Annals of Otology Rhinology and Laryngology

Transcutaneous Suture Tip Plasty: The Technique and Outcomes

22-04-2019 – Goksel Turhal,Murat Benzer,Fetih Furkan Sahin,Rasit Midilli,Bulent Karci,Mustafa Sahin,Sercan Gode

Journal Article

Radical resections and invasive techniques have been mostly replaced with more conservative techniques. The aim of this study was to assess the objective and the subjective functional and aesthetic outcomes of transcutaneous suture tip plasty. A total of 20 patients were included in the study. Patients were treated with transcutaneous suture tip plasty. Functional results were assessed with pre- and postoperative 6-month Sino-Nasal Outcome Test (SNOT-22) and acoustic rhinometry. The pre- and postoperative 6-month mean values of first minimal cross-sectional area (MCA1), second minimal cross-sectional area (MCA2), the distance from the tip of the probe to the first minimal cross-sectional area, the distance from the tip of the probe to the second minimal cross sectional area, nasal volume 1, and nasal volume 2 were measured. Facial analysis was made with the Rhinobase software, designed for facial analysis. The mean pre- and postoperative SNOT-22 scores were 25.55 ± 6.64 and 15.70 ± 8.11, respectively ( Especially in the era of minimal invasive surgery, transcutaneous suspension tip plasty is promising, with rapid and reliable functional and cosmetic results. Further studies with longer follow-up durations are needed to assess the long-term outcomes of this technique.

Double-Layer Tympanic Membrane Graft in Type I Tympanoplasty

17-04-2019 – Es-hak Bedri,Bilen Korra,Miriam Redleaf,Alemayehu Worku

Journal Article

Some discussion remains among otologists regarding the best grafts for tympanic membrane closure. It is unclear whether double-layer grafts are superior to single-layer and whether single-layer cartilage is superior to fascia or perichondrium alone. The objective of the current study was to examine the relative efficacy of single-layer versus double-layer tympanic membrane grafting techniques. A retrospective review of the medical records was used to address the objective of the study. Patients operated on in an over/under technique by the same surgeon underwent single-layer perichondrium or single-layer perichondrium with a cartilage island, or a double-layer of perichondrium combined with periochondrium with a cartilage island. The outcomes assessed were tympanic membrane reperforation and hearing improvement. A total of 135/177 (76%) perichondrium grafts had no reperforation, and 43/55 (78%) perichondrium with cartilage island grafts had no reperforation; 352/390 (90%) of the double-layer closures had no reperforation. There was no statistically significant difference in reperforation rates between the 2 single-layer techniques ( Double-layer closure gives lower tympanic membrane reperforation rates than does single-layer closure, as well as similar hearing outcomes.

Long-Term Voice and Swallowing Outcomes for Oral and Oropharyngeal Cancer Following Primary or Adjuvant Chemoradiation

22-04-2019 – Liuba Soldatova,Natasha Mirza

Journal Article

Chemoradiation (CRT) for nonlaryngeal head and neck cancer (HNC) can lead to voice and swallowing dysfunction. The purpose of this study was to examine voice and swallowing from the patient’s perspective at least 5 years after treatment. Patient survey. Twenty-eight patients treated with primary or adjuvant CRT at least 5 years ago (mean = 10.7 years, SD = 5.5, range, 5-28) completed a survey created based on previously validated questionnaires (the Patient Perception of Swallowing Function Questionnaire, PPSFQ; the Eating Assessment Tool, EAT-10; the Voice Handicap Index, VHI-10; the Voice Related Quality of Life, V-RQOL). Patients reported some voice and swallowing dysfunction (39% of V-RQOL scores in categories of fair, poor, or worst possible and 32% of VHI-10 scores ≥20 or greater than 50% of the maximum; 39% of PPSFQ scores greater than 50% of the maximum and 32% of EAT-10 scores ≥20 or 50% of the maximum). There was a correlation between V-RQOL and VHI-10 scores (Pearson product moment correlation coefficient r = .96, calculated probability value Perceived voice and swallowing dysfunction following CRT for nonlaryngeal HNC can persist or worsen beyond 5 years.

Sinonasal Disease in Total Laryngectomy Patients

24-04-2019 – Vijay A. Patel,Christopher D. Pool,Mitchell Dunklebarger,Eric Schaefer,Neerav Goyal

Journal Article

Total laryngectomy (TL) results in complete abolition of nasal airflow, with notable pathologic alterations of the intranasal mucosa, mucociliary clearance, and nasal cycle. Despite these observed morphological changes, it remains unclear whether this subpopulation of patients experiences clinically significant sinonasal disease. The goal of this study was to identify rhinosinusitis in TL patients using radiographic imaging. An Institutional Review Board-approved retrospective review (January 2005-July 2017) identified 50 patients who underwent radiographic imaging before and after TL. The Lund-Mackay Staging System (LM) was applied to 197 surveillance computed tomography scans. Surveyed patients also underwent investigation of current sinonasal symptomatology using the SNOT-22 questionnaire. Simple linear regression was modeled to LM scores; tests of statistical significance were estimated via the method of Kenward and Roger. The mean age was 62.4 years, with a 5:1 male-to-female ratio. The mean SNOT-22 score was 27.4 (range, 5-33). A median of 3 scans was obtained, 49% within 12 months after TL. The mean (± standard deviation) postoperative LM score was 2.7 ± 3.97 points (range, 0-19). For every 1 month after TL, postoperative LM was +0.01 point ( Preoperative sinonasal disease burden likely plays an important role in the development of clinically significant rhinosinusitis in TL patients. Correlating radiographic findings to validated outcome measures remains a critical aspect of determining optimal surgical candidates; this arena is still under investigation in this unique patient cohort.

The pH Value as a Factor Modifying Bacterial Colonization of Sinonasal Mucosa in Healthy Persons

24-04-2019 – Monika Morawska-Kochman,Katarzyna Jermakow,Kamil Nelke,Krzysztof Zub,Wojciech Pawlak,Krzysztof Dudek,Marek Bochnia

Journal Article

The aim of the present study is to determine and compare the range of p
H value in nasal and sinus cavities in vivo regarding the presence of bacteria colonizing sinonasal mucosa among healthy subjects. The nasal p
H value measurement using a portable p
H meter (Dx-p
H System, Restech) and the microbiological culture swab were taken from beneath the middle turbinate and in the sinus cavity in 39 healthy subjects during maxillary bone corrective osteotomy with the Le Fort I technique. The mean p
H value (independently of sex, Differences in the p
H value between the middle nasal meatus and the maxillary sinus are characteristic of healthy subjects and could be associated with the diverse bacterial flora. The role of bacteria

Assessing Change Over Time in Voice Handicap and Voice-Related Perceived Control Using Ecological Momentary Assessment

27-04-2019 – Viann N. Nguyen-Feng,Patricia A. Frazier,Ali Stockness,Scott Lunos,Alexis N. Hoedeman,Stephanie Misono

Journal Article

Voice handicap has generally been measured at a single timepoint. Little is known about its variability from hour to hour or day to day. Voice handicap has been shown to be negatively related to voice-related perceived control in cross-sectional studies, but the within-person variability in voice-related perceived control is also unknown. We aimed to use ecological momentary assessment (EMA) to (1) assess the feasibility of EMA to examine daily voice handicap and voice-related perceived control in patients with voice disorders, (2) measure within-person variability in daily voice handicap and perceived control, and (3) characterize temporal associations (eg, correlations over time) between daily voice handicap and perceived control. Adults with voice problems were recruited from a large public university medical center in the Midwest. They completed baseline measures, followed by twice-daily assessments, including selected items measuring voice handicap and perceived control, and then repeated the baseline measures at the final timepoint. Feasibility was assessed via completion rates. Within-person variability was measured using standard deviations. Temporal associations were characterized using simulation modeling analysis. EMA of voice handicap and perceived control was feasible in this patient population. Momentary voice handicap varied more than perceived control, though both were variable. Multiple patterns of temporal associations between daily voice handicap and perceived control were found. These findings identified important variability in (1) measures of voice handicap and perceived control and (2) their associations over time. Future EMA studies in patients with voice disorders are both feasible and warranted.

Intervention of Orai1 Influences the Response of Nuocytes From Allergic Rhinitis Mice to IL-33

02-05-2019 – Lin Lin,Jinjin Wei,Zheng Chen,Xinyue Tang,Fei Dai,Guangbin Sun

Journal Article

Nuocytes are essential in innate type-2 immunity and contribute to the exacerbation of allergic rhinitis (AR). This study aimed to evaluate the intervention of Orai1 on the response of nuocytes from AR mice to interleukin (IL)-33. We established a murine model of AR. Nuocytes were obtained from the mouse nasal-associated lymphoid tissue. Then, we assessed expressions of Orai1, Ca We showed that Orai1 and Ca These findings show that the intervention of Orai1 in nuocytes influences the response of nuocytes to rm

Effective Inexpensive Management of Necrotizing Otitis Externa Is Possible in Resource-Poor Settings

02-05-2019 – Vijayendra Honnurappa,Sangeetha Ramdass,Nilesh Mahajan,Vinay Kumar Vijayendra,Miriam Redleaf

Journal Article

Necrotizing otitis externa resolves best with antimicrobial treatment. How to care for these patients and monitor their resolution remains a problem. Our protocol in Bangalore can manage these patients inexpensively and well. Patients who were referred to our patients became the subjects for this paper. They were managed through our protocol, which consists of IV ciprofloxacin and meropenem, weekly labs, weekly examinations, and photodocumention. Fifty-one people presented with necrotizing otitis externa (NOE) between October 2015 and November 2017 and completed our entire protocol. Forty-six had complete resolution of their disease, while 5 had to undergo surgical removal of necrotic bone. Six of 8 patients with facial weakness had improvement in their House-Brackmann scores. Reduction of self-reported nocturnal pain, dissolution of ear canal granulations, and normalization of the erythrocyte sedimentation rate (ESR) proved to be the most accurate indicators of disease regression. Patients are monitored closely with review of their otalgia, examination of their canal, repeated ESRs, effective control of their diabetes, and radiological imaging. All this can be done in a resource-poor country, which in turn serves as a model for the wealthier nations.

Short-Term Risk Factor Profile of Pediatric Choanal Atresia Repair Using ACS-NSQIP National Database

09-05-2019 – Alexander P. Marston,Terral Patel,Shaun A. Nguyen,David R. White

Journal Article

The goal of this study is to describe the 30-day postoperative sequelae of pediatric choanal atresia repair and identify predictive factors for adverse events. The American College of Surgeons’ National Surgery Quality Improvement Program-Pediatric (NSQIP-P) database was searched between January 2012 and December 2015 to identify pediatric patients status post choanal atresia repair. Postoperative outcomes included surgical site complications, readmissions, and total length of stay. A total of 178 children underwent choanal atresia repair. The overall complication rate was 6.2%, while the 30-day readmission rate was 15%. Patients with CHARGE had a longer mean duration of hospitalization (26.91 days vs 8.05 days, Analysis of the 2012-2015 NSQIP-P data set reveals that patients with a diagnosis of CHARGE and those ≤10 days of age have a longer duration of hospitalization. Increased risk of postoperative complications and longer duration of hospitalization were both influenced by chronic steroid use and ventilator dependence.

