Showing papers in "Archives of Otolaryngology-head & Neck Surgery in 2007"

Transoral robotic surgery: radical tonsillectomy.

Abstract: Objective To describe and show the feasibility of a new surgical technique for transoral robotic surgery (TORS) radical tonsillectomy. Design A prospective, phase 1 clinical trial. Setting Academic, tertiary referral center. Patients A total of 27 participants were prospectively selected using a volunteer sample. All eligible patients agreed to participate in the study. Interventions Patients underwent TORS radical tonsillectomy for previously untreated invasive squamous cell carcinoma of the tonsillar region without free-flap reconstruction, staged neck dissection, and adjuvant therapy. Main Outcome Measures Outcome measures included final pathologic margin status, need for short- and long-term tracheotomy tube placement, and need for gastrostomy tube feedings among patients with a minimum 6-month follow-up. The incidence of significant postoperative complications was recorded. Results No mortality occurred. Final margins found to be negative for cancer were achieved in 25 of 27 patients (93%). Surgical complications included 1 case each of postoperative mucosal bleeding, delirium tremens, unplanned tracheotomy for temporary exacerbation of sleep apnea, and hypernasality and 2 cases of moderate trismus. Twenty-six of 27 patients (96%) were swallowing without the use of a gastrostomy. Conclusions Radical tonsillectomy using TORS is a new technique that offers excellent access for resection of carcinomas of the tonsil with acceptable acute morbidity. Future reports will focus on long-term oncologic and functional outcomes.

Pediatric Sleep Questionnaire: Prediction of Sleep Apnea and Outcomes

Abstract: Objectives To further validate a questionnaire about symptoms of childhood obstructive sleep apnea (OSA) and to compare the questionnaire with polysomnography in their ability to predict outcomes of adenotonsillectomy. Design Retrospective analysis of data from a longitudinal study. Setting University-based sleep disorders laboratory. Participants The Washtenaw County Adenotonsillectomy Cohort, comprising 105 children aged 5.0 to 12.9 years at entry. Intervention Parents completed the 22-item Sleep-Related Breathing Disorder (SRBD) scale of the Pediatric Sleep Questionnaire, and children underwent polysomnography before and 1 year after clinically indicated adenotonsillectomy (n = 78, usually for suspected OSA) or unrelated surgical care (n = 27). Main Outcome Measures Findings from commonly used hyperactivity ratings, attention tests, and sleepiness tests. Results At baseline, a high SRBD scale score (1 SD above the mean) predicted an approximately 3-fold increased risk of OSA on polysomnography (odds ratio, 2.80; 95% confidence interval, 1.68-4.68). One year later, OSA and symptoms had largely resolved, but a high SRBD score still predicted an approximately 2-fold increased risk of residual OSA on polysomnography (odds ratio, 1.89; 95% confidence interval, 1.13-3.18). Compared with several standard polysomnographic measures of OSA, the baseline SRBD scale better predicted initial hyperactivity ratings and 1-year improvement, similarly predicted sleepiness and its improvement, and similarly failed to predict attention deficit or its improvement. Conclusions The SRBD scale predicts polysomnographic results to an extent useful for research but not reliable enough for most individual patients. However, the SRBD scale may predict OSA-related neurobehavioral morbidity and its response to adenotonsillectomy as well or better than does polysomnography.

Treatment of sudden sensorineural hearing loss: I. A systematic review.

Abstract: Objective To identify, evaluate, and review randomized controlled trials (RCTs) on the treatment of sudden sensorineural hearing loss (SSHL). Data Sources A MEDLINE search and hand search were conducted to identify RCTs published between January 1966 and February 2006 in the English language on the treatment of SSHL. Search terms included hearing loss , sensorineural (MeSH term), sensorineural hearing loss (text words), and sudden deafness (text words). Study Selection Prospective RCTs on the treatment of patients diagnosed as having SSHL. Data Extraction One independent observer extracted study data. Validity was evaluated using standard criteria. Characteristics and results were reviewed systematically. Data Synthesis A total of 21 RCTs were identified regarding various treatments, including systemic and intratympanic steroids; antiviral and hemodilution agents; mineral, vitamin, and herbal preparations; batroxobin; carbogen; and hyperbaric oxygen. All studies used audiometric outcome measures. Only 2 studies used identical criteria to define SSHL. The method of randomization was described in 2 studies. Validity scores ranged from 2 to 8 (of 9). Positive results were reported favoring systemic steroids, intratympanic steroids, batroxobin, magnesium, vitamin E, and hyperbaric oxygen, although there were serious limitations in each study with a positive finding. There was no difference in audiometric outcomes reported across all studies of antiviral and hemodilution agents and no difference in one study of systemic steroids vs placebo. Conclusions To our knowledge, no valid RCT exists to determine effective treatment of SSHL. Systemic steroids cannot be considered the gold standard of treatment of SSHL, given the severe limitations of the landmark study supporting their use.

Esthesioneuroblastoma: a population-based analysis of survival and prognostic factors.

