asthenia, Strain (GBRAS) perceptual rating. Objective measures included semitone (ST) range, jitter%, shimmer%, noise-to-harmonic ratio, voicing, and maximum phonation time.
Results
Post-treatment, pVHI, jitter%, and ST were significantly improved for ANSA-RLN subjects compared to injection subjects. Improved function (laryngeal diadochokinesis, pVHI, GRBAS, and/or acoustic) was observed in all ANSA-RLN subjects who had vocal fold paralysis as the only laryngeal diagnosis.
Conclusions
This study presents one of the largest studies of pediatric vocal fold paralysis diagnosis and treatment. The study looks at the spectrum of function in patients with UVCP and looks at the outcomes of options: no treatment, injection laryngoplasty, and ANSA-RLN. Although surgical outcomes vary, both injection laryngoplasty and ANSA-RLN show benefit in laryngeal function, voice stability, voice capacity, perceptual rating, and pVHI scores. Both injection laryngoplasty and ANSA-RLN showed improvements post-treatment, and should be considered for management of pediatric UVCP. However, the ANSA-RLN group showed better and longer-lasting perceptual and acoustic parameters in comparison with the injection and control groups. Reinnervation, even long term after the onset of vocal fold paralysis, should be considered a viable permanent treatment for pediatric UVCP.
Level of Evidence
4 Laryngoscope, 2015
Effect of unilateral and simultaneous bilateral cochlear implantation on tinnitus: A randomized controlled trial
Alice Zon, Yvette E. Smulders, Geerte G. J. Ramakers, Inge Stegeman, Adriana L. Smit, Gijsbert A. Zanten, Robert J. Stokroos, Nadia Hendrice, Rolien H. Free, Bert Maat, Johan H. M. Frijns, Emmanuel A. M. Mylanus, Wendy J. Huinck, Vedat Topsakal, Rinze A. Tange, Wilko Grolman, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To determine the effect of cochlear implantation on tinnitus perception in patients with severe bilateral postlingual sensorineural hearing loss and to demonstrate possible differences between unilateral and bilateral cochlear implantation.
Study Design
Prospective study.
Methods
Thirty-eight adult patients were included in this prospective study, as part of a multicenter randomized controlled trial investigating the benefits of bilateral cochlear implantation versus unilateral cochlear implantation. Pre- and postoperative tinnitus perception scores were evaluated, before and 1 year after implantation on three tinnitus questionnaires; the Tinnitus Handicap Inventory (THI), the Tinnitus Questionnaire (TQ), and a visual analogue scale for tinnitus burden.
Results
Before implantation, the tinnitus prevalence was 42.1% (16 of 38) in the whole study group. One year after implantation, the tinnitus questionnaire scores had decreased in 71.4% according to the TQ and 80.0% according to the THI. Tinnitus was induced after cochlear implantation in six patients, five in the bilateral and one in the unilateral group.
Conclusions
Our study shows that cochlear implantation is effective in the reduction of tinnitus in patients with bilateral sensorineural hearing loss who suffered from preoperative tinnitus. Conversely, tinnitus may also increase or even be induced by the cochlear implantation itself. Cochlear implant candidates should be well informed about these possible consequences before undergoing surgery.
Level of Evidence
2b Laryngoscope, 2015
Does quality of life depend on speech recognition performance for adult cochlear implant users?
Natalie R. Capretta, Aaron C. Moberly, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Current postoperative clinical outcome measures for adults receiving cochlear implants (CIs) consist of testing speech recognition, primarily under quiet conditions. However, it is strongly suspected that results on these measures may not adequately reflect patients' quality of life (QOL) using their implants. This study aimed to evaluate whether QOL for CI users depends on speech recognition performance.
Study Design
Twenty-three postlingually deafened adults with CIs were assessed.
Methods
Participants were tested for speech recognition (Central Institute for the Deaf word and AzBio sentence recognition in quiet) and completed three QOL measures—the Nijmegen Cochlear Implant Questionnaire; either the Hearing Handicap Inventory for Adults or the Hearing Handicap Inventory for the Elderly; and the Speech, Spatial and Qualities of Hearing Scale questionnaires—to assess a variety of QOL factors. Correlations were sought between speech recognition and QOL scores. Demographics, audiologic history, language, and cognitive skills were also examined as potential predictors of QOL.
Results
Only a few QOL scores significantly correlated with postoperative sentence or word recognition in quiet, and correlations were primarily isolated to speech-related subscales on QOL measures. Poorer pre- and postoperative unaided hearing predicted better QOL. Socioeconomic status, duration of deafness, age at implantation, duration of CI use, reading ability, vocabulary size, and cognitive status did not consistently predict QOL scores.
Conclusion
For adult, postlingually deafened CI users, clinical speech recognition measures in quiet do not correlate broadly with QOL. Results suggest the need for additional outcome measures of the benefits and limitations of cochlear implantation.
Level of Evidence
4. Laryngoscope, 2015
A lean neck mass clinic model: Adding value to care
Brittny N. Tillman, Tiffany A. Glazer, Amrita Ray, J. Chad Brenner, Matthew E. Spector, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To demonstrate that ultrasound-guided fine needle aspiration (USFNA) with on-site cytopathologic analysis eliminates unnecessary diagnostic testing, return visits, and repeat procedures and optimizes quality of care.
Study Design
Retrospective cohort.
Methods
Sixty-one new patients (28 female; 33 male; age range = 19–85 years) were seen in our dedicated neck mass clinic over a 1-year period. All patients underwent USFNA of masses located in neck levels I–VI (n = 40), parotid gland (n = 20), or parapharyngeal space (n = 1). Each patient underwent two USFNA passes followed by on-site cytopathologic analysis with additional passes if required for diagnosis.
Results
Diagnosis was made in 93.4% (n = 57) of patients, allowing for counseling and treatment planning at the first visit. To obtain a diagnosis, more than half (57.4%, n = 35) of our patients required additional passes, which implies that they would have required an additional visit without on-site cytopathologic analysis. Treatment included observation in 42.6% (n = 26) of patients, surgery in 32.8 % (n = 20) of patients, and nonsurgical treatment (chemotherapy, radiation, other) in 24.6% (n = 15) of patients. The average time from check-in to checkout including the clinic visit, biopsy, and treatment counseling was 103 minutes, and the average round trip mileage traveled per patient was 127.6 miles.
Conclusions
The adult neck mass is a commonly encountered scenario in otolaryngology. For the patient, this can be a stressful situation in which timely and accurate diagnosis is critical. A dedicated lean neck mass clinic model with USFNA and on-site cytopathologic analysis can be both an efficient part of one's practice and a valuable addition to patient care.
Level of Evidence
4 Laryngoscope, 2015
What is the role of sentinel lymph node biopsy in early-stage oral cavity carcinoma?
Vikas Mehta, Cherie-Ann Nathan, 2015-08-11 16:19:20 PM
In response to the usefulness of the stay suture technique in tracheostomy
Sang Ha Lee, Kyung Hee Kim, Seung Hoon Woo, 2015-08-11 16:19:20 PM
Upper airway stimulation for obstructive sleep apnea: The surgical learning curve
Alexander W. Murphey, Andrew B. Baker, Ryan J. Soose, Tapan A. Padyha, Shaun A. Nguyen, Christopher C. Xiao, M. Boyd Gillespie, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To determine the effect of surgeon experience with an upper airway stimulation (UAS) system on surgical time and complication rates.
Study Design
Retrospective review.
Methods
Surgical procedure times and complication rates observed in patients implanted at 22 study centers as part of a phase III, multicenter surgical trial of upper airway nerve stimulation therapy for obstructive sleep apnea were reviewed.
Results
The study included 126 subjects who were predominantly male (83%), with a mean age of 54.5 years (range = 31–80 years), and the mean body mass index was 28.4 ± 2.6. There were an average of 5.7 (range = 1–22) surgical implants per site, with an average surgical time of 2.52 ± 0.98 hours (range = 1.08–6.0 hours). The surgical implant time decreased significantly with surgeon experience, from 2.98 ± 1.18 hours for a surgeon's first implant (n = 22) to 2.08 ± 0.55 hours for the fifth implant (n = 10, P = .025). Surgical time was inversely correlated with the site implant number (rho = −0.334, P < .001). Procedure-specific complications were uncommon and self-limited and did not decrease appreciably with increasing experience.
Conclusions
Surgical time for implantation of the UAS system decreased significantly after the first five implants and then stabilized. The rate of surgical complications did not decrease with surgeon experience, although this may be attributable to the low overall rate of serious surgical complications and low number of implants at some centers.
Level of Evidence
4 Laryngoscope, 2015
Rhinology and medical malpractice: An update of the medicolegal landscape of the last ten years
Anthony M. Tolisano, Grant A. Justin, Douglas S. Ruhl, Benjamin B. Cable, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Malpractice claims pertaining to rhinological procedures are a potentially important source of information that could be used to minimize the risk of future litigation and improve patient care.
Study Design
A retrospective review of a publicly available database containing jury verdicts and settlements.
Methods
The LexisNexis Jury Verdicts and Settlements database was reviewed for all lawsuits and out-of-court adjudications related to the practice of rhinology. Data including patient demographics, type of surgery performed, plaintiff allegation, nature of injury, outcomes, and indemnities were collected and analyzed.
Results
Of 85 cases meeting inclusion criteria, 42 were decided by a jury and 43 were adjudicated out of court. Endoscopic sinus surgery was the most commonly litigated surgery. The plaintiff was favored when the eye was injured (P = 0.0196), but the defendant was favored when neuropsychological injuries (P = 0.0137) or recurrent/worsened symptoms (P = 0.0050) were cited. No difference was found when death or skull base injuries occurred. When lack of informed consent was an allegation, the defendant was favored (P = 0.0001). A payout was made in two-thirds of cases overall, but the defendant was favored in two-thirds of cases decided by a jury. Payments were significant for both out-of-court settlements ($1.3 million) and jury verdicts ($2 million).
Conclusions
Endoscopic sinus surgery remains the most commonly litigated rhinology procedure and has the potential to result in large payouts. Meticulous dissection, recognition of complications, and documentation of informed consent remain paramount for providing optimal patient care.
Level of Evidence
N/A. Laryngoscope, 2015
Spontaneous middle cranial fossa cerebrospinal fluid otorrhea in adults
Neela Rao, Miriam Redleaf, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The goals of this study are to: 1) investigate the urgency for repair of middle cranial fossa spontaneous cerebrospinal fluid (CSF) leaks in adults, and 2) review the literature and treatment recommendations for adult spontaneous CSF otorrhea.
Data Sources
1) All patients who were referred to a tertiary center with spontaneous CSF otorrhea, exposed middle cranial fossa dura, or encephalocele from 2004 to 2015; and 2) landmark references on spontaneous CSF leaks
Review Methods
Electronic medical records of patients with a documented spontaneous CSF leak, exposed dura, or encephalocele were reviewed. Subjects were excluded if they had a congenital, traumatic, or iatrogenic CSF leak. Main outcome measure was duration of CSF leak and development of meningitis after clinical presentation.
Results
Twenty-two patients (27 ears) who were at risk for meningitis from spontaneous CSF otorrhea, encephalocele, or a dural breach with or without mastoiditis were evaluated. Duration of CSF leaks in patients who refused repair or who continued to have CSF leak after repair or prior to successful repair ranged from 4 months to 11 years. Duration of encephaloceles and dural exposure in an uninfected mastoid ranged from 24 months to 6 years. Only one patient presented with meningitis. None of these 22 patients developed meningitis during the time periods they were under our care.
Conclusion
Should patients with CSF otorrhea, exposed dura, or encephalocele refuse operation, it may be reasonable to follow them with close observation and education about warning signs for meningitis. Laryngoscope, 2015
Management of hearing loss and the normal ear in cases of unilateral Microtia with aural atresia
Kathleen R. Billings, Hannan Qureshi, Christopher Gouveia, Colleen Ittner, Stephen R. Hoff, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To identify the rate of hearing loss related to middle ear disease and the frequency of tympanostomy tube (TT) insertion in the contralateral ear of patients with unilateral microtia/aural atresia.
Study Design
Retrospective case series of patients less than 3 years of age with unilateral microtia/aural atresia treated at an urban, tertiary care children's hospital from 2008 to 2013.
Methods
Clinical and audiologic data were reviewed. Statistical analysis was performed to determine the relative risk of TT insertion in the normal ear.
Results
A total of 72 patients were included for analysis. The average age of patients at their initial otolaryngology visit was 3.3 months (range 0.08–1.67 years); 38 (52.8%) patients were males. Aural atresia involved the right ear in 43 (59.7%) cases. Five (6.9%) patients were syndromic. Abnormal audiometric testing of the normal ear was noted in 12 (16.7%), and 14 (19.4%) underwent TT during the first 3 years of life. Twelve children (85.7%) who had a TT placed were nonsyndromic. When compared to published norms for TT placement in the general population (6.8% of children < 3 year of age), a greater proportion of children with unilateral microtia/aural atresia had TT placement in the normal ear (z = 4.26, P < 0.0001).
Conclusion
Patients with unilateral microtia/aural atresia have increased rates of hearing loss and middle ear effusion leading to TT in their normal ear at a higher rate versus the general population. This information can help guide more vigilant care and audiologic follow-up in affected children.
Level of Evidence
4. Laryngoscope, 2015
The effects of treadmill running on aging laryngeal muscle structure
Heidi Kletzien, John A. Russell, Nadine P. Connor, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Age-related changes in laryngeal muscle structure and function may contribute to deficits in voice and swallowing observed in elderly people. We hypothesized that treadmill running, an exercise that increases respiratory drive to upper airway muscles, would induce changes in thyroarytenoid muscle myosin heavy chain (MHC) isoforms that are consistent with a fast-to-slow transformation in muscle fiber type.
Study Design
Randomized parallel group controlled trial.
Methods
Fifteen young adult and 14 old Fischer 344/Brown Norway rats received either treadmill running or no exercise (5 days/week/8 weeks). Myosin heavy chain isoform composition in the thyroarytenoid muscle was examined at the end of 8 weeks.
Results
Significant age and treatment effects were found. The young adult group had the greatest proportion of superfast-contracting MHCIIL isoform. The treadmill running group had the lowest proportion of MHCIIL and the greatest proportion of MHCIIx isoforms.
Conclusion
Thyroarytenoid muscle structure was affected both by age and treadmill running in a fast-to-slow transition that is characteristic of exercise manipulations in other skeletal muscles.
Levels of Evidence
NA. Laryngoscope, 2015
The Chronic Obstructive Sialadenitis Symptoms Questionnaire to assess sialendoscopy-assisted surgery
Annick Aubin-Pouliot, Elise A. Delagnes, David W. Eisele, Jolie L. Chang, William R. Ryan, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Introduce the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire to quantify chronic sialadenitis symptoms and assess the impact of sialendoscopic-assisted salivary duct surgery (SASDS).
Study Design
Retrospective outcome symptoms questionnaire study.
Methods
The COSS questionnaire assesses the severity of sialadenitis symptoms from 0 to 100. Patients who underwent SASDS from April 2006 to December 2013 completed the COSS questionnaire and the ShortForm8 Health Survey (SF-8) based on current symptoms, and reported whether they had complete, partial, or no symptomatic response to SASDS.
Results
Sixty-six of the 156 (43%) contacted patients completed the questionnaires who had had symptoms in 26 submandibular ducts and 53 parotid ducts. The mean COSS score was higher for parotid ducts (12.0; interquartile range [IQR] 1.0–20.0) than for submandibular ducts (7.6; IQR 0.5–15.0) but not significantly so (P = 0.20). Thirty-eight (60%) patients reported complete resolution of symptoms, with a mean COSS score of 4.5 (IQR 0–7). Twenty-one (33%) patients reported partial resolution, with a mean COSS score of 18.5 (IQR 11.3–22.8). Five (8%) patients reported no improvement, with a mean COSS score of 25.1 (IQR 15.2–35). Thirty-six (46%) ducts with sialoliths had a significantly lower mean COSS score (5.8; IQR 0−9.5) compared to those without sialoliths (14.2; IQR 4.5−21.5, P = 0.0004). There was no significant difference in SF-8 survey scores between these groups.
Conclusion
The COSS questionnaire is a novel survey instrument to measure obstructive sialadenitis symptom severity that could be helpful in defining outcomes of SASDS. COSS scores under 10 correlate with complete resolution of symptoms, whereas scores between 10 and 25 correlate with partial resolution.
Level of Evidence
4. Laryngoscope, 2015
Comparison of cadaveric and isomorphic three-dimensional printed models in temporal bone education
Jordan B. Hochman, Charlotte Rhodes, Dana Wong, Jay Kraut, Justyn Pisa, Bertram Unger, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Current three-dimensional (3D) printed simulations are complicated by insufficient void spaces and inconsistent density. We describe a novel simulation with focus on internal anatomic fidelity and evaluate against template/identical cadaveric education.
Study Design
Research ethics board-approved prospective cohort study.
Methods
Generation of a 3D printed temporal bone was performed using a proprietary algorithm that deconstructs the digital model into slices prior to printing. This supplemental process facilitates removal of residual material from air-containing spaces and permits requisite infiltrative access to the all regions of the model. Ten otolaryngology trainees dissected a cadaveric temporal bone (CTB) followed by a matched/isomorphic 3D printed bone model (PBM), based on derivative micro-computed tomography data. Participants rated 1) physical characteristics, 2) specific anatomic constructs, 3) usefulness in skill development, and 4) perceived educational value. The survey instrument employed a seven-point Likert scale.
Results
Trainees felt physical characteristics of the PBM were quite similar to CTB, with highly ranked cortical (5.5 ± 1.5) and trabecular (5.2 ± 1.3) bone drill quality. The overall model was considered comparable to CTB (5.9 ± 0.74), with respectable air cell reproduction (6.1 ± 1.1). Internal constructs were rated as satisfactory (range, 4.9–6.2). The simulation was considered a beneficial training tool for all types of mastoidectomy (range, 5.9–6.6), posterior tympanotomy (6.5 ± 0.71), and skull base approaches (range, 6–6.5). Participants believed the model to be an effective training instrument (6.7 ± 0.68), which should be incorporated into the temporal bone lab (7.0 ± 0.0). The PBM was thought to improve confidence (6.7 ± 0.68) and operative performance (6.7 ± 0.48).
Conclusions
Study participants found the PBM to be an effective platform that compared favorably to CTB. The model was considered a valuable adjunctive training tool with both realistic mechanical and visual character.
Level of Evidence
NA Laryngoscope, 2014
Voice and respiratory outcomes after permanent transoral surgery of bilateral vocal fold paralysis
Tadeus Nawka, Christian Sittel, Christoph Arens, Ruth Lang-Roth, Claus Wittekindt, Rudolf Hagen, Andreas H. Mueller, Ahmed I. Nasr, Orlando Guntinas-Lichius, Gerhard Friedrich, Markus Gugatschka, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Bilateral vocal fold paralysis (BVFP) is a rare but life-threatening condition mostly caused by iatrogenic damage to the peripheral recurrent laryngeal nerve. Endoscopic enlargement techniques have been the standard treatment for decades. However, prospective studies using internationally accepted phoniatric and respiratory evaluation guidelines are rare.
