Uvulopalatopharyngoplasty: Does Multilevel Surgery Increase Risk?

Objectives

(1) Determine the rate of postoperative complications, reoperation, readmission, and death after uvulopalatopharyngoplasty (UPPP) for sleep apnea through multi-institutional clinical data. (2) Compare outcomes of UPPP between multilevel and single-level procedures for the treatment of sleep apnea.

Study Design

Retrospective database analysis.

Methods

The American College of Surgeons National Surgical Quality Improvement Program—a nationally validated, prospective, multi-institutional database from 2005 to 2013—was analyzed for patients who underwent UPPP, per corresponding Current Procedural Terminology codes. Patients were categorized into 3 groups: UPPP alone, UPPP + nasal cavity (NC), and UPPP + base of tongue (BOT). Perioperative outcome measures of interest include surgical/medical complications, reoperation, readmission, and death. Comparisons were made among surgical groups through univariate cross-sectional analysis.

Results

A total of 1079 patients underwent UPPP; 413 patients had UPPP + NC; and 200 patients had UPPP + BOT procedures. One death was reported for the entire cohort of patients. Among all 3 groups (UPPP, UPPP + NC, and UPPP + BOT), no differences were noted in the rates of medical complications (P = .445), surgical complications (P = .396), reoperation (P = .332), and readmission (P = .447). However, the length of hospital stay in days was greatest for the UPPP + BOT group (UPPP, 0.81 ± 0.69; UPPP + NC, 0.87 ± 0.90; UPPP + BOT, 1.50 ± 2.70; P < .001).

Conclusion

These national data demonstrate no significant increase in risk when UPPP is performed as a single- or multilevel procedure. When indicated, UPPP with multilevel procedures may be safely performed for treatment of sleep apnea. These data set a benchmark for perioperative risk in UPPP surgery and will prove useful for counseling patients.

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Gabapentin for Perioperative Analgesia in Otorhinolaryngology-Head and Neck Surgery: Systematic Review

Objective

Recent research has investigated the role of gabapentin in perioperative pain relief in otorhinolaryngology–head and neck surgery. This review aims to identify whether sufficient evidence exists for the routine use of gabapentin in the perioperative setting.

Data Sources

MEDLINE, Cochrane CENTRAL, EMBASE, and Google Scholar.

Review Methods

A comprehensive systematic search was performed with keywords for articles up to November 2015. The systematic review included all randomized, placebo-, and active-controlled trials investigating the role of perioperative gabapentin for pain in otorhinolaryngology–head and neck surgery. The studies were assessed for risk of bias and selected and reviewed by the main author. Selected trials were required to have data in the form of pain intensity scores, analgesic consumption, adverse effects, or return to normal function.

Results

A total of 14 randomized controlled trials were included, of which 4 had an active control. The placebo-controlled trials included 4 for tonsillectomy, 3 for rhinology, and 3 for thyroidectomy. These studies were not suitable for meta-analysis. Trial quality involving gabapentin in tonsillectomy surgery is variable. The higher-quality studies reported significantly reduced analgesic consumption in the gabapentin groups, with the effect on pain scores less clear. There was a significant benefit, within the first 24 hours, in pain and analgesic consumption as compared with placebo favoring the gabapentin groups following rhinologic and thyroid surgery.

Conclusion

Overall, gabapentin appears to have a significant beneficial effect on perioperative pain relief and analgesic consumption in otorhinolaryngology–head and neck surgery procedures within the first 24 hours.

http://ift.tt/2gYwImm

Bimodal Stimulation in Prelingually Deaf Children: Lessons from a Cross-sectional Survey

Objective

(1) To survey the use of bimodal stimulation by prelingually deaf children receiving unilateral cochlear implantation and (2) to investigate demographic and audiologic factors explaining the use of bimodal stimulation.

Study Design

Cross-sectional survey.

Setting

Tertiary care institution.

Subjects and Methods

The study included 44 unilaterally implanted prelingually deaf children from a single institution, with a minimum follow-up of 1 year. During routine follow-up visits, an examiner interviewed parents on their children's use of bimodal stimulation. At the same time, residual hearing and hearing aid gain in the contralateral ear were assessed.

Results

Approximately half of patients (52%) used bimodal stimulation. On average, bimodal users showed better mean unaided and aided thresholds than nonbimodal users (P < .001). A mean 250- to 500-Hz unaided threshold ≤90 dB HL in the contralateral, nonimplanted ear was associated with a higher probability of bimodal use (P = .008). Parental satisfaction with the contralateral hearing aid was inversely correlated with mean 125- to 500-Hz and 1000- to 4000-Hz unaided thresholds (P < .001) and mean 250- to 500-Hz and 1000- to 4000-Hz aided thresholds (P < .001).

Conclusions

A mean 250- to 500-Hz unaided threshold ≤90 dB HL is associated with a higher probability of bimodal use by prelingually deaf children. Better residual hearing is associated with a higher degree of parental satisfaction with the contralateral hearing aid. This information could be useful to counsel parents of prelingually deaf children, when deciding between bimodal stimulation and simultaneous bilateral cochlear implantation.

http://ift.tt/2gMaeSz

Predicting Outcomes after Uvulopalatopharyngoplasty for Adult Obstructive Sleep Apnea: A Meta-analysis

Objective

Uvulopalatopharyngoplasty (UPPP) remains one of the most common surgical treatments for patients with obstructive sleep apnea. However, the results after UPPP are unpredictable. The purpose of this meta-analysis is to identify predictors of success after UPPP.

Data Sources

A literature search was performed utilizing PubMed, EMBASE, SCOPUS, and the Cochrane Library.

Review Methods

The keywords and medical subject heading terms used were uvulopalatopharyngoplasty and UPPP. Studies were included if UPPP was used as a single surgical procedure for the treatment of obstructive sleep apnea and results were presented separately as responder (surgical success) and nonresponder (surgical failure). Exclusion criteria included pediatric patients and other surgical procedures (eg, nasal and hypopharyngeal) performed at the same time as the UPPP. Age, body mass index, preoperative apnea-hypopnea index, Friedman stage, and several cephalometric variables were compared between responders and nonresponders.

Results

A total of 1257 studies were screened, with 15 studies included in this meta-analysis. Our results demonstrate that Friedman stage I is a strong predictor for success after UPPP, while Friedman stage III and low hyoid position are negative predictors. Age, body mass index, preoperative apnea-hypopnea index, and other cephalometric measurements were not significant.

Conclusion

Friedman stage and hyoid position are important predictors for UPPP.

http://ift.tt/2gYLysU

"Pretreatment Neutrophil-Lymphocyte Ratio in Salivary Gland Tumors Is Associated with Malignancy"

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Therapeutic Mastoidectomy in the Management of Noncholesteatomatous Chronic Otitis Media: Literature Review and Cost Analysis

Objective

Despite evidence that therapeutic mastoidectomy does not improve outcomes in noncholesteatomatous chronic otitis media, it remains widely performed. An up-to-date systematic review is undertaken and conclusions drawn regarding the best evidence-based practice of its management.

Data Sources

PubMed, Google Scholar, Medline Embase, Cochrane, and Web of Science.

Review Method

A combination of the following words was used: chronic otitis media, chronic suppurative otitis media, COM, CSOM, mastoidectomy, tympanoplasty, atelectasis, retraction, tympanic perforation, and therapeutic.

