European Archives of Oto Rhino Laryngology

European Archives of Oto Rhino Laryngology

A tiny retraction of the pars flaccida may conceal an attic cholesteatoma

04-12-2019 –

Abstract Objective The purpose of this study was to evaluate the possibility of attic cholesteatomas concealed within a tiny retraction of the pars flaccida (classification of Tos and Poulsen type I or II attic retraction) in patients with an intact pars tensa of the tympanic membrane. Methods The clinical records of patients with a tiny retraction of the pars flaccida and an intact pars tensa of the tympanic membrane who presented to the ear clinic of a tertiary care medical center for the first time between March 2012 and February 2015 were retrospectively reviewed. All patients who had an abnormal pars flaccida of the tympanic membrane were recommended to undergo temporal bone computed tomography (CT) scans. In cases of a soft tissue density lesion within Prussak’s space, an exploratory operation was recommended. Results Among 1320 adult patients, 146 patients (n = 168 ears) who had a tiny attic retraction with a normal pars tensa in unilateral or bilateral ears underwent temporal bone CT scans, and 18 ears had a soft tissue density lesion within Prussak’s space. Among the ears with a tiny retraction of the pars flaccida and a normal pars tensa, an attic cholesteatoma was suspected in 10.7% (n = 18 ears) of cases based on the CT scans. After exploratory operations, 2% of patients who underwent CT scans (3 out of 146 patients) and 23% of patients who had a soft tissue density lesion within Prussak’s space on CT scans (3 out of 13 operations) had an attic cholesteatoma. Conclusion All attic retractions which are even in cases of Tos type I or II should be examined closely using endoscopy, microscopy, and, if necessary, temporal bone CT scan.

Long-term residual hearing in cochlear implanted adult patients who were candidates for electro-acoustic stimulation

04-12-2019 –

Abstract Purpose To evaluate the long-term hearing outcomes in cochlear implanted adults with residual hearing at low frequencies, and the proportion of patients using electro-acoustic stimulation (EAS). Methods A monocentric retrospective cohort study was performed in a tertiary referral center. Population demographics, surgical approach, pre- and postoperative hearing at low frequencies, in the implanted and contralateral ear, were recorded as well as duration of EAS use. The percentage hearing preservation was calculated according to the formula S (HEARRING group). Results In total, 63 adults (81 ears) with residual hearing underwent cochlear implantation with intent to use EAS processors. Six different types of electrode array were implanted. The mean pure tone audiometry (PTA) shift after cochlear implantation was 16 ± 15 d
B HL (range 0–59 d
B HL). Half of the implanted ears had minimal hearing preservation or total hearing loss (HL) at 5.5 years and the cumulative risk of total HL was 50% at 7 years. During the follow-up, total HL occurred in 22 ears. The decrease in hearing levels was similar in both implanted and contralateral ear during follow-up (ns, F = 2.46 ± 3, Linear Mixed Model (LMM)). Only 44 patients found a benefit from EAS at the first fitting. At the last visit, EAS processors were fitted in 30% of the cases. The pre- and postoperative mean PTA thresholds were not predictive of EAS use (Cox’s proportional hazards analysis). Conclusions Postoperative residual hearing was observed in 93% of implanted ears, but only half of them had an initial benefit from EAS. No predictive factors were found to influence the use of EAS processors.

Sporadic and NF2-associated vestibular schwannoma surgery and simultaneous cochlear implantation: a comparative systematic review

04-12-2019 –

Abstract Purpose Cochlear implantation (CI) in patients with sensorineural hearing loss caused by a vestibular schwannoma (VS) represents a unique subtype of hearing rehabilitation, as the outcome may be compromised by vestibulocochlear nerve injury as part of the natural VS history or due to iatrogenic trauma induced by surgical tumor removal. This paper aims to review and report contemporary knowledge and practice regarding feasibility and outcomes of simultaneous vestibular schwannoma resection and cochlear implantation to serve as a reference and guide for future surgery and studies. Methods The current literature was searched systematically according to the PRISMA guidelines and after criteria-based selection, 29 studies were identified, including a total of 86 patients who had undergone surgical resection of a vestibular schwannoma and subsequent cochlear implantation in a single procedure. Results The postoperative outcomes were reported with a high degree of heterogeneity, hindering a proper meta-analysis. However, pooling those cases with reported speech discrimination outcomes demonstrated mean scores equivalent to moderate-to-high performance. A few cases had no audibility. A positive cochlear nerve test result was not a secure positive predictor of success. Complications were rare. Conclusion NF2-associated and sporadic VS had good and comparable postoperative outcomes despite significant differences in tumor size, location and surgical approach.