Abstract: Objectives To investigate the characteristics associated with survival in esthesioneuroblastoma and to determine whether the modified Kadish staging system can predict outcome. Design Retrospective population-based cohort study. Subjects All patients in the Surveillance, Epidemiology, and End Results tumor registry diagnosed as having esthesioneuroblastoma (1973-2002). Main Outcome Measures The modified Kadish stage and the overall and disease-specific survival rates were determined. Results The cohort included 311 patients with a mean age of 53 years and a unimodal age distribution. The overall 5- and 10-year survival rates were 62.1% and 45.6%, respectively. The modified Kadish staging system was applied to 261 patients. Kaplan-Meier analysis showed the overall and disease-specific survival rates at 10 years to be 83.4% and 90%, respectively, for patients with stage A disease; 49% and 68.3% for patients with stage B disease; 38.6% and 66.7% for patients with stage C disease; and 13.3% and 35.6% for patients with stage D disease. Log-rank test comparisons found Kadish stage (P Conclusion The modified Kadish staging system, lymph node status, treatment modality, and age are useful predictors of survival in patients who present with esthesioneuroblastoma.

Factors predictive of survival in advanced laryngeal cancer.

Abstract: Objective: To determine the factors predictive of improved survival among patients with advanced laryngeal cancer. Design: National hospital-based cancer registry. Patients:Patients treated with total laryngectomy (TL), radiation therapy alone (RT), or combined chemotherapy and radiation therapy (chemo-RT). Results: Of the 10590 patients meeting the initial inclusion criteria, 7019 had appropriate nonmissing values in all study variables and were included in the analysis. Overall, TL was significantly associated with increased likelihood of survival compared with RT or chemo-RT (P.001). Among patients with stage III cancer, TL and chemo-RT had similar impacts on survival (each showed increased survival compared with RT), whereas TL was associated with significantly greater survival than chemo-RT or RT among patients with stage IV disease (P.001). Overall survival was also decreased among men, black patients (compared with white patients), and patients with Medicare or Medicaid or those who were uninsured (compared with those with private insurance). Conclusions: Among patients with the most advanced disease (stage IV), TL was associated with increased survival compared with chemo-RT or RT, whereas both TL and chemo-RT improved survival over RT among patientswithstageIIIcancer.Insurancetypeandblackrace alsoshowedsignificantassociationswithsurvival,which may reflect barriers in access to care (P.001).

Treatment of sudden sensorineural hearing loss: II. A Meta-analysis.

Abstract: Objective To pool and meta-analyze the results of all randomized controlled trials (RCTs) on treatment of sudden sensorineural hearing loss (SSHL). Data Sources A MEDLINE search and hand search were conducted to identify RCTs published between January 1966 and February 2006 in the English language on the treatment of SSHL. Search terms included hearing loss , sensorineural (MeSH term), sensorineural hearing loss (text words), and sudden deafness (text words). Study Selection Prospective RCTs on the treatment of patients diagnosed as having sudden sensorineural hearing loss. Data Extraction A meta-analysis using the random effects model was conducted when data existed for 2 or more studies. Odds ratios (ORs), 95% confidence intervals (CIs), and tests for heterogeneity were reported. Data Synthesis Twenty RCTs were identified, of which 5 met inclusion criteria for meta-analysis. Pooling of data from 2 RCTs that compared steroids with placebo showed no difference between treatment groups (OR, 2.47; 95% CI, 0.89-6.84; P >=.08). No difference existed between patients treated with antiviral plus steroid therapy vs placebo plus steroid therapy (OR, 0.92; 95% CI, 0.29-2.92: P =.88). Finally, there was no difference between subjects treated with steroids vs subjects treated with any other active treatment (OR, 1.27; 95% CI, 0.64-2.55; P =.50). Conclusions Despite the traditional practice in North America of treating of SSHL with systemic steroids, a meta-analysis revealed no evidence of benefit of steroids over placebo. There was also no difference in the addition of antiviral therapy to systemic steroids, nor was there difference between systemic steroids and other active treatment.

Transoral laser microsurgery for advanced laryngeal cancer.

Abstract: Objective To report the oncologic and functional outcomes of transoral laser microsurgery (TLM) in the treatment of advanced laryngeal cancer. Design Prospective case series study. Setting Multi-institution (academic, tertiary referral centers). Patients A total of 117 patients with pathologically confirmed T2 to T4 lesions, stage III or stage IV, glottic or supraglottic carcinoma of the larynx were treated with TLM from 1997 to 2004. All patients had a minimum follow-up period of 2 years. Interventions Transoral laser microsurgery in 117 patients, neck dissection in 91 patients, and adjuvant radiotherapy in 45 patients. Main Outcome Measures End points analyzed included laryngeal preservation, overall survival, disease-free survival, local control, locoregional control, and distant metastases. Postoperative complications, tracheotomy rate, and feeding-tube dependence were also examined. Results The median follow-up period among surviving patients was 5 years. At 2 years, the percentage of patients with an intact larynx after treatment was 92%. The 2-year local control and locoregional control rates were 82% and 77%, respectively. The 2-year disease-free and overall survival rates were 68% and 75%, respectively. The 5-year Kaplan-Meier estimates were local control, 74%; locoregional, control, 68%; disease-free survival, 58%; overall survival, 55%; and distant metastases, 14%. Four patients (3%) experienced treatment-related deaths. Seven patients (6%) experienced a postoperative hemorrhage. Of those patients with organ preservation and no disease recurrence, 2 patients (3%) were tracheotomy dependent, and 4 patients (7%) were feeding-tube dependent. Conclusions In patients with advanced laryngeal cancer, TLM with or without radiotherapy is a valid treatment strategy for organ preservation. Furthermore, low morbidity and mortality and excellent oncologic and functional outcomes make TLM an attractive therapeutic option.