Determining Etiology of Facial Nerve Paralysis With MRI: Challenges in Malignancy Detection

09-05-2019 – Anthony M. Tolisano,Jacob B. Hunter,Mark Sakai,Joe Walter Kutz,William Moore,Marco Pinho,Brandon Isaacson

Journal Article

Compare experts’ ability to differentiate malignant and benign causes of facial nerve paralysis (FNP) using the initial presenting magnetic resonance image (MRI) for each patient. This retrospective case-controlled study compared MRIs for 9 patients with a malignant cause for FNP, 8 patients with Bell’s palsy, and 9 cochlear implant patients serving as controls. The initial presenting MRI for each condition was used such that raters were evaluating real-world rather than optimal studies. Three blinded expert raters independently evaluated each segment of the facial nerve for abnormalities, provided a diagnosis, and graded MRI quality. Cohen’s and Light’s kappa were used to calculate interrater reliability and overall index of agreement, respectively. MRI protocols for the malignancy group were universally suboptimal. There was poor agreement among raters for abnormalities of the facial nerve along the brainstem (0.13), geniculate (0.10), tympanic segment (0.12), and mastoid segment (0.13); moderate agreement along the cisternal segment (0.58) and internal auditory canal (0.55); and fair agreement along the labyrinthine segment (0.26) and extratemporal segment (0.36). Agreement regarding final diagnosis was fair (0.37) when compared to the true diagnosis. There were 2 false negative interpretations (failure to correctly identify malignancy) and 1 false positive interpretation. MRI for FNP is often initially performed with an incorrect protocol and thus may fail to reliably differentiate neoplastic from inflammatory FNP even when interpreted by experienced clinicians. Nevertheless, expert readers correctly diagnosed 87.5% of malignant causes of FNP despite these limitations.

The Interrelations Between Different Causes of Dizziness: A Conceptual Framework for Understanding Vestibular Disorders

25-04-2019 – Richard T. Zhu,Vincent Van Rompaey,Bryan K. Ward,Raymond Van de Berg,Paul Van de Heyning,Jeffrey D. Sharon

Journal Article

According to population-based studies that estimate disease prevalence, the majority of patients evaluated at dizziness clinics receive a single vestibular diagnosis. However, accumulating literature supports the notion that different vestibular disorders are interrelated and often underdiagnosed. Given the complexity and richness of these interrelations, we propose that a more inclusive conceptual framework to vestibular diagnostics that explicitly acknowledges this web of association will better inform vestibular differential diagnosis. A narrative review was performed using PubMed database. Articles were included if they defined a cohort of patients, who were given specific vestibular diagnosis. The interrelations among vestibular disorders were analyzed and placed within a conceptual framework. The frequency of patients currently receiving multiple vestibular diagnoses in dizziness clinic is approximately 3.7% (1263/33 968 patients). The most common vestibular diagnoses encountered in the dizziness clinic include benign paroxysmal positional vertigo (BPPV), vestibular migraine, vestibular neuritis, and Ménière’s disease. A review of the literature demonstrates an intricate web of interconnections among different vestibular disorders such as BPPV, vestibular migraine, Ménière’s disease, vestibular neuritis, bilateral vestibulopathy, superior canal dehiscence syndrome, persistent postural perceptual dizziness, anxiety, head trauma, and aging, among others.

Eagle’s Syndrome Diagnosis Requires Further Consideration

09-05-2019 – Zhengcai Lou

Letter, Comment

Response to “Letter to the Editor”: Eagle’s Syndrome Requires Further Consideration

02-05-2019 – Candace M. Waters,Sandra Ho,Adam Luginbuhl,Joseph M. Curry,David M. Cognetti

Letter, Comment

Affordable Rapid Olfaction Measurement Array: A Novel, Essential Oil-Based Test Strongly Correlated with UPSIT and Subjective Outcome Measures

16-08-2019 – Jennifer A. Villwock,Jennifer Li,Chelsea Moore,Alexander G. Chiu,Kevin J. Sykes

Journal Article

Olfactory dysfunction is an important facet of numerous disease states ranging from sinonasal disease to neurocognitive disorders. Due to expense and/or logistical barriers, objective olfactory testing is not common. We describe the creation of a novel, essential oil-based smell test, AROMA was developed for point-of-care olfactory testing and compared to the UPSIT, as well as subjective outcome measures as noted above. About 37 healthy controls were prospectively recruited to assess the reliability of AROMA using a test-retest protocol. An additional cohort of 38 participants with sinonasal disease were prospectively recruited to complete the AROMA and UPSIT, and were compared with a cohort of 30 healthy controls. Spearman correlation correlated AROMA and UPSIT results, patient age, SNOT-22, and perceived loss of smell. AROMA demonstrated good test-retest reliability ( AROMA has a strong correlation with UPSIT and may be more strongly correlated with sinonasal outcomes. Additionally, AROMA is reusable; level of odorant is not static; and AROMA can test both odor detection and identification. 2b.

Rhinotillexomania Manifesting as Empty Nose Syndrome

16-08-2019 – Eve Tranchito,Nipun Chhabra

Journal Article

To highlight a severe case of rhinotillexomania (compulsive nasal picking) and its potential to manifest as empty nose syndrome (ENS). A single case report with the presentation and management of a patient with severe rhinotillexomania who presented with chronic obstructive symptoms. We review the current literature on rhinotillexomania and ENS. This patient’s manifestations mimic the obstructive symptoms of ENS, despite widely patent nasal passages. This is the first report of rhinotillexomania manifesting with features of ENS.

Morphometric Differences in the Recurrent Laryngeal Nerve in Patients with Vocal Fold Paralysis

14-08-2019 – Melissa R. Chao,Katherine A. Howe,Jennifer L. Pierce,Amanda C. Stark,Marshall E. Smith,Michael B. Christensen

Journal Article

Injury to the recurrent laryngeal nerve (RLN), if severe enough, can result in vocal fold paralysis. Reinnervation surgery can improve patient outcomes, but previous studies have reported a negative correlation between time since onset of paralysis and surgical outcomes. The ability of the paralyzed nerve to serve as a conduit for donor nerve fibers may be a factor in the success of reinnervation; however, changes in RLN composition after paralysis have not been well studied. Therefore, we investigated the morphometric composition of explanted RLN sections from patients who had experienced vocal fold paralysis for varying length of times. Nine nerve sections from unilateral vocal fold paralysis (UVP) patients and seven control nerve sections were analyzed for morphometric parameters including fascicular area, fiber count, fiber density, fiber packing, mean g-ratio, and fiber diameter distribution. Nerves from UVP patients were also compared as a function of time since UVP onset. In comparison to control nerves, paralyzed nerves were found to have significantly lower fiber densities and fiber packing, higher mean g-ratio values, and a shift in diameter distributions toward smaller diameter fibers. With respect to paralysis duration, no significant differences were observed except in fiber diameter distributions, where those with paralysis for >2 years had distributions that were significantly shifted toward smaller diameter fibers. The morphometric data presented here suggest that correlations between the time since onset of vocal fold paralysis and reinnervation outcomes may be due to fiber size changes in the paralyzed nerve over time.

Attitudes of Clinicians about Screening Head and Neck Cancer Survivors for Lung Cancer Using Low-Dose Computed Tomography

14-08-2019 – Kimberly Dukes,Aaron T. Seaman,Richard M. Hoffman,Alan J. Christensen,Nicholas Kendell,Andrew L. Sussman,Miriam Vélez-Bermúdez,Robert J. Volk,Nitin A. Pagedar

Journal Article

National guidelines recommend lung cancer screening (LCS) using low-dose computed tomography (LDCT) for high-risk patients, including survivors of other tobacco-related cancers like head and neck cancer (HNC). This qualitative study investigated clinicians’ practices and attitudes toward LCS with LDCT with patients who have survived HNC, in the context of mandated requirements for shared decision making (SDM) using decision aids. Thematic analysis of transcribed semi-structured clinician interviews and focus group. Clinicians recognized LCS’ utility for some HNC survivors with smoking histories. However, they identified many challenges to SDM in diverse clinic settings, including time, workflow, uncertainty about guidelines and reimbursement, decision aids, competing patient priorities, unclear evidence, potentially heightened patient receptivity and stress, and the complexity of discussions. They also identified challenges to LCS implementation. While clinicians feel that LDCT LCS may benefit some HNC survivors, there are barriers both to implementing LCS SDM for these patients in primary care as currently recommended and to integrating it into cancer clinics. Challenges for SDM across settings include a lack of decision aids tailored to patients with cancer histories. Given recommendations to broaden LCS eligibility criteria, more research may be required before refinement of current guidelines.

Causative Factors for Complications in Transpalatal Advancement

14-08-2019 – Lyndon Chan,Leon Kitpornchai,Stuart Mackay

Journal Article

Transpalatal advancement (TPA) is a procedure that is used when modern variants of uvulopharyn-gopalatoplasty are unable to provide enough anterior traction. Although successful in reduction of obstructive sleep apnea (OSA) parameters, it also comes with procedure-specific risks. Formation of an oro-nasal fistula (ONF) is a complication that results in significant morbidity and a protracted treatment course. After approval from the University of Wollongong Health Research Ethics Committee, a retrospective chart review of all cases undergoing TPA performed by a single surgeon over a 10-year period from 2008 to 2018 was performed. Patients underwent pre- and postoperative level 1 or 2 polysomnography. Factors potentially contributing to palatal complications, as well as pre- and postoperative polysomnographic parameters, subjective sleep questionnaires, and body mass index (BMI) were statistically analyzed where a A total of 59 patients were included. Overall palatal complication rate was 25.4% (15/59), with the most common being transient velo-palatal insufficiency (VPI) (8/59, 13.6%). ONF developed in 4/59 (6.8%) of patients. None of the analyzed contributing factors for palatal complications were statistically significant, except the presence of a high-arched palate and development of ONF. All analyzed sleep parameters, as well as BMI, were significantly different when comparing pre- to postoperative results. This study suggests that TPA has a role in current sleep surgery paradigms and can significantly improve both objective and subjective outcome measures of OSA. Surgeons contemplating TPA on patients with high-arched hard palates should do so with caution.

Validation of the Maxillary Sinus Roof as a Landmark for Navigating the Pediatric Skull Base

09-08-2019 – Sean S. Evans,Catherine Banks,Joshua Richman,Audie Woolley,Do Yeon Cho,Bradford Woodworth

Journal Article

To define a new anatomic relationship in pediatric sinus surgery, assessing the maxillary roof as a constant safe landmark to avoid skull base injury in the pediatric population. Retrospective analysis. Tertiary care children hospital. A retrospective analysis was performed of all computed tomography scans of the sinuses and facial bones at the emergency department of a tertiary children’s hospital over the course of a year. Radiographic measurements included the lowest cribriform plate and planum sphenoidale (PS) heights, or posterior skull base when not yet pneumatized, as well as the highest maxillary roof height. The nasal floor was used for reference. Statistics were performed via Shapiro-Wilks test with a Three hundred and seven unique scans were reviewed (38.9% female; n = 122; Despite variation in sinus growth and development in children, the current study demonstrated the validity of the maxillary sinus roof as a constant safe landmark in the pediatric population, offering a novel anatomic relationship for teaching safety in performing pediatric sinus surgery. 4.