Deep neck space infections: an upward trend and changing characteristics

03-12-2019 –

Abstract Purpose This study reviews our experience with deep neck space infections (DNIs) requiring surgical intervention, including cervical necrotizing fasciitis. The aim of the study was to identify predisposing and aggravating factors of the disease and recognize the possible factors that can lead to life-threatening complications and slow down the healing process. Methods We compare the results to previous data from 1985 to 2005 to find possible alterations and changing trends. The characteristics of four lethal cases are described. This retrospective analysis includes patient data from 2004 to 2015 in tertiary referral hospital and in total, 277 patients were found. Results Surgical drainage through a neck opening ± intraoral incision was made in 215 (77.6%) patients, an intraoral incision was only made in 62 patients (22.4%). ICU care was needed in 66 (23.8%) cases. Odontogenic etiology (44.8%) was the most common origin. The most common comorbidity was a psychiatric disorder and/or dementia and occurred in 55 (19.9%) patients. Patients with underlying illnesses were more likely to be admitted to the ICU (p = 0.020), required a longer ICU stay (p = 0.004) and repeated surgery (p = 0.009). Gas formation seemed to be predictive of a more severe course of infection. Early extraction of the odontogenic foci was related to a lower length of stay (LOS) (p = 0.039). Conclusion The annual numbers have risen from 14 to 24 cases per year when compared to previous data. DNIs remain a cause of lethal complications; the mortality was 1.4% and overall complications occurred in 61 (22.0%) patients.

Efficacy of prophylactic central neck dissection in hemithyroidectomy for papillary thyroid carcinoma

02-12-2019 – SH Jin,IS Kim,YB Ji,CM Song,MS Chung,K Tae

Journal Article

Abstract Purpose To evaluate the efficacy of prophylactic central neck dissection (p
CND) in hemithyroidectomy for clinically node-negative papillary thyroid carcinoma (PTC). Methods We retrospectively analyzed 299 patients who underwent thyroid lobectomy with or without p
CND for unilateral PTC. Of the 299 patients, 245 (81.9%) underwent unilateral p
CND along with lobectomy, and 54 (18.1%) patients underwent lobectomy without p
CND. Propensity score matching was performed for five covariates to reduce selection bias. Results In the baseline cohort of 299 patients, mean age, extrathyroidal extension, T classification and stage were higher in the cases undergoing p
CND than in those not undergoing p
CND. After propensity score matching, the significant differences between the two groups seen in the baseline cohort disappeared. Recurrence rates and recurrence-free survival curves did not differ between the 2 matched groups each of 54 patients. Conclusion The value of p
CND in hemithyroidectomy for PTC is limited.

Risk factors of metastasis to the lymph nodes posterior to the right recurrent laryngeal nerve in papillary thyroid carcinoma

02-12-2019 – J Hou,H Shan,Y Zhang,Y Fan,B Wu

Journal Article

Abstract Purpose To investigate the risk factors of lymph node posterior to the right recurrent laryngeal nerve (LN-pr
RLN) metastasis in papillary thyroid carcinoma. Methods Clinicopathologic feature data of 427 patients with right or double lobes who underwent surgery between January 2014 to August 2019 in the Department of General Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, were retrospectively analyzed. The risk factors of LN-pr
RLN metastasis were analyzed by the Chi-squared test and multivariate logistic regression. Results LN-pr
RLN metastasis was detected in 96 patients. Univariate analysis showed that age, right-side tumor diameter, capsular invasion, comorbid adenoma, and VIa compartment LN metastasis were significantly associated with LN-pr
RLN metastasis (all P < 0.05). Multivariate logistic regression analysis showed that right-side tumor diameter, capsular invasion, and VIa compartment LN metastasis were independent risk factors of LN-pr
RLN metastasis (all P ≤ 0.001). The receiver operating characteristic curve showed that the cutoff value of the right tumor diameter for predicting LN-pr
RLN metastasis was 1.25 cm (sensitivity = 0.5, specificity = 0.819, area under the curve = 0.720, P < 0.001). Conclusion The incidence of LN-pr
RLN metastasis cannot be ignored, and our findings indicate that prophylactic LN-pr
RLN dissection should be performed in patients with right-side tumor diameter ≥ 1.25 cm, capsular invasion, and VIa compartment LN metastasis.

