European Archives of Oto Rhino Laryngology

Influence of proton pump inhibitor therapy on occurrence of voice prosthesis complications

17-01-2020 –

Abstract Purpose It has been shown that the reflux of the gastric content to the proximal oesophagus influences incidence of voice prosthesis (VP) complications in laryngectomized patients. We conducted prospective randomised study to investigate the relationship between pepsin concentration in saliva and occurrence of VP complications before and after 3 months of proton pump inhibitor (PPI) therapy. Methods 60 laryngectomized patients with VP and 30 controls were included in the study. Saliva samples were collected in the morning and concentration of pepsin were measured by Human Pepsin (PG) ELISA kit. Thirty-Four (57%) patients reported one or more VP complication and were randomised in two groups, with and without PPI therapy, 40 mg pantoprazole per day for 3 months. Results Patients who had longer time since last VP change had higher incidence of periprosthetic and transprosthetic leakage and Candida colonisation. Pepsin was found in all saliva samples. Median saliva pepsin concentration level did not significantly differ between laryngectomized patients and control subjects, or between patients with and without VP complications, and there was no correlation between saliva pepsin concentration levels and type of VP complication. After 3 months therapy, there was no difference in median saliva pepsin level or incidence of VP complication between patients with and without PPI therapy. Conclusion Although reflux was proposed to be associated with VP complications and pepsin was proven as a most sensitive and specific marker of EER, we did not find any statistically significant correlation between pepsin levels and occurrence of VP complications. A 3 months 40 mg pantoprazole therapy was ineffective in reduction of VP complications in our study group.

Modified facelift approach for posterior segmental mandibulectomy: a blend of oncology and cosmesis

16-01-2020 –

Abstract Background The approach to the mandible for segmental resection in malignant pathologies entails a lip-split, angle-split or visor flap incision with extension of the incision into the neck for performing neck dissection. The modified facelift approach with robot-assisted neck dissection can be used to achieve oncologically safe resections with good cosmesis. Methods Three patients meeting the inclusion criteria underwent the procedure at the Robotic facility of HCG Cancer Centre, Bangalore. Results The patients were analyzed on the basis of bone defect length, the margin status of primary, functional and aesthetic outcomes. One patient had wound dehiscence and needed secondary suturing. At 6 months, patients were satisfied with the aesthetic outcomes and functional results Conclusion Modified facelift approach is a feasible procedure ensuring better cosmesis without compromising oncological outcomes

Predicting the factors associated with central lymph node metastasis in clinical node-negative (cN0) papillary thyroid microcarcinoma

13-01-2020 – C Zhang,BJ Li,Z Liu,LL Wang,W Cheng

Journal Article

Abstract Purpose The aim of the present study was to investigate the risk factors associated with central lymph node metastasis (CLNM) in papillary thyroid microcarcinoma (PTMC). Methods A total of 553 patients with PTMC confirmed by histological examination, who underwent thyroidectomy and central neck dissection (CND), were enrolled. The clinicopathological and ultrasonographic features from the patients were analyzed retrospectively. Results PTMC patient age, Hashimoto thyroiditis (HT), tumor location, extrathyroidal extension (ETE), microcalcification and higher E values were correlated with the incidence of CLNM. Multivariate logistic regression analysis showed that age, HT, tumor location, ETE and Emax were related to the extent of CLNM. Chi-squared automatic interaction detection (CHAID) classification tree model showed that patients with tumor in upper/lower third combined ETE had a high risk of CLNM. Furthermore, c
N0 PTMC patients with age ≤ 45 years and ETE had more extensive CLNM. Conclusion Our observations could be helpful for the assessment of prognostic factors of PTMC patients with CLNM.