Study Design
Prospective observational multicenter study.
Methods
Twelve clinical centers screened 61 patients, of whom 36 were eligible according to the study protocol. Subjects were assessed with specific phoniatric and respiratory tests preoperatively and at 1 and 6 months postoperatively.
Results
Important respiratory parameters improved significantly 6 months postoperatively (peak expiratory and expiratory flow), confirming that a glottal enlargement effectively reduced the obstruction. Objective parameters dealing with voice quality worsened significantly (maximum phonation time, voice range profile, hoarseness), whereas subjective voice assessment (VHI-12) did not change significantly.
Conclusion
Endoscopic glottal enlargement is an effective method for relieving symptoms of dyspnea due to BVFP. Postoperatively, voice quality objectively worsened; however, this was not perceived by the patients themselves. Laryngostroboscopic findings did not correlate strongly with voice and respiratory outcomes.
Level of Evidence
2b. Laryngoscope, 2015
Canal wall reconstruction and conductive hearing preservation for temporal bone paraganglioma
Danielle S. Hoyne, Sarah E. Mowry, Marlan R. Hansen, 2015-08-11 16:19:20 PM
Propranolol and venlafaxine for vestibular migraine prophylaxis: A randomized controlled trial
Mehti Salviz, Turgut Yuce, Hurtan Acar, Abdullah Karatas, R. Murat Acikalin, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
We compared the effectiveness of venlafaxine and propranolol for the prophylaxis of vestibular migraine (VM).
Study Design
Prospective, randomized, controlled clinical trial.
Methods
Sixty-four subjects with definite VM were enrolled. The subjects were randomly assigned to receive propranolol (group P, n = 33) or venlafaxine (group V, n = 31) for VM prophylaxis. Dizziness Handicap Inventory (DHI) scores, the Vertigo Severity Score (VSS), and the number of vertiginous attacks were recorded before and 4 months after treatment. The Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) scores were also recorded to monitor the resolution of psychiatric symptoms.
Results
At 4 months after treatment, the DHI total score decreased from 55.8 ± 2.7 to 31.3 ± 3.7 and from 50.9 ± 2.5 to 19.9 ± 2.9 (P < .001), the mean number of total vertiginous attacks decreased from 12.6 ± 1.8 to 1.9 ± 0.7 and from 12.2 ± 1.8 to 2.6 ± 1.1 (P < .001), and VSS decreased from 7.3 ± 0.3 to 2.1 ± 0.4 and from 7.9 ± 0.3 to 1.8 ± 0.5 (P < .001) in groups P and V, respectively. However, the treatment effects were similar in both groups (P > .05). BAI scores significantly decreased in both groups, whereas BDI scores decreased only in group V.
Conclusions
This study provided evidence that venlafaxine and propranolol show equal effectiveness as prophylactic drugs for ameliorating vertiginous symptoms in VM patients. However, venlafaxine may be superior to propranolol in ameliorating depressive symptoms.
Level of Evidence
1b. Laryngoscope, 2015
REMODEL larger cohort with long-term outcomes and meta-analysis of standalone balloon dilation studies
Rakesh K. Chandra, Robert C. Kern, Jeffrey L. Cutler, Kevin C. Welch, Paul T. Russell, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To provide the final results from the REMODEL (randomized evaluation of maxillary antrostomy versus ostial dilation efficacy through long-term follow-up) full-study cohorts and perform meta-analyses of standalone balloon sinus dilation studies to explore long-term outcomes in a large patient sample.
Study Design
Randomized controlled trial and meta-analysis.
Methods
Final outcomes from the REMODEL randomized trial, including a larger cohort of 135 patients treated with functional endoscopic sinus surgery (FESS) or in-office balloon dilation, were evaluated. One hundred thirty patients had 12-month data, 66 had 18-month data, and 25 had 24-month data. In addition, a meta-analysis evaluated outcomes from six studies including 358 standalone balloon dilation patients with up to 24 months follow-up.
Results
Outcomes out to 2 years from the REMODEL full-study cohort are consistent with 6-month and 12-month outcomes. In the meta-analysis of standalone balloon dilation studies, technical success is 97.5%, and mean 20-item Sino-Nasal Outcomes Test scores are significantly and clinically improved at all time points (P < .0001). There are significant reductions (P < .0001) in work/school days missed, homebound days, physician/nurse visits, acute infections, and antibiotic prescriptions. Mean recovery time is 1.4 days. Comparison of 12-month symptom improvements and revision rates between the REMODEL FESS arm (n = 59), REMODEL balloon dilation arm (n = 71), and pooled single-arm standalone balloon dilation studies (n = 243) demonstrated no statistical difference.
Conclusions
All outcomes are comparable between FESS and balloon dilation at all time points from 6 months to 24 months. Balloon dilation produces faster recovery, less postoperative pain, and fewer debridements than FESS. There is significant, durable benefit in a large series of 358 patients undergoing standalone balloon dilation.
Level of Evidence
1b/2a. Laryngoscope, 2015
Posterior auricular artery fasciocutaneous island flap: lateral temporal soft tissue reconstruction
Benjamin P. Caughlin, Miriam Redleaf, 2015-08-11 16:19:20 PM
Quantitative assessment of the upper airway in infants and children with subglottic stenosis
Carlton Zdanski, Stephanie Davis, Yi Hong, Di Miao, Cory Quammen, Sorin Mitran, Brad Davis, Marc Niethammer, Julia Kimbell, Elizabeth Pitkin, Jason Fine, Lynn Fordham, Bradley Vaughn, Richard Superfine, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Determine whether quantitative geometric measures and a computational fluid dynamic (CFD) model derived from medical imaging of children with subglottic stenosis (SGS) can be effective diagnostic and treatment planning tools.
Study Design
Retrospective chart and imaging review in a tertiary care hospital.
Methods
Computed tomography scans (n = 17) of children with SGS were analyzed by geometric and CFD methods. Polysomnograms (n = 15) were also analyzed. Radiographic data were age/weight flow normalized and were compared to an atlas created from radiographically normal airways. Five geometric, seven CFD, and five polysomnography measures were analyzed. Statistical analysis utilized a two-sample t test with Bonferroni correction and area under the curve analysis.
Results
Two geometric indices (the ratio of the subglottic to midtracheal airway, the percent relative reduction of the subglottic airway) and one CFD measure (the percent relative reduction of the hydraulic diameter of the subglottic airway) were significant for determining which children with SGS received surgical intervention. Optimal cutoffs for these values were determined. Polysomnography, the respiratory effort-related arousals index, was significant only prior to Bonferroni correction for determining which children received surgical intervention.
Conclusions
Geometric and CFD variables were sensitive at determining which patients with SGS received surgical intervention. Discrete quantitative assessment of the pediatric airway was performed, yielding preliminary data regarding possible objective thresholds for surgical versus nonsurgical treatment of disease. This study is limited by its small, retrospective, single-institution nature. Further studies to validate these findings and possibly optimize treatment threshold recommendations are warranted.
Level of Evidence
4 Laryngoscope, 2015
Otolaryngology Needs in a Free Clinic Providing Indigent Care
Amanda Hu, Thomas Sibert, Wei Zhao, Vincent Zarro, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To determine the otolaryngology needs in a free clinic providing care to medically indigent patients, as perceived by the patients and health care providers.
Study Design
Cross-sectional survey.
Methods
A survey was administered to patients and health care providers of a free clinic from September 2014 through January 2015 in an urban, inner-city location.
Results
One hundred and thirty-seven patients (35.8% male, age 50.8 ± 13.0 years) completed the survey. Mean household income was $29,838 ± $10,425; 32.1% spoke English; 54.7% were employed; 10.2% had health insurance; and 37.2% had seen a primary care provider outside of the free clinic. The top three otolaryngology symptoms among patients were sleep apnea/snoring (39.4%), heartburn/reflux (30.7%), and dizziness (29.9%). Eleven health care providers (45% male, age 50.5 ± 15.3 years, 63.6% physician, 36% nurse) completed the survey. Providers perceived the following otolaryngology complaints as the most prevalent, in descending order: cough, nasal congestion, reflux/heartburn, sore throat, and ear infection/otalgia. Providers felt that sleep apnea and hearing loss were the less common otolaryngology complaints, whereas surveyed patients indicated these symptoms with high frequency. The most requested diagnostic tool among patients and providers was chest X-rays.
Conclusion
There are unmet otolaryngology needs in a free clinic. Medically indigent patients have significant barriers to accessing health care. Patient and provider perceptions of top otolaryngology complaints differed, but both identified access to chest X-rays as a major unmet need. Knowledge of patient perceptions may help providers elicit the breadth of otolaryngology complaints.
Level of Evidence
4. Laryngoscope, 2015
Normative data for rotational chair stratified by age
Fung M. Chan, Jessica Galatioto, Michael Amato, Ana H. Kim, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The purpose of this study is to examine the range of vestibulo-ocular reflex (VOR) gain on rotary chair (RC) testing in subjects without ear and vestibular problems stratified by age and gender.
Study Design
Prospective cross-sectional study.
Methods
One hundred subjects ranging in age from 6 to 78 years underwent RC testing. VOR gains at frequencies ranging from 0.01 to 0.64 Hz were recorded. The PROC MIXED procedure in SAS was used to analyze differences in VOR gain between gender and the following age groups: group 1 (6–12 years), group 2 (13–17 years), group 3 (18–30 years), group 4 (31–50 years), and group 5 (>50 years).
Results
Twenty subjects were recruited for each of the five groups. Group 1 showed the highest average VOR gain compared to all other age groups (P < .05). There was an inverse correlation between VOR gain and age (P < .05). The lowest frequency (0.01 Hz) had the highest correlation between VOR gain and age (r = −0.425; P < .0001).
Conclusions
Our study demonstrates VOR gain differences with age, especially in the preadolescent and geriatric groups. The current manufacturer-provided normative data do not serve as an accurate reference, especially for these two age groups. A larger population of all age groups should be compared to the current RC manufacturer normative values to ensure that they accurately reflect the true normative data.
Level of Evidence
2. Laryngoscope, 2015
Cricothyroid joint anatomy as a predicting factor for success of cricoid-thyroid approximation in transwomen
Sarina Tschan, Flurin Honegger, Claudio Storck, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Cricoid-thyroid approximation (CTA) performed to elevate the vocal pitch in transwomen fails in about one-third of the patients. The purpose of this study was to test the feasibility of predicting the likelihood of success of CTA by preoperative determination of the crico-thyroid joint (CTJ) type using three-dimensional (3-D) images derived from high-resolution computer tomography (HRCT).
Study Design
Prospective cohort study of 18 transwomen who underwent CTA at our institution.
Methods
All patients had a preoperative and a postoperative HRCT of the larynx, as well as pre- and postoperative measurements of the fundamental vocal pitch (F0).
Results
Three-dimensional images showed type A CTJs in 11 patients and type B or C CTJs in seven patients (see below for the definition of these types). Cricoid-thyroid approximation raised the F0 on average by 76 Hz in patients with type A CTJs and by 45 Hz in patients with type B/C CTJs. Moreover, CTA produced a vocal fold elongation of 17% in larynges with type A joint but only of 3% in larynges with type B/C joints.
Conclusion
Three-dimensional images allow the differentiation of type A versus type B/C CTJs but not the distinction between type B and type C CTJs. Both vocal pitch elevation and vocal fold elongation following CTA are significantly greater in patients with type A CTJs than in patients with type B/C CTJs. Based on these preliminary results, we recommend identifying the CTJ type on 3-D images and limiting CTA to patients with type A CTJs.
Level of Evidence
4. Laryngoscope, 2015
Retropharyngeal lymph node involvement in human papillomavirus–associated oropharyngeal squamous cell carcinoma
Michael Baxter, Jason Y. K. Chan, Wojciech K. Mydlarz, Salvatore V. Labruzzo, Ana Kiess, Patrick K. Ha, Nafi Aygun, Nishant Agrawal, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The purpose of this study was to retrospectively review patients with human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma (OPSCC) for the presence of retropharyngeal lymph nodes (RPLNs) prior to treatment using positron emission tomography/computed tomography (PET/CT), and to determine if the presence of RPLNs is of utility in predicting outcomes.
Study Design
Retrospective review of patient data from a single institution.
Methods
Two hundred thirty patients with a diagnosis of HPV-associated OPSCC were identified from 2002 to 2013. The presence of RPLNs was determined primarily from findings on PET/CT as reviewed in a standardized fashion by two neuroradiologists.
Results
Of the 230 patients, 165 had pretreatment PET/CT imaging available for review. There were a total of 16 patients (9.70%) with evidence of RPLNs. Among patients positive for RPLNs pretreatment, with an average follow-up of 2 years, there was a 5.2-times greater odds of having recurrence or death (31.3% vs. 8.1%, P = .004). When T and N stage were adjusted for with multiple regression, there was no significant association between RPLN status and recurrence free survival.
Conclusions
This is a unique investigation utilizing PET/CT to classify RPLN status in HPV-associated OPSCC. RPLNs were relatively common in our HPV-associated OPSCC cohort at 9.70%, at the low end of the quoted positivity of 10% to 27% in all OPSCC. A combination of PET/CT is useful in identifying RPLNs. Prospective investigation will be needed to determine the sensitivity and specificity of PET/CT in identifying RPLNs, and the precise impact of RPLNs on HPV-associated OPSCC treatment and outcomes.
Level of Evidence
4. Laryngoscope, 2015
Wound-healing effect of acupuncture for treating phonotraumatic vocal pathologies: A cytokine study
Edwin M. L. Yiu, Karen M. K. Chan, Nicole Y. K. Li, Raymond Tsang, Katherine Verdolini Abbott, Elaine Kwong, Estella P. M. Ma, Fred W. Tse, Zhixiu Lin, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Acupuncture is a less-invasive procedure when compared with surgical treatment for benign vocal pathologies caused by vocal overuse. This study aimed to determine the wound-healing effect of acupuncture in treating phonotraumatic vocal fold lesions.
Study Design
Two-way, mixed-model, between- and within-subjects, prospective randomized, placebo-controlled, blinded group design.
Methods
Seventeen dysphonic individuals with vocal nodules were recruited from a university clinic in Hong Kong. Each participant was randomly assigned to receive one session of either genuine or sham acupuncture. The genuine acupuncture group (n = 9) received needles puncturing nine voice-related acupoints for 30 minutes, whereas the sham acupuncture group (n = 8) received blunted needles stimulating the skin surface of the nine acupoints for the same frequency and duration. Laryngeal secretions were suctioned from the surface of the vocal folds immediately before, immediately after, and 24 hours after the acupuncture. The protein concentration levels of wound-healing–related cytokines (interleukin [IL]-1β and IL-10) in these secretion samples were measured.
Results
Following acupuncture, a significant increase in the anti-inflammatory cytokine IL-10 was found in the genuine acupuncture group (n = 9) but not in the sham acupuncture group (n = 8).
Conclusions
The findings showed that acupuncture of voice-related acupoints facilitated an anti-inflammatory process in phonotraumatic vocal pathologies. This could be considered as supporting evidence to consider acupuncture as a less-invasive alternative option, when compared to surgery, for treating phonotraumatic vocal pathologies.
Level of Evidence
1b Laryngoscope, 2015
Results of pediatric tympanoplasty on short-term surgical missions
Glenn Isaacson, Abebe Melaku, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To determine the safety and effectiveness of pediatric tympanoplasty performed on short-term international medical missions.
Study Design
Prospective observational study.
Methods
Ethiopian children who had dry or nearly dry tympanic perforations and bilateral conductive hearing losses underwent postauricular tympanoplasties with underlain temporalis fascia grafts. Pre- and postoperative air and bone audiometry was performed. Complications, graft success, hearing improvement, and dry ear at 6-month follow-up were evaluated.
Results
Patients were 7 to 25 years old (24 female ears, 20 male ears). The majority had subtotal perforations. Operative findings included ossicular erosions and fixation by hypertrophic mucosa. There were no major medical complications or deaths in this series.
Of 44 ears, 27 had complete pre- and postoperative audiometric data. Twenty-four of 44 surgeries resulted in an intact tympanic membrane. Twelve of 44 markedly reduced the perforation. Eight of 44 grafts failed. The mean improvement in PTA was 14 dB (range = −6–45 dB). Human immunodeficiency virus (HIV)+ patients had a high rate of graft failure (3/4) and comprised 38% (3/8) of complete graft failures (P = .015). Among the 20 ears with residual perforations, 14 were dry at 6-month follow-up. Of the six ears with drainage, three were HIV+ (P = .019).
Conclusions
Pediatric tympanoplasty is a safe procedure in a short-term surgical mission setting when high anesthetic and surgical standards are maintained. Surgical results were similar to those found in developing-world university hospitals, but were worse than in United States or European series. HIV+ children did worse than their HIV−/unknown peers, with a high rate of graft failure and persistent otorrhea.
Level of Evidence
4. Laryngoscope, 2015
Do otolaryngology residency applicants relocate for training?
Grant M. Gebhard, Leah J. Hauser, Miranda J. Dally, David A. Weitzenkamp, Cristina Cabrera-Muffly, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To determine whether there is an association between the geographic location of an applicant's undergraduate school, medical school, and residency program among matched otolaryngology residency applicants.
Study Design
Observational.
Methods
Otolaryngology residency program applications to our institution from 2009 to 2013 were analyzed. The geographic location of each applicant's undergraduate education and medical education were collected. Online public records were queried to determine the residency program location of matched applicants. Applicants who did not match or who attended medical school outside the United States were excluded. Metro area, state, and region were determined according to US Census Bureau definitions.
Results
From 2009 to 2013, 1,089 (78%) of 1,405 applicants who matched into otolaryngology residency applied to our institution. The number of subjects who attended medical school and residency in the same geographic region was 241 (22%) for metropolitan area, 305 (28%) for state, and 436 (40%) for region. There was no difference in geographic location retention by gender or couples match status of the subject. United States Medical Licensing Exam step 1 scores correlated with an increased likelihood of subjects staying within the same geographic region (P = .03).
Conclusions
Most otolaryngology applicants leave their previous geographic area to attend residency. Based on these data, the authors recommend against giving weight to geography as a factor when inviting applicants to interview.
Level of Evidence
NA Laryngoscope, 2015
Pediatric endoscopic ear surgery in clinical practice: Lessons learned and early outcomes
Michael S. Cohen, Lukas D. Landegger, Elliott D. Kozin, Daniel J. Lee, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Only a few reports describe the outcomes following endoscopic ear surgery (EES) in children for chronic ear disease. We differentiate between transcanal endoscopic ear surgery (TEES), where the case is performed with only endoscopic visualization, from non-TEES, where the endoscope is not used at all or used as an adjunct to the microscope. We hypothesize that EES is an effective approach to manage middle ear pathology using a transcanal approach in most cases, and can be incorporated into a pediatric otology practice with a neutral or positive effect on outcomes. Lessons learned during this process are analyzed and discussed.
Study Design
Single-institution, retrospective chart review of outcomes following TEES and non-TEES in children from January 1, 2013 through July 1, 2014.