Role of endoscopy in lateral skull base approaches to the petrous apex

02-12-2019 – D Marchioni,L Gazzini,M Bonali,N Bisi,L Presutti,A Rubini

Journal Article

Abstract Objective The aim of this article is to study the role and advantages of combined microscopic/endoscopic procedures or exclusive endoscopic approaches in the treatment of petrous apex pathologies. Methods The study was designed as a retrospective case series analysis. We included patients affected by pathologies of the petrous apex, who underwent microscopic/endoscopic-assisted or exclusive endoscopic procedures. Patient and pathology characteristics and surgical data (focusing on the involvement of the internal carotid artery (ICA) and facial nerve by the disease) were collected. Residual disease, detected through the endoscopic check, and the feasibility of endoscopic residual tumor removal were also evaluated. Finally, facial nerve and hearing functions were assessed pre- and postoperatively. Results The records of 75 patients undergoing lateral skull base surgery for petrous apex lesions, from May 2009 to March 2019, were collected. In 17 out of 75 patients, an exclusive endoscopic procedure was possible. The remaining 58 patients underwent a combined microscopic/endoscopic approach. In 15 cases, residual disease was found and removed endoscopically at the end of the microscopic procedure; in eight cases, the residual disease was medial and/or inferior to the horizontal segment of the ICA, while in two cases, it was located in the fundus of the internal auditory canal. In five cases, it involved the labyrinthine segment of the facial nerve. Conclusion Petrous apex surgery remains a traditional microscopic-based surgery, but the recent advent of endoscopic surgery has permitted an improvement in radicality minimizing the manipulation of neurovascular structures.

Assessment of the prelacrimal recess in maxillary sinus in different sex and age groups using cone beam computed tomography (CBCT)

02-12-2019 – Z Chen,J Wang,Q Wang,Q Lu,Z Zheng

Journal Article

Abstract Background The intranasal endoscopic prelacrimal recess approach (PLRA) to the maxillary sinus (MS) has been reported to treat many MS and skull base diseases. However, previous studies revealed that the width of the prelacrimal recess (PLR) shows a large individual variation. The purpose of this study was to ascertain the prevalence of the PLR in MS according to gender and age. Methods A series of 701 maxillofacial cone beam computed tomography (CBCT) scans from adult patients were analyzed retrospectively. Patients were divided into five age groups (18–24 years, 25–34 years, 35–44 years, 45–54 years, and ≥ 55 years) and by sex. The frequencies of occurrence of the PLR in the MS were calculated and compared. Results According to the findings obtained from our study, PLR was present in 81.5% of maxillary sinuses. No differences were found when the data distributions of right and left sides were compared. For individuals, the right and left sides were not always symmetrical. The probability of PLR was lesser among women than among men, but this differences was not significant. Another finding of our study was that the percentage of PLR decreased with increasing age among patients aged < 55 years, however, increased again among patients aged ≥ 55 years. Conclusion The anatomy of PLR varies among individuals. Careful analysis of individual anatomical structure characteristic is recommended when considering intranasal endoscopic PLRA to the MS. Besides, the age variation of PLR should be considered in order to avoid complications.