Results

From 1742 studies, 7 were selected for full analysis with respect to the benefit of mastoidectomy in the management of active and inactive mucosal chronic otitis media. Most were retrospective studies, with 1 prospective randomized controlled trial available. Overall, there was no evidence to support routine mastoidectomy in conjunction with tympanoplasty in chronic otitis media. For ears with sclerotic mastoids, the evidence suggested that there may be some benefit as a staged procedure. Two studies were analyzed for the benefit of mastoidectomy in addition to tympanoplasty for the management of the atelectatic ear (inactive squamous chronic otitis media). The conclusion was also that mastoidectomy added no benefit.

Conclusions

Examination of the available literature supports the notion that therapeutic mastoidectomy does not lend any additional benefit to the management of noncholesteatomatous chronic otitis media. This has implications for patient care, both clinically and financially. Further research, ideally in the form of a prospective, multi-institutional, geographically wide, ethnically diverse, randomized controlled trial, is needed to further support this notion.

http://ift.tt/2gYFvF2

Dual pH with Multichannel Intraluminal Impedance Testing in the Evaluation of Subjective Laryngopharyngeal Reflux Symptoms

Objectives

Minimal data exist to define the use of contemporary dual pH with multichannel intraluminal impedance (MII) probes integrating both pharyngeal acid and impedance sensors to evaluate laryngopharyngeal reflux (LPR) symptoms in a laryngology clinic population. This study was performed to review a series of patients tested with dual pH-MII for suspected LPR symptoms and to analyze pH-MII data findings for this patient cohort.

Study Design

Case series with planned data collection.

Setting

Tertiary laryngology clinic.

Subjects and Methods

Patients with symptoms suggestive of possible LPR (dysphonia, chronic cough, globus sensation, subglottic stenosis,) were evaluated with a dual pH-MII system, as well as previously validated reflux finding score (RFS) and reflux symptom index (RSI) instruments.

Results

A total of 109 patients were evaluated with dual pH-MII studies between 2010 and 2015, with 51 (47%) studies interpreted as "positive" for evidence of significant LPR, 43 (39%) as "negative," and 15 (14%) as "equivocal." Dual pH-MII data analysis showed that positive studies had an average of 2.84 pharyngeal acid exposures below pH 4 (vs 0.28 for negative) and 46 episodes of proximal reflux exposure (either acid or nonacid) by impedance detection (vs 30.6 for negative). RSI scores were significantly different between positive and negative studies, while RFS scores were not.

Conclusions

Dual pH-MII analysis is a useful supplementary tool to provide objective evidence of pharyngeal reflux exposure in patients with suspected LPR. RSI scores appear to correlate with objective evidence of acid exposure in the pharynx, while RFS scores do not.

http://ift.tt/2gM831i

Patient-Reported Outcome Measures Related to Laryngopharyngeal Reflux: A Systematic Review of Instrument Development and Validation

Objectives

Patient-reported outcome (PRO) measures are often used to diagnose laryngopharyngeal reflux (LPR) and monitor treatment outcomes in clinical and research settings. The present systematic review was designed to identify currently available LPR-related PRO measures and to evaluate each measure's instrument development, validation, and applicability.

Data Sources

MEDLINE via PubMed interface, CINAHL, and Health and Psychosocial Instrument databases were searched with relevant vocabulary and key terms related to PRO measures and LPR.

Review Methods

Three investigators independently performed abstract review and full text review, applying a previously developed checklist to critically assess measurement properties of each study meeting inclusion criteria.

Results

Of 4947 studies reviewed, 7 LPR-related PRO measures (publication years, 1991-2010) met criteria for extraction and analysis. Two focused on globus and throat symptoms. Remaining measures were designed to assess LPR symptoms and monitor treatment outcomes in patients. None met all checklist criteria. Only 2 of 7 used patient input to devise item content, and 2 of 7 assessed responsiveness to change. Thematic deficiencies in current LPR-related measures are inadequately demonstrated: content validity, construct validity, plan for interpretation, and literacy level assessment.

Conclusion

Laryngopharyngeal reflux is often diagnosed according to symptoms. Currently available LPR-related PRO measures used to symptomatically identify suspected LPR patients have disparate developmental rigor and important methodological deficiencies. Care should be exercised to understand the measurement characteristics and contextual relevance before applying these PRO measures for clinical, research, or quality initiatives.

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Structured Preoperative Phone Counseling by Junior Medical Staff for Improving the Consent Process for Tonsillectomy

Objective

To assess the effectiveness of preoperative phone counseling by junior medical staff for improving the standard of informed consent for tonsillectomy.

Study Design

Prospective randomized controlled trial.

Setting

District general hospital.

Subjects and Methods

A total of 43 patients undergoing tonsillectomy were randomly allocated to 2 groups. Group A (n = 25) underwent the conventional consent process by the consultant ear, nose, and throat surgeon at the time of assessment (which generally takes place 6 to 12 months prior to surgery due to wait-list times). Group B (n = 18) underwent this same consent process but received a structured preoperative phone call 2 to 3 weeks prior to the day of surgery. A preoperative questionnaire assessing the knowledge of tonsillectomy, perioperative course, and risks was completed on the day of surgery.

Results

Group B had a better recall of the risks of tonsillectomy, recalling 7.1 of the 10 most significant risks, as compared with 4.6 for group A (P = .017). Group B had a better awareness of tooth damage (78% vs 30% of patients, P ≤ .001), voice change (61 vs 19%, P = .005), and burns to lips and mouth (44% vs 8%, P = .005). Finally, 35% more patients from group B rated their understanding of tonsillectomy as good or very good (P = .017).

Conclusion

Preoperative phone counseling by junior medical staff closer to the time of surgery reinforces and clarifies the information previously provided by senior consultants at the time of initial consent for tonsillectomy.

http://ift.tt/2gM8OYb

Olfactory Outcomes after Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Meta-analysis

Objective

To use combined pre- and postsurgical olfactory outcomes to assess the impact of endoscopic sinus surgery on chronic rhinosinusitis–related olfactory impairment.

Data Sources

CINAHL, Cochrane, OVID, EMBASE, PubMed, and SCOPUS. Each database was searched from inception up to October 2015.

Review Methods

Studies were included that reported subjective or objective olfactory data in chronic rhinosinusitis patients before and after endoscopic sinus surgery.

Results

Thirty-one studies were used in the meta-analysis. Weighted mean differences of olfactory measures demonstrated significant improvement in mixed CRS patients (those with and without polyps) through visual analog scales (–0.83, P = .001), altered taste/smell item on Sinonasal Outcome Test (–1.32, P < .00001), 40-item Smell Identification Test (3.49, P = .0010), and Sniffin' Sticks identification (0.34, P = .03). Chronic rhinosinusitis mixed patients demonstrated nonsignificant improvements via Sniffin' Sticks threshold (1.60, P = .16) and Brief Smell Identification Test (0.20, P = .32). When separated, polyp patients and dysosmic patients experienced the highest levels of olfactory improvement. Polyp patients improved by 7.87 (P = .006) on the 40-item Smell Identification test, 11.54 (P < .0001) with the Sniffin' Sticks total score, and 2.57 (P < .00001) through Sniffin' Sticks identification. Dysosmic patients improved by 5.75 via the 40-item Smell Identification Test (P = .0001).