Methods
Procedures included tympanoplasty, ossiculoplasty, and cholesteatoma resection. Primary outcome measures included closure rate of tympanic membrane perforations, audiometric outcomes, and complications. Surgical times were reported as secondary measures.
Results
Ninety-four patients underwent 121 middle ear procedures. TEES was performed in 51/121 of cases (42.1%). Comparison of TEES versus non-TEES cases showed no significant difference in rate of tympanoplasty closure (P > .99). The mean pure-tone improvement following TEES tympanoplasty was −7.8 dB versus −1.33 dB for non-TEES cases (P = .03). Surgical times were similar between groups.
Conclusions
EES techniques were readily incorporated into a pediatric otology practice. A standardized EES classification system is useful for analyzing utilization patterns and results across institutions. Tympanic membrane closure rates and hearing outcomes were similar in TEES and non-TEES cases.
Level of Evidence
4. Laryngoscope, 2015
Sinonasal malignancies: A population-based analysis of site-specific incidence and survival
Rahul Dutta, Pariket M. Dubal, Peter F. Svider, James K. Liu, Soly Baredes, Jean Anderson Eloy, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Sinonasal malignancies vary in behavior according to histology and anatomical location. Incidence, survival, and optimal treatment for these lesions are thus uncertain in various cases. Our objective was to utilize a national population-based registry to identify the most common sinonasal histopathologies by anatomical site, and subsequently analyze the data by incidence trends, survival rates, patient demographics, and treatment modalities.
Study Design
Retrospective analysis of the United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry.
Methods
The SEER database was examined for patients diagnosed with sinonasal malignancies between 1973 and 2011. Data were stratified according to anatomical site, incidence, survival, histology, staging, and patient demographics. Therapy-based outcomes were analyzed for cases from 1983 to 2011.
Results
A total of 13,295 patients were identified, with an incidence of 0.83 per 100,000 people. Males comprised 58.6% of cases. Whites represented 81.5% of cases, while blacks comprised 8.7%. Squamous cell carcinoma was the most common histology (41.9%) across all sites of the sinonasal tract. The most common anatomical site of malignancy was the nasal cavity (45.7%), and least common was the frontal sinus (1.2%). For single sites, 5-year disease-specific survival (DSS) was highest for nasal cavity tumors (67.1%) and lowest for overlapping sinus malignancies (37.6%). The overall 5-year DSS for all sinonasal malignancies was 53.7%.
Conclusion
Sinonasal malignancies are rare entities with poor overall prognosis. By anatomical site, prognosis is best for nasal cavity cancers and worst for overlapping lesions.
Level of Evidence
4. Laryngoscope, 2015
Clinical relevance of quality of life in laryngomalacia
Prasad John Thottam, Jeffrey P. Simons, Sukgi Choi, Raymond Maguire, Deepak K. Mehta, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To examine aspects of laryngomalacia and correlate findings with quality of life (QOL).
Study Design
Prospective cross-sectional study.
Methods
Seventy-two patients with laryngomalacia were examined; the mean age was 8.8 weeks. Parents answered questions from the Infant and Toddler Quality of Life Questionnaire–47 (ITQOL-SF47). Fiberoptic laryngoscopy and endoscopic examination of swallowing (FEES) were performed. The presence of laryngomalacia-associated characteristics and swallowing status were recorded. Patient age, sex, presence of reflux, clinical severity, anatomical findings, and swallowing results were evaluated through logistic regression. Independent sample ttests were used to compare responses on the ITQOL-SF47. Overall laryngomalacia ITQOL-SF47 scores were compared to the scores of a large healthy sample population.
Results
Forty-three (60%) patients had mild laryngomalacia, and 61 (85%) patients had findings suggesting gastroesophageal reflux disease. The most common abnormality was shortened aryepiglottic folds. Ten patients failed FEES. Patients with moderate laryngomalacia (χ = 7.62; P = .006) or prolapsing cuneiforms (χ = 4.79; P = .029) were more likely to fail FEES. Laryngomalacia severity impacted parental perception of their child's health (P < .05). Parents of children who demonstrated aspiration or penetration reported significant emotional impact (mean = 56.9; t = 2.74; P = .008). The mean ITQOL-SF47 scores of patients were significantly lower in certain sections than the reported general sample population.
Conclusions
Epiglottal prolapse correlated with severity of laryngomalacia and cuneiform prolapse with swallowing dysfunction. Perceptions of worsening health and physical ability were related to severity of disease. Swallowing dysfunction had a significant emotional impact on parental daily life. Infants with laryngomalacia have a lower QOL
Level of Evidence
3 Laryngoscope, 2015
In response to is the OSA-18 predictive of obstructive sleep apnea: Comparison to polysomnography
Stacey L. Ishman, Christina J. Yang, Aliza P. Cohen, James R. Benke, Rebecca M. Anderson, Marie E. Madden, Jareen K. Meinzen-Derr, Meredith E. Tabangin, 2015-08-11 16:19:20 PM
Characterization of retentive capacity of the subpericranial pocket in cochlear implants with and without a pedestal
Blake C. Papsin, Sharon L. Cushing, Bradley J. Hubbard, Daniel D. E. Wong, Karen A. Gordon, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To quantify the retentive capacity (RC) of the subpericranial pocket (SpP) in children undergoing cochlear implantation (CI) and measure improvements in RC with the addition of a pedestal to the device base. Retention of a CI in an SpP relies on the integrity of surrounding tissues to determine device position and resist movement from external forces. We hypothesize that device position can be controlled and resistance to movement can be improved with placement of a small pedestal on the base of the CI receiver stimulator.
Study Design
Analysis of prospectively assembled data.
Methods
Ninety-seven patients (145 devices) underwent CI (48 bilateral, 49 unilateral). Intraoperatively, a force gauge measured the displacement force on a template Nucleus 5 (Cochlear Corporation, Sydney, Australia) implant placed in an SpP prior to routine suture fixation of a standard device. In 47 patients (64 devices), displacement forces were also measured for a custom template Nucleus 5 implant with pedestal.
Results
Average RC of the SpP for the standard device was 5.59 N ± 2.73 standard deviation (SD), which increased to 9.401 N ± 4.6267 SD with a pedestaled device. Resistance to displacement decreased significantly across trials in both groups (P <.0001). Retentive capacity of the SpP increased significantly with the addition of a pedestaled device (P < .0001). The interaction between device and trial was also found to be significant (P = .05).
Conclusions
The RC of the SpP in children and the ability to resist device migration in the absence of fixation may improve with the addition of a pedestal attached to the device.
Level of Evidence
2b. Laryngoscope, 2015
Development of a novel larynx pacemaker multichannel array electrode: In vivo animal analysis
Bernd Faenger, Nikolaus P. Schumann, Dirk Arnold, Roland Grassme, Orlando Guntinas-Lichius, Hans-Christoph Scholle, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Electrical stimulation of posterior cricoarytenoid muscle offers a physiological approach to retain the function of the paralyzed larynx muscle after paralysis. The aim of this study was to develop and evaluate a durable, biocompatible, and atraumatic array electrode for inclusion in a larynx pacemaker. In addition to developing the electrode array, an evaluation methodology using in vivo multichannel electromyography was assessed.
Study Design
In vivo test procedures for material evaluation: an animal model.
Methods
Over the research period, 42 array electrodes representing nine different prototypes were implanted in the triceps brachii muscle of 21 rats. Biocompatibility and atraumatic functions were evaluated via observation. Electrode function and durability were determined by comparison of daily electromyographic measurements of the muscle activity of the front leg (triceps brachii muscle) during locomotion.
Results
The used animal model demonstrated electrode material problems that could not be material evaluation from in vitro tests alone. Through use of this in vivo method, it was found that an array tip that is durable, biocompatible, and atraumatic should consist of many small electrode plates cast in flexible silicone. The connecting wires to the individual electrode plates should be Litz wire, which consists of multiple strands.
Conclusions
The here demonstrated in vivo test method was a suitable animal model for designing and evaluating electrodes to be further developed for inclusion in human implants.
Level of Evidence
N/A. Laryngoscope, 2015
Prefabricated auricular cartilage radial forearm free flap reconstruction for cricoid chondrosarcoma
Ryan S. Jackson, Eliot J. Martin, Eric J. Moore, 2015-08-11 16:19:20 PM
This case describes a subtotal cricoid cartilage defect reconstructed with a prefabricated composite free flap. A 61-year-old man with a chondrosarcoma of the cricoid cartilage required a subtotal cricoidectomy. The resulting defect was successfully reconstructed with a two-stage prefabricated radial forearm free flap utilizing auricular cartilage. Our case further adds to the evidence that prefabricated flaps are reliable in airway reconstruction. Additionally, this provides another option for laryngeal preservation in patients with laryngeal chondrosarcoma.
Level of Evidence
NA Laryngoscope, 2015
The economic impact of vocal attrition in public school teachers in Miami-Dade County
David E. Rosow, Mikhaylo Szczupak, Sandra Saint-Victor, Julia D. Gerhard, Carl DuPont, Kaming Lo, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Teachers are a known at-risk population for voice disorders. The prevalence and risk factors for voice disorders have been well studied in this population, but little is known about the associated economic cost. The purpose of this study is to assess the economic impact of voice dysfunction in teachers and understand the difference between the cost of absenteeism and presenteeism as a direct result of voice dysfunction.
Study Design
Cross-sectional analysis via self-administered online questionnaire.
Methods
A total of 14,256 public school teachers from Miami-Dade County, Florida, were asked to participate. Questions were formatted based on the previously validated Work Productivity and Activity Impairment: Specific Health Problem questionnaire adapted for hoarseness and voice disorders. Additional demographic questions were included in the questionnaire.
Results
A total of 961 questionnaire responses were received. The demographic characteristics of respondents closely matched known statistics for public school teachers in Miami-Dade County. Economic calculations were performed for each questionnaire respondent and summed for all respondents to avoid bias. Per week, absenteeism-related costs were $25,000, whereas presenteeism-related costs were approximately $300,000. These figures were used to extrapolate annual cost. Per year, absenteeism-related costs were $1 million, whereas presenteeism-related costs were approximately $12 million.
Conclusion
The economic impact of voice dysfunction on the teaching profession is enormous. With the above calculations only including lost wages and decreased productivity, the actual figures may in fact be larger (cost of substitute teachers, impact on nonwork activities, etc.). Research investigating preventative measures for voice dysfunction in teachers is necessary to reduce this costly issue.
Level of Evidence
2C. Laryngoscope, 2015
Internal to external jugular vein bypass allowing for simultaneous bilateral radical neck dissection
Moustafa Mourad, Masoud Saman, Yadranko Ducic, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The goal of the study was to determine the role of internal jugular vein (IJV) to external jugular vein (EJV) bypass grafting in the setting of bilateral radical neck dissection with IJV sacrifice.
Study Design
The study group consisted of eight patients who underwent bilateral radical neck dissection with IJV sacrifice. Demographic and oncologic parameters were defined for each patient, including age, gender, and pathology. Patients were monitored and evaluated for potential effects of increased intracranial pressure (ICP). Doppler ultrasonic evaluation was performed to assess patency of the site of anastamoses.
Results
In all, six patients underwent unilateral bypass grafting, whereas two patients underwent bilateral bypass grafts. Average age at time of surgery was 68.2 (range 56–71). Postoperatively, no sequelae of increased ICP were noted. Follow-up ultrasonic evaluation revealed patent vessels in all patients.
Conclusion
We presently report on the use of EJV-to-IJV bypass grafting for all patients undergoing bilateral radical neck dissection for extensive neck disease.
Level of Evidence
4. Laryngoscope, 2015
Effectiveness of mandibular advancement appliances in treating obstructive sleep apnea syndrome: A systematic review
Sara Serra-Torres, Carlos Bellot-Arcís, José M. Montiel-Company, Jaime Marco-Algarra, José M. Almerich-Silla, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Mandibular advancement devices are an alternative to continuous positive airway pressure for patients with mild or moderate obstructive sleep apnea/hypopnea syndrome (OSAHS). The main aim of this review was to assess the effectiveness of different devices in treating OSAHS, based on polysomnographic measurements such as the apnea/hypopnea index (AHI) and oxygen saturation, and on changes in the upper airway and improvements in the most common symptoms: snoring and somnolence. Their adverse effects were also noted.
Study Design
Systematic review.
Methods
Following an exhaustive search in the Medline, Scopus, and Cochrane Library databases, 22 articles published in the past 10 years met the quality and inclusion criteria.
Results
Using mandibular advancement devices during the hours of sleep helps to prevent snoring and excessive daytime sleepiness, reduce the AHI significantly, and bring about beneficial changes in the upper airway. Adjustable and custom-made mandibular advancement devices give better results than fixed and prefabricated appliances. Monobloc devices give rise to more adverse events, although these are generally mild and transient.
Conclusions
Mandibular advancement devices increase the area of the airway. They bring the soft palate, tongue, and hyoid bone forward and activate the masseter and submental muscles, preventing closure. All these effects reduce the AHI, increase the oxygen saturation, and improve the main symptoms of OSAHS.
Level of Evidence
NA Laryngoscope, 2015
Historical classics: Editorial
Myles L. Pensak, 2015-08-11 16:19:20 PM
Familial risk of pediatric chronic rhinosinusitis
Quinn Orb, Karen Curtin, Gretchen M. Oakley, Jathine Wong, Jeremy Meier, Richard R. Orlandi, Jeremiah A. Alt, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To determine the risk of chronic rhinosinusitis (CRS) in relatives of children with a diagnosis of CRS.
Study Design
Retrospective observational cohort study with population-based matched controls.
Methods
A unique genealogical database linked to medical records was used to identify subjects ≤12 years old with a diagnosis of CRS from 1996 to 2011. The familial recurrence risks of CRS in first- through fifth-degree relatives of probands were calculated using Cox models and compared to controls randomly selected from the Utah population and matched 10:1 on sex and birth year.
Results
We identified 496 pediatric patients with CRS. Siblings of patients with CRS demonstrated a 57.5-fold increased risk (P < 10−8) of also having pediatric CRS. First cousins had a 9.0-fold increased risk (P < 10−3) and second cousins had a 2.9-fold increased risk (P = .002) of pediatric CRS. First-degree relatives, second-degree relatives, and first cousins of pediatric cases demonstrated a significant increased risk of having adult CRS. Parents of probands demonstrated a 5.6-fold increased risk (P < 10−15). Fifty-five probands had one affected parent versus three probands with two affected parents.
Conclusions
In the largest population study to date of children with CRS, a significant familial risk is confirmed. Parents of probands were also at increased risk, although it was much more likely for one parent to be affected than both, suggesting a genetic component of the disease. Further understanding of the genetic basis of CRS and its interplay with environmental factors could clarify the etiology and lead to more effective targeted treatments.
Level of Evidence
3b Laryngoscope, 2015
Recurrent laryngeal nerve safety parameters of the Harmonic Focus during thyroid surgery: Porcine model using continuous monitoring
Che-Wei Wu, Young Jun Chai, Gianlorenzo Dionigi, Feng-Yu Chiang, Xiaoli Liu, Hui Sun, Gregory W. Randolph, Ralph P. Tufano, Hoon Yub Kim, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The Harmonic Focus (HF) is one of the most popular energy-based devices. The aim of this study was to provide recurrent laryngeal nerve (RLN) functional data that define the safety parameters of the HF during thyroidectomy.
Study Design
Prospective porcine model using continuous electrophysiologic monitoring.
Methods
Ten piglets were used. At varying distances from the RLN, the HF was activated (activation study). The HF was also applied directly on the RLN after activation on sternocleidomastoid muscle for 10 seconds with different cooling times (cooling study).
Results
In the activation study, there was no adverse electromyography (EMG) event at more than 1 mm distance. In the cooling study, there was no adverse EMG event after a 10-second cooling period. When the HF was cooled on the sternocleidomastoid muscle, there was no adverse EMG event after 2 seconds cooling time.
Conclusions
The safe distance of the HF was 1 mm, and it should be cooled for more than 10 seconds or 2 seconds after cooling on muscle. The HF should be used in a standardized manner to avoid RLN injury.
Level of Evidence
NA Laryngoscope, 2015
Effect of recurrent onabotulinum toxin a injection into the salivary glands: An ultrasound measurement
Isabel Cardona, Christine Saint-Martin, Sam J. Daniel, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Onabotulinum toxin A (OBTXA) injection is a well-established therapeutic option for the management of drooling. Many of the children treated undertake repeated injections every 3 to 6 months. We aimed to assess quantitative salivary gland changes via ultrasound imaging after intraglandular injection of OBTXA for sialorrhea treatment in children, as a method that suggests permanent changes in glandular size can cause a decrease in functionality or atrophy.
Study Design
Case-control study.
Methods
The parotid and submandibular glands of 22 patients with sialorrhea with previous repetitive OBTXA treatments were measured via ultrasound. These were compared with a control group of 38 healthy children.
Results
A total of 60 patients were included in the study (38 boys, 22 females). Body mass index, sex, and age were defined as confounders. The mean age was 7 years (standard deviation [SD] ±2.3 years) and 9 years (SD ±3.8 years) for treatment and control groups, respectively. There were no postinjection complications. We found significant decrease in the size dimensions (surface area and depth) of both submandibular glands and one parotid gland in the treatment group (P < .05). Significant smaller anterior-posterior dimension of the submandibular glands (P < .01) was also found.
Conclusions
The chronic use of intraglandular OBTXA reduced the size of the salivary glands measured ultrasonographically. Results were correlated with clinical outcomes. Pathological studies should be done to correlate whether ultrasound changes result in atrophy or apoptosis of the glands.
Level of Evidence
3b Laryngoscope, 2015
Role of saposin C and D in auditory and vestibular function
Lawrence R. Lustig, Sean Alemi, Ying Sun, Gregory Grabowski, Omar Akil, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Saposins are small proteins derived from a precursor protein, prosaposin. Each of the four saposins (A–D) is necessary for the activity of lysosomal glycosphingolipid hydrolases. Individual saposin mutations lead to lysosomal storage diseases, some of which are associated with hearing loss. Here we evaluate the effects of the loss of saposins C and D on auditory and vestibular function in transgenic mice.
Methods
Transgenic mice with either loss of saposin C function or a combined loss of saposin C + D function were studied. Light microscopy and immunofluorescence were used to evaluate histologic and morphologic changes in the auditory and vestibular organs. Acoustic brainstem response thresholds and distortion product otoacoustic emissions were used to study the auditory phenotype.
Results
A null mutation of saposin C did not result in any identifiable histologic changes or loss of hearing through postnatal day 55. Combined losses of saposins C and D similarly did not result in any changes in organ of Corti histology or loss of hearing. However, inclusions within the vestibular end organs was noted, consistent with afferent and efferent neuronal sprouting, although to a much milder degree than seen in the previously studied prosaposin knockout mouse.
Conclusions
Loss of saposin C and D function, although causing mild phenotypic changes in the vestibular end organs, otherwise results in minimal functional impairment and no changes in the auditory system. It is more likely that the auditory and vestibular effects of the loss of prosaposin are mediated through the actions of saposin A and/or B.