Incidence of vocal cord paralysis with and without recurrent laryngeal nerve monitoring during thyroidectomy.

Abstract: Objective To compare the incidence of postoperative vocal cord paresis or paralysis in a cohort of patients who underwent thyroidectomy with and without continuous recurrent laryngeal nerve (RLN) monitoring by a single senior surgeon. We hypothesize that continuous RLN monitoring reduces the rate of nerve injury during thyroidectomy Design Retrospective medical chart review. Setting Academic tertiary care medical center. Patients A total of 684 patients (1043 nerves at risk) who underwent thyroid surgery under general anesthesia. Main Outcome Measure Incidence of vocal cord paresis or paralysis in patients who underwent thyroid surgery with continuous RLN monitoring vs those undergoing surgery without continuous RLN monitoring. Results The incidence of unexpected unilateral vocal cord paresis based on RLNs at risk was 2.09% (n = 14) in the monitored group and 2.96% (n = 11) in the unmonitored group. This difference was not statistically significant. The incidence of unexpected complete unilateral vocal cord paralysis was 1.6% in each group. Two of the 5 paralyses in the unmonitored group and 7 of the 11 paralyses in the monitored group had complete resolution. Conclusions Monitoring of the RLN does not appear to reduce the incidence of postoperative temporary or permanent complete vocal cord paralysis. There appeared to be a slightly lower rate of postoperative paresis with RLN monitoring, but this difference was not statistically significant.

Chronic Periodontitis and the Risk of Tongue Cancer

Abstract: Objective To assess the association between the history of chronic periodontitis and the risk of tongue cancer. Design Case-control study using preexisting data from patients admitted between June 15, 1999, and November 17, 2005. Setting Department of Dentistry and Maxillofacial Prosthetics at Roswell Park Cancer Institute (RPCI), Buffalo, NY. Patients The cases comprised 51 non-Hispanic white men newly diagnosed as having primary squamous cell carcinoma of the tongue, and the controls, 54 non-Hispanic white men evaluated during the same period but with negative results for malignancy. Children (aged Main Outcome Measure Incidence of tongue cancer obtained from the RPCI Tumor Registry. Results After adjusting for the effects of age at diagnosis, smoking status, and number of teeth, each millimeter of alveolar bone loss was associated with a 5.23-fold increase in the risk of tongue cancer (odds ratio, 5.23; 95% confidence interval, 2.64-10.35). Conclusions This study suggests an association between chronic periodontitis and the risk of tongue cancer in men, independent of smoking status, age, race, ethnicity, and number of teeth. This association needs to be confirmed by larger studies using quantitative assessment of lifetime tobacco exposure. If this association is confirmed, it has a potential impact on understanding the etiology of oral cancer as well as on its prevention and control.

Expanding the differential diagnosis of chronic dizziness.

Abstract: Results:Nearly all patients with chronic subjective dizziness were diagnosed with psychiatric or neurologic illnesses. These included primary and secondary anxiety disorders (n=206 [59.7%]) and central nervous system conditions(n=133[38.6%]),specificallymigraineheadaches, mild traumatic brain injuries, and neurally mediated dysautonomias. A small number of patients (6 [1.7%]) had dysrhythmias. Four of 5 patients with migraine or dysrhythmias had comorbid anxiety. Conclusions: Chronic dizziness has several common causes, including anxiety disorders, migraine, traumatic brain injuries, and dysautonomia, that require differenttreatments.Keyfeaturesoftheclinicalhistorydistinguishtheseillnessesfromoneanotherandfromactive neurotologicconditions.Thehighprevalenceofsecondary anxiety may give a false impression of psychogenicity.

Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis.

Abstract: Objective To evaluate the effect of transcutaneous neuromuscular electrical stimulation (NMES) on swallowing rehabilitation. Data Sources MEDLINE, PubMed, CINAHL, NML, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, doc online, Google, and EMBASE were searched for studies using NMES to treat dysphagia between January 1966 and August 2006. Study Selection Included were published or unpublished, English-language, clinical trials with a quantifiable dependent variable. Data Extraction Two researchers independently performed data extraction. A random-effects model was used to pool study results. The Cochran Q test was used to evaluate heterogeneity, and a funnel plot and Egger test were used to evaluate publication bias. A best-research synthesis using a methodological quality analysis was conducted. Data Synthesis A total of 81 studies were reviewed. Seven were accepted for analysis. A significant summary effect size was identified for the application of NMES for swallowing (Hedges g , 0.66; P P P P = .25). Best-evidence synthesis showed indicative findings in favor of NMES for swallowing. Conclusions This preliminary meta-analysis revealed a small but significant summary effect size for transcutaneous NMES for swallowing. Because of the small number of studies and low methodological grading for these studies, caution should be taken in interpreting this finding. These results support the need for more rigorous research in this area.