Blocking long noncoding RNA MALAT1 restrained the development of laryngeal and hypopharyngeal carcinoma

02-12-2019 – E Xu,X Liang,Z Ji,S Zhao,L Li,J Lang

Journal Article

Abstract Purpose The long non-coding RNA MALAT1 is a predictive marker in several solid tumors with highly conserved sequences. However, the role of non-coding RNA in development of laryngeal or hypopharyngeal cancer remains unclear. Methods Tumor tissues and adjacent non-cancer tissues of 24 patients were collected. We detected the expression of MALAT1 in laryngeal cancer tissues and hypopharyngeal cancer tissues. Moreover, we developed a MALAT1 silencing model in human laryngeal tumor cells by transfecting MALAT1 small interfering RNA into human laryngeal carcinoma cell line Hep-2 and pharyngeal carcinoma cell line Fa
Du with Lipofectamine 2000 system. Cell cycle analysis, Cell Counting Kit-8 assay, Transwell assay, quantitative reverse transcription PCR, and wound-healing assays were performed to evaluate the impact of MALAT1 depletion on laryngeal or hypopharyngeal cancer cell’s growth, proliferation, apoptosis, invasion and migration. Results MALAT1 was significantly up-regulated in laryngeal and hypopharyngeal carcinoma cells. MALAT1 down-regulation induced the increased apoptosis of both cell lines and suppressed cells’ proliferation. Cells were arrested in G1/G2 phase and cells of S phase were significantly decreased. Down-regulation of MALAT1 expression can also inhibit the migration and invasion of laryngeal squamous cell carcinoma cell (Hep-2) and hypopharyngeal cancer cell (Fa
Du). Conclusion In summary, our deactivation model of MALAT1 disentangled the active function of it as a regulator of gene expression governing the hallmarks of laryngeal and hypopharyngeal cancer. Blocking this long non-coding RNA may restrain the development of laryngeal cancer.

Topical Collection: Sleep apnea syndrome: from the pathogenesis to the last therapies

01-12-2019 –


Correction to: Is there a relation between sudden sensorineural hearing loss and white matter lesions?

01-12-2019 – M Fusconi,G Attanasio,F Capitani,E Di Porto,D Diacinti,I Musy,M Ralli,G Ralli,A Greco,M de Vincentiis,C Colonnese

Published Erratum

In the original publication, fifth author’s surname was incorrectly published as “Diacinto”. The correct surname should read as “Diacinti”.

Aging effect on sleepiness and apneas severity in patients with obstructive sleep apnea syndrome

01-12-2019 – GJ Huang


Regenerating gene 1A single-nucleotide polymorphisms and nasopharyngeal carcinoma susceptibility

01-12-2019 – S Yasri,V Wiwanitkit


Ex-vivo surgical model for “Barbed Snore Surgery”: a feasibility study

01-12-2019 – V Rinaldi,A Costantino,A Moffa,M Casale

Journal Article

Abstract Introduction The “Barbed Snore Surgery” is one of the last technical innovations in palatal surgery for Obstructive Sleep Apnea. The availability of a low-cost surgical model able to replicate tissue consistency and main anatomical structures could be fundamental for the spreading of this surgery. The aim of this study was to assess the feasibility of an ex-vivo ovine model in the surgical training of BSS. Methods After adequate preparation of adult lamb heads, a post-graduate student with no surgical expertise was guided by a skilled surgeon in the execution of two BSS procedures: “Barbed Roman Blinds Technique” and “Barbed Anterior Pharyngoplasty”. Anatomical limitations and similarity with the human tissue were assessed and recorded during the simulation. Results All the procedures were successfully completed. Despite proportional differences, the palatal tissue was assessed as similar in consistency and thickness to the human tissue. The simulation was considered satisfactory and suitable for surgical training. Conclusion This ex-vivo ovine surgical model could represent the right tool for BSS training thanks to readily available and inexpensive specimens. Moreover, it appears to present the realistic anatomy and tissue consistence essential for an adequate surgical simulation.

In response to the ‘Letter to the Editor’ on the paper ‘Aging effect on sleepiness and apneas severity in patients with obstructive sleep apnea syndrome: a meta-analysis study’

01-12-2019 – G Iannella,G Magliulo,A De Vito,C Vicini


Development of scores assessing the refluxogenic potential of diet of patients with laryngopharyngeal reflux

01-12-2019 – JR Lechien,F Bobin,F Mouawad,K Zelenik,C Calvo-Henriquez,CM Chiesa-Estomba,N Enver,A Nacci,MR Barillari,A Schindler,L Crevier-Buchman,S Hans,V Simeone,E Wlodarczyk,B Harmegnies,M Remacle,A Rodriguez,D Dequanter,P Eisendrath,G Dapri,C Finck,P Karkos,H Pendleton,T Ayad,V Muls,S Saussez