Level of Evidence
NA. Laryngoscope, 2015
Potential correlations of dentogenic factors to the development of clinically verified fungus balls: A retrospective computed tomography–based analysis
Peter Valentin Tomazic, Eva Dostal, Marton Magyar, Doris Lang-Loidolt, Axel Wolf, Wolfgang Koele, Astrid Truschnegg, Heinz Stammberger, Michael Payer, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Fungus balls are a common disease of the paranasal sinuses, usually involving the maxillary sinus. To clarify the pathology, we analyzed patients treated for maxillary sinus fungus balls to see whether the latter correlated with dentogenic factors.
Study Design
Retrospective case analysis.
Methods
Cases of maxillary sinus fungus balls diagnosed between January 2000 and December 2013 were analyzed retrospectively. Patients' charts were reviewed for diagnosis, gender, and age. Paranasal sinus computed tomography (CT) scans were reviewed according to the side of the fungus ball, calcifications/opacifications, and dentogenic factors.
Results
In 98/102 patients (96.1%), 157 dentogenic factors could be identified on the side affected by a fungus ball. On the contralateral healthy side, there were 125 dentogenic factors. In four (3.9%) of the patients, no dentogenic pathology was identified on the CT scan. The presence of dentogenic factors (regardless of number) was significantly associated with a fungus ball compared to the healthy side (P = .024, χ2 test, odds ratio: 2.72 [95% confidence interval: 1.02–7.23]).
Conclusions
Dentogenic factors regardless of type potentially correlate with the presence of maxillary sinus fungus ball. Unlike the overall presence of dentogenic factors, the particular dentogenic factors in an individual patient do not significantly influence the development of fungus balls. After diagnosis of dentogenic pathology in penetrated maxillary sinus floors, patients should be closely monitored and informed about their higher risk of developing a fungus ball.
Level of Evidence
4. Laryngoscope, 2015
Phonatory aerodynamics in connected speech
Jackie L. Gartner-Schmidt, Ryoji Hirai, Christina Dastolfo, Clark A. Rosen, Lan Yu, Amanda I. Gillespie, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
1) Present phonatory aerodynamic data for healthy controls (HCs) in connected speech; 2) contrast these findings between HCs and patients with nontreated unilateral vocal fold paralysis (UVFP); 3) present pre- and post-vocal fold augmentation outcomes for patients with UVFP; 4) contrast data from patients with post-operative laryngeal augmentation to HCs.
Study Design
Retrospective, single-blinded.
Methods
For phase I, 20 HC participants were recruited. For phase II, 20 patients with UVFP were age- and gender-matched to the 20 HC participants used in phase I. For phase III, 20 patients with UVFP represented a pre- and posttreatment cohort. For phase IV, 20 of the HC participants from phase I and 20 of the postoperative UVFP patients from phase III were used for direct comparison. Aerodynamic measures captured from a sample of the Rainbow Passage included: number of breaths, mean phonatory airflow rate, total duration of passage, inspiratory airflow duration, and expiratory airflow duration. The VHI-10 was also obtained pre- and postoperative laryngeal augmentation.
Results
All phonatory aerodynamic measures were significantly increased in patients with preoperative UVFP than the HC group. Patients with laryngeal augmentation took significantly less breaths, had less mean phonatory airflow rate during voicing, and had shorter inspiratory airflow duration than the preoperative UVFP group. None of the postoperative measures returned to HC values. Significant improvement in the Voice Handicap Index-10 scores postlaryngeal augmentation was also found.
Conclusions
Methodology described in this study improves upon existing aerodynamic voice assessment by capturing characteristics germane to UVFP patient complaints and measuring change before and after laryngeal augmentation in connected speech.
Level of Evidence
4. Laryngoscope, 2015
Soot and house dust mite allergen cause eosinophilic laryngitis in an animal model
Peter C. Belafsky, Janice Peake, Suzette M. Smiley-Jewell, Sunil Verma, James Dworkin-Valenti, Kent E. Pinkerton, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Chronic laryngitis (CL) is common and costly. One of the most common causes of CL is thought to be laryngopharyngeal reflux, although a significant percentage of individuals fail to get better with acid suppressive therapy. The role of other potential causes of CL such as allergy and environmental pollution has not been thoroughly investigated.
Purpose
To evaluate the association between iron soot, house dust mite allergen (HDMA), and CL in an established animal model.
Methods
Twenty-four guinea pigs were separated into four 6-week exposure groups: 1) saline (allergen control) + filtered air (pollution control); 2) HDMA (Dermatophygoides farinae) + filtered air; 3) saline + combustion particulates; or 4) HDMA + combustion particulates. The primary outcome measure was mean eosinophil profile (MEP) in glottic, subglottic, and trachea epithelium and submucosa.
Results
The combination of iron soot and HDMA caused eosinophilia (elevated MEP) in the glottic (P < 0.06), subglottic (P < 0.05), and trachea (P < 0.05) submucosa and epithelium (P < 0.05).
Conclusion
The combination of HDMA and iron soot resulted in laryngeal eosinophilia in an established guinea pig model of CL. The data support the notion that factors other than reflux may cause CL. Further investigation into eosinophilic laryngitis as a distinct clinical entity caused by exposure to environmental allergen and pollution is warranted.
Level of Evidence
N/A. Laryngoscope, 2015
Tracheoesophageal voice after total laryngopharyngectomy reconstruction: Jejunum versus radial forearm free flap
Daniel G. Deschler, Marc W. Herr, Joann R. Kmiecik, Rosh Sethi, Glenn Bunting, 2015-08-11 16:19:20 PM
Objective/Hypothesis
Tracheoesophageal (TE) voice restoration after laryngopharyngectomy with jejunal (Jej) flap and radial forearm flap (RFF) reconstruction has been successfully completed and studied for both techniques, but no direct comparisons exist. We undertook this study to directly compare TE voice in patients with total laryngopharyngectomy (TLP) reconstruction using the Jej and the RFF in a comprehensive and rigorous manner.
Study Design
Retrospective cohort study.
Methods
Forty patients after total laryngectomy or TLP were grouped by pharyngeal closure method: 18 primary closure (STL), 10 jejunal flap (TLP-Jej), and 12 radial forearm flap (TLP-RFF). Voice recordings underwent objective acoustic analysis and blinded subjective assessment by trained and naïve listeners. Quality-of-life (QOL) assessments were obtained in all subjects using general health, disease-specific, and voice-specific survey tools.
Results
All studies groups had similar demographics. Acoustic analysis demonstrated no differences in fundamental frequency or intensity levels. Subjective assessment demonstrated statistically significant inferior voice function of the reconstructed patients (TLP-Jej and TLP-RFF) compared to STL subjects for nearly all parameters tested by both naïve and trained listeners. No differences were noted between TLP-Jej and TLP-RFF subjects for any of the parameters evaluated. Overall, trained listeners assessed TE voice more favorably compared to naïve listeners in a significant manner. The three QOL surveys revealed no significant differences between TLP-Jej and TLP-RFF subjects.
Conclusion
Tracheoesophageal voice in TLP-Jej and TLP-RFF subjects was equivalent but inferior to STL subjects. Reconstructed subjects had no differences in general, disease-specific, and voice-specific quality of life.
Level of Evidence
2b. Laryngoscope, 2015
Differential roles for the thyroarytenoid and lateral cricoarytenoid muscles in phonation
Dinesh K. Chhetri, Juergen Neubauer, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Laryngeal adductor muscle dysfunction is a common cause of voice disorders. Reconstitution of adductor muscle function is often the target of therapy, but the effects of these muscles on voice production remain to be fully understood. This study investigated the differential roles of thyroarytenoid (TA) and lateral cricoarytenoid (LCA) muscles on voice production.
Study Design
Basic science study using an in vivo canine model of phonation.
Methods
The TA and LCA muscle nerve branches were stimulated to obtain seven graded levels of muscle activation, from threshold to maximal contraction. The effects of LCA muscle activation alone, TA muscle activation alone, and combined TA and LCA muscle activation on phonation onset parameters were investigated. Phonatory posture, phonation onset type, fundamental frequency (F0), phonation onset pressure, and airflow were evaluated.
Results
LCA muscle activation closed the posterior glottis, but the midmembranous gap remained. TA muscle activation closed the membranous glottis, but the posterior gap remained. Complete glottal closure was obtained only with combined TA and LCA muscle activation. Phonation onset with the LCA muscle alone was characterized by multiple modes (soft, aperiodic, periodic), whereas with the TA muscle alone it was abrupt and periodic but had significant baseline noise. Combined muscle activation led to elimination of baseline noise with stable abrupt periodic onset of phonation. Combined muscle activation was also necessary for F0 variation. The LCA muscle assisted the TA muscle in increasing subglottal pressure while concurrently reducing phonation onset airflow.
Conclusions
The TA muscle is necessary for F0 variation, stable onset phonation, and increased subglottal pressure, but needs the LCA muscle for optimal effectiveness and to reduce airflow requirements with increased activation.
Level of Evidence
NA Laryngoscope, 2015
Comparative effectiveness of propranolol and botulinum for the treatment of essential voice tremor
Natalie Justicz, Edie R. Hapner, Joshua S. Josephs, Benjamin C. Boone, Hyder A. Jinnah, Michael M. Johns, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To assess the comparative effectiveness of botulinum toxin and propranolol in patients with essential vocal tremor (EVT).
Study Design
Individual prospective cohort study.
Methods
Study patients were recruited at the Emory Voice Center from patients seeking treatment for EVT. Exclusion criteria included current β-blocker treatment, spasmodic dysphonia, or other disease that prevented the use of propranolol therapy. A 10-week washout period from prior botulinum toxin treatment occurred before enrollment. Patients were assessed via the Voice-Related Quality-Of-Life (VRQOL) questionnaire, Quality of life in Essential Tremor questionnaire, and blinded perceptual voice assessment. These assessments were made at baseline voice 2 weeks after propranolol therapy and 4 weeks after botulinum toxin injection.
Results
Eighteen patients were enrolled. After 2 to 4 weeks of propranolol therapy (with a maximum dosage of 60 mg to 90 mg per day), patients report an average ΔVRQOL of 9.31. Six patients report significant VRQOL improvement >10, with the rest reporting changes between −7.5 and 7.5. Fifteen patients were followed for at least 4 weeks after botulinum toxin injection, reporting an average improvement in scaled VRQOL of 22.00. Blinded perceptual voice assessment demonstrates an improvement in overall severity of tremor with botulinum toxin.
Conclusions
In some patients with EVT, propranolol led to significant vocal improvement with no major side effects. Although botulinum toxin remains the gold-standard therapy for patients with EVT, propranolol represents a possible alternative or adjuvant therapy for certain patients.
Level of Evidence
2b. Laryngoscope, 2015
Effects of different bronchoalveolar lavage methods on tracheobronchial foreign body patients
Hua-Nan Luo, Si-Jing Ma, Hai-Li Guo, Zheng-Hui Wang, Xiao-Yong Ren, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To compare the different effects of bronchoalveolar lavage (BAL) with diverse combinations of lidocaine, epinephrine, and dexamethasone on pediatric patients with an inhaled tracheobronchial foreign body (TFB).
Study Design
Randomized controlled study.
Methods
Two hundred forty cases of pediatric patients with inhaled TFB were included in this study, and were randomly divided into four groups using three kinds of drugs for BAL, namely 0.9% saline (S) group, 2% lidocaine with diluted epinephrine (LE) group, 2% lidocaine with diluted epinephrine and 0.5% dexamethasone (LED), control group (C) without BAL. The incidences of intraoperative or postoperative complications and recovery periods were compared. Meanwhile, the concentrations of interleukin (IL)−1β, IL-6, and tumor necrosis factor (TNF)-α in BAL fluids and plasma were evaluated by enzyme-linked immunosorbent assay.
Results
The incidences of bronchospasm, hypoxemia, and postoperative fever were significantly lower in the LED group than other groups (P < .001). Fever after the TFB removal procedure appeared later in the LED group than the other groups. The improvement and healing periods in the LE and LED groups were significantly shorter than those in the C and S groups (P < .001). The concentrations of IL-1β, IL-6, and TNF-α in BAL fluids were significantly higher in the LE and LED groups than those in the S group (P < .001), but those in the plasma of the C and S groups were lower compared with the LE and LED groups (P < .001).
Conclusions
BAL with lidocaine, epinephrine, and dexamethasone could promote recovery for TFB patients and reduce incidences of complications, possibly by regulating release of proinflammatory cytokines.
Level of Evidence
1b. Laryngoscope, 2015
In reference to the usefulness of the stay suture technique in tracheostomy
Satvinder Singh Bakshi, 2015-08-11 16:19:20 PM
Pediatric facial fractures: Demographic determinants influencing clinical outcomes
Kenny H. Chan, Dexiang Gao, Michael Bronsert, Keely M. Chevallier, Jonathan N. Perkins, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
There is limited data linking demographic determinants to clinical outcomes in facial trauma, particularly when comparing regional to national datasets; these are the aims of the present study.
Study Design
Retrospective chart review.
Methods
A 10-year, retrospective single-institutional chart review was undertaken at Children's Hospital Colorado (CHC) to characterize a pediatric population with facial fractures. A comparative analysis between the CHC and National Trauma Data Bank (NTDB) datasets was also conducted.
Results
In the CHC dataset, increased hospital stay was positively predicted by bilateral mandible fracture, skull, intracranial, spine, thoracic, abdominal, and limb injuries. Predictors of increased intensive-care unit (ICU) stay included skull, spine, and limb injuries. The CHC cohort had younger subjects, more females, fewer African Americans, and more Hispanics than the NTDB dataset. They were more likely to be injured by nonviolent activities than by altercations. Divergent facial and associated injuries between the datasets were found. Multivariate models showed longer length of hospital stay for the CHC group (P = .0085), but the NTDB group had higher ICU admission (P = .04) and longer lengths of ICU stay (P = .007).
Conclusion
The demographic disparities (age, ethnicity, mechanism of injury, and injury type) resulted in divergent injury patterns and likely influenced clinical outcomes.
Level of Evidence
4. Laryngoscope, 2015
The effects of Anesthesia and opioids on the upper airway: A systematic review
Zarmina Ehsan, Mohamed Mahmoud, Sally R. Shott, Raouf S. Amin, Stacey L. Ishman, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Drug-induced sleep endoscopy (DISE) is used to determine surgical therapy for obstructive sleep apnea (OSA); however, the effects of anesthesia on the upper airway are poorly understood. Our aim was to systematically review existing literature on the effects of anesthetic agents on the upper airway.
Data Sources
PubMed, CINAHL, EBM reviews and Scopus (all indexed years).
Review Methods
Inclusion criteria included English language articles containing original human data. Two investigators independently reviewed all articles for outcomes related to upper airway morphology, dynamics, neuromuscular response, and respiratory control.
Results
The initial search yielded 180 abstracts; 56 articles were ultimately included (total population = 8,540). The anesthetic agents studied were: topical lidocaine, propofol, dexmedetomidine, midazolam, pentobarbital, sevoflurane, desflurane, ketamine, and opioids. Outcome measures were diverse and included imaging studies, genioglossus electromyography, endoscopic airway assessment, polysomnography, upper airway closing pressure, and clinical evidence of obstruction. All agents caused some degrees of airway collapse. Dexmedetomidine did not have dose-dependent effects when evaluated using cine magnetic resonance imaging, unlike sevoflurane, isoflurane, and propofol, and caused less dynamic collapse than propofol.
Conclusions
Studies assessing the effect of anesthesia on the upper airway in patients with and without OSA are limited, and few compare effects between agents. Medications with minimal effect on respiratory control (e.g., dexmedetomidine) may work best for DISE. Laryngoscope, 2015
Allergic reaction to ortho-phthalaldehyde following flexible laryngoscopy
Kimberly Atiyeh, Ajay Chitkara, Stratos Achlatis, Ryan C. Branski, Milan R. Amin, 2015-08-11 16:19:20 PM
Flexible laryngoscopes are common outpatient surveillance tools. Cleansing of these scopes between patients must be quick, effective, and safe. One sterilant that largely meets these criteria is ortho-phthalaldehyde (OPA); however, infrequently, patients may develop allergic reactions to it. We present three cases of patients who developed significant allergic reactions following repeated laryngoscopic examinations. Subsequent intradermal allergy testing confirmed sensitivity to OPA. In addition, we reviewed the current literature, which includes 17 similar reactions reported in nine patients across disciplines. Allergic reaction to OPA is uncommon, but a potentially under-reported severe complication of repeated endoscopy.
Level of Evidence
NA Laryngoscope, 2015
Testimony by otolaryngologists in defense of tobacco companies 2009–2014
Robert K. Jackler, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To examine expert testimony offered by otolaryngologists in defense of the tobacco industry and to assess whether opinions rendered were congruent with evidence in the scientific literature.
Methods
Data sources include publically available expert witness depositions and trial testimony of board-certified otolaryngologists employed by the tobacco industry in defense of lawsuits brought by smokers suffering from head and neck cancer. The cases, adjudicated in Florida between 2009 and 2014, focused on whether smoking caused the plaintiff's cancer.
Results
The study includes nine legal cases of upper aerodigestive tract cancer involving six otolaryngologists serving as expert witnesses for the tobacco industry. Cancer sites included larynx (5), esophagus (2), mouth (1), and lung (1). Five of the six otolaryngologists consistently, over multiple cases, offered opinions that smoking did not cause the plaintiff's cancer. By highlighting an exhaustive list of potential risk factors, such as human papillomavirus (HPV), alcohol, asbestos, diesel fumes, salted fish, mouthwash, and even urban living, they created doubt in the minds of the jurors as to the role of smoking in the plaintiff's cancer. Evidence shows that this testimony, which was remarkably similar across cases, was part of a defense strategy shaped by tobacco's law firms.
Conclusions
A small group of otolaryngologists regularly serve as experts on behalf of the tobacco industry. Examination of their opinions in relation to the scientific literature reveals a systematic bias in interpreting the data relating to the role played by smoking in head and neck cancer causation.
Level of Evidence
N/A. Laryngoscope, 2015
Varicella-zoster virus–specific cell-mediated immunity in Ramsay Hunt syndrome
Shin-Ichi Haginomori, Takahiro Ichihara, Atsuko Mori, Atsuko Kanazawa, Ryo Kawata, Huamin Tang, Yasuko Mori, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The etiology of Ramsay Hunt syndrome (Hunt syndrome) is reactivation of latent varicella-zoster virus (VZV) in the geniculate ganglion of the facial nerve, leading to neuritis. Although the mechanism of the VZV reactivation is unclear, one possibility is that the reactivation involves a low level of VZV-specific cell-mediated immunity (CMI). The aim of this study was to clarify the characteristics of the VZV-specific CMI in Hunt syndrome compared to that in Bell's palsy, and to obtain clues to its role in the development of Hunt syndrome.
Study Design
Prospective study.
Methods
We determined the median spot numbers and examined VZV-specific CMI in patients with Hunt syndrome and with Bell's palsy using interferon-γ enzyme-linked immunospot (ELISPOT) assays. We analyzed the relationship between the value of VZV-specific CMI and days from disease onset.