Application of 3D reconstruction for midline glossectomy in OSA patients

13-01-2020 – H Lu,J Qin,R Yue,C Liu,S Li,D Wu

Journal Article

Abstract Objective To explore the application of three-dimensional (3D) reconstruction technology for midline glossectomy in patients with obstructive sleep apnea (OSA). Methods Fifteen patients with OSA were included in this study. Each of them received computed tomography angiography (CTA) examination of lingual arteries in the resting tongue position and fully extended tongue position respectively. The two-dimensional CTA images were converted to 3D models using 3D reconstruction technology. We simulated the midline glossectomy in different tongue positions with a safe margin of 3 mm. The differences in the distances between bilateral lingual arteries, the depths of the lingual arteries and the surgical resectable volumes of the tongue were compared between different tongue positions in 3D models. Results The depths of the lingual arteries, the distances between bilateral lingual arteries based on three measuring sections and the surgical resectable volumes of the tongue in the fully extended tongue position were significantly smaller than those in the resting tongue position (P < 0.01 or 0.05). Conclusion The 3D reconstruction technology can show the course of lingual artery stereoscopically and visually, and can be more beneficial to guide surgery than two-dimensional examination. Lingual artery examination in the fully extended tongue position has higher specificity in displaying intraoperative actual situation.

Risk factors predisposing for recurrent laryngeal nerve palsy following thyroid malignancy surgery: experience from a tertiary oncology centre

11-01-2020 – SS Nayyar,S Thiagarajan,A Malik,A Chakraborthy,P Velayutham,D Chaukar

Journal Article

Abstract Background Postoperative recurrent laryngeal nerve (RLN) palsy is one of the major morbidities encountered after thyroid surgery. The risk further increases when surgery is performed for thyroid malignancies. Methodology A retrospective study of patients who underwent hemi, total or completion thyroidectomy at our institute between June 2017 to May 2019 were analyzed. We assessed factors that predisposed to the development of RLN palsy. Results The study comprised of 228 patients. A total of 400 nerves were at risk. The RLN palsy rate was 6.8% (n = 27). On univariate and multivariate analysis, the risk of RLN palsy was seen most with p
T4a tumor (OR = 8.5), gross extra-thyroidal extension (ETE) (OR = 3.5) and tracheo-esophageal groove (TEG) (OR = 2.8) involvement, followed by aggressive histopathology, and central compartment node positivity. Conclusion p
T4a tumors, gross ETE, and TEG involvement were the leading causes predisposing for the development of RLN palsy in our series.

The novel indicators of moderate to severe sleep apnea: fibrinogen to albumin ratio vs. CRP to albumin ratio

09-01-2020 – O Hizli,S Cayir,Y Coluk,S Kayabasi,G Yildirim

Journal Article

Abstract Purpose This study aimed at investigating the association of severity of obstructive sleep apnea with the markers of inflammation as fibrinogen to albumin ratio and C-reactive protein to albumin ratio. Methods We included 126 patients admitted to sleep disorders outpatient clinic. We constituted four groups by reference to the apnea–hypopnea index (mild-moderate-severe sleep apnea and control group). We investigated the difference of white blood cell, fibrinogen to albumin ratio, C-reactive protein to albumin ratio, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, and hemoglobin among the groups. Results Neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, and hemoglobin did not significantly differ among four groups (p = 0.39, p = 0.06, and p = 0.31, respectively). A significant difference of fibrinogen to albumin ratio and C-reactive protein to albumin ratio was evident among four groups (p < 0.001). Fibrinogen to albumin ratio and C-reactive protein to albumin ratio did not significantly differ between the mild sleep apnea and control groups (p = 0.65, and p = 0.85, respectively), but were significantly greater in moderate sleep apnea group compared with the control group (p < 0.001 and p = 0.001, respectively). Also, fibrinogen to albumin ratio and C-reactive protein to albumin ratio were significantly greater in the severe sleep apnea group compared with the control group (p < 0.001). Fibrinogen to albumin ratio and C-reactive protein to albumin ratio did not significantly differ between the severe sleep apnea and moderate sleep apnea groups (p = 0.49, and p = 0.58, respectively). Conclusion Higher fibrinogen to albumin ratio and C-reactive protein to albumin ratio may be predictive of inflammation in patients with moderate-to-severe sleep apnea.