Conclusion

Endoscopic sinus surgery improves nearly all subjective and objective measures of olfaction in chronic rhinosinusitis patients. Patients with nasal polyposis or preoperative olfactory dysfunction improve to a greater degree.

http://ift.tt/2gYxUWK

Auricular Split-Thickness Skin Graft for Ear Canal Coverage

Split-thickness skin graft (STSG) continues to be the preferred means of external auditory canal (EAC) reconstruction. We thus sought to describe our experience using skin from the posterior aspect of the auricle (SPAA) as a donor site in EAC reconstruction. Grafts were, on average, 5 x 10 mm in size and obtained with a No. 10 blade after tumescence injection. The cases of 39 patients who underwent 41 procedures were retrospectively reviewed. Of the 38 patients with both 3- and 6-month follow-ups, no postoperative stenosis or bony exposure occurred. STSG from the SPAA can be a good option in EAC reconstruction. Total EAC/tympanic membrane coverage can be obtained with STSG from the SPAA.

http://ift.tt/2gM61hY

Does the Preoperative Administration of Steroids Reduce Intraoperative Bleeding during Endoscopic Surgery of Nasal Polyps?

Objectives

Corticosteroids are frequently used in a range of otorhinolaryngologic conditions due to their anti-inflammatory and antiedematous properties. In this meta-analysis, we aimed to assess the role of preoperative steroids for attenuating intraoperative bleeding during endoscopic sinus surgery among patients with nasal polyps.

Data Sources

PubMed, SCOPUS, EMBASE, the Web of Science, and Cochrane database.

Methods

Literature was screened from January 1980 to January 2016. Five articles comparing patients who were preoperatively administered steroids (steroid groups) with patients who received a placebo or no treatment (control group) were included for analysis, which encompassed intraoperative bleeding, endoscopic surgical field visibility, operative time, and side effects during endoscopic sinus surgery.

Results

Intraoperative bleeding and operative time during endoscopic sinus surgery in the steroid group were significantly reduced as compared with the control group. Additionally, the preoperative administration of steroids had a significant effect on improving endoscopic surgical field visibility during sinus surgery. There were no significant adverse effects reported in the enrolled studies. In subgroup analyses of these results, steroids showed similar effects on intraoperative bleeding regardless of administration type (topical or systemic).

Conclusion

This study demonstrated that the preoperative administration of steroids in patients with nasal polyps could effectively reduce intraoperative bleeding. However, the duration of treatment and dosing standard require further investigation, and more trials need to be included.

http://ift.tt/2gYCzrO

Discharge Destination after Head and Neck Surgery: Predictors of Discharge to Postacute Care

Objective

In recent decades, there has been a reduction in the length of postoperative hospital stay, with a corresponding increase in discharge to postacute care. Discharge to postacute care facilities represents a meaningful patient-centered outcome; however, little has been published about this outcome after head and neck surgery.

Study Design

Retrospective review of national database.

Setting

American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2013.

Subjects and Methods

We compared the rate of discharge to home versus postacute care facilities in patients admitted after head and neck surgery and used multivariable logistic regression to identify predictors of discharge to postacute care.

Results

The overall rate of discharge to postacute care facilities after head and neck surgery (n = 15,890) was 15.7% after major surgery (including laryngectomy, composite resection, and free tissue transfer), 4.4% after moderate surgery (including regional tissue transfer, oropharyngeal or oral cavity resection, and neck dissection), and 1.1% after minor head and neck surgery (including endocrine or salivary gland surgery). On multivariable analysis, significant preoperative predictors of discharge to postacute care were advanced age, functional status, major or moderate surgical procedures, tracheostomy, advanced American Society of Anesthesiologists class, low body mass index, and dyspnea.

Conclusion

Our study indicates that patients undergoing major or moderate head and neck surgery, patients with reduced functional status, and patients with advanced comorbidities are at substantial risk of discharge to postacute care. The possibility of discharge to postacute care should be discussed with high-risk patients.

http://ift.tt/2gMaDVb

Parathyroid 4D-CT: Multi-institutional International Survey of Use and Trends

Four-dimensional computed tomography (4D-CT) is a new modality for preoperative localization of parathyroid adenomas. We performed a survey study to describe the role and trends in the utilization of 4D-CT. Of 361 radiologists, 200 (55%) reported that 4D-CT was used in their practices. Nineteen (10%) used 4D-CT as the first-line imaging study; 155 (76%) reported that 4D-CT played a secondary role; and 26 (13%) reported that it is performed routinely in combination with ultrasound and scintigraphy. Early adopters of 4D-CT (use for >3 years) were 3 times more likely to use 4D-CT in a first-line role (18%) when compared with radiologists who used 4D-CT for ≤3 years (6%; P < .05). In conclusion, more than half of radiologists perform 4D-CT, and a majority reported that 4D-CT plays a secondary role. However, this role may change, as utilization is increasing and radiologists may follow early adopters, who are more likely to use it as a first-line study.

http://ift.tt/2gYCynK

Laryngology in Art: The Portrait of Dr Wilhelm Mayer-Hermann

Otto Dix's portrait of the laryngologist Dr Wilhelm Mayer-Hermann represents a shining example of Neue Sachlichkeit, or New Objectivity, offering a return to unsentimental reality and a focus on the objective world, as opposed to the more abstract and idealistic tendencies of expressionism. However, precious little is known about the subject of the portrait. This article examines the portrait and attempts to shed light on the life and career of the Dr Wilhelm Mayer-Hermann.

http://ift.tt/2gM5XhY

Nonthyroid Metastasis to the Thyroid Gland: Case Series and Review with Observations by Primary Pathology

Objective

Nonthyroid metastases to the thyroid gland can cause morbidity, including dysphagia, dysphonia, and airway compromise. Because metastatic malignancies portend a poor prognosis, obtaining equipoise between treatment morbidity and local disease progression is paramount. We reviewed cases of nonthyroid metastases to determine treatment and prognostic recommendations.

Study Design

Case series with chart review.

Setting

Tertiary care hospital.

Subjects and Methods

We searched PubMed for reported cases between 1994 and September 2013 using search terms as follows: any combination of primary tumor locations and thyroid, as well as the terms thyroid and metastasis. Only unique cases of nonthyroid metastases were included. Combined with 17 additional tumors at our own institution, we found 818 unique nonthyroid metastases, of which 384 had management and survival data available.

Results

Renal cell carcinoma was most common, presenting in 293 (35.8%) patients, followed by lung and gastrointestinal malignancies. Patients were treated with total thyroidectomy (34.0%), subtotal thyroidectomy including lobectomy (32.6%), and no surgery (33.5%). Surgical management was associated with improved survival duration (P < .01). Locoregional recurrence was less likely in patients treated with total versus partial thyroidectomy (4.8% vs 13%). Extent of surgical management did not have a significant effect on patient survival. Delayed presentation was associated with improved survival duration (P = .01).

Conclusions

Nonthyroid metastases to the thyroid gland are unusual tumors. Surgical intervention is associated with improved survival, but expected morbidity of untreated tumors is difficult to assess. Site of origin, time to diagnosis, and surgical approach are related to survival and recurrence rates.

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Prevalence and Surgical Implications of Dural Enhancement at the Porus Acusticus in Vestibular Schwannomas

Objective

Demonstrate the association of radiographic dural enhancement with increased tumor adherence at the porus acusticus, which may influence completeness of resection and facial nerve outcome.

Study Design

Case series with chart review.

Setting

Academic referral center.

Subjects and Methods

A total of 205 consecutive patients with histopathologically confirmed vestibular schwannoma (VS) were evaluated. Patients with tumors exhibiting dural enhancement on postgadolinium T1-weighted magnetic resonance imaging were identified and compared with matched controls. Completeness of resection, intraoperative details, and facial nerve outcomes were analyzed.