Nasal Saline for Chronic Sinonasal Symptoms A Randomized Controlled Trial

Abstract: Objective To determine if isotonic sodium chloride (hereinafter “saline”) nasal irrigations performed with large volume and delivered with low positive pressure are more effective than saline sprays at improving quality of life and decreasing medication use. Design A prospective, randomized controlled trial. Setting Community. Participants A total of 127 adults with chronic nasal and sinus symptoms. Interventions Patients were randomly assigned to irrigation performed with large volume and delivered with low positive pressure (n = 64) or spray (n = 63) for 8 weeks. Main Outcome Measures Change in symptom severity measured by mean 20-Item Sino-Nasal Outcome Test (SNOT-20) score; change in symptom frequency measured with a global question; and change in medication use. Results A total of 121 patients were evaluable. The irrigation group achieved lower SNOT-20 scores than the spray group at all 3 time points: 4.4 points lower at 2 weeks (P = .02); 8.2 points lower at 4 weeks (P Conclusion Nasal irrigations performed with large volume and delivered with low positive pressure are more effective than saline sprays for treatment of chronic nasal and sinus symptoms in a community-based population. Trial Registration clinicaltrials.gov Identifier:NCT00318006

Robotic Skull Base Surgery Preclinical Investigations to Human Clinical Application

Abstract: Objective To develop a minimally invasive surgical technique for the treatment of parapharyngeal space and infratemporal fossa skull base neoplasms using the technical and optical advantages of robotic surgical instrumentation. Design A robotics skull base surgery program at the University of Pennsylvania, Philadelphia, was initiated in the fall of 2005. Six experimental procedures focusing on developing approaches to the parapharyngeal space and infratemporal fossa were performed on a total of 2 cadavers and 1 mongrel dog. Based on the preclinical work, transoral robotic surgery (TORS) was then performed in February 2007 on 1 human patient with a parapharyngeal to infratemporal fossa cystic neoplasm as part of a large prospective human trial. Setting In each cadaver and in the dog, a TORS approach to parapharyngeal space and infratemporal fossa was performed bilaterally and in an approved training facility using the da Vinci Surgical System. For the human surgical case, a TORS approach was evaluated on one side for a benign neoplasm. The human patient underwent TORS of the parapharyngeal space and infratemporal fossa under an institutional review board–approved prospective clinical trial. Patients For the human clinical trial, a TORS approach was evaluated for a patient with a benign neoplasm of the parapharyngeal space and infratemporal fossa. Main Outcome Measures The ability to access and dissect tissues within the various areas of the parapharynx and infratemporal fossa was evaluated, and techniques to enhance visualization and instrumentation were developed. Results Using TORS approaches permitted excellent access, visualization, and tissue dissection within the parapharyngeal space and infratemporal fossa in both the cadaver and canine experiments. In the first known human surgical case, TORS was used to remove a parapharyngeal space and infratemporal fossa cystic neoplasm. Wide visualization, followed by complete resection using the identical techniques developed in the preclinical models, was achieved. The robotic procedure allowed adequate and safe identification of the internal carotid artery and cranial nerves, and excellent hemostasis was achieved with no complications during or after surgery. Conclusions The TORS approaches provided excellent 3-dimensional visualization and instrument access that allowed successful parapharyngeal space and infratemporal fossa surgical resections from cadaver models to the first known human patient application. Robotic surgery for the skull base holds potential as a minimally invasive approach to skull base neoplasms; however, continued development and investigation is warranted in a prospective human clinical trial before final conclusions can be drawn as to the full advantages and limitations of this approach.

Robotic Endoscopic Surgery of the Skull Base : A Novel Surgical Approach

Abstract: Objective To describe a novel robotic surgical approach that allows adequate endoscopic access for resection of tumors involving the anterior and central skull base and allows 2-handed, tremor-free, endoscopic dissection and precise suturing of dural defects. Design Transnasal endoscopic approaches are being increasingly used for surgical access and resection of tumors of the anterior and central skull base. One major disadvantage of this approach is the inability to provide watertight dural closure and reconstruction, which limits its safety and widespread adoption in surgery of intracranial skull base tumors. Other disadvantages include limited depth perception and several ergonomic constraints. Four human cadaver specimens were used for this study. The surgical approach starts with bilateral sublabial incisions and wide anterior maxillary antrostomies (Caldwell-Luc). Transantral access to the nasal cavity is gained through bilateral wide middle meatal antrostomies. A posterior nasal septectomy facilitates bilateral access by joining both nasal cavities into 1 surgical field. The da Vinci Surgical System is then “docked” by introducing the camera arm port through the nostril and the right and left surgical arm ports through the respective anterior and middle antrostomies, into the nasal cavity. A 5-mm dual-channel endoscope coupled with a dual charge-coupled device camera is inserted in the camera port and allows for 3-dimensional visualization of the surgical field at the surgeon's console. Using the robotic surgical arms, the surgeon may perform endoscopic anterior or posterior ethmoidectomy, sphenoidotomy, or resection of the middle or superior turbinates depending on the extent of needed surgical exposure. In addition, resection of the cribriform plate is performed robotically with sharp dissection of the skull base. The dural defect is then repaired with a 6-0 nylon suture. Results Adequate access to the anterior and central skull base, including the cribriform plate, fovea ethmoidalis, medial orbits, planum sphenoidale, sella turcica, suprasellar and parasellar regions, nasopharynx, pterygopalatine fossa, and clivus, was obtained in all cadaveric dissections. The 3-dimensional visualization obtained by the dual-channel endoscope at the surgeon's console provided excellent depth perception. The most significant advantage was the ability of the surgeon to perform 2-handed tremor-free endoscopic closure of dural defects. Conclusions Transantral robotic surgery provides adequate endoscopic access to the anterior and central skull base. To our knowledge, this is the first study to report the feasibility and advantages of robotic-assisted endoscopic surgery of the skull base. This novel approach also allows for 3-dimensional, 2-handed, tremor-free endoscopic dissection and precise closure of dural defects. These advantages may expand the indications of minimally invasive endoscopic approaches to the skull base.