Feasibility of ovine and porcine models for simulation training in parotid surgery and facial nerve dissection

08-01-2020 – TD Milner,S Okhovat,M McGuigan,WA Clement,T Kunanandam

Journal Article

Abstract Purpose To assess and compare the feasibility of using ovine and porcine models as surgical simulation training tools for otolaryngology trainees performing parotid surgery and facial nerve dissection. Methods Trainees performed parotid surgery (total parotidectomy, retrograde facial nerve dissection and facial nerve grafting) on an ovine and porcine model. Participants completed a 22-item, five-point Likert scale questionnaire on each model, assessing three validation domains; face validity (FV), global content validity (GCV) and task-specific content validity (TSCV). Data were prospectively collected and analysed using descriptive and non-parametric statistics. Results Twelve trainees completed two consecutive parotidectomies and facial nerve dissections on an ovine and porcine model. Twenty-four dissections were completed. Validation questionnaires were completed for each model by all trainees. The ovine model achieved median validation threshold scores (≥ 4/5) for all aspects of FV, GCV and TSCV. The porcine model did not achieve validation threshold scores for any aspect of the validation questionnaire. Comparison of the ovine and porcine model demonstrated that the ovine model was statistically superior to the porcine model across most validation criteria excluding realistic appearance of skin, identification and ligation of the trans-oral parotid duct and facial nerve grafting. Conclusion Adequate experience with facial nerve dissection during parotid surgery is vital to ensuring good outcomes and avoiding complications. This study is the first to compare validity of two animal models for simulation training in parotid surgery and facial nerve dissection. We have validated the ovine model as a useful tool for simulation training and advocate its incorporation into otolaryngology training programmes.

Prognostic value of the posterior cricoarytenoid muscle atrophy in computerized tomography scans for unilateral vocal fold paralysis recovery

08-01-2020 – DY Lee,D Kogay,S Song,YJ Shim,BH Kim,YJ Jin,SD Kim,Y Kim,EJ Chung,TK Kwon

Journal Article

Abstract Objectives To evaluate the prognostic value of the posterior cricoarytenoid (PCA) muscle atrophy observed on neck computed tomography (CT) in patients with unilateral vocal fold paralysis. Methods CT images of 87 subjects with unilateral vocal fold paralysis (UVFP) were evaluated to analyze the PCA muscle atrophy and to measure the severity of the PCA muscle atrophy in semi-quantitative manner. The grading of the PCA muscle atrophy was compared with the recruitment pattern of laryngeal electromyography (LEMG) and restoration of vocal fold movement. Results The PCA muscle was identifiable on CT in 73 subjects. Using the PCA muscle atrophy as an indicator of UVFP, we correctly predicted the paralysis in 69 (94.5%). Grade of the PCA muscle atrophy is significantly correlated with recruitment pattern of LEMG. If the positive result is defined as the PCA muscle showed moderate to severe degree of atrophy, we could predict the persistent UVFP in 88% of patients. Conclusions PCA muscle atrophy identified on CT scan in patients with UVFP, is associated with low rates of return of mobility in the affected vocal fold.

The role of multidisciplinary decision making in oropharyngeal cancer: do we follow guidelines and are treatment decisions being implemented?

08-01-2020 – R Ghazal Asswad,S Alvi,K Davies,TM Jones,DW Hamilton,C Brammer,J Lancaster,C Loh,S Tandon,N Roland