Intranasal Septal Splints: Prophylactic Antibiotics and Nasal Microbiology

08-08-2019 – Amit Ritter,Uri Alkan,Dafna Yahav,Ethan Soudry,Ella Reifen

Journal Article

Intranasal septal splints are often used in nasal septal surgeries. Routine use of postoperative antibiotics is an accepted practice, although data regarding its efficacy in preventing postsurgical complications are limited. This study aimed to examine bacterial colonization on septal splints following prophylactic antibiotic therapy and the association with postoperative infections. Fifty-five patients underwent septoplasty by a single surgeon between March 2015 and April 2016. All had intranasal septal splints and were given antibiotic prophylaxis for 7 days until removal of splints. Nasal cultures were taken before surgery, and septal splints were examined for bacterial colonization following their removal. Thirty-six patients (65%) had positive nasal culture prior to surgery. The most common isolates were Increased bacterial growth and emergence of resistant strains were observed on intranasal septal splints despite prophylactic antibiotic treatment. Nonetheless, this did not translate into clinical infection. Thus, considering antibiotics overuse and increasing bacterial resistance, further research is needed to determine the role of antibiotic prophylaxis in the setting of intranasal splints.

Caudal Septal Division and Interposition Batten Graft: A Novel Technique to Correct Caudal Septal Deviation in Septoplasty

07-08-2019 – Shin Ae Kim,Yong Ju Jang

Journal Article

Correction of caudal septal deviation is a challenging task that may require multiple surgical approaches. To introduce a novel technique – caudal septal division and interposition batten graft – and evaluate its surgical outcomes in patients undergoing correction of caudal septal deviation. The surgical procedure includes a division of the deviated caudal L-strut preserved after resection of the deviated quadrangular septal cartilage at the central portion. A batten graft made of septal cartilage or bone is interposed between the cut ends of the caudal L-strut, the upper part of which mobilized toward the more concave side of the nasal cavity, and then sutured. The medical records of 29 patients with caudal septal deviation who underwent septoplasty using caudal L-strut division and interposition batten graft technique between January 2016 and March 2018 were retrospectively reviewed. Patient satisfaction and symptom improvement were evaluated by using the Nasal Obstruction Symptoms Evaluation scores. Endoscopic assessment of deviation correction was performed and postoperative complications were analyzed. Of the 29 patients, 19 (65.5%) answered the telephonic interview. Mean Nasal Obstruction Symptoms Evaluation scores were 62.1 preoperatively and 9.2 postoperatively, exhibiting significant improvement ( Caudal septal division and interposition batten graft can serve as an alternative surgical approach with acceptable surgical outcomes for managing severely deviated caudal septum. 4.

Clinical Analysis of Pediatric Thyroid Cancer: A Single Medical Institution Experience of 18u2009Years

03-08-2019 – Hyung Kwon Byeon,Sang Bin Kim,Hyeon Seok Oh,Hong Kyu Kim,In Hak Choi,Hyunjung Kim,Jae-Gu Cho,Kyung Ho Oh,Seung-Kuk Baek,Jeong-Soo Woo,Soon-Young Kwon,Hoon Yub Kim,Kwang Yoon Jung

Journal Article

The incidence of pediatric thyroid cancer is relatively low compared to the disease in adults. This study aims to present the data in our institution on pediatric thyroid cancer patients, with particular emphasis on the risk factors of recurrence together with treatment outcomes. Between January 2000 and July 2018, patients 1 cm showed higher rate of lymph node metastasis and extrathyroidal extension than tumors ≤1 cm. All patients survived with nine PTC patients who displayed treatment failure. Age, tumor size, multifocality, lateral lymph node metastasis, and postoperative thyroglobulin levels were significant prognosticators for disease recurrence. Pediatric thyroid cancer is relatively rare and should be considered a specific disease entity with respect to the thyroid cancer in adults, since there are several distinctive characteristics.

Cochlear-Vestibular Impairment due to West Nile Virus Infection

01-08-2019 – Daniela Parrino,Giuseppe Brescia,Maria Vittoria Trimarchi,Giulia Tealdo,Lolita Sasset,Anna Maria Cattelan,Roberto Bovo,Gino Marioni

Journal Article

West Nile virus (WNV) has been spreading over the last 20 years. Human infection is asymptomatic in most cases. When the disease becomes clinically manifest, it may involve a range of issues, from a mild infection with flu-like symptoms to a neuroinvasive disease. Albeit rarely, WNV-associated sensorineural hearing loss (SNHL) has also been reported. Here we describe two new cases of SNHL and balance impairment caused by WNV infection. The patients were investigated with repeated audiometric tests and, for the first time, videonystagmography was also used. Unlike findings in the few other published cases, an improvement in audiometric thresholds and vestibular function was documented in both of our patients. In the light of our findings, a prospective study would be warranted on a large series of patients with WNV infection in order: (i) to better define the epidemiology of the related cochlear-vestibular involvement; and (ii) to elucidate the virus-related changes to peripheral and central auditory and vestibular functions.

Blast-Induced Cholesteatomas After Spontaneous Tympanic Membrane Healing

01-08-2019 – Omer J. Ungar,Shahaf Shilo,Wengier Anat,Oren Cavel,Ophir Handzel,Yahav Oron

Journal Article

To characterize blast-induced cholesteatomas (BIC) in terms of symptoms, presentation, and location within the middle ear cleft (MEC). A search for all English language articles in “MEDLINE” via “PubMed” and “Google Scholar” was conducted. A total of 67 ears with BIC were included. Fifty-eight ears in which the traumatic perforation failed to spontaneously close were excluded, leaving seven case reports (eight patients, nine ears) for statistical analysis. Time between blast exposure to spontaneous tympanic membrane (TM) closure was 16 days to 10 months. Time between blast exposure and cholesteatoma diagnosis was 5 months to 4 years. The cholesteatomas were diagnosed due to symptoms in two ears, as asymptomatic finding on physical examination in one ear and as asymptomatic finding in axial imaging in three ears. BICs can develop behind intact tympanic membrane or along with TM perforation. Based on the current review, when a TM perforation and spontaneous healing were documented, after blast exposure, MRI scan is an integral component of the follow-up. The optimal timing for MRI performance after blast exposure, is yet to be identified.

Open Airway Surgery in a Paraplegic: The Importance of an Adequate Cough

31-07-2019 – Shaunak N. Amin,Jennifer P. Rodney,Alexander Gelbard

Journal Article

To describe a case of open airway surgery with postoperative respiratory complications in a paraplegic woman and to review the unique respiratory physiology seen in patients with a history of cervical or thoracic spinal cord injury (SCI). Case report and literature review. We describe the case of a 25-year-old paraplegic who developed tracheal stenosis after tracheotomy, eventually requiring tracheal resection and re-anastomosis. Her postoperative course was complicated by mucus plugging and severe atelectasis, necessitating reintubation. After extubation, the patient reported difficulty expectorating secretions ever since her SCI, requiring manual abdominal pressure from her family members to assist her when she needed to cough. This first report of cricotracheal resection in a patient with paraplegia following SCI highlights the importance of an

Clinical Approach After Complicated Ear Mold Fitting: A Case Series of Six Patients and Evaluation of Literature

31-07-2019 – Cindy van den Boer,Erik van Spronsen,Carlijn T. Q. Holland,Fenna A. Ebbens,Jérôme J. Waterval

Journal Article

Insertion of mold material into the middle ear is a complication of molding procedure for ear impression. These cases are referred to an ENT specialist. There is no standardized approach to this problem. Literature shows different clinical strategies. The aim of this study is to share our experience and to analyze the adverse outcome of different clinical approaches. A case series of six patients with molding material inside the middle ear after complicated molding procedure for swimming earplugs are described. Additionally, available literature was reviewed to analyze results of the clinical approach after iatrogenic molding procedures. Forty-nine ears were included. In-office removal of the material is associated with a significant risk of adverse outcome if the eardrum cannot be examined. This also accounts for ossicular involvement. Temporal bone CT is advised in patients after complicated ear mold fitting if the tympanic membrane cannot be examined completely or the middle ear is involved. Blind removal should be avoided. Retroauricular transcanal tympanotomy or transmastoidal tympanotomy with facial recess approach is best practice in case the mold material has entered the middle ear. A clinical treatment algorithm is presented.

Anterior Skull Base Reconstruction following Ablative Surgery for Osteoradionecrosis: Case Report and Review of Literature

27-07-2019 – Katya Chapchay,Jeffrey Weinberger,Ron Eliashar,Neta Adler

Journal Article

Osteoradionecrosis is one of many potentially severe complications of radiotherapy for nasopharyngeal carcinoma. Osteoradionecrosis of the skull base is life-threatening due to the critical proximity of the pathological process to vital structures, for example, the intracranial cavity, the upper spine, and major blood vessels. Reconstructive options following surgical debridement of the anterior skull base and upper spine osteonecrosis have been scarcely described in the literature. We present a rare case of osteoradionecrosis of the clivus and cervical vertebrae C1-C2 in a patient previously treated with chemoradiotherapy for nasopharyngeal carcinoma, presenting as severe soft tissue infection of the neck. Aggressive surgical debridement and reconstruction with a two-paddle free anterolateral thigh flap was performed using a combination of transcervical and transnasal endoscopic approaches. A novel endoscopic procedure in the sphenoid sinus enabled flap anchoring in this complex area. Surgical modalities for osteoradionecrosis of the skull base and upper spine are discussed and review of the literature is presented. Reconstruction of the anterior skull base with a well-vascularized free flap following ablative surgery should be considered in management of life-threatening osteoradionecrosis of the area. Endoscopic opening of the sphenoid sinus and creating a funnel-shaped stem is a newly described technique that guarantees precise placement of the flap and is a valuable adjunct to the reconstructive armamentarium.

Acellular Dermal Matrix Mistaken as Recurrence of Malignancy Following Surgery on Positron Emission Tomography/Computed Tomography: A Case Report

27-07-2019 – Seokhwan Lee,Soo-Keun Kong,Seong Hwan Bae,Kyoungjune Pak,Se-Joon Oh

Journal Article

To report a rare clinical presentation of an acellular dermal matrix (ADM) used during lateral temporal bone resection mimicking recurrence of cancer of external auditory canal (EAC) on positron emission tomography/computed tomography (PET/CT) 9 months after surgery. Case report and literature review. A 71-year-old woman underwent lateral temporal bone resection 9 months earlier for management of squamous cell carcinoma of the EAC. She exhibited recurrence of the tumor on Care should be taken when using an ADM during malignant tumor surgery if the site of surgery is not conducive for fine needle aspiration or biopsy.

Ectopic Thymus: An Unusual Case of Subglottic Mass

19-07-2019 – Irene Paraboschi,Federica Fati,Francesca Rizzo,Oliviero Sacco,Nicola Stagnaro,Girolamo Mattioli,Alessandro Simonini,Oscar Mazzei,Michele Torre

Journal Article

The aim of our study is to report a case of a child with subglottic thymus that was suspected during diagnostic work-up for severe airway obstruction, excised surgically and confirmed with final histopathological examination. Moreover, we performed a narrative literature review to outline clinical and diagnostic features of this rare condition and to report suggestions for the management of subglottic masses. We report the case of a 7-month-old boy who was admitted to our Pediatric Airway Team Unit due to a history of worsening biphasic stridor and recurrent episodes of upper airway obstruction. The successful diagnostic work-up and a narrative literature of analogous cases of subglottic thymus were reported. Ectopic thymus is a very rare condition in which thymic tissue is found outside the normal pathway of its embryonic migration. It usually presents as a cystic or, more rarely, solid mass, showing an indolent course toward spontaneous involution. In some cases, however, it becomes symptomatic exerting compression on surrounding vital structures. Due to its rarity, the initial diagnosis is normally mistaken with inflammatory diseases or malignancies and the definitive diagnosis is only achieved after histological examination of the excised specimen. To our knowledge, only four other cases of subglottic ectopic thymic tissue have been reported in the English literature so far and the diagnosis has never been suspected preoperatively. It is mandatory to consider ectopic thymic tissue in the differential diagnosis in children presenting with airways obstruction in order to prevent unnecessary, extensive, and exploratory surgery.