Results

Excluding strictly intracanalicular tumors (n = 32, 16%) and those with NF2 (n = 10, 4.9%), the presence of dural enhancement was radiographically confirmed in 16 (9.8%) cases. Paired analysis did not reveal significant baseline differences between cases and controls. Subtotal resection was performed in 5 (31%) of the 16 patients with tumors exhibiting dural enhancement, in contrast to 1 (3%) of the matched controls (P = .01). Four (25%) demonstrated increased tumor adherence at the porus acusticus intraoperatively, compared with 1 control (3%, P = .04). Long-term facial nerve function was similar between cases and controls (81% vs 84% House-Brackmann I-II function, P = 1.00).

Conclusion

Dural enhancement is present in approximately 10% of extracanalicular VS. Dural enhancement at the porus acusticus may represent hypervascularity, dural reaction, or infiltration, and portends increased tumor adherence and greater likelihood of subtotal resection to preserve facial nerve function. To our knowledge, this is the first series that reports the prevalence of this phenomenon in VS and the potential surgical implications. Recognition preoperatively may be valuable toward patient counseling.

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Health Literacy Assessment in an Otolaryngology Clinic Population

Objective

To assess health literacy in an adult tertiary care otolaryngology clinic population and to explore potential determinants of inadequate health literacy.

Study Design

Cross-sectional study.

Setting

Tertiary care otolaryngology clinic.

Subjects and Methods

The study population included all adult patients treated at 3 of Stanford University's adult otolaryngology clinic sites between March 1 and 11, 2016. Data were collected via an anonymous questionnaire. Health literacy was assessed with the Brief Health Literacy Screen.

Results

Ten percent of patients had inadequate health literacy. White race (odds ratio [OR], 0.23) and having English as the primary language (OR, 0.12) were associated with adequate health literacy, while high school or lower level of education (OR, 3.2) was associated with inadequate health literacy. Age, sex, and Hispanic ethnicity were not associated with health literacy.

Conclusion

Our study highlights the need for health literacy screening in the otolaryngology clinic setting and identifies sociodemographic risk factors for inadequate health literacy. Further studies are needed to assess the impact of health literacy on patient outcomes and to test specific interventions to address health literacy and health outcomes.

http://ift.tt/2gYDKYm

Perceptual Assessment of Velopharyngeal Dysfunction by Otolaryngology Residents

Objective

To assess the ability of otolaryngology residents to rate the hypernasal resonance of patients with velopharyngeal dysfunction. We hypothesize that experience (postgraduate year [PGY] level) and training will result in improved ratings of speech samples.

Study Design

Prospective cohort study.

Setting

Otolaryngology training programs at 2 academic medical centers.

Subjects and Methods

Thirty otolaryngology residents (PGY 1-5) were enrolled in the study. All residents rated 30 speech samples at 2 separate times. Half the residents completed a training module between the rating exercises, with the other half serving as a control group. Percentage agreement with the expert rating of each speech sample and intrarater reliability were calculated for each resident. Analysis of covariance was used to model accuracy at session 2.

Results

The median percentage agreement at session 1 was 53.3% for all residents. At the second session, the median scores were 53.3% for the control group and 60% for the training group, but this difference was not statistically significant. Intrarater reliability was moderate for both groups. Residents were more accurate in their ratings of normal and severely hypernasal speech. There was no correlation between rating accuracy and PGY level. Score at session 1 positively correlated with score at session 2.

Conclusion

Perceptual training of otolaryngology residents has the potential to improve their ratings of hypernasal speech. Length of time in residency may not be best predictor of perceptual skill. Training modalities incorporating practice with hypernasal speech samples could improve rater skills and should be studied more extensively.

http://ift.tt/2gMa51m

Scratching Below the Surface

Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage. On a summer afternoon, a…

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Prognostic impact of adjuvant chemotherapy in high-risk nasopharyngeal carcinoma patients

Publication date: January 2017
Source:Oral Oncology, Volume 64
Author(s): Yi-Chun Liu, Wen-Yi Wang, Chih-Wen Twu, Rong-San Jiang, Kai-Li Liang, Ching-Te Wu, Po-Ju Lin, Jing-Wen Huang, He-Yuan Hsieh, Jin-Ching Lin
ObjectivesTo investigate the prognostic impact of adjuvant chemotherapy (AdjCT) in patients with high-risk nasopharyngeal carcinoma (NPC).Materials and methodsA total 403 NPC patients with at least one of the following criteria (1) neck node>6cm; (2) supraclavicular node metastasis; (3) skull base destruction/intracranial invasion plus multiple nodes metastasis; or (4) multiple neck nodes metastasis with one of nodal size>4cm were retrospectively reviewed. All patients finished curative radiotherapy±neoadjuvant/concurrent chemotherapy. Post-radiation AdjCT consisted of tegafur-uracil (two capsules twice daily) for 12months. We analyzed the treatment outcome between patients with (n=154) and without (n=249) AdjCT.ResultsBaseline patient characteristics at diagnosis (age, gender, pathological type, performance status, T-classification, N-classification, and overall stage) were comparable in both arms. After a median follow-up of 72months for surviving patients, 31.8% (49/154) and 42.2% (105/249) in patients with and without AdjCT developed tumor relapse respectively (P=0.0377). AdjCT improved both overall survival (HR 1.89, 95% CI 1.37–2.61, P=0.0001) and progression-free survival (HR 1.42, 95% CI 1.03–1.96, P=0.0322). There were significant reduction in distant failures (P=0.0016) but not in local (P=0.8587) or regional (P=0.8997) recurrences for patients who received AdjCT.ConclusionAdjCT can reduce distant failure and improve overall survival in high-risk NPC patients after curative radiotherapy±neoadjuvant/concurrent chemotherapy.



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Dermatophagoides pteronyssinus: Changes in sensitisation in the past 11 years and comparison with other centres in Mexico

Publication date: Available online 30 November 2016
Source:Allergologia et Immunopathologia
Author(s): E.M. Navarrete-Rodríguez, J.R. Fernández-Soto, B.E. Del Rio-Navarro, O.J. Saucedo-Ramírez, J.J.L. Sienra-Monge
BackgroundHouse dust mites are a ubiquitous air allergen in the human habitat. It has been shown that exposure to them is a fundamental factor in sensitisation and development of atopic disease. The objective of the study was to analyse changes in sensitisation to Dermatophagoides pteronyssinus (Der p.) in children treated in a tertiary level care hospital in Mexico City for a period of 11 years and compare with other studies carried out in Mexico.MethodsA retrospective study was performed at the Hospital Infantil de México Federico Gómez (HIMFG). Information was gathered from skin tests for Der p. performed in the Allergy Laboratory from January 2004 to April 2015. Patients 2–18 years old who presented for examination of some type of allergic condition and who had immediate hypersensitivity tests to Der p. were included in the study. Results were compared with prior reports from other institutions. Descriptive analysis and χ² statistics were used.ResultsA total of 8794 patients were included in the study; 49.3% of the tests (95% CI 48–50) were positive for Der p. The percentage of monosensitised to mites was 2.7% for Der p. (95% CI 2–3). A significant difference was found between the results of older patients and those <6 years old. The frequency of sensitisation had a tendency to decrease during the 11 years analysed in all age groups.Conclusions and clinical relevanceThe frequency of sensitisation to Der p. increased with age until reaching adolescence. In the last 11 years a decrease in sensitisation to this air allergen was observed.