Journal Article

Abstract Purpose A multidisciplinary team (MDT) approach to cancer management is gold-standard. With an increasing disease incidence and growing research into human papillomavirus (HPV)-related oropharyngeal cancer (OPC), updated UK management guidelines were recently published. This study aimed to evaluate the MDT decision-making process among OPC patients at a tertiary centre. Methods MDT meetings over a 12-month period were analysed retrospectively. MDT decisions were compared with guidelines and patient records examined to identify decision implementation. Reasons behind any discordant decisions were explored. Results This study included 140 OPC patients. Thirty-three (23.6%) were not tested for HPV. Patients over 70 years with a smoking history treated palliatively were less likely to be tested (P = 0.017). Eighty-five percent of MDT decisions followed guidelines with the majority not complying (76.2%) related to patient comorbidity. Ten decisions (7.1%) were not implemented. Reasons included: Seven due to patient choice, of which four patients (57.1%) were only seen following the MDT meeting, and three due to clinician decisions as new clinical information emerged. Conclusion The majority of MDT decisions followed guidelines and any discordant decisions were justifiable. Discussing management options with patients beforehand facilitates decision implementation as decisions can potentially change after seeing the patient. Progress is still needed with regards to HPV testing. Reasons for not testing could include subliminal decision-making among clinicians, and patients falling between centres. Crucially, the role of the MDT in head and neck cancer should be to ratify decisions rather than making them, hence the need to see patients prior to MDT discussion.

A letter in response to the article entitled ‘Utility of a smartphone‐enabled otoscope in the instruction of otoscopy and middle ear anatomy’

07-01-2020 – J Schuster-Bruce,A Davies,H Conchie,E Shamil,A Waddell


Letter to Editor concerning the “Therapeutic strategies in the treatment of Meniere’s disease: the Italian Experience”

07-01-2020 – A Scarpa,M Ralli,P De Luca,L Savignano,FM Gioacchini,E Cassandro,C Cassandro


Abstract In this letter, we discuss possible alternatives and future perspectives in the therapy of Meniere’s disease. Special attention should be paid to the role of dietary restrictions for glucose in patients with Meniere’s disease, as there is a strong evidence about the presence of insulin receptors in the saccule, the main structure affected by pathological changes due to endolymphatic hydrops; to the possible use of endogenous antisecretory factor administered in specially processed cereals; and to the effects of low-dose intratympanic gentamicin, especially in patients with intractable Meniere’s disease.

Response to the letter to the editor: "Score risk scale as a prognostic factor after sudden sensorineural hearing loss"

02-01-2020 – A Sousa Menezes,D Ribeiro,A Lima,D Miranda,J Guimarães,L Dias


Abstract We appreciate the opportunity to comment the observations on our paper entitled "Score risk scale as a prognostic factor after sudden sensorineural hearing loss", by Capuano et al. This letter highlights several important points, including the role of hyperbaric oxygen therapy and the possible association between patent foramen ovale and sudden sensorineural hearing loss (SSHL). Further research is needed to strengthen the association between cardiovascular risk and SSHL. We thank the authors for their insights into our paper and for adding their experience and observations on the potential role of cardiovascular risk in the etiology of SSHL.

Letter to the editor “Associations among sleep symptoms, physical examination, and polysomnographic findings in children with obstructive sleep apnea”

02-01-2020 – MS Luo


Dyna-CT of the temporal bone for case-specific three-dimensional rendering of the stapedial muscle for planning of electrically evoked stapedius reflex threshold determination during cochlear implantation directly from the stapedius muscle via a retrofacial approach: a pilot study

02-01-2020 – GF Volk,R Aschenbach,M Gadyuchko,T Bitter,S Koscielny,U Teichgräber,O Guntinas-Lichius

Journal Article

Abstract Purpose Evaluation of 3D Dyna-CTs to improve cochlear implantation (CI) planning and intraoperative electrically elicited stapedius reflex threshold (ESRT) measurements. Methods A prospective observational cohort study was performed. Anonymized data collection of Dyna-CTs and CI surgeries in which a retrofacial approach was implemented to access the stapedius muscle. 3D Dyna-CTs of 30 patients and the intraoperative confirmation of the predication in 5/30 patients during CI surgery were evaluated. Inter-rater reliability was also analyzed along with the predictive value of this evaluation. Results 36 representative structures of the middle and inner ear and 3D renderings of the Dyna-CTs were evaluated by four otoneurological surgeons. Fleiss’ kappa values for the evaluation of the visibility were high (> 0.7) for most of the anatomical structures. The stapedius muscle was visible in 90% of the cases. Using the 3D data, the retrofacial access to the stapedius muscles was estimated as feasible in 86.7%. Fleiss’ kappa value of the evaluation of the accessibility was 0.942. The intraoperative exploration of the stapedius muscle confirmed the preoperative prediction in all five selected patients (four patients with predicted accessibility and one patient with predicted inaccessibility). Conclusions The use of Dyna-CT and 3D rendering is a helpful tool for preoperative planning of cochlear implantations and ESRT measurements from the stapedius muscle via the retrofacial approach.