Unsupervised Learning Techniques for the Investigation of Chronic Rhinosinusitis

19-07-2019 – Abigail Walker,Pavol Surda

Journal Article

This article reviews the principles of unsupervised learning, a novel technique which has increasingly been reported as a tool for the investigation of chronic rhinosinusitis (CRS). It represents a paradigm shift from the traditional approach to investigating CRS based upon the clinically recognized phenotypes of “with polyps” and “without polyps” and instead relies upon the application of complex mathematical models to derive subgroups which can then be further examined. This review article reports on the principles which underlie this investigative technique and some of the published examples in CRS. This review summarizes the different types of unsupervised learning techniques which have been described and briefly expounds upon their useful applications. A literature review of studies which have unsupervised learning is then presented to provide a practical guide to its uses and some of the new directions of investigations suggested by their findings. The commonest unsupervised learning technique applied to rhinology research is cluster analysis, which can be further subdivided into hierarchical and non-hierarchical approaches. The mathematical principles which underpin these approaches are explained within this article. Studies which have used these techniques can be broadly divided into those which have used clinical data only and that which includes biomarkers. Studies which include biomarkers adhere closely to the established canon of CRS disease phenotypes, while those that use clinical data may diverge from the typical “polyp versus non-polyp” phenotypes and reflect subgroups of patients who share common symptom modifiers. Artificial intelligence is increasingly influential in health care research and machine learning techniques have been reported in the investigation of CRS, promising several interesting new avenues for research. However, when critically appraising studies which use this technique, the reader needs to be

The Effects of Endoscopic Sinus Surgery on Voice Characteristics in Chronic Rhinosinusitis Patients

18-07-2019 – Danny B. Jandali,Ashwin Ganti,Inna A. Husain,Pete S. Batra,Bobby A. Tajudeen

Journal Article

Functional endoscopic sinus surgery (FESS) is a standard treatment modality for patients with chronic rhinosinusitis (CRS) who have failed appropriate medical therapy. However, FESS entails modification of the upper airway tract that may alter phonatory resonance and produce voice changes. The effects of FESS on postoperative voice characteristics in patients with CRS have yet to be quantitatively assessed. Patients with severe CRS who underwent FESS at a tertiary care referral center between May and October 2017 were prospectively enrolled. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and the Voice Handicap Index (VHI) were used to quantitatively evaluate voice characteristics and quality of life, respectively. Preoperative and postoperative CAPE-V and VHI scores were compared with postoperative scores for each patient. Sino-Nasal Outcome Test (SNOT-22) scores were also obtained to assess changes in patient symptoms. 18 CRS patients undergoing FESS were enrolled. The average preoperative Lund-Mackay score was 14, indicating baseline severe CRS. Postoperative assessments demonstrated a statistically significant decrease in CAPE-V (45-27, Patients with CRS experience a significant improvement in voice characteristics and vocal quality of life following FESS. Furthermore, this appears to correlate with a significant decrease in self-reported disease severity. These findings may augment the discussion of potential benefits of FESS to a new potential domain for voice quality.

Transoral Tubed Supraglottoplasty: A New Minimally Invasive Procedure for Aspiration

17-07-2019 – Yue Ma,Matthew R. Naunheim,Jill Gregory,Peak Woo

Journal Article

We describe a new procedure for aspiration called tubed supraglottoplasty (TS). TS is a transoral procedure that approximates the aryepiglottic (AE) folds and arytenoids. This narrows the laryngeal inlet. This procedure has been used to improve swallowing and reduce aspiration in patients with vocal fold paralysis. We describe the technical aspects of TS and report on 11 patients. TS is done by oral intubation followed by suspension laryngoscopy. An incision is made along the AE fold into the posterior commissure and then continued to the opposite AE fold. Dissection within this incision creates two mucosal flaps, one based on the laryngeal surface and the other on the pharyngeal surface. Two 1-cm releasing incisions are made at each end of the AE fold. The laryngeal mucosal flap is approximated using a 3-0 self-locking running suture. The pharyngeal mucosal flap is approximated as a second layer. This double-layered mucosal V-Y advancement flap builds up the posterior laryngeal height. It narrows and “tubes” the supraglottis. All patients tolerated TS without airway complications. Ten of the 11 patients reported improved swallowing function with less aspiration. Six of the 8 patients with prior G-tubes had their gastrostomy tube removed. Postoperative laryngoscopy showed a narrowed “tubed” supraglottis with a higher posterior wall preventing spillover and aspiration. An improved Functional Oral Intake Scale was recorded in ten of eleven patients. TS is a minimally invasive procedure that can improve swallowing and reduce aspiration.

Investigation of Novel Grafts in Use for Pediatric Tympanoplasty

13-07-2019 – Christine Barron,Jordan Lukens,Weston Niermeyer,Amanda Onwuka,Tendy Chiang,Charles Elmaraghy

Journal Article

To evaluate the impact of allograft and xenograft in pediatric tympanoplasty on patient outcomes. A retrospective cohort study of 50 pediatric patients undergoing tympanoplasty at a single tertiary pediatric hospital system that received either autograft, allograft, or xenograft. Patients were evaluated for persistent perforation, recurrent perforation, revision surgery, and postoperative infection. Hearing outcomes, operative charges, and operative time were also evaluated. Statistical analyses included chi-square and Fisher exact tests for categorical data and Wilcoxon-Mann-Whitney tests for continuous data. Half of the cohort received autografts, whereas 38% received xenografts and 14% received allografts. Although there was not a significant difference in charges associated with these procedures, xenografts had the shortest mean operative time (mean: 39 vs 68 minutes in autografts, Similar rates of complications were observed among autografts, xenografts, and allografts, providing preliminary evidence that they are safe to use in pediatric tympanoplasty.

Detection of Microbiota in Post Radiation Sinusitis

13-07-2019 – Timothy J. Stoddard,Varun V. Varadarajan,Peter T. Dziegielewski,Brian J. Boyce,Jeb M. Justice

Journal Article

A shift in the microbiota of chronic rhinosinusitis has been described after radiotherapy to the sinonasal cavity and skull base. There is a paucity of literature characterizing the bacteriology of post radiation sinusitis using next-generation gene sequencing techniques. This study aims to describe and compare the microbial flora of rhinosinusitis after radiotherapy using both culture and molecular techniques for microbial DNA detection. The medical records of patients treated with external beam radiation for sinonasal, nasopharyngeal, or skull base malignancy were reviewed at a tertiary care facility. Patients’ sinonasal cavities were swabbed for routine culture or brushed for molecular gene sequencing. Swab specimens were processed for standard microbial culture, and brush specimens were sent for gene sequencing at Micro Gen
X Laboratory (Lubbock, Texas, USA). Twenty-two patients were diagnosed with chronic sinusitis after undergoing radiotherapy. The bacteriology of post radiation sinusitis appears to resemble the microorganisms responsible for chronic sinusitis in healthy adults. Next generation gene sequencing techniques may reveal additional organisms responsible for sinusitis and provide complementary results that may impact the medical treatment of post radiation sinusitis.

Quality of Voice and Prognostic Markers for the Recovery of Vocal Fold Paralysis After Thyroid Surgery

12-07-2019 – Rudolf Reiter,Adrienne Heyduck,Thomas Karl Hoffmann,Sibylle Brosch,Maria Anna Buchberger,Katharina Schorer,Theresa Weber,Anja Pickhard

Journal Article

This study is set to analyze clinicopathological factors predicting the recovery of unilateral vocal fold paralysis (UVP) in patients after thyroid gland surgery. The quality of voice was additionally assessed in these patients. The charts and videolaryngostroboscopy (VLS) examinations of 84 consecutive patients with a complete UVP after surgery of the thyroid gland were retrospectively reviewed. Patients were divided into 2 groups: patients who fully recovered from vocal fold paralysis and those who failed to recover after a follow-up of 12 months. The quality of voice was analyzed among other things by determining the Voice Handicap Index (VHI). The UVP fully recovered in 52 of 84 (61.9%) patients. Positive mucosal waves (p
MWs) on the paralyzed side, a minimal glottic gap <3 mm seen at the first postoperative VLS, age ≤50 years, and surgery duration ≤120 minutes were associated factors for a complete recovery of nerve function. The voice parameters improved independently from recovery of the paralysis in 90% of the patients. For patients with a poor prognosis of a UVP, early intervention may be beneficial. Thus, predicting factors for a full recovery of vocal fold motion would be a valuable tool. In our cohort, about 60% of recoveries could have been predicted using the above-mentioned parameters. Good quality of voice was independently reached in 90% of the cases.

Submental Island Flap: A Technical Update

11-07-2019 – Joseph Zenga,Kevin S. Emerick,Daniel G. Deschler

Journal Article

In recent years, the submental island flap has demonstrated decreased cost and morbidity as compared with free tissue transfer and has been widely applied to a range of head and neck defects. Several studies, however, continue to report a high rate of submental flap complications including partial necrosis and venous congestion. The object of this report is to describe a technical modification to the submental flap harvest which increases efficiency and reliability. Single institutional case series with chart review. The essential technical details and technique modifications of the submental flap harvest are described, and a case example is discussed. Between January 2018 through January 2019, 24 submental island flaps were performed. All flaps included the mylohyoid muscle which was delineated with manual blunt dissection. Reconstructive indications included oral cavity and oropharyngeal wounds as well as facial cutaneous and lateral skullbase defects. There were no flap-related complications. Manual blunt dissection of the mylohyoid muscle and its inclusion in the submental island flap increases efficiency and reliability.

Spindle Cell Lipomas of the Respiratory Tract: A Case Report and Comprehensive Literature Review

11-07-2019 – Jonathan Reid,Bret Wehrli,Leigh J. Sowerby

Journal Article

Spindle cell lipomas (SCLs) are benign tumors that are characteristically present on the upper back and neck, but in rare cases present throughout the respiratory mucosa, causing hoarseness, stridor, dyspnea, and obstruction. To highlight the importance of considering SCL in the diagnosis of benign respiratory tract tumors, a literature review identified all published cases of respiratory tract SCLs, including 2 from our institution: one case in the nasopharynx and 1 in the nasal valve. All case reports, series and literature reviews from the English literature from 1975 through March 2018 were systematically identified for review in the MEDLINE, EMBASE, and Scopus databases. Two additional cases from our institution were described. In total, 24 cases of SCL in the respiratory tract were identified for review. Two cases from our institution are described here, bringing the total of reported cases to 26. Extensive analyses of oral cavity SCLs already exist, so we excluded this site from our review and focused on sites where SCLs may present with respiratory symptoms. Excluding the oral cavity and oropharynx, the most common location described is the larynx. All 26 cases were treated with excision. One tumor required a second surgery, but there were no other complications nor recurrences. Although rare, SCLs may arise from throughout the respiratory tract and cause dyspnea, hoarseness and stridor. Spindle cell lipoma should be considered in the differential diagnosis of a respiratory tract mass. This diagnosis confers a good prognosis and patients may be reassured that surgery is almost always curative.