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Recommendations for neoadjuvant pathologic staging (ypTNM) of cancer of the esophagus and esophagogastric junction for the 8th edition AJCC/UICC staging manuals

SUMMARY

We report analytic and consensus processes that produced recommendations for neoadjuvant pathologic stage groups (ypTNM) of esophageal and esophagogastric junction cancer for the AJCC/UICC cancer staging manuals, 8th edition. The Worldwide Esophageal Cancer Collaboration provided data for 22,654 patients with epithelial esophageal cancers; 7,773 had pathologic assessment after neoadjuvant therapy. Risk-adjusted survival for each patient was developed. Random forest analysis identified data-driven neoadjuvant pathologic stage groups wherein survival decreased monotonically with increasing group, was distinctive between groups, and homogeneous within groups. An additional analysis produced data-driven anatomic neoadjuvant pathologic stage groups based only on ypT, ypN, and ypM categories. The AJCC Upper GI Task Force, by smoothing, simplifying, expanding, and assessing clinical applicability, produced consensus neoadjuvant pathologic stage groups. Grade and location were much less discriminating for stage grouping ypTNM than pTNM. Data-driven stage grouping without grade and location produced nearly identical groups for squamous cell carcinoma and adenocarcinoma. However, ypTNM groups and their associated survival differed from pTNM. The need for consensus process was minimal. The consensus groups, identical for both cell types were as follows: ypStage I comprised ypT0-2N0M0; ypStage II ypT3N0M0; ypStage IIIA ypT0-2N1M0; ypStage IIIB ypT3N1M0, ypT0-3N2, and ypT4aN0M0; ypStage IVA ypT4aN1-2, ypT4bN0-2, and ypTanyN3M0; and ypStage IVB ypTanyNanyM1. Absence of equivalent pathologic (pTNM) categories for the peculiar neoadjuvant pathologic categories ypTisN0-3M0 and ypT0N0-3M0, dissimilar stage group compositions, and markedly different early- and intermediate-stage survival necessitated a unified, unique set of stage grouping for patients of either cell type who receive neoadjuvant therapy.

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Recommendations for pathologic staging (pTNM) of cancer of the esophagus and esophagogastric junction for the 8th edition AJCC/UICC staging manuals

SUMMARY

We report analytic and consensus processes that produced recommendations for pathologic stage groups (pTNM) of esophageal and esophagogastric junction cancer for the AJCC/UICC cancer staging manuals, 8th edition. The Worldwide Esophageal Cancer Collaboration provided data for 22,654 patients with epithelial esophageal cancers; 13,300 without preoperative therapy had pathologic assessment after esophagectomy or endoscopic treatment. Risk-adjusted survival for each patient was developed using random survival forest analysis to identify data-driven pathologic stage groups wherein survival decreased monotonically with increasing group, was distinctive between groups, and homogeneous within groups. The AJCC Upper GI Task Force, by smoothing, simplifying, expanding, and assessing clinical applicability, produced consensus pathologic stage groups. For pT1-3N0M0 squamous cell carcinoma (SCC) and pT1-2N0M0 adenocarcinoma, pT was inadequate for grouping; subcategorizing pT1 and adding histologic grade enhanced staging; cancer location improved SCC staging. Consensus eliminated location for pT2N0M0 and pT3N0M0G1 SCC groups, and despite similar survival, restricted stage 0 to pTis, excluding pT1aN0M0G1. Metastases markedly reduced survival; pT, pN, and pM sufficiently grouped advanced cancers. Stage IIA and IIB had different compositions for SCC and adenocarcinoma, but similar survival. Consensus stage IV subgrouping acknowledged pT4N+ and pN3 cancers had poor survival, similar to pM1. Anatomic pathologic stage grouping, based on pTNM only, produced identical consensus stage groups for SCC and adenocarcinoma at the cost of homogeneity in early groups. Pathologic staging can neither direct pre-treatment decisions nor aid in prognostication for treatment other than esophagectomy or endoscopic therapy. However, it provides a clean, single therapy reference point for esophageal cancer.

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Issue Information

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Recommendations for clinical staging (cTNM) of cancer of the esophagus and esophagogastric junction for the 8th edition AJCC/UICC staging manuals

SUMMARY

We report analytic and consensus processes that produced recommendations for clinical stage groups (cTNM) of esophageal and esophagogastric junction cancer for the AJCC/UICC cancer staging manuals, 8th edition. The Worldwide Esophageal Cancer Collaboration (WECC) provided data on 22,123 clinically staged patients with epithelial esophageal cancers. Risk-adjusted survival for each patient was developed using random survival forest analysis from which (1) data-driven clinical stage groups were identified wherein survival decreased monotonically and was distinctive between and homogeneous within groups and (2) data-driven anatomic clinical stage groups based only on cTNM. The AJCC Upper GI Task Force, by smoothing, simplifying, expanding, and assessing clinical applicability, produced (3) consensus clinical stage groups. Compared with pTNM, cTNM survival was "pinched," with poorer survival for early cStage groups and better survival for advanced ones. Histologic grade was distinctive for data-driven grouping of cT2N0M0 squamous cell carcinoma (SCC) and cT1-2N0M0 adenocarcinoma, but consensus removed it. Grouping was different by histopathologic cell type. For SCC, cN0-1 was distinctive for cT3 but not cT1-2, and consensus removed cT4 subclassification and added subgroups 0, IVA, and IVB. For adenocarcinoma, N0-1 was distinctive for cT1-2 but not cT3-4a, cStage II subgrouping was necessary (T1N1M0 [IIA] and T2N0M0 [IIB]), advanced cancers cT3-4aN0-1M0 plus cT2N1M0 comprised cStage III, and consensus added subgroups 0, IVA, and IVB. Treatment decisions require accurate cStage, which differs from pStage. Understaging and overstaging are problematic, and additional factors, such as grade, may facilitate treatment decisions and prognostication until clinical staging techniques are uniformly applied and improved.

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A 14-Year-Old Boy with Unusual Presentation of Respiratory Distress

There are multiple cardiac etiologies for wheezing and respiratory distress which require a high degree of suspicion for the pediatrician to diagnose. We present a case of a patient with a history of long-standing mild persistent asthma with minimal improvement on controller and bronchodilator therapies who presented to the emergency room with acute respiratory distress. When he demonstrated a lack of improvement with traditional respiratory therapies, additional etiologies of respiratory distress were considered. Ultimately an echocardiogram was performed, which revealed the diagnosis of cor triatriatum. He underwent surgical resection of his accessory membrane and has had no additional symptoms of asthma since repair.

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Therapy of sinonasal malignancies invading the orbit- orbital exenteration versus preservation of the orbit plus radiotherapy

Publication date: Available online 30 November 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Ali-Farid Safi, Lars Behn, Daniel Rothamel, Orlando Guntinas-Lichius, Dirk Beutner, Hans-Joachim Nickenig, Joachim Zöller, Matthias Kreppel




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Despite numerous recent advances in dermatological therapy, the need for inpatient dermatology care remains considerable

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Saisonale Unterschiede von Tympanogramm- und Mittelohrbefund bei Kindern

Zusammenfassung

Hintergrund

Eine bakterielle oder virale Otitis media acuta tritt in den Wintermonaten bekanntlich häufiger auf. Zu saisonalen Unterschieden des Mittelohrbefundes liegen nur wenige ältere Studien vor. Diese Studien basieren lediglich auf einem Tympanogramm ohne Korrelation zum intraoperativen Mittelohrbefund. Mit dieser Arbeit wurde der Frage nachgegangen, ob sich saisonale Unterschiede sowohl im präoperativen Tympanogramm als auch im korrespondierenden intraoperativen Befund bei Kindern mit chronischen Mittelohrproblemen zeigen.