Results
The median spot number in Hunt syndrome (87.3 spot-forming cells [SFCs]/4 × 105 peripheral blood mononuclear cells [PBMCs]) was higher than that in Bell's palsy (62.3 SFCs/4 × 105 PBMCs). Hunt syndrome showed a strong relationship between the ELISPOT count and days from onset (r = 0.65). Within the first 5 days from onset, no ELISPOT counts higher than 80 SFCs/4 × 105 PBMCs were observed. On the other hand, no correlation was observed between the ELISPOT count and days from onset in patients with Bell's palsy (r = −0.19).
Conclusions
These results suggest that VZV-specific CMI in Hunt syndrome is low at disease onset and increases rapidly thereafter. Consequently, reduced VZV-specific CMI may play an important role in the reactivation of VZV in the facial nerve, leading to Hunt syndrome.
Level of Evidence
4 Laryngoscope, 2015
Selective reinnervation for bilateral vocal cord paralysis using the superior laryngeal nerve
Michael I. Orestes, Dinesh K. Chhetri, Gerald Berke, 2015-08-11 16:19:20 PM
Facial palsy after neck arteriovenous fistula embolization
Dong Hoon Lee, Joon Kyoo Lee, Tae Mi Yoon, Sang Chul Lim, Tae Sun Kim, 2015-08-11 16:19:20 PM
Facial palsy after embolization of neck arteriovenous fistula is an extremely rare complication. In our case, complete facial palsy occurred after embolization and was successfully treated with superficial parotidectomy, vessel ligation, and plug removal. We report the first case of unusual facial palsy that developed 13 days after neck arteriovenous fistula embolization. As a result of our findings, we recommend, when a patient suffers from acute ipsilateral facial palsy after arteriovenous fistula embolization, the clinician should consider the possibility of complications of embolization, and immediate and appropriate management should be performed. Laryngoscope, 2015
Historical classics: Editorial
Mark S. Courey, 2015-08-11 16:19:20 PM
Botulinum toxin management of spasmodic dysphonia (laryngeal dystonia): A 12-year experience in more than 900 patients
Andrew Blitzer, Mitchell F. Brin, Celia F. Stewart, 2015-08-11 16:19:20 PM
The paralyzed larynx: An electromyographic study in dogs and humans
Herbert H. Dedo, 2015-08-11 16:19:20 PM
Should otolaryngologists pay more attention to nasal swell bodies?
Michael Wotman, Ashutosh Kacker, 2015-08-11 16:19:20 PM
What is the risk of malignant transformation of vestibular schwannoma following radiosurgery?
Elizabeth A. Nicolli, Michael Ruckenstein, 2015-08-11 16:19:20 PM
Modified olfactory training in patients with postinfectious olfactory loss
Aytug Altundag, Melih Cayonu, Gurkan Kayabasoglu, Murat Salihoglu, Hakan Tekeli, Omer Saglam, Thomas Hummel, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Patients with olfactory dysfunction benefit from repeated exposure to odors, so-called olfactory training (OT). This does not mean occasional smelling but the structured sniffing of a defined set of odors, twice daily, for a period of 4 months or longer. In this prospective study, we investigated whether the effect of OT might increase through the use of more odors and extension of the training period.
Study Design and Methods
This study shows OT results when performed with four or 12 odors for 36 weeks in patients with postinfectious olfactory dysfunction. A total of 85 subjects participated (mean age 45.6 ± 10.5 years, range 24–68 years). Three groups were formed: 1) In the modified olfactory training (MOT) group, patients used three sets of four different odors sequentially. 2) Participants in the classical odor training (COT) group used four odors. 3) Participants in the control group did not perform OT. All groups were matched for age and sex distribution of participants.
Results
Both participants in the COT and MOT groups reached better scores than controls in terms of odor discrimination and odor identification. Continuing OT with four different odors after the 12th and 24th weeks produced better results in terms of odor discrimination and odor identification scores as compared to using the same four odors throughout the entire study.
Conclusion
This study confirmed the effectiveness of OT. Increasing the duration of OT and changing the odors enhances the success rate of this therapy.
Level of Evidence
2b. Laryngoscope, 125:1763–1766, 2015
Management of non-invasive rhinosinusitis in the immunosuppressed patient population
Ashley M. Dao, Shruthi K. Rereddy, Sarah K. Wise, John M. DelGaudio, Zara M. Patel, 2015-08-11 16:19:20 PM
Objective
Rhinologists are seeing an increasing number of immunosuppressed patients. Currently, no treatment paradigm exists for treating acute and chronic noninvasive rhinosinusitis (ARS, CRS) in this growing population. This study aims to identify patient and treatment factors that affect rhinosinusitis outcomes in this vulnerable population.
Study Design
Prognostic retrospective cohort study.
Methods
Immunocompromised patients treated by rhinologists for ARS or CRS 10/2007 to 10/2012 were identified by rhinosinusitis diagnostic codes, codes for transplant, cancer, HIV, diabetes, and codes indicating immunosuppression in the intensive care setting. Associations between patient factors and outcome were analyzed by logistic regression. Associations between treatment and outcome were analyzed by Firth logistic regression.
Results
A total of 132 subjects were identified. Of those, 90.9% had CRS and 9.1% had ARS; 12.9% were transplant patients; 47% were diabetic; 37.9% were cancer patients; and 16.7% were in the intensive care unit. Patients with higher American Society of Anesthesiologists (ASA) scores had decreased disease resolution (odds ratio [OR] = 0.5, P = 0.021). Transplant patients (OR = 22.5, P = 0.001), diabetics patients (OR = 6.4, P = 0.017), cancer patients (OR = 5.4, P = 0.046), and patients with prior medical therapy for rhinosinusitis (OR = 5.84, P < 0.001) had increased disease resolution compared to immunosuppressed critical care patients. Patients treated with antibiotics alone had no statistically significant difference in disease resolution compared to those receiving no treatment. In contrast, treatment plans including surgery were associated with greater disease resolution.
Conclusion
This data indicates that surgical treatment provides improved outcomes for patients presenting with acute exacerbations of rhinosinusitis related to their immunocompromised state. Given the limited study population, these findings may not apply to HIV-positive or ARS patients, and further study should be undertaken in these groups.
Level of Evidence
4. Laryngoscope, 125:1767–1771, 2015
Geographic variation of endoscopic sinus surgery in the united states
Luke Rudmik, Chantal E. Holy, Timothy L. Smith, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The objective of this study was to examine the rates and geographic variation of endoscopic sinus surgery (ESS) in a representative sample of the US working population.
Study Design
Observational cohort study using the MarketScan Commercial Claim and Encounters database.
Methods
All patients who received ESS between 2009 and 2013 were included. The annual adjusted rates of ESS per 1,000 people were calculated for each US state. Geographic variations were evaluated using the extremal quotient (EQ), weighted coefficient of variation (CV), systematic component of variance (SCV), and empirical Bayes statistic. The χ2 statistic tests was used to quantify variation of the adjusted ESS rates across states within the US.
Results
The annual adjusted rate of ESS was 0.94 per 1,000 people in the US. South Dakota and Alabama were observed to have the highest rates of ESS, 1.80 and 1.69, respectively. Vermont and Arkansas were observed to have the lowest rates of ESS, 0.51 and 0.57, respectively. The mean EQ was 4.54, indicating a four- to fivefold difference between the highest (South Dakota) and lowest (Vermont) states. The mean CV was 31.4 and mean SCV was 10.1, which demonstrates very high variation.
Conclusions
This study observed very high geographic variation in the rates of ESS across the United States. Given that practice variation indicates the presence of potentially harmful and inefficient unwarranted care, outcomes from this study indicate a need to further evaluate the delivery of ESS to improve overall health system performance.
Level of Evidence
2b. Laryngoscope, 125:1772–1778, 2015
The predictive value of the preoperative Sinonasal outcome test-22 score in patients undergoing endoscopic sinus surgery for chronic rhinosinusitis
Claire Hopkins, Luke Rudmik, Valerie J. Lund, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
With the aim of facilitating preference-sensitive decision making regarding elective endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS), we set out to evaluate the predictive value of the 22-item Sinonasal Outcome Test (SNOT-22) patient-reported outcome measure and to compare outcomes of a UK cohort with a similar United States/Canadian–based study.
Study Design
Prospective observational cohort study,
Methods
Patients electing ESS in 87 UK hospitals were enrolled. The primary outcome was change in SNOT-22 score 3 months after surgery. Patients were categorized according to baseline SNOT-22 score, and the proportion of patients achieving a SNOT-22 minimal clinically important difference (MCID) of 8.9 was calculated, as well as the percentage change in SNOT-22 score.
Results
A total of 2,263 patients were included within this study. There was an average 40% reduction in SNOT-22 scores following surgery, and 66% of patients overall achieved the MCID. The proportion of patients achieving the MCID increased significantly with increasing baseline SNOT-22. Patients with a preoperative score of <20 failed to achieve a mean improvement greater than the MCID. Patients with a score of >30 had a greater than 70% chance of achieving the MCID. CRS patients with polyps had greater improvement than patients with CRS without polyps. The predictive value of the SNOT-22 is similar in the UK cohort, although overall patients did not benefit from surgery as much as their North American counterparts.
Conclusions
Medically recalcitrant patients with CRS considering surgery should make decisions guided by their preoperative quality-of-life impairment, as measured by the SNOT-22.
Level of Evidence
2b Laryngoscope, 125:1779–1784, 2015
Complication rates after functional endoscopic sinus surgery: Analysis of 50,734 Japanese patients
Sayaka Suzuki, Hideo Yasunaga, Hiroki Matsui, Kiyohide Fushimi, Kenji Kondo, Tatsuya Yamasoba, 2015-08-11 16:19:20 PM
Objective
The complication rates associated with different types of functional endoscopic sinus surgery (FESS) remain to be fully examined.
Study Design
Retrospective cohort study.
Methods
We extracted data from the Japanese Diagnosis Procedure Combination database on 50,734 patients (aged ≥ 16 years) who underwent FESS for chronic rhinosinusitis between 2007 and 2013. We focused on specific types of surgery and stratified the patients into three groups: group 1 (single sinus surgery), group 2 (multiple sinus surgery), and group 3 (whole sinus surgery). Patient characteristics and early postoperative complications including cerebrospinal fluid (CSF) leakage, orbital injury, severe hemorrhage, and toxic shock syndrome (TSS) that occurred during 1 to 2 weeks of each hospitalization were compared. Multivariable logistic regression analysis was performed to assess the association between overall complication rate and background characteristics, with adjustment for within-hospital clustering.
Results
The overall complication rate was 0.50%; the rates of CSF leakage, orbital injury, hemorrhage requiring surgery, blood transfusion, and TSS were 0.09%, 0.09%, 0.10%, 0.18%, and 0.02%, respectively. Ethmoidectomy combined with sphenoidotomy was associated with higher overall complication rates (1.40%). The rate of orbital injury was highest in group 2, whereas that of other complications did not differ significantly among the groups. Extent of FESS showed no significant association with overall complication rate.
Conclusion
More extensive FESS was not associated with increased rates of postoperative CSF leakage, hemorrhage, or TSS. Multiple sinus surgery was associated with a higher rate of orbital injury. The extent of surgery did not significantly affect the overall complication rate.
Level of Evidence
2b. Laryngoscope, 125:1785–1791, 2015
Impact of postoperative pneumonia following Pituitary surgery
Stuti V. Desai, Christina H. Fang, Milap D. Raikundalia, Soly Baredes, James K. Liu, Jean Anderson Eloy, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Postoperative pneumonia (PNA) has been identified as a preventable never event by the Centers for Medicare and Medicaid Services (CMS). The CMS has discussed possibly discontinuing reimbursement for this postoperative complication. In this study, risk factors, patient outcomes, and hospital charges of care associated with postoperative PNA in patients undergoing pituitary surgery were evaluated.
Methods
Discharge data of patients who underwent pituitary surgery between 2002 and 2010 were obtained from the National Inpatient Sample database. Demographics, preexisting comorbidities, postoperative complications, morbidity, length of hospital stay, and hospital charges were analyzed.
Results
A total of 15,317 patients were included in this analysis. Ninety-eight patients (0.6%) were diagnosed with PNA postoperatively. There was a significant association between postoperative PNA and older age (P < 0.001), male gender (P = 0.044), and transfrontal surgical approach (P < 0.001). Patients with anemia, congestive heart failure, chronic pulmonary disease, diabetes mellitus, fluid and electrolyte disorders, paralysis, and weight loss had a significantly higher rate of PNA. Patients with PNA had a significantly higher mortality (P < 0.001). They also incurred on average over four times the hospital charges and nearly five times longer hospitalizations compared to patients without PNA.
Conclusions
Variables associated with an increased risk of postoperative PNA in patients undergoing pituitary surgery include older age, male gender, and transfrontal surgical approach. Patients with postoperative PNA had a longer length of hospital stay, higher hospital charges, and increased mortality.
Level of Evidence
2C. Laryngoscope, 125:1792–1797, 2015
Histopathology of idiopathic lateral skull base defects
Aaron K. Remenschneider, Elliott D. Kozin, Hugh Curtin, Felipe Santos, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The objective of this study was to utilize techniques of otopathology to gain insight into the pathogenesis, sites of origin, and associated findings in idiopathic lateral skull base defects.
Study Design
Histopathologic analysis of temporal bones from an otopathology repository.
Methods
Specimens from a human temporal bone repository were investigated for clinical or otopathologic evidence of occult bony dehiscence indicating communication between the subarachnoid space and air cells of the temporal bone. Specimens were examined by light microscopy, organized by fistula site, and histopathologically described. Premortem patient demographics and clinical history was reviewed.
Results
Specimens from 52 individuals met inclusion criteria. Three distinct fistula pathways were determined: transdural, labyrinthine, and perilabyrinthine. Transdural fistulae occur most commonly as the result of arachnoid granulations along the middle or posterior fossa dura (n = 30) and are frequently incidental findings in specimens of older individuals (median age at death: 81 years). Labyrinthine fistulae (n = 10) were noted with cochlear malformations when modiolar atresia permits cerebrospinal fluid (CSF) flow into a common intracochlear scala and oval window perilymphatic fistula results. Perilabyrinthine fistulae (n = 7) were observed through three congenitally unfused tracts: the tympanomeningeal fissure, the petromastoid canal, or an extension of the subarachnoid space into the fallopian canal.
Conclusions
Idiopathic lateral skull base defects occur in three distinct anatomic locations with consistent histopathologic findings. In the absence of clear radiographic localization, patient age and associated cochlear defects may assist in the determination of the site of CSF leak. These data have implications for surgical approaches of CSF fistula repair.
Level of Evidence
NA Laryngoscope, 125:1798–1806, 2015
Accidental dropping or misplacement of free flaps
Mark K. Wax, Neal D. Futran, Eben L. Rosenthal, Keith E. Blackwell, Steven Cannady, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Standard operating procedures have been developed in many surgical practices to ensure quality of care as it relates to specimens removed from the body. Most of these specimens are sent to pathology. Some, such as calvarial bone harvested during craniotomy are replaced in the body. Free tissue transfer involves harvesting tissue from one body site, storage for a variable period of time outside of the body, and then insertion in another location. As with any system there is ample opportunity for accidental "misplacement." We undertook a multi-institutional study to examine the incidence, etiology, and opportunity for process improvement.
Study Design
Retrospective review.
Methods
A retrospective review was performed at five institutions (8,382 free flaps).
Results
Thirteen (0.15%) flaps were dropped or wrapped in a towel/sponge and placed in a waste bucket. Eight radial forearm, three fibula, one latissimus dorsi, and one anterolateral thigh flap were misplaced. All flaps were retrieved, washed in saline/betadine, and implanted into the patient. All flaps survived; no altered outcomes were encountered. The etiology of the misplacement of the free tissue from the sterile field included miscommunication among nursing staff (seven), miscommunication among medical staff (two), and dropping the flap (four). As a result of these events, changes in the handling procedures were instituted including standard labeling methodologies and communication strategies.
Conclusions
Inadvertent misplacement of free tissue from the sterile field does occur in a sporadic fashion. Process improvement evaluation at all institutions led to improved strategies for prevention. No long-lasting altered outcomes were encountered.
Level of Evidence
4 Laryngoscope, 125:1807–1810, 2015
The role of postoperative hematoma on free flap compromise
Faisal I. Ahmad, Deniz Gerecci, Javier D. Gonzalez, Jessica J. Peck, Mark K. Wax, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Hematomas may develop in the postoperative setting after free tissue transfer. When hematomas occur, they can exert pressure on surrounding tissues. Their effect on the vascular pedicle of a free flap is unknown. We describe our incidence of hematoma in free flaps and outcomes when the flap is compromised.
Study Design
Retrospective chart review of 1,883 free flaps performed between July 1998 and June 2014 at a tertiary referral center.
Methods
Patients with free flap compromise due to hematoma were identified. Etiology, demographic data, and outcomes were evaluated.
Results
Eighty-eight (4.7%) patients developed hematomas. Twenty (22.7%) of those had flap compromise. Twelve compromises (60%) showed evidence of pedicle thrombosis. The salvage rate was 75% versus 54% in 79 flaps with compromise from other causes (P = .12). Mean time to detection of the hematoma was 35.3 hours in salvaged flaps compared to 91.6 hours in unsalvageable flaps (P = .057). Time to operating room (OR) from detection was 2.8 hours in salvageable flaps compared to 12.4 hours in nonsalvageable flaps (P = .053). The salvage rate for flaps that returned to the OR in <5 hours was 93.3% compared to 20% (P = .0049) for those that did not. Vascular thrombosis reduced salvage rate to 58.3% from 100% (P = .002) when there was no thrombosis.
Conclusions
In our series hematomas developed rarely. When they did, 23% went on to develop flap compromise. Prompt recognition and re-exploration allowed for a high salvage rate. Vessel thrombosis predicted inability to salvage the flap.
Level of Evidence
4 Laryngoscope, 125:1811–1815, 2015
A randomized controlled trial of simulation-based training for ear, nose, and throat emergencies
Matthew Edward Smith, Annakan Navaratnam, Lily Jablenska, Panagiotis A. Dimitriadis, Rishi Sharma, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Life-threatening ear, nose, and throat (ENT) emergencies are uncommon but require immediate skilled management. We investigated if traditional lecture-based teaching can be improved by a simulation and lecture hybrid approach.
Study Design
A single-blinded, prospective, randomized controlled trial.
Methods
Two groups of interns with no previous ENT experience were randomized to one of two training groups: a simulation/lecture hybrid group or a lecture-only control group. Both groups received 90 minutes of training covering the assessment of critically ill patients and four ENT emergency topics. Both groups received the same initial lecture slides. The control group received additional slides, and the simulation group received simulated emergency scenario training using basic mannequins. Following the training, candidates were asked to provide feedback on their perception of training, and they were formally assessed with a standardized one-to-one viva.
Results
Thirty-eight interns were recruited: 18 in the control group and 20 in the simulation group. The candidates in the simulation group performed significantly better in all viva situations (P < .05) and had better perception of learning (P < .05). Additionally, the simulation group was more likely to recommend the training to a colleague (P < .05).