Diagnostic Protocol for Detecting Otosclerosis on High-Resolution Temporal Bone CT

10-07-2019 – Lisa A. Brown,Burce Ozgen Mocan,Miriam I. Redleaf

Journal Article

To present a systematic checklist to improve diagnosing otosclerosis (OS) on high-resolution computed tomography (HRCT) of the temporal bones and review this protocol’s efficacy in diagnosing OS on HRCT. A retrospective case series was performed at a University Referral Hospital in urban Chicago, Illinois. High-resolution computed tomographies of the temporal bone were reviewed including 17 ears in the test group with surgically confirmed OS and 21 ears in the control group surgically confirmed to not have OS. Preoperative HRCTs were evaluated by a single neuroradiologist using a systematic protocol created to assist in diagnosing OS. This looked for radiolucency at the fissula ante fenestram and pericochlear region, and new bone formation around the oval and round windows. The radiologist accurately diagnosed OS in all 17 test group ears and ruled out OS in all 21 control group ears using the protocol. All 17 test ears were read to have lucency at the fissula ante fenestram, 9 (53.0%) to have new bone formation, and 8 (47.1%) to have cochlear lucency. The radiologist was more confident in diagnosing OS when cochlear lucency was present with the fissula ante fenestram lucency. This HRCT checklist is a highly accurate tool for evaluating the presence of OS when images are reviewed in the systematic fashion described. Imaging prior to surgery aids in counseling patients, preparing surgically, and excluding other pathologies.

Why Central Neck Dissection Works (and Fails) for Recurrent Thyroglossal Duct Remnants

04-07-2019 – Glenn Isaacson,Adam Kaplon,Derrick Tint

Journal Article

To review the patient characteristics and outcomes for children and undergoing central neck dissection for control of recurrent thyroglossal duct cysts and fistula following prior Sistrunk procedures and children requiring surgery for refractory infection. We performed a computerized review of all children who were evaluated for thyroglossal duct cysts during the years 1999-2018 by a single surgeon operating at an urban children’s hospital and an outpatient surgical center. Those requiring a central neck dissection for control of recurrent disease or intractable infection were identified. Age at time of surgery, sex, surgical procedure, and postoperative complications were recorded. These data were combined with similar data from a published report by the same surgeon in the years 1990-1998 to complete a 28-year review. 18 central neck dissections were performed including 13 for recurrent thyroglossal duct remnants after Sistrunk procedures and 5 primary surgeries for intractable infection. Ages ranged from 3 to 19 years (median = 10 years) and 13 of 18 were girls (72%). Four children had their first Sistrunk surgery performed by the senior author. Three children operated elsewhere had intact hyoid bones at the time of revision surgery, suggesting less-than-Sistrunk primary surgeries. Central neck dissection controlled disease in the lower neck in all cases. One child re-fistulized at the level of the hyoid. Central neck dissection in combination with a Sistrunk-type dissection of the tongue base is effective in the control of recurrent infection following unsuccessful Sistrunk surgery and aids in dissection for children with intractable infection. Although this technique reliably controls infrahyoid disease and improves access to the hyoid and posterior hyoid space, it does nothing to address the difficulties of following the thyroglossal tract into the tongue base.

Direct Visualization of Laryngeal Mucociliary Clearance in Adults

04-07-2019 – Luke M. O’Neil,Niall D. Jefferson

Journal Article

Mucociliary clearance is a protective mechanism of the respiratory tract that facilitates the removal of foreign particles and microorganisms. There is a paucity of data on the mucociliary clearance in the adult larynx. Our study aims to visualize and describe the mucociliary clearance of the adult larynx in healthy subjects. Subjects were identified from a volunteer database. Exclusion criteria included laryngeal disease, previous laryngeal surgery, recent upper respiratory infection, and current smoking. A high-definition videolaryngoscope was used to visualize the larynx. The larynx was topicalised with local anesthetic. Methylene blue was placed on both false vocal cords and at the petiole of the epiglottis. Dye clearance was recorded and analyzed. In total, 10 participants participated, 7 men and 3 women, with a mean age of 42 ± 15.7 years (range: 25-71). The average reflux symptom index score was 1.4. Clearance of the dye from the false vocal cords followed a uniform lateral flow, up onto the aryepiglottic folds. The dye from the petiole had minimal vertical movement. Swallowing cleared dye from the aryepiglottic folds. The average time for dye clearance to the aryepiglottic fold was 2.21 ± 1.14 minutes. This is the first study visualizing the mucociliary clearance of the larynx. Ciliary directionality was consistent in the participants studied, with dye moving superolateral from the false cords to the aryepiglottic fold. Swallowing was an effective mechanism for clearance from the endolarynx, when the dye had reached the aryepiglottic fold. Future research can study potential alterations in laryngeal mucociliary clearance in chronic disease states.

Three Cases of Primary Ciliary Dyskinesia Combined With Reduced Exhaled Nitric Oxide

04-07-2019 – Sung Min Han,Chi Sang Hwang,Hyun Jong Jeon,Ho Young Lee,Hyung-Ju Cho,Dong-Joon Park

Journal Article

The diagnosis of primary ciliary dyskinesia (PCD) is often delayed in part related to the limitations of the available diagnostic tests. We present 3 cases of PCD diagnosed using an exhaled nitric oxide (e
NO) measurement. Three cases with a clinical phenotype consistent with PCD were evaluated using an e
NO assay with additional transmission electron microscopy (TEM) and/or genetic panel testing. One male and 2 female patients presented with common symptoms included recurrent respiratory infection from early childhood and a history of neonatal respiratory distress as term newborn. Two of them had situs inversus totalis. Fractional e
NO measurement revealed extremely low NO levels, and subsequently, TEM analysis confirmed ciliary ultrastructural defects in all patients. One patient had compound heterozygous mutation of the PCD-causative gene ( Our report stresses the reliability of e
NO measurement in the diagnosis of PCD, accompanied by clinical phenotypes and additional diagnostic tools, such as TEM analysis and genetic testing.

Awareness of European Otolaryngologists and General Practitioners Toward Laryngopharyngeal Reflux

01-07-2019 – Jerome R. Lechien,Francois Mouawad,Geoffrey Mortuaire,Marc Remacle,Francois Bobin,Kathy Huet,Andrea Nacci,Maria Rosaria Barillari,Lise Crevier-Buchman,Stéphane Hans,Camille Finck,Lee M. Akst,Petros D. Karkos

Journal Article

To investigate the current trends in management of laryngopharyngeal reflux (LPR) among young European otolaryngologists and general practitioners (GP). An international survey was sent to European general practitioners and all otolaryngologists under 45 years old from the 2017 IFOS meeting. This survey was conducted by the LPR Study Group of YO-IFOS (Young Otolaryngologists of the International Federation of Otolaryngological Societies). Among the 2500 attendees, 230 European otolaryngologists (response rate = 9%) completed the survey; an additional 70 GPs also completed the survey. GPs did not differentiate between gastroeosophageal reflux disease (GERD) and LPR, overstating GERD-related symptoms (ie, heartburn and regurgitations) in LPR clinical presentation and relying on gastrointestinal endoscopy for LPR diagnosis. Otolaryngologists also believe that GERD-related symptoms are prevalent in LPR. Knowledge of nonacid and mixed LPR and use of multichannel intraluminal impedance-p
H monitoring are still limited in both groups. A therapeutic dichotomy exists between groups: GPs mainly use a 4-week once daily empiric proton pump inhibitors (PPIs) trial, while otolaryngologists use PPIs twice daily for a longer therapeutic period ranging from 8 to 12 weeks. More than 50% of GPs and otolaryngologists believe that they are not adequately knowledgeable and skilled about LPR. The majority of GPs and otolaryngologists do not believe themselves to be sufficiently informed about LPR, leading to different practice patterns and grey areas. The elaboration of international recommendations in the management of reflux is needed to improve practices.

Curved Laryngopharyngoscope With Flexible Next-Generation Robotic Surgical System for Transoral Hypopharyngeal Surgery: A Preclinical Evaluation

21-06-2019 – Kohtaro Eguchi,Jason Y. K. Chan,Ichiro Tateya,Akira Shimizu,F. Christopher Holsinger,Taro Sugimoto

Journal Article

The indication of transoral robotic surgery for hypopharyngeal cancer is limited because of poor accessibility. The aim of this study was to explore the efficacy of a curved laryngopharyngoscope used in combination with a next-generation flexible robotic surgical system for accessing and resecting the hypopharynx. A comparative evaluation of the curved laryngopharyngoscope versus standard straight-blade retractors using the flexible robotic surgical system was conducted on 2 cadavers. End points measured included visualization, accessibility, and ease of dissection for accessing and resecting the hypopharynx. Visualization, accessibility, and dissection were superior with the curved laryngopharyngoscope in all subareas of the hypopharynx. The advantages of accessibility and visualization were much more evident in the cadaver with a high body mass index. These preclinical data suggest that using a curved laryngopharyngoscope in combination with a flexible robotic surgical system may lead to technical innovations concerning transoral surgery of the hypopharynx.

Management of Vocal Fold Paralysis and Dysphagia for Neurologic Malignancies in Children

19-06-2019 – Peter Nagy,Nicholas Beckmann,Steven Cox,Anthony Sheyn

Journal Article

To evaluate our experience with a significant number of brain malignancy-related vocal fold paralysis patients and their response to vocal cord-related therapies. Vocal fold paralysis is a potentially devastating complication of various types of pediatric diseases and surgeries that can lead to significant vocal and swallowing difficulties. While there is significant data in the literature on outcomes of children treated for vocal fold paralysis following cardiac or thyroid surgery, there is a scarcity of such information on children following the treatment of neurologic malignancy. Records of 19 patients at a tertiary center who were treated for neurologic malignancies and developed either unilateral or bilateral vocal fold paralysis were reviewed for vocal fold pathology and vocal fold paralysis treatment-related variables, including initial diagnosis, management with observation or speech therapy, duration of therapy, pre- and postintervention swallow studies, and surgical intervention. Bilateral vocal fold paralysis was noted in 26% (5/19) patients. Eighty-four percent (16/19) of patients had stable or improved ability to vocalize and swallow following therapy. There was no statistically significant difference in speech or swallowing improvement after speech therapy alone or speech therapy in combination with injection laryngoplasty ( Patients with vocal fold paralysis secondary to neurologic malignancy can have an improvement in speech and swallowing after a variety of treatments, including speech therapy or early injection laryngoplasty. There was no statistically significant difference in improvement based on the type of intervention utilized. A larger sample size is needed to conclude whether surgical intervention combined with speech therapy leads to more rapid and significant functional improvement than speech therapy alone.

Unusual Nasal Insufficiency in an Infant: What’s Behind the Nostril?