Patienten und Methode

In diese retrospektive Studie wurden Patienten eingeschlossen, die zwischen Januar und Dezember 2011 eine Parazentese mit oder ohne Paukenröhrcheneinlage in der Charité – Universitätsmedizin Berlin erhielten. Wintermonate wurden entsprechend der katarrhalen Phasen von November bis April und Sommermonate von Mai bis Oktober definiert. Das präoperative Tympanogramm und der dokumentierte intraoperative Mittelohrbefund wurden auf saisonale Unterschiede hin statistisch analysiert.

Ergebnisse

Es wurden 654 Ohren von 206 männlichen und 127 weiblichen Patienten mit einem Durchschnittsalter von 3,7 ± 2,5 Jahren ausgewertet. Überwiegend fand sich ein Tympanogramm vom Typ B (n = 376; 57,5%), wobei das Mittelohr in bis zu 19,1% der Fälle luftgefüllt war. Intraoperativer Mittelohrbefund und präoperatives Tympanogramm wiesen keinen signifikanten saisonalen Unterschied auf (p > 0,05).

Schlussfolgerung

Für Kinder mit typischer Anamnese einer chronischen nichteitrigen Otitis media und chronischer Tubenventilationsstörung ist die Parazentese mit oder ohne Paukenröhrcheneinlage saisonal unabhängig indiziert. Eine abwartende Haltung mit Hoffnung auf Besserung in den Sommermonaten ist anhand der erhobenen Ergebnisse nicht sinnvoll.

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Diagnose und Behandlung des tränenden Auges

Zusammenfassung

Das tränende Auge ist ein häufiges Symptom, mit dem der Augen- und der HNO-Arzt konfrontiert werden. Die Ursachen können vielfältig sein und alle Bereiche des Tränensystems von den sekretorischen Anteilen bis zu den ableitenden Tränenwegen betreffen. Häufig verursachen auch Störungen in der Zusammensetzung des Tränenfilms die Symptome, die von der klassischen Epiphora über Sehstörungen und Tränenfilminstabilität mit möglicher Beschädigung der Augenoberfläche führen können. Die Kenntnis und das Verständnis der zugrunde liegenden pathologischen Veränderungen und Differenzialdiagnosen ist wichtig, um eine adäquate Therapie einleiten zu können und einen evtl. nichtindizierten chirurgischen Ansatz zu vermeiden.

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Preoperative surgical simulation and validation of the line of resection in anterolateral craniofacial resection of advanced sinonasal sinus carcinoma

Abstract

Background

The purpose of this study was to assess the usefulness and accuracy of preoperative 3D virtual simulation of anterolateral craniofacial resection in cases of advanced sinonasal sinus carcinoma.

Methods

Seven patients with advanced (T4 classification) sinonasal sinus carcinoma who underwent anterolateral craniofacial resection in our hospital between 2011 and 2013 were included in this study. Postsimulation CT images were fused with postoperative CT images and differences between the planned and actual osteotomy were measured in 3 regions of the skull base.

Results

The differences ranged from 0 mm to 5.8 mm (average, 3.1 mm) at the inferior wall of the cavernous sinus, from 0.8 mm to 8.3 mm (average, 3.5 mm) at the inferior wall of the sphenoid sinus, and from 0 mm to 13.6 mm (average, 2.3 mm) in the palatine bone.

Conclusion

Preoperative 3D virtual surgical simulation and postoperative feedback can contribute to training for surgeons. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

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Correlative study of dose to thyroid and incidence of subsequent dysfunction after head and neck radiation

ABSTRACT

Background

Thyroid dysfunction is common after radiotherapy (RT) for patients with head and neck cancers. We attempted to discover RT dose parameters that correspond with RT-induced thyroid dysfunction.

Methods

Records of 102 patients who received RT from 2008 to 2010 were reviewed with respect to thyroid function. Abnormalities were grouped in 2 ways: (1) none, transient, or permanent; and (2) overt or subclinical.

Results

At median follow-up of 33.5 months, incidence of any thyroid abnormality was 39.2% (women vs men – 50% vs 35%). Permanent dysfunction was seen in 24.5% with higher incidence in women versus men (42.9% vs 17.6%; p = .0081). Permanent abnormalities most strongly correlated with D_50% (p = .0275). V_50Gy also correlated with thyroid dysfunction post-RT (p = .0316). Concurrent chemotherapy increased permanent dysfunction (p = .0008).

Conclusion

Achieving D_50% <50 Gy, V₅₀ <50%, and mean dose <54.58 Gy during RT planning may decrease the incidence; whereas female sex and concurrent chemotherapy seem to increase the risk of RT-induced hypothyroidism. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

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Zika Virus and Patient Blood Management.

Sporadic Zika virus infections had only occurred in Africa and Asia until an outbreak in Micronesia (Oceania) in 2007. In 2013 to 2014, several outer Pacific Islands reported local outbreaks. Soon thereafter, the virus was likely introduced in Brazil from competing athletes from French Polynesia and other countries that participated in a competition there. Transmission is thought to have occurred through mosquito bites and spread to the immunologically naive population. Being also a flavivirus, the Zika virus is transmitted by the Aedes mosquito that is endemic in South and Central America that is also the vector of West Nile virus, dengue, and chikungunya. In less than a year, physicians in Brazil reported a many-fold increase in the number of babies born with microcephaly. Despite initial skepticism regarding the causal association of the Zika virus epidemic and birth defects, extensive basic and clinical research evidence has now confirmed this relationship. In the United States, more than 4000 travel-associated infections have been reported by the middle of 2016 to the Centers for Disease Control and Prevention. Furthermore, many local mosquito-borne infections have occurred in Puerto Rico and Florida. Considering that the virus causes a viremia in which 80% of infected individuals have no symptoms, the potential for transfusion transmission from an asymptomatic blood donor is high if utilizing donor screening alone without testing. Platelet units have been shown to infect 2 patients via transfusion in Brazil. Although there was an investigational nucleic acid test available for testing donors, not all blood centers were initially required to participate. Subsequently, the US Food and Drug Administration issued a guidance in August 2016 that recommended universal nucleic acid testing for the Zika virus on blood donors. In this report, we review the potentially devastating effects of Zika virus infection during pregnancy and its implication in cases of Guillain-Barre syndrome in adults. Furthermore, we urge hospital-based clinicians and transfusion medicine specialists to implement perisurgical patient blood management strategies to avoid blood component transfusions with their potential risks of emerging pathogens, illustrated here by the Zika virus. Ultimately, this current global threat, as described by the World Health Organization, will inevitably be followed by future outbreaks of other bloodborne pathogens; the principles and practices of perioperative patient blood management will reduce the risks from not only known, but also unknown risks of blood transfusion for our patients. (C) 2016 International Anesthesia Research Society

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Donor site morbidity and quality of life after microvascular head and neck reconstruction with free fibula and deep-circumflex iliac artery flaps

Bone defects after resective tumor surgeries often require the use of microvascular reanastomized bone grafts for reconstruction. The decision as to which specific flap is most suitable for the particular patient is dependent on various factors. The aspects donor site morbidity and quality of life are rarely taken into account in this connection. The aim of this study was to analyze whether these factors, in the future, should influence the choice of donor site.

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Patient-specific polymethylmethacrylate prostheses for secondary reconstruction of large calvarial defects: A retrospective feasibility study of a new intraoperative moulding device for cranioplasty

The aim of this study was to review a new template-based technique for intraoperative patient-specific cranioplasty manufacturing (PSCM) with polymethylmethacrylate (PMMA) to cover large calvarial defects.