Parapharyngeal Space Schwannomas: Preoperative Imaging Determination of the Nerve of Origin

Abstract: Objectives To determine if preoperative radiographic cross-sectional images can predict the nerve of origin of a parapharyngeal schwannoma and, specifically, whether it originates from the vagus nerve or the cervical sympathetic chain. Design A retrospective review. Setting Academic medical center. Patients The study population comprised 12 patients who underwent surgical resection of schwannomas of the parapharyngeal space. The nerve of origin was identified based on operative findings and postoperative physical examinations. Of the 12 patients, 11 underwent preoperative magnetic resonance imaging and 1 underwent preoperative contrast-enhanced computed tomography. A CAQ (Certificate of Added Qualification)–certified neuroradiologist reviewed the imaging studies, blinded to the surgically determined nerve of origin. For each case, it was predicted whether the tumor arose from the vagus nerve or sympathetic chain based on the location of the schwannoma with reference to the carotid sheath vessels. Main Outcome Measure Identification of the nerves of origin using the displacement of vessels as a marker. Results At the time of operation, it was determined that 5 patients (42%) had schwannomas from the cervical sympathetic chain and 7 patients (58%) had schwannomas of the cervical vagus nerve. By imaging, the nerve of origin was successfully determined in 4 of 5 cases of sympathetic chain schwannoma (80%) and in 7 of 7 cases of vagal nerve schwannoma (100%). Schwannomas of the cervical sympathetic chain were found to displace both the carotid and jugular vessels without separating them. Vagal nerve schwannomas were found to separate the carotid arteries from the internal jugular vein. A vagal nerve schwannoma may also displace the sheath vessels posteriorly, without splaying them. Conclusions Carotid and jugular vessel displacement, as determined by cross-sectional imaging, can predict the likely nerve of origin of a parapharyngeal space schwannoma. This determination allows for effective preoperative counseling regarding the expected sequelae of surgical resection.

The sensitivity and specificity of high-resolution imaging in evaluating perineural spread of adenoid cystic carcinoma to the skull base

Abstract: Objective To evaluate the sensitivity and specificity of computed tomography (CT) and magnetic resonance imaging (MRI) in detecting perineural spread (PNS) of adenoid cystic carcinoma of the head and neck to the skull base. Design Adenoid cystic carcinoma of the head and neck frequently exhibits PNS across the skull base. Failure to detect PNS before treatment can have significant negative consequences on the planning and outcome of therapy. High-resolution CT, MRI, or both are used to evaluate the presence of PNS; however, their accuracy in detecting perineural involvement has not yet been determined. Patients Twenty-six consecutive patients with adenoid cystic carcinoma, who were treated with cranial base resection, were included in this study. The surgical resection specimens of all patients were thoroughly examined by 1 pathologist for the presence of PNS along cranial nerves or their named branches. A total of 38 nerves were examined, and PNS was defined as the presence of tumor in the perineural or endoneural space. The results of the preoperative imaging studies (CT and/or MRI) were then reviewed retrospectively by 1 head and neck radiologist, who was unaware of the pathology report. Radiological evidence of PNS was considered to be present on CT, MRI, or both if nerves showed evidence of thickening (regardless of enhancement), contrast enhancement (regardless of size), or widening of their bony foramina or canals. Results Histopathologic evidence of PNS was present in 25 (66%) of 38 named nerves. The sensitivity and specificity of CT in detecting PNS were 88% and 89%, respectively. Magnetic resonance imaging had a higher sensitivity (100%) and specificity (85%). Conclusions Perineural spread across the skull base is a frequent occurrence in patients with adenoid cystic carcinoma of the head and neck. Magnetic resonance imaging has a higher sensitivity and specificity than CT in detecting PNS along the base of the skull.

Sentinel lymph node biopsy for sebaceous cell carcinoma and melanoma of the ocular adnexa.