17-06-2019 – Fabian Alzate Amaya,Liliana F. Invencio da Costa,Alejandro Martinez Moran,Roberto Alvarez Rodriguez

Journal Article

Inflammatory myofibroblastic tumor (IMT) is a rare benign lesion, especially in the pediatric age. There are several cases described in pulmonary, digestive and renal localizations, but involvement in head and neck area is infrequent. Case report and review of the literature. A 1 year and 11 months old child, during 2 months had clinical signs of nasal respiratory insufficiency and epistaxis subsequently developing a purulent rhinorrhea and a sleep apnea. His pediatrician previously requested a sinus and cavum X-ray with the finding of an image compatible with an intranasal mass. Endoscopic resection was performed of the mass with further immunohistochemical analysis showing the result of a lesion compatible with IMT. Even though there are very few cases in scientific literature of a tumor with these characteristics in infants, IMT must be present as a differential diagnosis of intranasal masses. The role of the pathologist is essential to reach the definitive diagnosis and the performance of an early surgical treatment decreases aesthetic consequences in this pathology.

eHealth Literacy in Otolaryngology Patients

14-06-2019 – Christopher Eric Bailey,William J. Kohler,Chadi Makary,Kristin Davis,Nicholas Sweet,Michele Carr

Journal Article

The aim of this study was to compare e
Health literacy-one’s perception of one’s ability to use the Internet for health care-among otolaryngology patients in 3 geographic settings of the same department. An academic otolaryngology department. Patients’ opinions and perceptions of their e
Health literacy were assessed with a validated paper survey administered in the summer of 2017. Of 381 asked, 351 people completed the survey, 149 at a university town teaching hospital clinic (group A), 101 at a nearby rural clinic (group B), and 101 at a remote rural clinic (group C). Mean scores were 30.80, 28.97, and 29.03 for groups A, B, and C, respectively. The overall mean was 29.76 ± 5.97. Three surveys reported the minimum score of 8, and 26 reported the maximum score of 40. Results were statistically significantly different among all sites ( Otolaryngology patients in a university town had better e
Health literacy than patients in more rural settings, suggesting that online medical resources and access points are less likely to be useful in rural populations.

Type I Posterior Glottic Stenosis: Natural History and In-Office Management

04-06-2019 – Valeria Silva Merea,Babak Sadoughi

Journal Article

To review the natural history of type I posterior glottic stenosis (PGS-I) and its treatment outcomes through a case presentation and demonstrate the feasibility of in-office management of PGS-I. The case of a middle-aged woman who developed PGS-I after prolonged intubation is presented. A review of the literature on management and treatment outcomes of PGS-I is also performed. Initially presenting with a large granuloma that failed conservative management, the patient deferred surgical intervention and developed unilateral vocal fold hypomobility with posterior glottic synechia. The adhesion was successfully ablated in the office with potassium-titanyl-phosphate (KTP) laser; however, vocal fold hypomobility persisted after treatment. This case illustrates the natural history of the development of PGS-I, demonstrates the feasibility of office-based management of this condition, and provides further evidence that lysis of PGS-I synechia does not uniformly lead to restoration of normal laryngeal function and mobility.

Small Cell Carcinoma in the Head and Neck

04-06-2019 – Takahiro Wakasaki,Ryuji Yasumatsu,Muneyuki Masuda,Mioko Matsuo,Akihiro Tamae,Kazuhiko Kubo,Ryunosuke Kogo,Ryutaro Uchi,Masahiko Taura,Takashi Nakagawa

Journal Article

Small cell carcinomas in extrapulmonary sites (ESm
CCs) are very rare. ESm
CCs originating in the head and neck account for approximately 10% of all ESm
CCs, and there are few reports about this disease. ESm
CCs have an aggressive natural history characterized by widespread metastasis. The aim of this study was to investigate the characteristics and outcomes of patients with ESm
CCs of the head and neck. The outcomes of 21 patients with ESm
CCs of the head and neck treated between January 2001 and December 2015 at the authors’ hospital and associated facilities were reviewed. There were 18 men and 3 women, and the median age was 74 years (range, 53-91 years). The tumor site was the larynx in 6 patients; the paranasal sinus in 5; the hypopharynx in 3; the oropharynx in 2; the nasopharynx in 2; and the oral cavity, salivary gland, and primary unknown in 1 patient each. The extent of the disease was staged as follows: stage I or II, 3 cases; stage III, 4 cases; stage IVA, 9 cases; stage IVB, 1 case; and stage IVC, 4 cases. The median observation time was 17 months (range, 1-103 months). Four patients (19%) had distant metastasis at initial treatment, and 13 patients (62%) developed distant metastasis within 3 years. Treatments were administered, including radical surgery (9 patients), radiation therapy (5 patients), chemoradiotherapy (7 patients), and chemotherapy (6 patients). The 1- and 3-year overall survival rates of patients were 56% and 37%, respectively. More than half of the patients died of distant metastasis. ESm
CCs of the head and neck have a poor prognosis, similar to those of carcinomas in many other sites. Control of distant metastasis would contribute to improving the prognosis of ESm
CCs of the head and neck. Further studies are required for better understanding these disease entities and their response to treatment modalities.

Revision Stapes Surgery in a Tertiary Referral Center: Surgical and Audiometric Outcomes

04-06-2019 – Esther E. Blijleven,Inge Wegner,Rinze A. Tange,Hans G.X.M. Thomeer

Journal Article

To evaluate pure-tone audiometric results in otosclerosis patients undergoing revision stapes surgery following previous middle ear interventions. A retrospective cohort study was performed in a tertiary referral center. Consecutive otosclerosis patients who underwent revision stapes surgeries, following previous middle ear interventions, for persistent conductive hearing loss, recurrent conductive hearing loss, or vertigo and had available postoperative pure-tone audiometry were included. Mean pre- and postoperative air conduction, bone conduction, and air-bone gap averaged over 0.5, 1, 2, and 3 k
Hz were obtained. Audiometric outcomes were obtained at 7 weeks postoperatively. In total, 63 consecutive otosclerosis patients who underwent 66 revision stapes surgeries were included. Air-bone gap improved significantly with a mean gain of 19 d
B (95% CI, 15-22). Air conduction improved significantly with a mean gain of 18 d
B (95% CI, 14-23). Bone conduction did not change significantly, with a mean deterioration of 0 d
B (95% CI, -2 to 1). Air-bone gap closure to 10 d
B or less was achieved in 38% of cases and to 20 d
B or less in 80% of cases. Indication for surgery, previous type of procedure, primary cause of failure, and current surgical technique were not significantly associated with air-bone gap closure to 10 d
B or less. Indication for surgery and primary cause of failure were associated with one another. Compared to the available literature, a slightly larger gain in air conduction and air-bone gap was achieved in our study. Air-bone gap closure to 10 d
B or less was achieved less often in our study.

The Genetic and Molecular Determinants of Juvenile Nasopharyngeal Angiofibroma: A Systematic Review

31-05-2019 – Jaime Doody,Eelam A. Adil,Cameron C. Trenor,Michael J. Cunningham

Journal Article

Juvenile nasopharyngeal angiofibroma (JNA) is a rare vascular tumor of unknown etiology. Studies investigating the molecular and genetic determinants of JNA are limited by small sample size and inconsistent approaches. The purpose of this study is to examine all eligible JNA studies in aggregate, applying qualitative analysis to highlight areas of particular relevance, including potential targets for therapeutic intervention. The PubMed, MEDLINE, Embase, Web of Science, Cochrane, and CINAHL databases were screened with inclusion and exclusion criteria applied to all citations. Manuscripts investigating the genetic determinants, histopathogenesis, and heritability of juvenile nasopharyngeal angiofibroma were included. Non-English studies, case reports, and articles focusing on clinical management without original data were excluded. Full text articles were obtained. A qualitative synthesis of data was performed. A total of 59 articles met criteria for inclusion. These were divided into 6 categories based on the primary topic or target discussed, (1) steroid hormone receptors, (2) chromosomal abnormalities, (3) growth factors, (4) genetic targets, (5) molecular targets, (6) Wnt cell signaling, and (7) studies that overlapped multiple of the aforementioned categories. Although relatively low n values prevent definitive conclusions to be drawn, a predominance of certain molecular targets such as vascular endothelial growth factor (VEGF) and Wnt/β-catenin pathway intermediaries is apparent. Although the etiology of JNA remains elusive, contemporary molecular genetic investigation holds promise for risk stratification and could form the basis of a modernized staging system. A multicenter clinical registry and linked tissue bank would further promote the search for JNA specific biomarkers.

Salivary Clear Cell Carcinoma Clinicopathologic Characteristics and Outcomes: A Population-Based Analysis

30-05-2019 – Daniel D. Sharbel,Aykut A. Unsal,Michael W. Groves,William G. Albergotti,J. Kenneth Byrd

Journal Article

Salivary clear cell carcinoma is an uncommon, low-grade malignancy for which limited data describing predictive clinicopathologic factors and treatment outcomes exist because of rarity. The authors queried the Surveillance, Epidemiology, and End Results database from 1982 to 2014. Multivariate Cox and Kaplan-Meier analyses were performed to determine disease-specific survival (DSS) and predictive clinicopathologic factors. One hundred ninety-eight patients with salivary clear cell carcinoma were included. Overall incidence was 0.011 per 100 000 individuals, with no significant annual percentage change across years (-0.93%, P = .632). Five-, 10-, and 20-year DSS rates were 81.3% (n = 117), 69.6% (n = 94), and 55.3% (n = 68), respectively. Men (hazard ratio, 4.74; P = .0087) and patients with regional (hazard ratio, 5.59; P = .018) or distant (hazard ratio, 8.9; P = .01) metastases carried a worse prognosis. Five-year DSS was greater in patients with localized disease (96.36%, P < .0001) than those with regional or distant metastases. Treatment with surgery alone had better 10-year DSS (86.3%) compared with treatment with combination radiation and surgery (57.6%) or radiation monotherapy (18.75%, P < .0001). Salivary clear cell carcinoma carries an overall good prognosis. Patients with localized disease and those treated with surgery alone have more favorable prognoses. Male patients and those with regional or distant metastatic disease at time of presentation carry a worse prognosis. N/A.

Tympanomastoidectomy for Cholesteatoma in Children: Audiometric Results

29-05-2019 – Sharon Tzelnick,Dan Yaniv,Eyal Raveh,David Ulanovski,Ohad Hilly

Journal Article

The aim of this study was to investigate the audiometric outcomes of tympanomastoidectomy in children with cholesteatoma and to evaluate factors that may affect outcomes. A retrospective cohort study was conducted. All pediatric patients diagnosed with cholesteatoma who underwent primary canal wall-up tympanomastoidectomy with or without ossicular reconstruction from 2009 to 2016 at a tertiary university-affiliated pediatric medical center were included. Pure tone average (PTA) and air-bone gap (ABG) at 0.5, 1, 2, and 4 k
Hz were compared before and after surgery. The cohort included 100 children (104 tympanomastoidectomies) of mean age 10.35 ± 3.6 years. The mean duration of follow-up was 35.4 ± 24.1 months. At surgery, 22 patients (21.2%) had intact ossicular chains, and 82 (78.8%) had ossicular discontinuity. Fifty-three patients (51%) underwent ossicular reconstruction, either partial (34 patients [64.1%]) or total (19 patients [35.8%]). In comparison with preoperative audiometry, there was a statistically significant improvement in PTA-ABG at the first postoperative examination (27.5 ± 12.7 vs 21.1 ± 11.1 d
B, P = .001) and at the end of follow-up (20.2 ± 12.7 d
B, P = .003) . Overall, values of less than 20 d
B were measured in 34% of patients preoperatively and 73% postoperatively. On subgroup analysis, in patients who underwent any ossicular reconstruction, PTA-ABG was significantly improved relative to the preoperative value (28.1 ± 14.7 d
B) at both the first (19.1 ± 11.9 d
B, P = .006) and last (22.4 ± 15.1 d
B, P = .011) audiometry examinations. Hearing outcomes after pediatric cholesteatoma surgery are diverse and related to several factors. The authors found that ossicular reconstruction improves audiometric outcomes, and the changes remain stable over time. IIB.