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Patient-specific Biodegradable Implant in Pediatric Craniofacial Surgery

Surgical correction of premature fusion of calvarial sutures involving the fronto-orbital region can be challenging due to the demanding three-dimensional (3D) anatomy. If fronto-orbital advancement (FOA) is necessary, surgery is typically performed using resorbable plates and screws that are bent manually intraoperatively. A new approach using individually manufactured resorbable implants (KLS Martin Group, Tuttlingen, Germany) is presented in the current paper. Preoperative CT scan data were processed in iPlan (ver.

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Therapy of sinonasal malignancies invading the orbit- orbital exenteration versus preservation of the orbit plus radiotherapy

There are no funding disclosures from any authors.

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Medical students’ understanding of oral and maxillofacial surgery: an Irish perspective

Oral and Maxillofacial Surgery (OMFS) remains an enigmatic specialty in Irish medicine and many students are unaware of its scope and the unique career pathway involved. We performed a multicentre cross-sectional study to identify their ability to identify the requirements for entry to specialty training year 3 (ST3) in OMFS, to assess their awareness of OMFS surgeons, and their general awareness of, and exposure to, the specialty. Data were collected through an electronic questionnaire. Participants were asked to select the most suitable surgical specialty to treat a number of common conditions in the head and neck, and to choose the requirements they deemed essential for specialist training.

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Editorial Board

Publication date: December 2016
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 133, Issue 6





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Ameloblastic fibro-odontosarcoma of the mandible in a pediatric patient

Publication date: December 2016
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases, Volume 133, Issue 6
Author(s): S.-J. Chen, X.-W. Zheng, X. Lin, H. Liu
IntroductionAmeloblastic fibro-odontosarcoma is an extremely rare subtype of odontogenic sarcoma, with only 13 cases reported in the literature.Case reportA 4-year-old male presented with a painless mandibular swelling, which appeared 4months previously. Cone beam computed tomography revealed an extensive, ill-circumscribed, multilocular radiolucency of the right mandible extending from the first deciduous molar to the ramus with slightly dense opacities. Histological examination of the incisional biopsy specimen revealed a biphasic tumor with sarcomatous mesenchyme and benign ameloblastic epithelial component compatible with a diagnosis of ameloblastic fibrosarcoma. A right hemimandibular resection was performed. Areas of deposition of dentinoid and enamel material closely adjacent to ameloblastic epithelium were noted in the excised specimen. A final diagnosis of ameloblastic fibro-odontosarcoma was made. After four years of close follow-up, there is no sign of recurrence or metastasis.ConclusionAlthough rare, ameloblastic fibro-odontosarcoma should be considered in the differential diagnosis of jaw lesions with radiographic radiolucencies exhibiting poorly circumscribed outlines and containing radiopaque material. Definite diagnosis depends on histopathological examination. Complete surgical excision is the treatment of choice.



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Transoral-transcervical oropharyngectomy without mandibulotomy, associated to fasciocutaneous radial forearm free-flap reconstruction, for oropharyngeal cancer: Postoperative course, oncologic and functional results, and prognostic factors

Publication date: Available online 30 November 2016
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): M. Roux, O. Dassonville, M. Ettaiche, G. Poissonnet, A. Sudaka, A. Bozec
ObjectiveTo analyze postoperative course, oncologic and functional results and prognostic factors of transoral-transcervical oropharyngeal cancer surgery without mandibulotomy, associated to radial forearm free-flap reconstruction.Material and methodsRetrospective analysis of computerized medical records of all patients who underwent this type of surgery in our institution between 2004 and 2014. Predictive factors of oncologic and functional results were investigated on univariate and multivariate analyses.ResultsForty-four patients (37 male, 7 female; mean age, 62.3±9.3years) were included. Three-year overall, disease-specific and recurrence-free survival was 90%, 92% and 79%, respectively. Functional scores were satisfactory (normal or slight impairment) for feeding, speech and oral opening functions in 86%, 93% and 100% of cases, respectively. ASA score≥III had significantly negative impact on overall survival (P=0.005) and on feeding (P=0.01) and speech (P=0.01).ConclusionTransoral-transcervical oropharyngeal cancer surgery without mandibulotomy provided excellent oncologic and functional outcomes; it is an advantageous alternative to the conventional conservative transmandibular oropharyngectomy.



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Benefits, pitfalls and risks of phytotherapy in clinical practice in otorhinolaryngology

Publication date: Available online 30 November 2016
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): O. Laccourreye, A. Werner, L. Laccourreye, P. Bonfils
ObjectivesTo elucidate the benefits, pitfalls and risks of phytotherapy in the clinical practice of otorhinolaryngology.Material and methodsThe PubMed and Cochrane databases were searched using the following keywords: phytotherapy, phytomedicine, herbs, otology, rhinology, laryngology, otitis, rhinitis, laryngitis and otorhinolaryngology. Seventy-two articles (18 prospective randomized studies, 4 Cochrane analyses, 4 meta-analysis and 15 reviews of the literature) devoted to clinical studies were analyzed. Articles devoted to in vitro or animal studies, biochemical analyses or case reports (including fewer than 10 patients) and articles dealing with honey, aromatherapy or minerals were excluded.ResultsPer os ginkgo biloba has no indications in tinnitus, presbycusis or anosmia following viral rhinitis. Traditional Asian medicine has no proven benefit in sudden deafness or laryngeal papillomatosis. Per os mistletoe extracts associated to conventional treatment for head and neck squamous cell carcinoma does not increase 5-year survival. Extracts of various herbs, notably echinacea, eucalyptus, petasites hybridus, pelargonium sidoides, rosemary, spirulina and thyme, show superiority over placebo for rhinosinusitis and allergic rhinitis, as does gingko biloba for selected vertigo. There have been encouraging preliminary results for intratumoral injection of mistletoe in head and neck carcinoma and acupoint herbal patching for allergic rhinitis. Herb intake should be screened for in case of certain unexplained symptoms such as epistaxis, headache or dizziness, or signs suggesting allergy. Phytotherapy should be interrupted ahead of surgery and/or chemotherapy.ConclusionScientific proof of the benefit of phytotherapy in otorhinolaryngology remains to be established but, given its widespread use and the reported data, knowledge of this form of treatment needs to be developed.



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Effect of Nerve Stimulation Use on the Success Rate of Ultrasound-Guided Subsartorial Saphenous Nerve Block: A Randomized Controlled Trial.

Background and Objectives: Ultrasound-guided subsartorial saphenous nerve block is commonly used to provide complete surgical anesthesia of the foot and ankle in combination with a popliteal sciatic nerve block. However, in part owing to its small caliber and absence of a prominent vascular landmark in the subsartorial plane distal to the adductor canal, the saphenous nerve is more difficult to reliably block than the sciatic nerve in the popliteal fossa. Although the saphenous nerve is a sensory nerve only, neurostimulation can be used to elicit a "tapping" sensation on the anteromedial aspect of the lower leg extending toward the medial malleolus. Our objective was to test the hypothesis that the addition of nerve stimulation use to an ultrasound (US)-guided technique will increase the success rate of subsartorial saphenous nerve block. Methods: With institutional human ethics board approval and participants' written informed consent, we enrolled 80 patients undergoing foot and ankle surgery in a randomized, single-blinded, parallel-group clinical trial. Patients were randomly assigned to receive US-guided subsartorial saphenous nerve block either alone (US group) or with the use of additional nerve stimulation (NS group; time limit, 5 minutes). For saphenous nerve blockade, all patients received 10 mL of 0.5% ropivacaine. The primary end point was complete absence of sensation to pinprick at 30 minutes at two different anatomic areas in the distribution of the saphenous nerve (2 cm proximal to the medial malleolus and 10 cm distal to the medial tibial condyle). Secondary end points included decreased sensation at 30 minutes and block failure (normal sensation) at 30 minutes. This trial was registered at ClinicalTrials.gov: NCT02382744. Results: All 80 patients completed the trial (40 patients in each group). Twenty-two patients (55%) in the NS group versus 18 (45%) in the US group had complete absence of sensation to pinprick at 30 minutes at both anatomic areas of assessment (Fisher exact test, P = 0.25 [one sided]; 95% confidence interval of difference in proportions, -11.9% to 31.9%). The percentages of patients with any evidence of block (decreased or complete absence of sensation) at both areas at 30 minutes were 92.5% (NS) and 97.5% (US), respectively (P = 0.62 [two sided]); corresponding failure rates (normal sensation) were 7.5% (NS) and 2.5% (US). In the NS group, no response in the saphenous nerve distribution was elicited within 5 minutes of stimulation time limit in 20% of patients (n = 8). All of the patients in the NS group with normal sensation at 30 minutes (n = 3) were among this subcohort. Conclusions: The addition of the use of nerve stimulation did not improve the success rate of US-guided subsartorial saphenous nerve block. However, in the NS group, an inability to elicit a "tapping" sensation in the saphenous nerve distribution was associated with block failure. Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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Predictors of outcome with cetuximab and paclitaxel for head and neck squamous cell carcinoma