Abstract: Objective To provide clinical details and long-term outcome data for a series of patients with eyelid or conjunctival melanoma or eyelid sebaceous cell carcinoma who underwent sentinel lymph node (SLN) biopsy. Design Retrospective interventional case series with review of clinical records and pathologic specimens. Setting Tertiary comprehensive cancer center. Patients Twenty-five consecutive patients treated at 1 institution for eyelid or conjunctival melanoma or eyelid sebaceous cell carcinoma from December 2000 to October 2004. Interventions Surgical removal of the eyelid or conjunctival tumor and SLN biopsy. Main Outcome Measures Local treatment modalities; lymphatic basins in which SLNs were identified; status of SLNs; false-negative rate; and long-term patterns of local recurrence, regional and distant metastasis, and survival. Results Seven patients had conjunctival melanoma, 8 had eyelid-margin melanoma with a considerable palpebral conjunctival component, and 10 had eyelid sebaceous cell carcinoma. The SLNs were identified in all but 1 patient by using technetium Tc 99m sulfur colloid as a tracer. Intraoperatively, in 16 patients in whom blue dye was used in addition to technetium Tc 99m sulfur colloid during mapping, no SLN was blue. One patient with conjunctival melanoma and 1 patient with eyelid melanoma had a histologically positive SLN. Two patients with eyelid melanoma and 2 patients with eyelid sebaceous cell carcinoma had negative findings from SLN biopsy but developed recurrence in their regional lymph nodes during the follow-up period. Overall, during follow-up, 2 of 10 patients with sebaceous cell carcinoma (20%) and 5 of 15 patients with eyelid or conjunctival melanoma (33%) had regional lymph node metastasis. Four patients with melanoma who had regional metastasis also developed distant organ metastasis. Two patients with sebaceous cell carcinoma—1 with regional metastasis and 1 without—developed distant organ metastasis. Conclusions The detection of histologically positive SLNs in this series of patients may justify further study of SLN biopsy for high-risk patients with ocular adnexal melanoma or eyelid sebaceous cell carcinoma. The false-negative rate is higher than that reported for SLN biopsy at most other anatomic sites. Patients with negative findings from SLN biopsy still require careful long-term follow-up because they may develop regional or distant metastasis.

Complications of Tonsillectomy A Comparison of Techniques

Abstract: Objective To compare the postoperative complications of intracapsular tonsillectomy using a microdebrider with traditional electrodissection tonsillectomy. Design Retrospective chart review. Setting Tertiary care pediatric referral center. Patients The medical records of 2944 patients undergoing tonsillectomy with or without adenoidectomy at our institution between January 1, 2002, and May 31, 2005, were reviewed. Main Outcome Measures Incidence of delayed postoperative hemorrhage, return to the hospital or emergency department for pain or dehydration, and the need for revision surgery. Results There were 1731 patients in the intracapsular tonsillectomy group and 1212 in the traditional electrodissection tonsillectomy group. The incidence of delayed hemorrhage was 1.1% in the intracapsular tonsillectomy group and 3.4% in the traditional electrodissection tonsillectomy group ( P P P = .002). Eleven patients (0.64%) in the intracapsular tonsillectomy group required revision tonsillectomy. Conclusion Intracapsular tonsillectomy has a lower incidence of postoperative hemorrhage and pain leading to hospital-based evaluation compared with traditional electrodissection tonsillectomy.

Surgical Treatment for Empty Nose Syndrome

Abstract: Objectives To detail empty nose syndrome (ENS), an iatrogenic disorder characterized by a patent airway but a subjective sense of poor nasal breathing, and to explore repair options for patients with ENS. Design A case series of 8 patients with ENS detailing symptoms before and after submucosal implantation of acellular dermis. Setting Academic medical center. Patients Subjects who were evaluated for abnormal nasal breathing and determined to have ENS. Patients were diagnosed as having ENS if they described characteristic symptoms, had evidence of prior nasal turbinate surgery, and their symptoms improved after they underwent a cotton test. Intervention Acellular dermis was implanted submucosally to simulate missing turbinate tissue. Main Outcome Measures Symptoms and symptom scores for the 20-item Sino-Nasal Outcome Test completed before and after the implantation were gathered. Results A statistically significant improvement in symptom scores for the Sino-Nasal Outcome Test was noted ( P ≤ .02). Conclusions Careful assessment allows reconstructive surgery through submucosal implantation of acellular dermis. Symptoms of patients with ENS can improve with surgical therapy.

Biofilm surface area in the pediatric nasopharynx: Chronic rhinosinusitis vs obstructive sleep apnea.

Abstract: Objective To compare the percentage of mucosal surface area of adenoids infected with biofilms removed from children with chronic rhinosinusitis (CRS) vs children with obstructive sleep apnea (OSA). Design Comparative microanatomical investigation of adenoid mucosa from patients with CRS and OSA using scanning electron microscopy. Setting University-affiliated hospitals and ambulatory surgery center. Patients Four girls and 12 boys ranging in age from 3 months to 10 years. Main Outcome Measure Measurements of biofilm coverage of the entire adenoidal surface. Results Adenoids removed from patients with CRS had dense mature biofilms covering the mucosal surface; they had a mean of 94.9% of their mucosal surface covered with mature biofilms, compared with a mean of 1.9% coverage on the adenoids removed from patients with OSA. This difference was statistically significant at P Conclusions Adenoids removed from patients with CRS had almost their entire mucosal surface covered with biofilms vs scant coverage for patients with OSA. Biofilms in the nasopharynx of children with CRS may act as a chronic reservoir for bacterial pathogens resistant to standard antibiotics. The mechanical debridement of the nasopharyngeal biofilms may explain the observed clinical benefit associated with adenoidectomy in this subset of pediatric patients.