Review: Thieme MedOne Otolaryngology

29-05-2019 – Danielle Bottalico

Journal Article

Outcomes Following Transoral Laser Microsurgery With Resection of Cartilage for Laryngeal Cancer

28-05-2019 – Brent A. Chang,David G. Lott,Thomas H. Nagel,Brittany E. Howard,Richard E. Hayden,Michael L. Hinni

Journal Article

The ability to treat more advanced laryngeal cancers by transoral approaches has expanded significantly in the past several decades. Transoral management of laryngeal cancers that require removal of the laryngeal framework is controversial. Resecting cartilage through endoscopic means carries inherent technical challenges and the question of oncologic safety. We describe a retrospective review of patients undergoing resection of the thyroid cartilage during transoral laser microsurgery (TLM) for laryngeal cancer over a 10-year period. Only patients with 5-year follow-up were included. Fourteen patients were identified that underwent attempted endoscopic resection of the thyroid cartilage. Preoperative staging ranged from T1 to T4 laryngeal cancers. Most patients underwent resection of the thyroid cartilage either for close proximity of the tumor to cartilage or microscopic involvement of the inner perichondrium, although 6 patients had gross invasion of the cartilage. Twelve patients underwent successful endoscopic clearance. Two patients were converted to total laryngectomy either at the time of surgery or shortly after due to extent of disease that was deemed not amenable to endoscopic resection. Overall 5-year survival was 71%. Disease-free survival was 62% at 5 years. The majority of patients avoided gastrostomy and tracheostomy tube dependence. One patient underwent total laryngectomy following initial TLM for chronic aspiration. We conclude that TLM for laryngeal cancer performed with removal of thyroid cartilage is feasible. Both oncologic and functional outcomes are reasonable in a select group of patients. This paper describes that cartilage can be resected endoscopically in the appropriate setting and not necessarily that cartilage invasion should routinely be treated with TLM.

Safety and Efficacy of a Trans-Eyelid Facial Rejuvenation Surgery Combining Partial Repositioning of Orbital Fat and Midface Lift in Chinese Patients: A Prospective Case Series

28-05-2019 – Yin Liu,Minqin Xiao,Yanan Zhao,Wei Qiu,Hong Xiao

Journal Article

To describe the combined technique of midface lift and partial release of orbital fat for facial rejuvenation and evaluate the safety and aesthetic results. This was a single-center study that included patients who underwent facial rejuvenation from January 2010 to December 2016. The orbital fat was partially removed, and the cheek fat pads were repositioned to exfoliate the myocutaneous flaps of the lower eyelids and midface through a sub-ciliary incision. The cheek soft tissue pads and orbital fat were restored and sutured to the periorbital membranes and orbital margins. Postoperatively, the patients were examined at 6 and 18 months for changes in the shapes of cheeks, eyelid joints, sunken eyepit, and nasolabial sulcus along with procedural complications. A total of 179 (177 women; 2 men) eligible patients with a mean age of 47.17 years underwent the procedure. The shapes of cheeks and eyelid joints of all patients improved, along with shallowing of the sunken eyepit and nasolabial sulcus at 6- and 18-month follow-up. The surgical procedure involved minor trauma without facial scarring, lower eyelid flinch, and dislocation. None of the patients reported complications of nerve injuries, long-term chemosis conjunctiva, periocular swelling, or dislocation of the lower eyelids. Only 2 patients who underwent subsequent pouch surgeries had slight ectropion, which was restored within 4 months of surgery. To conclude, the combined partial orbital fat repositioning and midface lift via sub-ciliary approach is a successful treatment option for facial rejuvenation with no major complications.

Symptom Profile of Chronic Rhinosinusitis Versus Obstructive Sleep Apnea in a Tertiary Rhinology Clinic

23-05-2019 – Keven Ji,Thomas J. Risoli,Maragatha Kuchibhatla,Lyndon Chan,Ralph Abi Hachem,David W. Jang

Journal Article

Patients with undiagnosed obstructive sleep apnea (OSA) often present to an otolaryngologist with symptoms of chronic rhinosinusitis (CRS). This study analyzes symptom profiles of such patients to help identify those who may benefit from polysomnography. This is a 2-year retrospective analysis of adult patients at an academic practice with a rhinologic chief complaint. Results of the 22-Item Sinonasal Outcomes Test (SNOT-22) were compared between patients with untreated OSA without CRS (OSA group) and a control group of CRS patients (CRS group). Univariate analysis with Bonferroni correction and multiple logistic regression were used. Forty-one patients were included in the OSA group (mean apnea-hypopnea index = 28.8, SD = 21.0) and 124 patients in the CRS group. CRS group demonstrated higher scores in nasal, extra-nasal, and ear/facial symptom domains ( P < .001), while OSA group displayed higher psychological ( P = .020) and sleep domain scores ( P = .048). Nasal discharge ( P < .001) and loss of smell/taste ( P = .004) scores were higher in CRS group, whereas facial pain ( P = .285) and nasal obstruction ( P = .822) were not significantly different. On logistic regression, thick nasal discharge, loss of smell/taste, and ear pain were predictive of CRS, while waking up tired was predictive of OSA. Finally, OSA group was more likely to choose a sleep-related issue as a most important symptom (MIS) ( P < .001). OSA and CRS have significant overlap in symptom profiles. The SNOT-22 can help identify those with undiagnosed OSA. OSA should be suspected in patients who report a sleep-related item as a MIS and display higher psychological and sleep domain scores.

The Value of Dynamic Voice CT Scan for Complex Airway Patients Undergoing Voice Surgery

22-05-2019 – Mathieu Bergeron,Robert J. Fleck,Stephanie R.C. Zacharias,Meredith E. Tabangin,Alessandro de Alarcon

Journal Article

Dynamic voice computerized tomography (DVCT) is a novel technique that provides additional information to characterize laryngeal function for patients with complex airway history that may alter surgical decisions. The goal of this study was to evaluate the impact of DVCT on decision making for reconstructive voice surgery for a cohort of post-airway reconstruction dysphonia patients. Retrospective chart review at a pediatric tertiary care center for patients with history of complex airway surgery and subsequent reconstructive voice surgery for dysphonia between 2010 and 2016. The study group had a DVCT prior to surgery while the control group underwent surgery without a DVCT. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and pediatric Voice Handicap Index (p
VHI) scores were evaluated by the voice clinic team (otolaryngologist, speech therapist) before and after voice surgery. Twenty-one patients were analyzed (14 female, 67%) with a mean age (SD) of 14 (4.5) years old. Ninety percent (17/21) had a prior tracheostomy and a mean (SD) of 2.6 (1.3) airway surgeries. Twelve patients (57%) underwent DVCT prior to reconstructive voice surgery. CAPE-V baseline scores were similar between study and controls (means [SE] = 49 [4.6] and 57 [6.0], P = .72). However, scores significantly improved for the study group after voice surgery (mean [SE] = 31 (4.7), P < .0001) while controls did not improve (58 [5.7], P = .99). Baseline VHI scores were similar between both groups: mean (SE) = 54 (5.4) versus 52 (6.2), respectively, P = .99. Postsurgically, VHI scores were also similar between both groups (means [SE]: 46 [7.1] vs 47 [4.5], P = .99). Reconstructive voice surgery for study patients included posterior cricoid reduction (46%), vocal fold medialization/augmentation (46%), and laryngeal reinnervation (7.7%) while all controls underwent a single treatment (vocal fold medialization/augmentation). Patients with preoperative DVCT were more likely to have improvement. DVCT appeared to have altered surgical decision making and has allowed tailoring of reconstructive surgery to specific patients' needs. DVCT could represent an important tool prior to reconstructive surgery to guide the choice of surgical procedures for complex airway patients.

Book Review: Clinical Esophagology and Transnasal Esophagoscopy

17-05-2019 – Michael Z. Lerner

Effects of OSA Surgery on Ophthalmological Microstructures

16-05-2019 – Pei-Wen Lin,Hsin-Ching Lin,Michael Friedman,Hsueh-Wen Chang,Anna M. Salapatas,Meng-Chih Lin,Chien-Hung Chin

Journal Article

Obstructive sleep apnea/hypopnea syndrome (OSA) could compromise oxygenation of the optic nerve and cause glaucomatous optic neuropathy; however, there were no studies to investigate the changes of visual function and retinal microstructures in OSA patients after upper airway surgery. We aim to assess the changes in the visual sensitivity and retinal fiber layer thickness in OSA patients before and after surgery. This prospective single-blind study enrolled patients with OSA from a tertiary academic medical center who had unsuccessful conservative therapy and then underwent surgery. The patients were referred for comprehensive ophthalmologic evaluation at baseline and 6 months after OSA surgery. The polysomnographic findings were collected pre- and postoperatively. Visual sensitivities on standard automated perimetry (SAP) were assessed. Peripapillary retinal nerve fiber layer (RNFL) thickness and macular layer (ML) thickness parameters were measured by spectral-domain optical coherence tomography (OCT). A total of 108 OSA patients were enrolled. Six months after surgery, the major parameters of polysomnography (PSG), mean deviation, and pattern standard deviation of SAP significantly improved in these OSA patients. Regarding the OCT parameters, thickness of ML in the nasal-outer, superior-inner, temporal-inner, inferior-inner, nasal-inner sectors, and total ML thickness significantly increased 6 months after upper airway surgery in the severe OSA group (apnea/hypopnea index ⩾30 per hour). The visual sensitivities on SAP, ML thickness on OCT, and oxygenation status on PSG significantly improved 6 months after upper airway surgery in patients with severe OSA. Upper airway surgery may ameliorate the microstructures of the retina in patients with severe OSA.

Survival Outcomes for Advanced Cutaneous Squamous Cell Carcinoma of the Head and Neck

16-05-2019 – Christopher Blake Sullivan,Nicholas S. Andresen,Nicholas Kendell,Zaid Al-Qurayshi,Nitin A. Pagedar

Journal Article

Survival outcomes for advanced non-melanoma skin cancers of the head and neck treated with surgical resection are not well described in the literature. We aimed to describe outcomes for T3 and T4 cutaneoous squamous cell carcinoma of the head or neck treated with surgical resection at 1 tertiary academic medical center. We analyzed a retrospective cohort of patients diagnosed with T3 or T4 cutaneous squamous cell carcinoma (SCC) of the head or neck from 2005 to 2016 treated with definitive surgical resection. Survival outcomes were examined using Kaplan-Meier analysis, and multivariate analysis was completed with Cox proportional hazard model. Forty-three patients met inclusion criteria. The mean age at diagnosis was 74.7 years (SD = 10.2), and 34 (79.1%) patients were male. Twelve (27.9%) patients were immunosuppressed. Radical resection, defined as temporal bone resection, orbital exenteration, calvarial resection, mandibulectomy, or maxillectomy, was performed in 25 (58.1%) cases. Final surgical margins were positive in 19 (44.2%) cases. Patients with tumors of the scalp/neck had a 1-year survival probability of 85.7%, and the probability of survival 1 year after a neck dissection was greater than 93%. Anatomical subsites, specifically scalp/neck tumors, tended to have worse overall survival. Positive final margins tended to indicate a worse prognosis, and overall survival and recurrence were not significantly different among patients who underwent radical surgical resection compared to soft tissue resection.