Objectives

Identify predictors of outcome in patients with recurrent/metastatic head and neck squamous cell carcinoma (RMHNSCC) treated with weekly cetuximab and paclitaxel (CP).

Study Design

Retrospective analysis.

Methods

Patients with RMHNSCC treated with CP were identified and patient data was recorded. The Kaplan-Meier method was used to estimate outcomes, and Cox regression analysis was used to examine outcome predictors.

Results

Fifty-nine patients initiated CP between January 2007 and June 2014. Median age was 56 (range: 39–80) years. The most common primary sites were the oropharynx in 22 (37%) patients, oral cavity in 19 (32%), and larynx in 11 (19%). Eastern Cooperative Oncology Group performance status (ECOG PS) was 0 in seven (12%), 1 in 32 (54%), and 2 in 16 (28%) patients. In 44 (75%) patients, CP was used as a first-line R/M regimen. Median number of cycles was five (range: 1–29). Dose modifications were necessary in 27 (46%) patients. The objective response rate was 47.5%, with 27 (45.8%) partial responses and one (2%) complete response. With a median follow-up of 13.4 months, median progression-free (PFS) and overall survival (OS) were 7.7 and 13.2 months, respectively. On multivariable analysis, an ECOG of 2 of 3 was associated with inferior OS (hazard ratio [HR]: 3.94; P = 0.01; 95% confidence interval [CI]: 1.1–14.04) and PFS (HR: 7.29; P < 0.01; 95% CI: 2.1–26.0) compared to an ECOG 0 of 1. First-line CP administration was associated with superior PFS compared to second line (HR: 2.6; P = 0.02; 95% CI:1.2–5.5).

Conclusions

CP is well tolerated in this population of patients, with favorable tumor efficacy. First-line use and an ECOG 0 of 1 points appears to confer superior outcomes.

Level of Evidence

4. Laryngoscope, 2016

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Incidence of contralateral–bilateral nodes in the human papillomavirus era

Objectives/Hypothesis

HPV-positive oropharyngeal squamous cell carcinoma has a more favorable prognosis when compared to HPV-negative disease, regardless of the presence of nodal metastases. However, the importance of contralateral neck treatment based on HPV status has not been well studied. Given the historically poor prognostic implications of cervical nodal metastases, this study sought to elucidate the relationship between HPV status and contralateral/bilateral nodal metastasis in patients with oropharyngeal squamous cell carcinoma.

Study Design

Retrospective cohort analysis.

Methods

Data were collected on patients with oropharyngeal squamous cell carcinoma from 2001 to 2014. Nodal status was determined by contrast-enhanced computed tomography, positron emission tomography, or surgical pathology when available. Survival rates and associations between HPV status and demographic/tumor characteristics were assessed.

Results

Of 178 total patients, 46 (26.0%) had contralateral/bilateral metastases. There was no significant difference in incidence of contralateral/bilateral nodal metastases between HPV-positive and HPV-negative patients (24.6% vs. 29.1%, P = .53). Tonsil primaries had significantly lower incidence of contralateral/bilateral nodal metastases compared to tongue base (20.9% vs. 34.3%, P = .048). On multivariate regression, tumor size was the only factor associated with contralateral/bilateral nodal metastases (T4 vs. T1–3 odds ratio = 5.15, 95% confidence interval: 2.4-11.2). Five-year overall survival among all patients with and without contralateral/bilateral nodal metastases was 45.4% and 65.2%, respectively (P = .007).

Conclusions

Our results did not show a significantly different incidence of contralateral/bilateral nodal metastases between HPV-positive and HPV-negative patients. T4 stage and tongue base location, however, were associated with contralateral disease. These data suggest treatment of bilateral necks might be warranted in these cases, regardless of HPV status.

Level of Evidence

4 Laryngoscope, 2016

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Is sinus surgery indicated for recurrent acute rhinosinusitis?

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Computed tomography anatomy of the paranasal sinuses and anatomical variants of clinical relevants in Nigerian adults

Publication date: Available online 30 November 2016
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Author(s): Regina Chinwe Onwuchekwa, Nengi Alazigha
AimThe aim of the study is to show the anatomy of the paranasal sinuses as delineated by the computed tomography and to describe the variants which not only predispose to chronic sinusitis but may lead to complications in endoscopic sinonasal surgery.IntroductionThe paranasal sinuses are group of air filled spaces surrounding the nasal cavity. Paranasal sinuses start developing from the primitive choana at 25–28weeks of gestation. Three projections arise from the lateral wall of the nose and serve as the beginning of the development of the paranasal sinuses.Materials and methodsThis was a prospective study carried out in a tertiary institution. 110 patients without paranasal sinus symptoms who presented for head computed tomography studies and gave consent for a coronal section scan of the paranasal sinuses to be taken in addition to the axial section of the head were included in the study. The CT examination was performed with GE Hispeed-NX/I Base-2002 Dual Slice Helical Computed tomography machine.ResultsThere were 48 females and 62 males giving a male female ratio of 1:1.3. Among these 229 cases of anatomical variants were observed. The commonest anatomical variants were pneumatisation of the middle nasal turbinates (32.73%). This is followed by agger nasi cells 23.64%, Haller's cells 20.91%, septal deviation 20.18% and sphenoid sinus septation (18%).ConclusionComputed tomography is the gold standard in the radiologic investigation of the paranasal sinuses, either for diagnosis for sinonasal lesions or pre and post-surgical assessment. Its capability in delineating the anatomical variants in paranasal sinuses protects against iatrogenic injury to essential structures around the paranasal sinuses and recurrent diseases from extramural cells.



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Facial nerve palsy after transarterial embolization of dural arteriovenous fistula

Publication date: Available online 30 November 2016
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Author(s): Lim Eng Haw, Mohd Khairi Md Daud
Dural arteriovenous fistulas are abnormal connections between the dural arteries and dural veins or venous sinuses. These intracranial vascular malformations can present with a variety of features ranging from completely asymptomatic to fatal intracranial haemorrhage. With the advent of newer endovascular treatment techniques, most dural arteriovenous fistulas can be effectively managed with transvenous or transarterial embolization procedures. However, these procedures are not without complications. Herein, we report a case of facial nerve palsy following embolization of posterior fossa dural arteriovenous fistula.



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