Conclusions
We have demonstrated that replacing traditional lecture-based training with a mixture of lectures and emergency scenario simulation is more effective at preparing junior doctors for ENT emergencies, and better met their learning needs. Implementing this kind of teaching is feasible with a minimum of additional resources or time.
Level of Evidence
1b Laryngoscope, 125:1816–1821, 2015
Cephalosporin use in penicillin-allergic patients: A survey of otolaryngologists and literature review
Michael J. Persky, Scott A. Roof, Yixin Fang, Daniel Jethanamest, Max M. April, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
This study investigated the differences between the standard guidelines and the practice patterns of otolaryngologists in managing "penicillin-allergic" patients. A major goal was to identify factors influencing an otolaryngologist's choice of antibiotic.
Study Design
Cross-sectional survey.
Methods
Four hundred seventy members of the American Society of Pediatric Otolaryngologists (ASPO) and 150 general otolaryngologists from the Florida Society of Otolaryngology (FSO) were surveyed.
Results
Ninety-six ASPO members (20.4%) and 22 members of FSO (14.6%) responded. When asked about the management of a pediatric patient with acute otitis media and a history of a nonsevere immunoglobulin E (IgE)-mediated amoxicillin allergy, 54% of ASPO respondents indicated they would initiate guideline-recommended cefdinir, whereas only 27% of FSO respondents chose cefdinir (P = .02). Otolaryngologists who are fellowship trained in pediatrics or have pediatric-focused practices were significantly more likely to prescribe cefdinir. Overall, 57% of respondents indicated that they were familiar with the literature regarding the cross-reactivity of β-lactams, but only 25% of respondents felt that they could easily differentiate a potentially life-threatening IgE-mediated allergy from a non–IgE-mediated drug intolerance.
Conclusions
The data show differences between the current recommendations and the behavior of otolaryngologists. Pediatric otolaryngologists were more familiar with the guideline-recommended therapy, likely from their frequent exposure to patients requiring a β-lactam. Nevertheless, most otolaryngologists could benefit from increased awareness of the current literature. Patients may be receiving less than optimal medication management due to a misidentification of those at risk of life- threatening allergic cross-reactions.
Level of Evidence
NA Laryngoscope, 125:1822–1826, 2015
Transcartilaginous ear piercing and infectious complications: A systematic review and critical analysis of outcomes
Michael Sosin, Jason M. Weissler, Marisa Pulcrano, Eduardo D. Rodriguez, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The purpose of this systematic review was to critically analyze infectious complications and treatment following transcartilaginous ear piercing.
Data Sources
MEDLINE Pubmed database.
Review Methods
A MEDLINE PubMed database search using free text, including "ear chondritis," "ear perichondritis," "ear cartilage piercing," and "auricle piercing," yielded 483 titles. Based on set inclusion and exclusion criteria, the titles, abstracts, and full text articles were reviewed for inclusion and underwent data extraction. Pooled outcomes are reported.
Results
A total of 29 articles met inclusion criteria, including 66 patients. The mean age of the patients was 18.7 ± 7.6 years (range: 11–49), 87.5% female. Ear deformity was more likely to occur following postpiercing perichondritis of the scapha 100% versus the helix 43% (P = 0.003). Mean duration of symptoms prior to patients seeking medical attention was 6.1 ± 4.1 days. Greater than 5 days of symptoms prior to seeking treatment was significantly more likely to result in hospitalization. Pseudomonas aeruginosa accounted for 87.2% infections. Of the patients with Pseudomonas, 92.3% were hospitalized versus 75% of the patients infected withStaphylococcus aureus. Initial oral antibiotics prescribed did not target the cultured bacterium in 53.3% of cases; of these, 87.5% were hospitalized.
Conclusions
Transcartilaginous postpiercing infection may lead to ear deformity and hospitalization. Patients (customers) and practitioners must be aware of optimal treatment strategies to minimize associated morbidity. Scapha piercing and delay in presentation are associated with poorer outcomes. Pseudomonas is the most common bacterial infection. Initial antibiotic selection must be optimized accordingly. Laryngoscope, 125:1827–1834, 2015
Management of the thyroid gland during total laryngectomy in patients with laryngeal squamous cell carcinoma
Moustafa Mourad, Masoud Saman, Raja Sawhney, Yadranko Ducic, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The goal of the study was to determine the role of routine total thyroidectomy and hemithyroidectomy in patients undergoing total laryngectomy for laryngeal squamous cell carcinoma.
Study Design
The study group consisted of 343 patients who underwent total laryngectomy (98 treated with surgery alone, 136 treated following radiation failure, and 109 following chemoradiation failure). Total thyroidectomy was performed in all obstructing and bilateral lesions or if there was suspicion of contralateral lobe involvement. Hemithyroidectomy was performed in all lateralized lesions. Retrospective histopathologic analysis of thyroid specimens was subsequently performed.
Results
In all, 262 patients underwent total thyroidectomy during total laryngectomy, six of which demonstrated squamous cell carcinoma evident within the thyroid gland (4 from transglottic lesions, 2 from subglottic lesions). Hemithyroidectomy was performed in 81 patients, with only one patient demonstrating evidence of squamous cell carcinoma within the thyroid gland. Hypothyroidism was observed in 88% (n = 61) of patients who underwent thyroid lobectomy alone, requiring hormone supplementation.
Conclusion
Routine surgical management of the thyroid gland should not be performed, except in cases of subglottic primary lesions, lesions with significant subglottic extension, or transglottic lesions. Despite efforts to preserve the contralateral thyroid lobe in cases of selective lobectomy, these patients often have a high rate of hypothyroidism, and a total thyroidectomy should be considered when involvement of the thyroid gland is suspected.
Level of Evidence
N/A. Laryngoscope, 125:1835–1838, 2015
Robotic nasopharyngectomy via combined endonasal and transantral port: A preliminary cadaveric study
Hyung-Ju Cho, Ju Wan Kang, Hyun Jin Min, Hyo Jin Chung, Do Yang Park, Jong Gyun Ha, Seung Hak Baek, Joo-Heon Yoon, Chang-Hoon Kim, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The objective of this study was to determine the potential role of a surgical robotic system in nasopharyngeal surgery using bilateral transantral or combined endonasal/transantral port.
Study Design
The da Vinci robot (Intuitive Surgical Inc., Sunnyvale, CA) was used to perform dissection of the skull base on a whole fresh-frozen cadaver.
Methods
Bilateral mega-antrostomy was done with the usual endoscopic sinus surgery equipment. To obtain an accessible bilateral working space, posterior septectomy was performed. Next, bilateral anterior maxillary windows were created through a gingivobuccal incision. The 8.5-mm-diameter 0° or 30° three-dimensional camera arm was introduced into a nostril. The two 5-mm-diameter articulating EndoWrist arms entered through the transantral or endonasal port. For the dissection, Maryland articulated forceps, needle driver, and monopolar spatula- or hook-type electrocauterizer were used.
Results
The 8.5-mm diameter of the camera arm was easily inserted into the nostril. Excellent access to the nasopharyngeal area from the level of the palate up to the skull base crossing the sphenoid prow was possible. Bilateral robotic arms were able to move inside the nasopharyngeal space, and the target dissection area could be accessed fully via the transantral or endonasal port.
Conclusions
This is the first report about the feasibility of bilateral transantral or combined transantral/endonasal port for robotic nasopharyngectomy. Robotic removal of the entire nasopharyngeal area was successfully achieved without transpalatal or facial skin incision. These new approaches may be applied to selected patients with nasopharyngeal carcinoma or other pathologic tumors involving the nasopharynx.
Level of Evidence
NA Laryngoscope, 125:1839–1843, 2015
Self-reported Tobacco use does not correlate with carcinogen exposure in smokers with head and neck cancer
Samir S. Khariwala, Steven G. Carmella, Irina Stepanov, Dipankar Bandyopadhyay, Heather H. Nelson, Bevan Yueh, Dorothy K. Hatsukami, Stephen S. Hecht, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Head and neck squamous cell carcinoma (HNSCC) is strongly associated with tobacco use. We sought to examine the relationship between self-reported tobacco use and the level of urinary tobacco carcinogen metabolites in a cohort of patients with HNSCC.
Study Design
Cross-sectional analysis.
Methods
Eighty-four cigarette smokers with head and neck cancer completed tobacco and alcohol use questionnaires, and the following urinary tobacco metabolites were quantified: 1-hydroxypyrene (1-HOP), N'-nitrosonornicotine and its glucuronides (total NNN), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and its glucuronides (total NNAL), and cotinine. A cross-sectional analysis was performed with assessment of correlation coefficients.
Results
When analyzed based on self-reported cigarettes per day (CPD), no significant correlation with any of the studied tobacco carcinogen metabolites was found. However, urinary cotinine showed significant correlation with total NNN, total NNAL, and 1-HOP. Total NNN, total NNAL, and 1-HOP showed significant correlation with each other suggesting exposure occurs to each proportionally.
Conclusions
In smokers with HNSCC, self-reported tobacco use does not predict actual carcinogen exposure. In contrast, urinary cotinine levels significantly correlate with carcinogen levels. Therefore, urinary cotinine is the preferred value for estimating carcinogen dose in these patients. 1-HOP levels were significantly associated with total NNN and total NNAL suggesting that smokers are exposed to these carcinogens proportionally. These data indicate that utilizing conventional methods of estimating tobacco exposure (CPD) may not accurately approximate exposure to tobacco carcinogens in smokers with HNSCC. These data have implications for future studies focused on screening and epidemiology of smokers with HNSCC.
Level of Evidence
NA Laryngoscope, 125:1844–1848, 2015
Effectiveness of selective neck dissection in head and neck cancer: The experience of two Italian centers
Luigi Barzan, Renato Talamini, Giovanni Franchin, Marco Pin, Marina Silvestrini, Giuseppe Grando, Stefania Galla, Maria Gabriella Savignano, Gianluca Armas, Francesco Margiotta, Valentina Vanoni, Elena Magri, Cesare Grandi, 2015-08-11 16:19:20 PM
Objective
The aim of this study was to evaluate the oncologic outcomes after a selective neck dissection (SND), both in elective and therapeutic settings, with particular regard to regional recurrence rate.
Methods
Retrospective analysis of 827 patients with head and neck primary tumors submitted to SND from 1999 to 2011 in two large hospital centers of northern Italy.
Results
A total of 40 neck recurrences were found in the whole series, with the same incidence after primary or salvage surgery (4.4% and 5.2%, respectively), but only 22 neck recurrences occurred in the same side of the dissected neck (3.0%). Factors predicting an increase of ipsilateral neck relapse were pathologically positive nodes, number of positive nodes, and nodal ratio (ratio between positive nodes and total nodal removed), but the risk of regional relapse did not exceed 5.0% in any subgroups. A total of 320 patients (39%) had postoperative radiotherapy (52.0% and 22.0% after primary and salvage surgery, respectively). Considering the primary surgery group alone, postoperative radiotherapy produced only a light reduction of homolateral neck recurrence rate in patients with pathological positive nodes (2.4% vs. 5.0%), but it impacted significantly disease-specific survival, both in pathological classification of nodes (pN)1 and pN2–3 patients.
Conclusion
The SND can be considered a safe and sound procedure both in primary surgery and in salvage setting. Postoperative radiotherapy adds minor advantage to regional control only in node-positive patients but may impact survival.
Level of Evidence
4. Laryngoscope, 125:1849–1855, 2015
Histopathologic margin distance in survival in resection of cutaneous melanoma of the head and neck
James Teng, Travis Halbert, Timothy L. McMurry, Paul A. Levine, J. Jared Christophel, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Treatment of cutaneous melanoma involves surgical excision with wide clinical margins. No guidelines regarding safe histopathologic margin distance exist. This study examines the impact of histopathologic margin, measured from closest cut edge of the specimen, on overall survival in resection of cutaneous melanoma of the head and neck. We hypothesize that close histopathologic margins (<2 mm) are associated with decreased survival.
Study Design
Retrospective chart review.
Methods
A total of 637 patients were treated for cutaneous melanoma of the head and neck between 2001 and 2011. Demographics, tumor characteristics, histopathologic margin distance (from a pathology database), and survival data from state health registries and health system clinical data repositories were used to create a dataset. Cox regression models and Kaplan-Meier curves were used to analyze data, adjusting for age, tumor location, ulceration, and depth of invasion (DOI).
Results
When analyzing for overall survival, Cox multivariate regression analysis showed age (hazard ratio [HR] = 1.0–1.1), DOI (HR = 1.2–1.5), ulceration (HR = 1.3–3.8), and subsite (ear, HR = 1.0–3.9) were significant predictors of survival. Histopathologic margin distance was not significant for predicting survival. Three percent of histopathologic margins were <1 mm.
Conclusions
In a large dataset of head and neck cutaneous melanoma, known factors associated with overall survival (age, DOI, ulceration, subsite) proved significant, validating the dataset. Examining the effect of histopathologic margin distance on survival, while controlling for these factors, we failed to reject the null hypothesis. Margin distance as measured by histopathology does not affect survival.
Level of Evidence
4. Laryngoscope, 125:1856–1860, 2015
The value of 18F-FDG-PET/CT imaging in oral cavity cancer patients following surgical reconstruction
Julian Müller, Martin Hüllner, Klaus Strobel, Gerhard F. Huber, Irene A. Burger, Stephan K. Haerle, 2015-08-11 16:19:20 PM
Objective
Follow-up of patients with oral cavity squamous cell carcinoma (OCSCC) after tumor resection and reconstruction with tissue transfer is challenging. We compared contrast-enhanced computed tomography (ceCT), 18F-fluorodeoxyglucose-positron emission tomography combined with noncontrast enhanced CT (18F-FDG-PET/CT), and 18F-FDG-PET combined with ceCT (18F-FDG-PET/ceCT) to determine the accuracy for detection of residual/recurrent disease after flap reconstruction for OCSCC.
Study Design and Methods
Two readers (R1, R2) retrospectively reviewed a total of 27 18F-FDG-PET/ceCT scans in patients after resection of stage II to IV OCSCC. They recorded the presence of local persistence/recurrence (LR), lymph node metastasis, or distant metastasis independently for ceCT, 18F-FDG-PET/CT, and 18F-FDG-PET/ceCT. Histological workup, imaging follow-up, or clinical follow-up served as the standard of reference. Maximum standardized uptake value (SUVmax) was evaluated to discriminate between physiological uptake and LR.
Results
The highest accuracy to detect LR was achieved with 18F-FDG-PET/ceCT, with a sensitivity/specificity of 88%/89% and 88%/79% for R1 and R2, respectively, as compared to ceCT with 75%/79% for R1 and 88%/68% for R2 and 18F-FDG-PET/CT with 88%/58% for both R1 and R2. Receiver-operating-characteristic analysis determined a cutoff value for SUVmax of 7.2, yielding a sensitivity and specificity of 75% and 94%, respectively, to distinguish LR from physiological 18F-FDG uptake.
Conclusion
18F-FDG-PET/ceCT seems to be the most reliable tool for locoregional surveillance of OCSCC patients after resection and reconstruction.
Level of Evidence
4. Laryngoscope, 125:1861–1868, 2015
Complications and mortality following surgery for oral cavity cancer: Analysis of 408 cases
Zachary G. Schwam, Julie A. Sosa, Sanziana Roman, Benjamin L. Judson, 2015-08-11 16:19:20 PM
Objectives
To analyze the postoperative complications and mortality for oral cavity cancers, their time course, and to identify modifiable risk factors associated with their occurrence.
Study Design
Retrospective cohort study.
Methods
Patients undergoing surgery for oral cavity cancer were identified in the American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File (2005–2010). Overall and disease-specific complication and mortality data were analyzed using chi-square and multivariate regression analysis.
Results
There were 408 cases identified. The overall 30-day complication and mortality rates were 20.3% and 1.0%, respectively. The most common adverse events were reoperation (9.6%), infectious (6.6%), and respiratory (5.1%) complications. Twenty patients (4.9%) experienced postdischarge complications. Fifty-two percent of postdischarge wound dehiscences and 67% of postdischarge surgical-site infections occurred by postdischarge day 7, and 91% of all postdischarge complications occurred by postdischarge day 14. Smoking was independently associated with respiratory (odds ratio [OR] 3.59, P = .008) and surgical site complications (OR 5.13, P =.004). Neck dissection was independently associated with respiratory (OR 6.17, P = .001), surgical site (OR 6.30, P = .003), and infectious (OR 3.83, P = .003) complications.
Conclusion
Current smokers and those undergoing neck dissection are at high risk of postoperative complications after oral cavity cancer surgery. Less than 5% of patients experienced postdischarge complications, nearly all of which occurred by postdischarge day 14. Most early postdischarge complications occurred at the surgical site. In order to mitigate postdischarge complications and their sequelae, early clinical follow-up should be sought for high-risk patients.
Level of Evidence
4. Laryngoscope, 125:1869–1873, 2015
Patient-perceived benefit of sialendoscopy as measured by the Glasgow Benefit Inventory
Bue A. Meier, René Holst, Lars P. Schousboe, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Evaluate the patient-perceived effect of sialendoscopy on patients with obstructive symptoms from the salivary glands.
Study Design
Retrospectively identified cohort used for a prospective study of all consecutive patients at the Department of Otorhinolaryngology at Vejle Hospital, Vejle, Denmark, March 2009 to December 2013.
Methods
By chart review we recorded the patient's age, gender, date of the sialendoscopy, type of gland, sialolithiasis, successful extraction of sialolithiasis, stenosis of salivary ducts, dilation, type of saliva, and surgeon. The follow-up was done by applying the Glasgow Benefit Inventory questionnaire by letter and telephone.
Results
There were 130 sialendoscopies performed on 116 patients. Of these, 24 patients were excluded due to subsequent surgery. Thus, 92 patients were eligible, of whom 80 responded, giving an 87% response rate. The Glasgow Benefit Inventory score had a predicted overall mean of 13.4 (95% confidence interval: 9.9 to 17.2). Significant positive outcomes by multiple regression were the presence of stones (P = 0.015) and examination of the parotid gland (P = 0.041).
Conclusions
Overall, there is a significant patient-perceived benefit from sialendoscopy, which is comparable to the benefit from tonsillectomy. The benefit is significantly higher if stones are found than not and for examination of the parotid gland as compared to the submandibular gland.
Level of Evidence
4 Laryngoscope, 125:1874–1878, 2015
Nearly 3,000 salivary stones: Some clinical and epidemiologic aspects
Paolo E. Sigismund, Johannes Zenk, Michael Koch, Mirco Schapher, Mihael Rudes, Heinrich Iro, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To investigate epidemiological features and symptoms of sialolithiasis and their implications for diagnosis and management.
Study Design
Retrospective cohort study.
Methods
Retrospective analysis on 2,322 patients with sialolithiasis, between 1987 and 2009. The statistical significance between two sample distributions was computed using analysis of variance Student t test for two-tailed distribution.