Journal Article

Abstract Objective To develop clinical tools assessing the refluxogenic potential of foods and beverages (F&B) consumed by patients with laryngopharyngeal reflux (LPR). Methods European experts of the LPR Study group of the Young-Otolaryngologists of the International Federation of Oto-rhino-laryngological societies were invited to identify the components of Western European F&B that would be associated with the development of LPR. Based on the list generated by experts, four authors conducted a systematic review to identify the F&B involved in the development of esophageal sphincter and motility dysfunctions, both mechanisms involved in the development of gastroesophageal reflux disease and LPR. Regarding the F&B components and the characteristics identified as important in the development of reflux, experts developed three rational scores for the assessment of the refluxogenic potential of F&B, a dish, or the overall diet of the patient. Results Twenty-six European experts participated to the study and identified the following components of F&B as important in the development of LPR: p
H; lipid, carbohydrate, protein composition; fiber composition of vegetables; alcohol degree; caffeine/theine composition; and high osmolality of beverage. A total of 72 relevant studies have contributed to identifying the Western European F&B that are highly susceptible to be involved in the development of reflux. The F&B characteristics were considered for developing a Refluxogenic Diet Score (REDS), allowing a categorization of F&B into five categories ranging from 1 (low refluxogenic F&B) to 5 (high refluxogenic F&B). From REDS, experts developed the Refluxogenic Score of a Dish (RESDI) and the Global Refluxogenic Diet Score (GRES), which allow the assessment of the refluxogenic potential of dish and the overall diet of the LPR patient, respectively. Conclusion REDS, RESDI and GRES are proposed as objective scores for assessing the refluxogenic potential of F&B composing a dish or the overall diet of LPR patients. Future studies are needed to study the correlation between these scores and the development of LPR according to impedance–p
H study.

Effects of pentoxifylline and tocopherol on a rat-irradiated jaw model using micro-CT cortical bone analysis

01-12-2019 – TTH Nguyen,MY Eo,MH Seo,H Myoung,SM Kim,JH Lee

Journal Article

Abstract Purpose A combination of pentoxifylline (PTX) and tocopherol (TP) is believed to reduce chronic fibrosis and induce bone healing in osteoradionecrosis (ORN) of the mandible, but evidence of its therapeutic effectiveness for cortical bone is lacking. This study was designed to determine the effect of combined PTX and TP (PTX + TP) on mandibular cortical bone remodeling in a rat model of ORN, using micro-CT and histological analysis. Methods Forty-eight 8-week-old male Sprague–Dawley rats were randomly divided into irradiated (n = 40) and non-irradiated (n = 8) groups. Animals in the irradiated group were divided into four sub-groups, including PTX, TP, PTX + TP, and normal saline. Three weeks after irradiation, mandibular posterior tooth extraction was performed, and animals were sacrificed 7 weeks after irradiation. The mandibles were analyzed using micro-CT and histological evaluation. Results The alveolar bone height, cortical bone thickness, cortical bone volume, and total cortical bone surface of the PTX + TP group were significantly greater than those of other irradiated groups (p < 0.05). In 3D reconstructed images, the residual volumes of cortical and cancellous bone were inadequate in the irradiated groups. Conclusion We found that a combination of PTX and TP improved quality and quantity of cortical bone in irradiated rat mandibles, thus providing supporting evidence of its utility as a treatment and prophylactic agent in ORN. We observed inadequate volumes of cortical and cancellous bone in ORN mandibles, suggesting that cortical bone could play an important role in further ORN studies.