Nasolacrimal Duct Management During Endoscopic Sinus and Skull Base Surgery

15-05-2019 – Janine M. Rotsides,Alexa Franco,Abdullah Albader,Roy R. Casiano,Seth M. Lieberman

Journal Article

To evaluate rates of epiphora after transection and marsupialization of the nasolacrimal duct (NLD) during endoscopic sinus and skull base surgery. The nasolacrimal canal forms part of the medial wall of the maxillary sinus. Transecting the NLD is sometimes necessary for tumor resection or surgical access to maxillary sinus and infratemporal fossa pathology. There is no consensus for the endoscopic management of the NLD when only the duct is transected without involving the nasolacrimal sac. Medical records of 29 patients from 2 academic institutions who underwent endoscopic sinus and skull base surgery with transection of the NLD were retrospectively reviewed. Whether the duct was marsupialized or simply transected was recorded, and the postoperative rate of epiphora was calculated. Mean age was 59 years (range, 14-86 years). Mean follow-up was 10.5 months (range, 1-33 months). The NLD was marsupialized in 16 (55%) and simply transected in 13 (45%) patients. Six patients underwent postoperative radiation. No patients in the marsupialization group had epiphora postoperatively, all with Munk score of 0. One patient in the transection group developed postoperative epiphora with Munk score of 1. Pathology included inverted papilloma (8), acute on chronic inflammation (6), B-cell lymphoma (3), juvenile nasopharyngeal angiofibroma (2), squamous cell carcinoma (2), Schneiderian papilloma (2), metastatic melanoma (1), HPV-related carcinoma (1), adenocarcinoma (1), benign epithelial cyst (1), adenoid cystic carcinoma (1), and erosive chronic sinusitis without nasal polyposis (1). Management after transection of the NLD varies widely. The duct may be simply transected or marsupialized, or a formal dacryocystorhinostomy can be performed. The surgeon must also choose whether to place a stent. Based on our small series and review of the literature, marsupialization or simple transection of the NLD results in a low rate of postoperative epiphora in the setting of endoscopic sinus and skull base surgery.

Quantification of Voice Type Components Present in Human Phonation Using a Modified Diffusive Chaos Technique

14-05-2019 – Boquan Liu,Evan Polce,Hayley Raj,Jack Jiang

Journal Article

Signal typing has been used to categorize healthy and disordered voices; however, human voices are likely comprised of differing proportions of periodic type 1 elements, type 2 elements that are periodic with modulations, aperiodic type 3 elements, and stochastic type 4 elements. A novel diffusive chaos method is presented to detect the distribution of voice types within a signal with the goal of providing an objective and clinically useful tool for evaluating the voice. It was predicted that continuous calculation of the diffusive chaos parameter throughout the voice sample would allow for construction of comprehensive voice type component profiles (VTCP). One hundred thirty-five voice samples of sustained /a/ vowels were randomly selected from the Disordered Voice Database Model 4337. All samples were classified according to the voice type paradigm using spectrogram analysis, yielding 34 type 1, 35 type 2, 42 type 3, and 24 type 4 voice samples. All samples were then analyzed using the diffusive chaos method, and VTCPs were generated to show the distribution of the 4 voice type components (VTC). The proportions of VTC The diffusive chaos method demonstrates proficiency in generating comprehensive VTCPs for disordered voices with varying severity. In contrast to acoustic parameters that provide a single measure of disorder, VTCPs can be used to detect subtler changes by observing variations in each VTC over time. This method also provides the advantage of quantifying stochastic noise components that are due to breathiness in the voice.

Stapedectomy Is Rewarding: But How to Prove It?

13-05-2019 – Johanna Wickemeyer,Virginie Achim,Miriam Redleaf

Journal Article

To demonstrate that neurotologists enjoy performing stapedectomies. A group of survey recipients consisting of 174 neurotologists who perform stapedectomy, a nonoverlapping control group of 145 head/neck oncologists who perform parotidectomy, and a second nonoverlapping control group of 365 pediatric otolaryngologists who perform tonsillectomy. Responses to surveys distributed by electronic mail to the 3 nonoverlapping recipient groups during nonoverlapping 4-week periods. During the 4-week survey periods, 84 of 174 neurotologists (48%) responded, while 33 of 145 oncologists (23%) and 87 of 365 pediatric otolaryngologists (24%) responded. Most neurotologists performed stapedectomy (80/84; 95% of survey responders), while 33 of 33 (100% of survey responders) oncologists performed parotidectomy and 87 of 87 (100% of survey responders) pediatric otolaryngologists performed tonsillectomy. Seventy-six of the 80 neurotologists who performed stapedectomies (95%) enjoyed performing it, slightly more than the 30 of the 33 oncologists who performed parotidectomies (91%) and appreciably more than the 67 of 87 pediatric otolaryngologists who performed tonsillectomies (77%). Twenty-three neurotologists (30%) would sacrifice vacation time to perform additional stapedectomies, slightly more than 8 oncologists (27%) for additional parotidectomies and more than the 7 pediatric otolaryngologists (10%) for additional tonsillectomies. Ten (13%) of the neurotologists, 3 (9%) of the oncologists, and 1 (2%) of the pediatric otolaryngologists would sacrifice 5 or more vacation days to perform more of the procedures. Our data suggest that neurotologists enjoy performing stapedectomy.

Perceived Preparedness of Facial Plastic Surgery Fellows Over Time: A Survey of AAFPRS Fellowship Directors

13-05-2019 – Tsung-yen Hsieh,Daniel Columcille O’Brien,Jonathan Sykes,Lane Darwin Squires

Journal Article

Assess the effects of American Council for Graduate Medical Education (ACGME) resident work hour restrictions on the preparedness of incoming facial plastic surgery fellows as assessed by American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) fellowship directors. Observational survey study evaluating the perception of ACGME resident duty hour change on resident surgical and clinical skills from fellowship directors of AAFPRS fellowship programs in the US. A cross-sectional survey was sent to 47 fellowship directors of AAFPRS fellowship programs. Perceived change in resident clinical and surgical skills were measured using a 5-point Likert scale (1 = significantly improved, 2 = improved, 3 = neither improved nor worsened, 4 = worsened, 5 = significantly worsened) to evaluate 15 benchmarks. Responses received from 36 fellowship directors. The results indicate no statistically significant perceived trend of ACGME duty hour reform on fellows for AAFPRS fellowships among fellowship directors. However, cohort analysis demonstrated that fellowship directors with more than 10 years of service perceived a more negative impact in 2 clinical benchmarks (assessment/planning and basic exposure) over time. The study results appear to show no significant perceived trend over time on the effect of duty hour reform on fellows for AAFPRS fellowships among fellowship directors. However, there are some apparent opinion differences between fellowship directors separated by years of service, with more negative perceptions noted in 2 clinical areas by those with more than 10 years of service. This study is in line with the more recent literature that suggests a trend toward a less negative perception of the duty hour change. This may suggest resident education is adapting to the ACGME duty hour regulations.

Candidiasis Causing Vocal Fold Leukoplakia: Review of Clinical and Pathological Results of 289 Cases With Vocal Fold Leukoplakia

10-05-2019 – Murat Gumussoy,Ulku Kucuk

Journal Article

In laryngology practice, vocal fold leukoplakia is frequently evaluated by suspension laryngoscopy and biopsy examination upon the patient’s complaints of hoarseness and dysphonia. The purpose of the present study is to investigate and analyze risk factors, diagnosis, treatment, and follow-up results of cases with Candida leukoplakia. Retrospective case control study. Tertiary medical center. Patients with a diagnosis of vocal fold leukoplakia who underwent direct laryngoscopy and biopsy between 2007 and 2017 and diagnosed as candida or noncandida in their histopathology were assigned into 2 groups. Then they were compared in terms of their demographic characteristics, predisposing factors, diagnosis, treatment, and follow-up results. Of the 289 vocal fold leukoplakia cases, 36 were candida, and 253 were noncandida. The mean age of the patients with Candida leukoplakia was 60.86 years. As for the age groups, the largest group (26.1%) was in the seventh decade ( P < .001). The use of inhaled corticosteroids was a significant risk factor ( P < .001). For their medical therapy, the patients were administered fluconazole 200 mg per day for 3 weeks, and the treatment yielded successful results in 91.66% of them. In 5 of the patients, candida leukoplakia and superficial epithelial dysplasia were observed, and no malignant transformation was observed during a mean follow-up of 28 ± 13 months. Candidiasis causing vocal fold leukoplakia is rare, and we report the findings of the largest published case series to date. Eliminating predisposing factors and administrating oral fluconazole 200 mg for 3 weeks are sufficient for medical treatment.

Automatic Registration for Navigation at the Anterior and Lateral Skull Base

09-05-2019 – Julia Kristin,Manuel Burggraf,Dirk Mucha,Christoph Malolepszy,Silvan Anderssohn,Joerg Schipper,Thomas Klenzner

Journal Article

Navigation systems create a connection between imaging data and intraoperative situs, allowing the surgeon to consistently determine the location of instruments and patient anatomy during the surgical procedure. The best results regarding the target registration error (measurement uncertainty) are normally demonstrated using fiducials. This study aimed at investigating a new registration strategy for an electromagnetic navigation device. For evaluation of an electromagnetic navigation system and comparison of registration with screw markers and automatic registration, we are calculating the target registration error in the region of the paranasal sinuses/anterior and lateral skull base with the use of an electromagnetic navigation system and intraoperative digital volume tomography (cone-beam computed tomography). We carried out 10 registrations on a head model (total n = 150 measurements) and 10 registrations on 4 temporal bone specimens (total n = 160 measurements). All in all, the automatic registration was easy to perform. For the models that were used, a significant difference between an automatic registration and the registration on fiducials was evident for just a limited number of screws. Furthermore, the observed differences varied in terms of the preferential registration procedure. The automatic registration strategy seems to be an alternative to the established methods in artificial and cadaver models of intraoperative scenarios. Using intraoperative imaging, there is an option to resort to this kind of registration as needed.

Outcomes Using a Postoperative Protocol in Pediatric Single-Stage Laryngotracheal Reconstruction

15-02-2019 – Prasad John Thottam,Taylor Gilliland,Nicholas Ettinger,Rahul Baijal,Deepak Mehta

Journal Article

The aim of this study was to evaluate single-stage laryngotracheal reconstruction (ss
LTR) outcomes before and after the implementation of a postoperative care protocol in pediatric patients. A case-control study with chart review was conducted at 2 tertiary academic centers from 2010 to 2016. Pediatric patients who underwent ss
LTR with a postoperative care protocol were compared with those who did not receive care under this protocol. Data regarding perioperative management were collected and compared using χ Nineteen patients completed ss
LTR after the protocol was initiated, and 26 prior patients were used as control subjects. Planned extubation failed in 9 patients (35%) in the control group compared with 1 patient (5%) in the protocol group ( P < .05). Using a structured protocol demonstrated a decrease in delayed extubation and intensive care unit stay ( P < .05). Despite more postprotocol patients' requiring posterior graft placement, preprotocol patients were less likely to be extubated within 7 days ( P < .05). The authors propose an intensive care unit protocol that uses a combination of pharmacologic agents to optimally reduce the risk for adverse events that delay time to extubation and thus decannulation. Timely extubation was more likely with the use of this postoperative care protocol using a multidisciplinary approach involving otolaryngologists, pharmacists, intensivists, and anesthesiologists.