Amplification and Overexpression of HER2/neu Gene and HER2/neu Protein in Salivary Duct Carcinoma of the Parotid Gland

Abstract: Objectives To detect amplification of the HER2/neu gene by means of fluorescence in situ hybridization (FISH) in a series of 13 salivary duct carcinomas (SDCs) and to compare the results with immunohistochemical (IHC) assessment of HER2/neu protein expression. Design Retrospective analysis. Setting Department of Pathology, University of Brescia. Patients We studied 13 cases of SDC diagnosed between January 1, 1997, and June 30, 2004, all arising from the parotid gland. Twelve patients were treated with surgery and radiotherapy, and 1 patient received only palliative radiotherapy. Seven patients died of disease, 3 patients were alive with disease, and 3 were free of disease. Main Outcome Measures HER2/neu protein expression and HER2/neu gene amplification detected by means of IHC assessment and FISH, respectively. Results With IHC assessment, 10 cases showed overexpression (grade 3+) of HER2/neu protein, whereas 3 cases were negative for this protein (grade 0/1+). Using FISH, amplification of the HER2/neu gene was found in 8 of the 10 grade 3+ cases, whereas none of the cases negative for the protein according to IHC assessment had amplification of the gene. Because of the small number of patients, it was not possible to statistically correlate HER2/neu protein expression or HER2/neu gene amplification and survival. Conclusion Our data demonstrate that HER2/neu protein is frequently overexpressed in SDC, and in contrast to previous reports, overexpression of the protein is associated in most cases with HER2/neu gene amplification.

Assessing Impairment and Disability of Facial Paralysis in Patients With Vestibular Schwannoma

Abstract: Objective To evaluate facial impairment and disability with respect to quality of life in patients with facial paresis after vestibular schwannoma surgery. Design Cross-sectional observational study. Setting Academic, tertiary care hospital. Patients All consecutive patients during a 5-year period who underwent vestibular schwannoma surgery. Main Outcome Measures The validated, patient-graded Facial Clinimetric Evaluation (FaCE) scale questionnaire was administered to all study patients. Main outcome measures included total and social function FaCE scores. Subgroup analysis was performed on patient factors (age and sex), surgical factors (tumor size and time since operation), and House-Brackmann grade. Results A total of 56 FaCE questionnaires were returned (85% response rate): 28 patients (50%) had normal facial function (House-Brackmann grade I), and 28 patients (50%) had abnormal facial function (House-Brackmann grades II-VI). There were no demographic differences between the normal and abnormal groups. The normal group had a total FaCE score of 96.2 compared with 67.1 in the abnormal group ( P P Conclusions Facial paresis is an important complication of vestibular schwannoma surgery and will impair a patient's quality of life. The level of impairment may not be predicted by a patient's age, sex, tumor size, time since operation, or severity of facial paresis.

Aspiration in Chemoradiated Patients With Head and Neck Cancer

Abstract: Setting: Academic institution. Patients: One hundred thirty patients with advanced HNC underwent chemoradiation therapy at our institution between 1998 and 2002 as part of a larger, multiinstitutional, prospective study of induction chemotherapy followed by chemoradiation therapy; the 118 patients (91%) for whomoropharyngeal motility (OPM) study data were available are discussed in this article. Main Outcome Measures: Incidence of trace (5% of swallowed bolus) and frank (5%) aspiration (deep laryngeal or tracheal penetration) as determined by pretreatment and posttreatment OPM studies and correlation of the findings with the patients’ reported symptoms. Results: Eighty-one patients (69%) underwent at least 1OPMstudydemonstratingaspirationwithinthefirstyear after chemoradiation therapy, with 30 (25%) demonstratingfrankaspiration.Ofthepatientswhoaspirated,61(75%) reportednosymptomsofcoughingorchoking(80%oftrace and 67% of frank aspirators). The patients with cancer of the larynx and hypopharynx were more likely to be aspirators (P=.007 and P=.004, respectively). Of the 62 patientswithavailablepretreatmentOPMdata,33(53%)dem

Improved behavior and sleep after adenotonsillectomy in children with sleep-disordered breathing.