Results
A total of 2,959 calculi were identified by means of ultrasound. Of those, 80.4% were located in the submandibular duct system (53% hilar/proximal, 37% distal, 10% intraparenchymal) and 19.6% were parotid stones (83% in Stensen's duct, 17% intraparenchymal). Sialoliths had been discovered beforehand in the submandibular gland (P = 0.00024; t test). Symptoms, measured from first visit, lasted on average 26 months (range: 1 day–30 years). The main group suffered from swelling (50.3%), followed by painful swelling (41.6%) and pain (3.1%). Multiple stones were found in 16.9% of patients (18.1% in the submandibular gland; 14.3% in the parotid). Average stone diameter in the submandibular gland was 8.3 mm (range 1–35 mm), and the stones were in Lustmann group II (46%). In the parotid gland, the average diameter was 6.4 mm (range 1–31 mm), and 51% were in Lustmann group I.
Conclusion
Nowadays, epidemiologic features and clinical manifestations of sialolithiasis play an important role, assisting not only in diagnosis but also in determining appropriate treatment. Due to their location and smaller diameter, parotid stones in some cases can only be treated using a mini-invasive endoscopic technique. Submandibular stones more often require a combined approach.
Level of Evidence
4 Laryngoscope, 125:1879–1882, 2015
Unusual airway complication after percutaneous tracheotomy: Case report and literature review
Christopher Roxbury, Jesse Qualliotine, Daniela Molena, Young Kim, 2015-08-11 16:19:20 PM
We report a case of a 59-year-old male who experienced tracheoesophageal fistula and grade IV subglottic stenosis after percutaneous dilation tracheotomy. Although percutaneous tracheotomy is considered a safe procedure that is often performed in the intensive care unit setting, it is not without complications. While subglottic stenosis and tracheoesophageal fistula are known complications of percutaneous tracheotomy, this report discusses a patient who experienced both complications simultaneously. The purpose of this report is to discuss potential serious complications of percutaneous tracheotomy and their management, and to review the literature on percutaneous tracheotomy complications.
Level of Evidence
NA Laryngoscope, 125:1883–1885, 2015
Ultrasonographic evaluation of geniohyoid muscle and hyoid bone during swallowing in young adults
Xin Feng, Michael S. Cartwright, Francis O. Walker, Jessica H. Bargoil, Yunping Hu, Susan G. Butler, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The geniohyoid muscle plays an important role in hyoid bone movement. Adequate hyoid bone movement during swallowing is important for effective bolus flow and pharyngeal clearing. The aim of this study was to estimate the relationship between the geniohyoid muscle size and function and hyoid bone movement during swallowing in healthy young adults, as measured via ultrasound, in different body positions.
Study Design
Cross-sectional study.
Methods
Forty young (20–40 years old) adults (20 male and 20 female) participated. The cross-sectional area of the geniohyoid muscle at rest (seated position), the geniohyoid muscle contraction velocity, and the hyoid bone displacement during swallowing 10 mL of mineral water were measured by ultrasound in seated, supine, and right lateral decubitus positions.
Results
The size of the geniohyoid muscle correlated with body height. Males had larger geniohyoid cross-sectional area than females and greater maximal and anterior hyoid displacement during swallowing than females, and maximal and anterior hyoid bone displacement during swallowing correlated with the size of geniohyoid muscle only when the body was in the supine position; these two movements were positively correlated to each other.
Conclusions
Genders vary in hyoid bone movement during swallowing, and the correlation between geniohyoid muscle size and hyoid bone displacement varies among different body positions during swallowing. This investigation also illuminates the use of ultrasound in providing quantitative measures of geniohyoid muscle and hyoid bone displacement during swallowing.
Level of Evidence
2c. Laryngoscope, 125:1886–1891, 2015
Effect of resection depth of early glottic cancer on vocal outcome: An optimized finite element simulation
Ted Mau, Anil Palaparthi, Tobias Riede, Ingo R. Titze, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To test the hypothesis that subligamental cordectomy produces superior acoustic outcome than subepithelial cordectomy for early (T1–2) glottic cancer that requires complete removal of the superficial lamina propria but does not involve the vocal ligament.
Study Design
Computer simulation.
Methods
A computational tool for vocal fold surgical planning and simulation (the National Center for Voice and Speech Phonosurgery Optimizer-Simulator) was used to evaluate the acoustic output of alternative vocal fold morphologies. Four morphologies were simulated: normal, subepithelial cordectomy, subligamental cordectomy, and transligamental cordectomy (partial ligament resection). The primary outcome measure was the range of fundamental frequency (F0) and sound pressure level (SPL). A more restricted F0-SPL range was considered less favorable because of reduced acoustic possibilities given the same range of driving subglottic pressure and identical vocal fold posturing.
Results
Subligamental cordectomy generated solutions covering an F0-SPL range 82% of normal for a rectangular vocal fold. In contrast, transligamental and subepithelial cordectomies produced significantly smaller F0-SPL ranges, 57% and 19% of normal, respectively.
Conclusion
This study illustrates the use of the Phonosurgery Optimizer-Simulator to test a specific hypothesis regarding the merits of two surgical alternatives. These simulation results provide theoretical support for vocal ligament excision with maximum muscle preservation when superficial lamina propria resection is necessary but the vocal ligament can be spared on oncological grounds. The resection of more tissue may paradoxically allow the eventual recovery of a better speaking voice, assuming glottal width is restored. Application of this conclusion to surgical practice will require confirmatory clinical data.
Level of Evidence
N/A. Laryngoscope, 125:1892–1899, 2015
Impact of Irradiation on laryngeal hydration and lubrication in rat larynx
Songyi Lee, Jeong-Seok Choi, Hun Jung Kim, Young-Mo Kim, Jae-Yol Lim, 2015-08-11 16:19:20 PM
Objectives
The larynx is susceptible to irradiation, which causes significant vocal fold (VF) edema and dehydration shortly after radiotherapy for head and neck cancers. However little is known about radiation-induced damage to VF liquid homeostasis. To evaluate the effects of irradiation on VF hydration and lubrication, we investigated changes in water transporters (aquaporins [AQPs]) and mucin production in vivo and ex vivo, as well as morphometric changes in the laryngeal mucosa and glands of irradiated rat larynges.
Study Design
Animal study.
Materials and Methods
Local irradiation at 18 Gy was delivered to rat larynges. Histologic changes in laryngeal mucosa and glands were observed by light microscopy, and the distributions of AQPs and mucin were investigated by immunofluorescence staining 3 months after irradiation. Early effects on gene regulation of AQPs and mucin were evaluated by quantitative real-time polymerase chain reaction of the extirpated VFs and subglottic laryngeal mucosa at 12, 24, and 72 hours after irradiation.
Results
Laryngeal glands exhibited severe atrophic changes and showed decreased density throughout the irradiated larynx. The expression of AQP1, 4, 5, and mucin in VFs, as well as AQP5 and mucin in submucosal laryngeal glands, decreased significantly 3 months after irradiation. An ex vivo study revealed that the gene expression of AQP5 in VF tissues was significantly downregulated at 12 hours postirradiation.
Conclusion
Laryngeal irradiation induces damage in laryngeal mucosal barriers and alters laryngeal liquid homeostasis, which may be one reason for vocal dysfunction following irradiation.
Level of Evidence
N/A. Laryngoscope, 125:1900–1907, 2015
Psychological effects of dysphonia in voice professionals
Ziya Salturk, Tolgar Lutfi Kumral, Imran Aydoğdu, Ahmet Arslanoğlu, Güler Berkiten, Güven Yildirim, Yavuz Uyar, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To evaluate the psychological effects of dysphonia in voice professionals compared to non–voice professionals and in both genders.
Study Design
Cross-sectional analysis.
Methods
Forty-eight 48 voice professionals and 52 non–voice professionals with dysphonia were included in this study. All participants underwent a complete ear, nose, and throat examination and an evaluation for pathologies that might affect vocal quality. Participants were asked to complete the Turkish versions of the Voice Handicap Index-30 (VHI-30), Perceived Stress Scale (PSS), and the Hospital Anxiety and Depression Scale (HADS). HADS scores were evaluated as HADS-A (anxiety) and HADS-D (depression). Dysphonia status was evaluated by grade, roughness, breathiness, asthenia, and strain (GRBAS) scale perceptually. The results were compared statistically.
Results
Significant differences between the two groups were evident when the VHI-30 and PSS data were compared (P = .00001 and P = .00001, respectively). However, neither HADS score (HADS-A and HADS-D) differed between groups. An analysis of the scores in terms of sex revealed that females had significantly higher PSS scores (P = .006). The GRBAS scale revealed no difference between groups (P = .819, .931, .803, .655, and .803, respectively). No between-sex differences in the VHI-30 or HADS scores were evident
Conclusions
We found that voice professionals and females experienced more stress and were more dissatisfied with their voices.
Level of Evidence
4. Laryngoscope, 125:1908–1910, 2015
Minimally invasive management of tracheoesophageal fistula with T-tube
Christopher Tran, Daniel S. Fink, Melda Kunduk, Andrew J. McWhorter, 2015-08-11 16:19:20 PM
Single intratympanic gentamicin injection in Ménière's disease: VOR change and prognostic usefulness
Pedro Marques, Raquel Manrique-Huarte, Nicolas Perez-Fernandez, 2015-08-11 16:19:20 PM
Objective
Assess angular vestibular-ocular reflex (VOR) changes after treatment with intratympanic gentamicin (ITG) for Ménière's disease (MD) and impact on short-term follow-up.
Design
Prospective study.
Methods
Patients submitted to ITG for unilateral MD. The gain VOR and the presence of compensatory saccades elicited by rapid head impulses were measured using the video head impulse test (vHIT).
Results
The study included 31 subjects (mean age: 59 years). Functional Level Scale (FLS) distributions were 35,5% (FLS3); 32,2% (FLS4); and 32,2% (FLS5). Mean follow-up was 21 ± 7 months. Multiple injections were needed in nine patients.
VOR gain in the treated ear was significantly reduced in all subjects and for all the semicircular canals (paired samples t test; P < 0,05). Gain averages after treatment were 0,61 (superior); 0,69 (horizontal); and 0,47 (posterior). A horizontal canal VOR gain superior to 0,80 after treatment was associated with the need for a second gentamicin injection (Chi-square; P = 0,003). Gain asymmetry between the symptomatic and asymptomatic ear (GASM) was increased after treatment. The rate of vestibular function reduction was 47,9%; 26,0%; and 35,8% for the superior, horizontal, and posterior canals, respectively. According to the receiving operator characteristic curve, the amount of change in GASM must be greater than 7 in order to predict the avoidance of a second procedure (area under the curve [AUC] horizontal canal = 0,861) and the amount of vestibular function reduction in the pathologic ear in patients with a controlled disease must be greater than 17,8% (AUC horizontal canal = 0,843).
Conclusions
When evaluated with the vHIT, intratympanic gentamicin changes in VOR seem to foresee short-term control of vertigo attacks.
Level of Evidence
4. Laryngoscope, 125:1915–1920, 2015
A new method for evaluating lateral semicircular canal cupulopathy
Chang-Hee Kim, Jung Eun Shin, Yong Won Kim, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Persistent direction-changing positional nystagmus (DCPN) during the supine head-roll test is a typical finding of cupulopathy. The aim of this study was to introduce a simple method of evaluating patients with cupulopathy (light cupula and heavy cupula), which is performed in a seated position, and investigate its diagnostic utility and use for lateralization.
Study Design
Retrospective case series.
Methods
Using video-oculography, nystagmus during head roll in the leaning and bending head positions while seated upright was evaluated in 26 patients with cupulopathy (five light cupula and 21 heavy cupula). The diagnosis of cupulopathy was confirmed with the supine head-roll test.
Results
Spontaneous nystagmus while seated upright was directed toward the ipsilesional side in heavy cupula and the contralesional side in light cupula. The first null point was identified when the head was slightly bent in the pitch plane in all 26 patients. Head rolling elicited a persistent geotropic DCPN in light cupula patients and persistent apogeotropic DCPN in heavy cupula patients during both leaning and bending head positions. In both light and heavy cupula, nystagmus disappeared when the head was turned slightly toward the affected side in both leaning (second null point) and bending (third null point) head positions.
Conclusions
Cupulopathy and its affected side can be diagnosed by identifying the three null points while seated upright.
Level of Evidence
4. Laryngoscope, 125:1921–1925, 2015
Epidemiology of otologic diagnoses in United States emergency departments
Elliott D. Kozin, Rosh K.V. Sethi, Aaron K. Remenschneider, Alyson B. Kaplan, Daniel A. del Portal, Stacey T. Gray, Mark G. Shrime, Daniel J. Lee, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Otologic complaints may place a significant burden on emergency departments (EDs) in the United States; however, few studies have comprehensively examined this discrete patient population. We aimed to identify utilization of EDs by patients with primary otologic complaints.
Study Design
Retrospective analysis of the Nationwide Emergency Department Sample (NEDS) from 2009 through 2011.
Methods
The NEDS database was queried for patient encounters with a primary otologic diagnosis based on International Classification of Diseases, Ninth Revision codes (380–389). Weighted estimates for demographics, diagnostic characteristics, socioeconomic status, and trends over time were extracted. Predictors of mortality and admission were determined by multivariable logistic regression.
Results
A weighted total of 8,611,282 visits between 2009 and 2011 were attributed to otologic diagnoses, representing 2.21% of all ED visits. Stratified by patient age, otologic diagnoses encompassed 1.01% and 6.79% of all adult and pediatric ED visits, respectively. The majority of patients were treated and released (98.17%). The average age of patients presenting with an otologic complaint was 17.9 years (standard error = 0.23). Overall, 62.7% of patients who presented with an otologic complaint were 0 to 17 years old. The most common diagnoses among all age groups included otitis media not otherwise specified (NOS) (60.6%), infected otitis externa NOS (11.8%), and otalgia NOS (6.8%).
Conclusions
We provide a comprehensive overview of otologic complaints that are an overlooked diagnostic category in public health research. NEDS data demonstrate a significant number of visits related to otologic complaints, especially in the pediatric population, that are nonemergent.
Level of Evidence
4 Laryngoscope, 125:1926–1933, 2015
A ten-year review of soft tissue reactions around percutaneous titanium implants for auricular prosthesis
Sevasti Tzortzis, Konstantina Tzifa, Theofano Tikka, Steve Worrollo, Joanne Williams, Andrew P. Reid, David Proops, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Soft tissue reactions around abutments are the most common complications of percutaneous osseointegrated implants. The main objective of this study was to review our series of osseointegrated implants, evaluate the degree of adverse skin reactions around the auricular abutments, and compare with skin reactions in the pediatric bone-anchored hearing aid (BAHA) population. The reason for comparing these two groups was the difference in abutment shape and position in skin with different characteristics.
Study Design
A retrospective case analysis of 131 patient notes.
Methods
We retrospectively studied 131 pediatric and adult patients who underwent an osseointegrated auricular prosthesis over a 10-year period (1997–2007).
Results
There were 95 adults and 36 children who had been implanted and fitted with an auricular prosthesis during the 10-year study period. All patients were followed up postoperatively for a 2-year minimum up to a 14-year maximum follow-up. Thirteen (13/36, 36%) children and seven adults (7/95, 7%) had a skin reaction around the ear prosthesis.
Conclusions
The literature review has supported our study results and has shown that children have higher skin reactions in both BAHA and auricular prostheses than adults. Adverse skin reactions in the pediatric auricular group were significantly lower that the pediatric BAHA group.
Level of Evidence
4 Laryngoscope, 125:1934–1939, 2015
Assessment of superior semicircular canal thickness with advancing age
Shaun Davey, Christian Kelly-Morland, John S. Phillips, Ian Nunney, Davina Pawaroo, 2015-08-11 16:19:20 PM
Objective
To determine whether superior semicircular canal dehiscence (SSCD) is more prevalent with advancing age.
Study Design
Retrospective observational study.
Methods
High-resolution computed-tomographic temporal bone scans were identified for patients of all ages and analyzed by two independent assessors. Multiplanar reconstruction was applied, and the thinnest area of temporal bone overlying each superior semicircular canal (SSC) was measured.
Results
A sample of 121 patients was analyzed that contained an almost identical number of male and female patients. In total, 242 temporal bone images were reviewed. Patients' ages ranged between 6 and 86 years. Age was shown to have a significant linear relationship (P < 0.001) such that for every unit increase in age the predicted thickness was reduced by 0.0047 mm.
Conclusions
The thickness of the SSC decreases with advancing age.
Level of Evidence
4. Laryngoscope, 125:1940–1945, 2015
Pain in cochlear implant recipients: An uncommon, yet serious, consequence of cochlear implantation
Yisgav Shapira, Yifat Yaar-Soffer, Minka Hildesheimer, Lela Migirov, Yael Henkin, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
We describe pain around the receiver/stimulator [RS] presenting months to years after implantation.
Study Design
A retrospective chart review.
Methods
We performed a retrospective review of all cochlear implant recipients complaining of pain around their RS through the years 2009 through 2013, with a follow-up of at least 6 months. Excluded from the study were patients with an identifiable cause for their pain such as trauma, local infection, or skin breakdown. The therapy regimen and outcomes were reviewed.
Results
Thirty patients complained of delayed pain over their RS, representing 2.8% of 1,044 implantations performed at the Sheba Medical Center, Tel Hashomer, Israel, as of 2013. The time from implantation to the presentation of pain ranged from 3 months to 12 years. The pain was perceptible even when the external magnet and processor were not used, and was usually most obvious in specific points around the RS. Seventy-seven percent of our patients responded well to conservative therapy. Fifteen (50%) responded to prolonged antibiotic treatment. Five patients (17%) responded to antiinflammatories alone. One patient (3%) responded to deactivation of two electrodes. Six patients (20%) required reimplantation, after which the pain resolved in all. At explantation, no signs of infection, foreign body reaction, or obvious device damage were found.
Conclusion
Delayed pain around the RS that is unrelated to use is a serious consequence of cochlear implantation, and in some cases, those necessitating reimplantation, should be considered a major complication.
Level of Evidence
4. Laryngoscope, 125:1946–1951, 2015
Sequential bilateral cochlear implantation in the adolescent population
David R. Friedmann, Janet Green, Yixin Fang, Kelsey Ensor, J. Thomas Roland, Susan B. Waltzman, 2015-08-11 16:19:20 PM
Objectives
To examine the variables affecting outcomes for sequential bilateral cochlear implantation patients in the adolescent population.
Study Design
Retrospective chart review at tertiary care center.
Methods
Main outcome measures were open set speech recognition tests at the word (Consonant-Nucleus-Consonant/Phonetically Balanced Kindergarten List Test [CNC/PBK]) and sentence levels in noise (Hearing in Noise Test-Noise [HINT-N]) in different test conditions with respect to the age at first and sequential implantation, as well as the interval between implants.
Results
Despite a mean age at sequential implantation of 13.5 years, sequential bilateral implanted adolescents revealed significant improvement in the sequential cochlear implant (CI2) ear. The mean time interval between implants was 8.2 years. A wide range of performance was noted, and age at implantation and interval between first cochlear implant (CI1) and CI2 did not predict outcome. Mean CNC/PBK score with CI1 alone was 83.0%, with the CI2 alone was 56.5%, and with bilateral implants was 86.8%. Sentence scores (HINT-N) were 89.5% for CI1, 74.2% for CI2, and 94.4% for bilateral CI condition. The clinical relevance of these enhanced perception abilities requires attention to individual device use, performance with the first implant, and subjective benefits reported by patients.