Outcomes of endoscopic transcanal type 1 cartilage tympanoplasty

01-12-2019 – D Özdemir,A Özgür,G Akgül,M Çelebi,DM Mehel,T Yemiş

Journal Article

Abstract Purpose We aimed to evaluate air–bone GAP (ABG), graft success and hearing gain according to the size and location of perforation in patients who underwent endoscopic transcanal type 1 cartilage tympanoplasty due to the tympanic membrane perforation and chronic otitis media. Methods The 104 patients (52 male and 52 female) who underwent endoscopic transcanal type 1 cartilage tympanoplasty, were evaluated retrospectively. Tragal cartilage grafts were utilized in all patients. Perforation size/location, duration of surgery, pre-operative and post-operative (6th month) average ABG, and pure-tone audiometric results (at 500–1000–2000–4000 Hz) as well as overall graft success were evaluated. Results The mean duration of surgery was 45.60 ± 17.39 min. Perforations were most frequently located in anterior quadrant with moderate sized. The post-operative air-conduction results were significantly improved at 500–1000–2000–4000 Hz frequencies. Similarly, pre-operative air-conduction pure-tone average (PTA) (35.36 ± 11.9 d
B) was significantly decreased (22.34 ± 7.9 d
B) after postoperative 6 months (p ≤ 0.001). The overall graft success rate was 93.2%. Moreover, pre-operative mean ABG (19.82 ± 7.4 d
B) was significantly decreased (9.05 ± 4.3 d
B) after postoperative 6 months (p ≤ 0.001). Conclusions Endoscopic transcanal type 1 cartilage tympanoplasty achieved a high graft success rate, and improved hearing results, regardless of the perforations location and size. Endoscopic tympanoplasty provides high patient safety and comfort in middle-ear surgery by wide visualization, easy applicability, short-operation duration, low complication risk, and less invasive approach.

Prospective evaluation of oral corticosteroid as a predictor of postoperative olfactory recovery after functional endoscopic surgery for nasal polyposis

01-12-2019 – P Rives,F Espitalier,G Michel,X Blanc,C Fortun,O Malard

Journal Article

Abstract Purpose Anticipating the possibility of olfactory recovery after functional endoscopic surgery (FES) in nasal polyposis (NP) is difficult. The main objective of this study was to assess the predictive factors of recovering the sense of smell after radical bilateral ethmoidectomy. Secondary objectives were to identify other predictors of olfactory recovery. Methods Open prospective study was conducted at the Nantes University Hospital including all patients with NP operated on in the Ear, Nose, and Throat Department between January 2011 and September 2017. These patients underwent functional endoscopic surgery (radical ethmoidectomy) after medical treatment failure. Olfaction was quantified prospectively and systematically during the preoperative consultation using a visual analog scale. Multivariate analysis evaluated the presence of predictive factors of postoperative olfactory recovery. Results One hundred nineteen patients were included in the study. Overall, olfaction was partially improved after surgery. For patients who presented greater than 50% recovery of olfaction after systemic corticosteroid therapy before surgery, we observed a predictive better rate of olfactory recovery after surgery (p < 0.001). Age over 65 years, a history of sinonasal surgery, associated asthma, and bacterial colonization were not associated with less postoperative olfactory recovery. Conclusion This study identified an objective factor that may influence olfactory recovery after FES using a therapeutic trial for olfactory recovery after oral corticosteroid treatment taken before surgery.

Transoral robotic tongue base reduction and supraglottoplasty combined with maxillomandibular advancement: a new option for selected sleep apnea patients? Preliminary report

01-12-2019 – I Dallan,L Cristofani-Mencacci,V Seccia,C Cambi,G Fiacchini,S Berrettini,B Brevi

Journal Article

Abstract Purpose Transoral robotic surgery (TORS) and maxillo-mandibular advancement (MMA) are effective options for obstructive sleep apnea patients. Identification of the correct candidate is by far the most important item in achieving a succesful outcome. As a consequence, not all patients can be managed successfully via one or the other procedure. To overcome the limits of any single procedure we have combined, in a very selected population of patients, TORS tongue base reduction and MMA. Preliminary data are encouraging, in terms of both AHI and ESS. Methods A retrospective cohort study was conducted on five patients treated with combined TORS-MMA surgery. Demographic and clinical data, pre-operative and post-operative PSG and ESS were collected. Results Three of five patients were recruited. All patients presented severe OSAHS. Mean AHI and ESS went respectively from 48 and 12 pre-operatively to 19 and 4 post-operatively. Minor bleeding occurred in two patients. No significant sequelae have been reported. Conclusions Combined TORS and MMA is feasible and safe. Our very preliminary data are encouraging, in terms of both AHI and ESS. Long-term follow-up and a larger amount of subjects are needed to confirm this surgical approach as a valuable option for selected OSAHS patient.