Redefining adequate margins in oral squamous cell carcinoma: outcomes from close and positive margins

02-01-2020 – PV Jain,R Sharan,K Manikantan,GM Clark,S Chatterjee,I Mallick,P Roy,P Arun

Journal Article

Abstract Purpose Adequacy of surgical margins impacts outcomes in oral cancer. We sought to determine whether close and positive margins have different outcomes in patients with oral cancer. Methods Retrospective data from 612 patients with oral carcinoma were analyzed for the effect of margin status on locoregional recurrence-free survival (LRFS), disease-free survival (DFS) and overall survival (OS). Results A total of 90 cases (14.7%) had close margins and 26 patients (4.2%) had positive margins. Recurrences were documented in 173 patients (28%), of which 137 (22% of the study sample) were locoregional, and 164 patients (27%) had died. Among patients with close or positive margins, a cutoff of 1 mm optimally separated LRFS (adjusted p = 0.0190) and OS curves (adjusted p = 0.0168) whereas a cutoff of 2 mm was sufficient to significantly separate DFS curves (adjusted p = 0.0281). Conclusions Patients with oral carcinoma with positive margins (< 1 mm) had poorer outcomes compared to those with close margins (1–5 mm) in terms of LRFS, DFS and OS. There is a suggestion that a cutoff of < 2 mm might provide slightly more separation for DFS.

Correction to: Voice rehabilitation for laryngeal cancer after radiotherapy: a systematic review and meta-analysis

01-01-2020 – M Taito,S Taito,M Banno,T Fujiwara,H Okamura,H Tsujimoto,Y Kataoka,Y Tsujimoto

Published Erratum

In the original publication of the article, the reference 14 was published incorrectly. The correct reference is given below.

Letter to editor: Primary hyperparathyroid surgery under local anesthesia: benefits of hypnosis

01-01-2020 – S Mayilvaganan,RB Panchangam


In reply to: “Dynamic imaging in suspected eagle syndrome”

01-01-2020 – VA Ayyildiz,FA Senel,A Dursun,K Ozturk


Dynamic imaging in suspected Eagle syndrome

01-01-2020 – EN Siniscalchi


Pharyngeal reconstruction using a U-shaped pectoralis major myocutaneous flap: an effective technique that should not be forgotten

01-01-2020 – YH Chu,WS Lai,YY Lin,SC Liu,JC Lee

Journal Article

Abstract Introduction Although free tissue transfer is thought the best option for head and neck reconstruction, the pectoralis major myocutaneous flap (PMMCF) remains an important alternative method. The aim of this study was to assess the use of the PMMCF with the prevertebral fascia to close a pharyngeal defect. Materials and methods This was a retrospective study of 30 patients who underwent circumferential pharyngeal defect reconstruction with a U-shaped PMMCF from 2009 to 2018. The flap was primarily used to reconstruct defects after tumor extirpation. Results One patient (3.3%) died of an acute myocardial infarction within 24 h of the operation. Six cases (20.0%) developed a pharyngocutaneous fistula; one of them required debridement, while the others spontaneously healed with conservative treatment. Seven cases (23.3%) developed tracheal stomal stenosis. Twenty-four (80.0%) of these cases could eat a regular diet, while the other five cases needed tube feeding. Conclusion In patients with late-stage laryngopharyngeal cancer, reconstructing circumferential pharyngeal defects with the U-shaped PMMCF is an expedient alternative to free tissue transfer.