Conclusions
Bilateral sequential cochlear implantation leads to improved speech perception in the adolescent population and should be considered in this population, even after a long period of deafness and despite a prolonged interval between implants. Numerous factors affect the ability to predict performance, but age at implantation and interimplant interval were not correlated with performance measures. Extensive preoperative counseling and individualized evaluation are critical to ensure that patients and families understand the range of possible outcomes.
Level of Evidence
4 Laryngoscope, 125:1952–1958, 2015
Treatment of horizontal canal BPPV: Pathophysiology, available maneuvers, and recommended treatment
Yahav Oron, Smadar Cohen-Atsmoni, Assaf Len, Yehudah Roth, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To describe the pathophysiology of horizontal canal benign paroxysmal positional vertigo, the available maneuvers for its management, and the recommended treatment.
Data Sources
PubMed, Cochrane library.
Review Methods
Review of the available literature.
Results
Two theories of pathophysiology underlying the disease are described, along with available maneuvers reflecting those theories; and videos of the maneuvers are provided. A comparison of available treatments is made.
Conclusion
A variety of maneuvers is available related to the pathophysiology underlying the disease. The treatment chosen should be appropriate to the patients' ages, general conditions, and other diseases they may have. No treatment was found to be superior over the others regarding the success rate. In the case of geotropic nystagmus, the Gufoni maneuver is superior in its ease of performance. When it comes to apogeotropic nystagmus, the Barbecue and Gufoni maneuvers have comparable success rates. Laryngoscope, 125:1959–1964, 2015
Surgical management for benign paroxysmal positional vertigo of the superior semicircular canal
James G. Naples, Marc D. Eisen, 2015-08-11 16:19:20 PM
Benign paroxysmal positional vertigo of the superior semicircular canal is a rare form of BPPV. It accounts for 1% to 3% of cases. The characteristic nystagmus is positional, down-beating, with a torsional component elicited by the Dix-Hallpike maneuver. Symptoms of superior semicircular canal BPPV often resolve spontaneously; however, it can be refractory to repositioning maneuvers. Surgical management is described for posterior semicircular canal BPPV. To date, however, there is only one reported case of surgical management for superior semicircular canal BPPV. Here we show video documentation of positional, down-beating nystagmus and describe a case of superior semicircular canal BPPV requiring canal occlusion with successful resolution of symptoms. Laryngoscope, 125:1965–1967, 2015
Recovery of hearing after surgical removal of Intralabyrinthine schwannoma
Jong Joo Lee, Hye Jin Lim, Hun Yi Park, Yun-Hoon Choung, 2015-08-11 16:19:20 PM
Intralabyrinthine schwannomas (ILSs) are rare benign tumors arising from the distal part of the cochleovestibular nerve confined within the labyrinth. Patients with ILSs complain of hearing loss, vertigo, tinnitus, and ear fullness. Surgical treatment of ILS is performed in special cases such as in cases of patients with nonserviceable hearing, progressive hearing loss, intractable vertigo, or tumor extension. We present an unusual case of a patient with intralabyrinthine schwannoma who underwent surgery to treat progressive hearing loss and recovered his hearing after surgery. Laryngoscope, 125:1968–1971, 2015
Intraoperative acupuncture for posttonsillectomy pain: A randomized, double-blind, placebo-controlled trial
Gabriel J. Tsao, Anna H. Messner, Jeannie Seybold, Zahra N. Sayyid, Alan G. Cheng, Brenda Golianu, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To evaluate the effect of intraoperative acupuncture on posttonsillectomy pain in the pediatric population.
Study Design
Prospective, double-blind, randomized, placebo-controlled trial.
Methods
Patients aged 3 to 12 years undergoing tonsillectomy were recruited at a tertiary children's hospital between February 2011 and May 2012. Participants were block-randomized to receive acupuncture or sham acupuncture during anesthesia for tonsillectomy. Surgeons, staff, and parents were blinded from treatment. Tonsillectomy was performed by one of two surgeons using a standard technique (monopolar cautery), and a single anesthetic protocol was followed. Study endpoints included time spent in the postanesthesia care unit, the amount of opioids administered in the perioperative period, and pain measures and presence of nausea/vomiting from postoperative home surveys.
Results
Fifty-nine children aged 3 to 12 years were randomized to receive acupuncture (n = 30) or sham acupuncture (n = 29). No significant demographic differences were noted between the two cohorts. Perioperative data were recorded for all patients; 73% of patients later returned home surveys. There were no significant differences in the amount of opioid medications administered or total postanesthesia care unit time between the two cohorts. Home surveys of patients but not of parents revealed significant improvements in pain control in the acupuncture treatment-group postoperatively (P = 0.0065 and 0.051, respectively), and oral intake improved significantly earlier in the acupuncture treatment group (P = 0.01). No adverse effects of acupuncture were reported.
Conclusions
This study demonstrates that intraoperative acupuncture is feasible, well tolerated, and results in improved pain and earlier return of diet postoperatively.
Level of Evidence
1b. Laryngoscope, 125:1972–1978, 2015
Pediatric airway reconstruction with a prefabricated auricular cartilage and radial forearm free flap
Faisal I. Ahmad, Karla O'Dell, Jessica J. Peck, Mark K. Wax, Henry A. Milczuk, 2015-08-11 16:19:20 PM
Prefabricated composite free flaps for complex airway reconstruction have been described for an adult series at our institution. We extended this approach to a pediatric patient with lifelong subglottic stenosis who had failed previous open airway reconstructions. A staged procedure was utilized in which a composite graft was created using conchal cartilages and a radial forearm free flap. This reconstruction improved the patency of her airway and decreased her dependency on intermittent airway dilations. Airway reconstruction with prefabricated conchal cartilage composite free flaps may be used as a salvage procedure for complex pediatric airway reconstruction when other methods have failed. Laryngoscope, 125:1979–1982, 2015
Clinical predictors of effective continuous positive airway pressure in patients with obstructive sleep apnea/hypopnea syndrome
Chi-Chih Lai, Michael Friedman, Hsin-Ching Lin, Pa-Chun Wang, Michelle S. Hwang, Cheng-Ming Hsu, Meng-Chih Lin, Chien-Hung Chin, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To identify standard clinical parameters that may predict the optimal level of continuous positive airway pressure (CPAP) in adult patients with obstructive sleep apnea/hypopnea syndrome (OSAHS).
Study Design
This is a retrospective study in a tertiary academic medical center that included 129 adult patients (117 males and 12 females) with OSAHS confirmed by diagnostic polysomnography (PSG).
Methods
All OSAHS patients underwent successful full-night manual titration to determine the optimal CPAP pressure level for OSAHS treatment. The PSG parameters and completed physical examination, including body mass index, tonsil size grading, modified Mallampati grade (also known as updated Friedman's tongue position [uFTP]), uvular length, neck circumference, waist circumference, hip circumference, thyroid-mental distance, and hyoid-mental distance (HMD) were recorded.
Results
When the physical examination variables and OSAHS disease were correlated singly with the optimal CPAP pressure, we found that uFTP, HMD, and apnea/hypopnea index (AHI) were reliable predictors of CPAP pressures (P = .013, P = .002, and P < .001, respectively, by multiple regression). When all important factors were considered in a stepwise multiple linear regression analysis, a significant correlation with optimal CPAP pressure was formulated by factoring the uFTP, HMD, and AHI (optimal CPAP pressure = 1.01 uFTP + 0.74 HMD + 0.059 AHI − 1.603).
Conclusions
This study distinguished the correlation between uFTP, HMD, and AHI with the optimal CPAP pressure. The structure of the upper airway (especially tongue base obstruction) and disease severity may predict the effective level of CPAP pressure.
Level of Evidence
4. Laryngoscope, 125:1983–1987, 2015
Volumetric MRI analysis pre- and post-Transoral robotic surgery for obstructive sleep apnea
Rebecca C. Chiffer, Richard J. Schwab, Brendan T. Keenan, Ryan C. Borek, Erica R. Thaler, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
To quantitatively measure volumetric changes in upper airway soft tissue structures using magnetic resonance imaging (MRI) pre- and post transoral robotic surgery for obstructive sleep apnea (OSA-TORS).
Study Design
Prospective, nonrandomized, institutional board-approved study.
Methods
Apneics undergoing OSA-TORS, which included bilateral posterior hemiglossectomy with limited pharyngectomy and uvulopalatopharyngoplasty, had upper airway MRIs pre- and postoperatively. Changes (percent and absolute values) in upper airway and surrounding soft tissue volumes were calculated. We assessed whether there were significant volumetric changes and if changes correlated with apnea-hypopnea index (AHI) changes.
Results
Nineteen MRIs and 18 polysomnograms were analyzed pre- and postoperation. Total airway volume increased by 19.4% (P = 0.030). Soft palate and tongue volumes decreased by 18.3% (P = 0.002) and 5.8% (P = 0.013), respectively. Retropalatal and total lateral wall volumes decreased by 49.8% (P = 0.0001) and 17.9% (P = 0.008), respectively. Changes in other structures were not significant. Eleven patients had surgical success, with a mean AHI decrease of 52.9; six were nonsuccesses with a mean AHI decrease of 4.5 (P =0.006). Decreased retropalatal lateral wall volume correlated with decreased AHI.
Conclusion
Airway, tongue, soft palate, and lateral wall volumes change significantly after OSA-TORS. Changes in the volume of the lateral walls correlated with changes in AHI. Volumetric upper airway MRI may be a helpful tool to better understand reasons for surgical success.
Level of Evidence
4. Laryngoscope, 125:1988–1995, 2015
Electrophysiologic identification and monitoring of the external branch of superior laryngeal nerve during thyroidectomy
Emad Kandil, Salah Eldin Mohamed, Ahmed Deniwar, Hossam Mohamed, Paul Friedlander, Rizwan Aslam, Ahmad Saeed, Ibrahim Musa, Gregory Randolph, 2015-08-11 16:19:20 PM
Objective
The aim of the study is to examine the correlation between weight, gender, and race with external branch of superior laryngeal nerve (EBSLN) visualization. Furthermore, we compared normative EBSLN neural-monitoring values to those of the recurrent laryngeal nerve (RLN).
Study Design
Retrospective study.
Setting
North American tertiary academic hospital.
Subjects and Methods
A retrospective, institutional review board-approved review was carried out on patients undergoing thyroid surgery by a single surgeon over 3.5 years. Preoperative and postoperative laryngoscopy was done on all patients in accordance with recently published American Academy of Otolaryngology voice optimization at thyroidectomy guidelines, and patients' clinical and operative relevant data were collected.
Results
A total of 447 nerves were at risk in 371 thyroidectomy patients. Of these nerves at risk, 237 (53.02%) were visualized and stimulated. The average amplitude and latency for the EBSLN were significantly lower when compared to the amplitude and the latency of RLN stimulation (P < 0.0001, P < 0.0001, respectively). There was no gender or racial disparity. Out of our study population, the EBSLN was identified in 64.56% in nonobese patients, whereas it was only 40.00% in obese patients (P < 0.001). Additionally, of the 56 patients in whom the EBSLN was visualized on one side and who further underwent bilateral neck exploration, 41 (73%) had visualization of the nerve on the contralateral side as well.
Conclusion
EBSLN is less likely to be visualized in obese patients; however, there was no gender or racial disparity. Stimulation of EBSLN was felt to be a useful adjunct during superior pole dissection to assure the nerve integrity.
Level of Evidence
4. Laryngoscope, 125:1996–2000, 2015
Biomechanical evaluation of human and porcine Auricular cartilage
David A. Zopf, Colleen L. Flanagan, Hassan B. Nasser, Anna G. Mitsak, Farhan S. Huq, Vishnu Rajendran, Glenn E. Green, Scott J. Hollister, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The mechanical properties of normal auricular cartilage provide a benchmark against which to characterize changes in auricular structure/function due to genetic defects creating phenotypic abnormalities in collagen subtypes. Such properties also provide inputs/targets for auricular reconstruction scaffold design. Several studies report the biomechanical properties for septal, costal, and articular cartilage. However, analogous data for auricular cartilage are lacking. Therefore, our aim in this study was to characterize both whole-ear and auricular cartilage mechanics by mechanically testing specimens and fitting the results to nonlinear constitutive models.
Study Design
Mechanical testing of whole ears and auricular cartilage punch biopsies.
Methods
Whole human cadaveric ear and auricular cartilage punch biopsies from both porcine and human cartilage were subjected to whole-ear helix-down compression and quasistatic unconfined compression tests. Common hyperelastic constitutive laws (widely used to characterize soft tissue mechanics) were evaluated for their ability to represent the stress-strain behavior of auricular cartilage.
Results
Load displacement curves for whole ear testing exhibited compliant linear behavior until after significant displacement where nonlinear stiffening occurred. All five commonly used two-term hyperelastic soft tissue constitutive models successfully fit both human and porcine nonlinear elastic behavior (mean R2 fit >0.95).
Conclusions
Auricular cartilage exhibits nonlinear strain-stiffening elastic behavior that is similar to other soft tissues in the body. The whole ear exhibits compliant behavior with strain stiffening at high displacement. The constants from the hyperelastic model fits provide quantitative baselines for both human and porcine (a commonly used animal model for auricular tissue engineering) auricular mechanics.
Level of Evidence
NA Laryngoscope, 125:E262–E268, 2015
Gene expression demonstrates an immunological capacity of the human endolymphatic sac
Martin Nue Møller, Svend Kirkeby, Jonas Vikeså, Finn Cilius Nielsen, Per Cayé-Thomasen, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
The purpose of the present study is to explore, demonstrate, and describe the expression of genes related to the innate immune system in the human endolymphatic sac. It is hypothesized that the endolymphatic sac has a significant immunological function in the human inner ear.
Study Design
DNA microarrays and immunohistochemistry were used for analyses of fresh human endolymphatic-sac tissue samples.
Methods
Twelve tissue samples from the human endolymphatic sac were obtained during translabyrinthine surgery for vestibular schwannoma. Microarray technology was used to investigate tissue sample gene expression using adjacent dura mater as control. The expression of genes specific for the innate immune system was determined and results for selected key molecules verified by immunohistochemistry.
Results
A comprehensive overview of expressed genes of the innate immune system was obtained. Multiple key elements of both the cellular and humoral innate immune system were expressed, including Toll-like receptors 4 and 7, as well as beta-defensin and lactoferrin.
Conclusions
The present data provides the first direct evidence of an immunological capacity of the human endolymphatic sac. At the molecular level, the endolymphatic sac is capable of antigen recognition and processing for initiation of an immune response. In addition, potent molecules directly toxic to invading pathogens are expressed by the sac epithelium.
This evidence strongly supports the endolymphatic sac as a significant immunological entity of the inner ear.
Level of Evidence
N/A. Laryngoscope, 125:E269–E275, 2015
Noninvasive depth-resolved optical measurements of the tympanic membrane and middle ear for differentiating otitis media
Guillermo L. Monroy, Ryan L. Shelton, Ryan M. Nolan, Cac T. Nguyen, Michael A. Novak, Malcolm C. Hill, Daniel T. McCormick, Stephen A. Boppart, 2015-08-11 16:19:20 PM
Objective/Hypothesis
In this study, optical coherence tomography (OCT) is used to noninvasively and quantitatively determine tympanic membrane (TM) thickness and the presence and thickness of any middle-ear biofilm located behind the TM. These new metrics offer the potential to differentiate normal, acute, and chronic otitis media (OM) infections in pediatric subjects.
Study Design
Case series with comparison group.
Methods
The TM thickness of 34 pediatric subjects was acquired using a custom-built, handheld OCT system following a traditional otoscopic ear exam.
Results
Overall thickness (TM and any associated biofilm) was shown to be statistically different for normal, acute, and chronic infection groups (normal-acute and normal-chronic: P value < 0.001; acute-chronic: P value = 0.0016). Almost all observed scans from the chronic group had an accompanying biofilm structure. When the thickness of the TM and biofilm were considered separately in chronic OM, the chronic TM thickness correlated with the normal group (P value = 0.68) yet was still distinct from the acute OM group (P value < 0.001), indicating that the TM in chronic OM returns to relatively normal thickness levels.
Conclusion
Identifying these physical changes in vivo provides new metrics for noninvasively and quantitatively differentiating normal, acute, and chronic OM. This new diagnostic information has the potential to assist physicians to more effectively and efficiently screen, manage, and refer patients based on quantitative data.
Level of Evidence
4. Laryngoscope, 125:E276–E282, 2015
Electrophysiologic monitoring correlates of recurrent laryngeal nerve heat thermal injury in a porcine model
Yi-Chu Lin, Gianlorenzo Dionigi, Gregory W. Randolph, I-Cheng Lu, Pi-Ying Chang, Shan-Yin Tsai, Hoon Yub Kim, Hye Yoon Lee, Ralph P. Tufano, Hui Sun, Xiaoli Liu, Feng-Yu Chiang, Che-Wei Wu, 2015-08-11 16:19:20 PM
Objectives/Hypothesis
Thermal injury to the recurrent laryngeal nerve (RLN) may not be visually apparent and may go unrecognized intraoperatively. This study aimed to investigate the heat thermal tolerance of RLN and evaluate the electrophysiologic correlates of electromyographic (EMG) signal change during an acute RLN heat damage.
Study Design
Prospective porcine model with continuous intraoperative neuromonitoring (CIONM).
Methods
Ten pigs (20 RLNs) undergoing CIONM had their EMG tracings recorded and correlated with heated normal saline (NS) irrigation of varying temperature and duration.
Results
In the initial pilot study, the EMG was without change during incremental heated NS irrigation (40/45/50/55 °C for 60 seconds), but adverse EMG combined events (CE) (amplitude decrease with a concordant latency increase) occurred and degraded to loss of signal (LOS) (by 17.5 ± 1.3 seconds) when the temperature was elevated to 60 °C (n = 4). Another 16 RLNs were evaluated to further compare the EMG pattern after various degrees of thermal stress (60/70 °C for 30/20 seconds). Electromyographic recordings showed CEs and LOS in all RLNs, and only six of eight RLNs with 60 °C exposure showed slight EMG amplitude recovery (16%–35%) after 20 minutes. None of the injured nerve segments were visually apparent, but all were detectable by IONM.
Conclusion
Sixty degrees Celsius is a critical temperature to cause RLN thermal injury. Continuous intraoperative neuromonitoring can be used as a tool for the early detection of acute thermal stress and may guide use of energy-based devices during thyroid procedures.
Level of Evidence
N/A. Laryngoscope, 125:E283–E290, 2015
In reference to First use of a computer-assisted operator-controlled flexible endoscope for transoral surgery
Vyas M. N. Prasad, Marc Remacle, Georges Lawson, 2015-08-11 16:19:20 PM
Τρίτη 11 Αυγούστου 2015
The Laryngoscope
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