Abstract: Objective To determine changes in behavior and sleep in children before and after adenotonsillectomy for sleep-disordered breathing (SDB) using the validated Pediatric Sleep Questionnaire (PSQ) and Conners' Parent Rating Scale–Revised Short Form (CPRS-RS). Design Prospective, nonrandomized study. Setting Ambulatory surgery center affiliated with an academic medical center. Patients A total of 117 consecutive children (61 boys and 56 girls) (mean [SD] age, 6.5 [3.1] years) who were clinically diagnosed as having SDB and who had undergone adenotonsillectomy. Complete follow-up data were available in 71 of 117 patients (61%). Interventions Parents completed the PSQ and CPRS-RS before surgery and 6 months after surgery. Main Outcome Measures Changes in age- and sex-adjusted T scores for all 4 CPRS-RS behavior categories (oppositional behavior, cognitive problems or inattention, hyperactivity, and Conners' attention-deficit/hyperactivity disorder [ADHD] index) were determined for each subject before and after surgery. Changes in PSQ scores from a select 22-item sleep-related breathing disorder subscale were also determined. Results Preoperatively, the mean (SD) T scores on the CPRS-RS for oppositional behavior, cognitive problems or inattention, hyperactivity, and ADHD index were 59.4 (13.7), 59.5 (13.6), 62.0 (14.4), and 59.9 (13.4), respectively. A T score of 60.0 in any category placed a child in the at-risk group. Postoperatively, T scores for each category were 51.0 (9.6), 51.2 (8.8), 52.4 (10.52), and 50.6 (7.8), respectively. All changes were statistically significant ( P P = .004 for ADHD index and cognitive problems, P = .008 for oppositional behavior) and after surgery ( P = .049 for cognitive problems, P = .03 for oppositional behavior). Higher baseline T scores for the CPRS-RS were associated with larger changes in T scores for the CPRS-RS in all 4 domains (oppositional behavior, cognitive problems or inattention, hyperactivity, and ADHD index). Conclusions Children diagnosed as having SDB experience improvement in both sleep and behavior after adenotonsillectomy. The PSQ and CPRS-RS may be useful adjuncts for screening and following children who undergo adenotonsillectomy for SDB.

Immune Activation by Epidermal Growth Factor Receptor–Specific Monoclonal Antibody Therapy for Head and Neck Cancer

Abstract: Objective To determine if the epidermal growth factor receptor (EGFR)-specific monoclonal antibodies (mAbs) cetuximab or panitumumab mediate in vitro immune activation against squamous cell carcinoma of the head and neck (SCCHN) cell lines. Design In vitro study. Setting Basic science research laboratory. Intervention Squamous cell carcinoma of the head and neck cell lines were treated with the Food and Drug Administration–approved EGFR-specific mAbs cetuximab or panitumumab in the presence or absence of peripheral blood mononuclear cells from healthy donors. Main Outcome Measures Cetuximab and panitumumab were compared in terms of their cytotoxic effects, ability to induce apoptosis, bind to EGFR, and block phosphorylation of this receptor in SCCHN cell lines. Results We demonstrate that both cetuximab and panitumumab have similar levels of EGFR binding, induction of apoptosis, cell lysis, and inhibition of phospho-EGFR in SCCHN cell lines, suggesting similar direct effects. However, neither of these mAbs demonstrated in vitro antitumor activity when used alone. In contrast, in the presence of peripheral blood lymphocytes, either of them can mediate antibody-dependent cell cytotoxicity in vitro when used in doses similar to those found in patients receiving them clinically. Conclusion We propose that antibody-dependent cell cytotoxicity may constitute an important antitumor mechanism that could contribute to overall clinical effectiveness of EGFR-specific antibodies.

Robotic Surgery in the Pediatric Airway: Application and Safety

Abstract: Objective To assess the application and safety of transoral robotic surgery in the pediatric airway. Design An institutional review board–approved study. Experimental laryngeal surgery was performed on 4 pediatric cadaver larynxes as controls. Application of robotic equipment for laryngeal surgery was attempted on 5 patients. Setting Tertiary care pediatric medical center. Patients Five patients with laryngeal cleft and 4 pediatric cadaver larynxes. Interventions (1) The da Vinci Surgical Robot (Intuitive Surgical Inc, Sunnyvale, Calif) was used on 4 cadaver larynxes and assessed for the dexterity, precision, and depth perception that it allowed the surgeon during laryngeal surgery. Procedures were documented with still and video photography. (2) The da Vinci Surgical Robot was used through a transoral approach to attempt repair of a laryngeal cleft in 5 pediatric patients who were under spontaneously breathing general anesthesia. Results (1) Use of the surgical robot on cadaver larynxes provided great dexterity and precision, delicate tissue handling, good 3-dimensional depth perception, and relatively easy endolaryngeal suturing. (2) The surgical robot could not be used for repair of laryngeal cleft on 3 patients owing to limited transoral access. However, 1 patient with a type 1 laryngeal cleft and 1 patient with a type 2 laryngeal cleft underwent transoral robotic repair with great success. Conclusions Surgical robots provide the ability to manipulate instruments at their distal end with great precision, increased freedom of movement, and excellent 3-dimensional depth perception. The size of the equipment can be a limiting factor with regard to the application and success of the transoral approach to airway surgery. We believe that further advances in device technology and a new generation of robotic equipment will facilitate the incorporation of surgical robotics in the advancement of minimally invasive endoscopic airway surgery.

Patient-reported factors associated with discontinuing employment following head and neck cancer treatment.

Abstract: Objective To evaluate patients' reported reasons for discontinuing employment following treatment for head and neck cancer (HNC). Discontinuing employment is a serious problem for patients with HNC and has an impact on many aspects of their lives. Design Prospective, observational outcomes study. Setting Tertiary care institution. Patients A total of 666 patients with carcinomas of the head and neck who were treated from January 1, 1998, to October 31, 2004. Interventions Patients provided information about the status of their employment at the time of diagnosis and then at 3, 6, 9, and 12 months after diagnosis. Patients who discontinued employment after treatment rated the importance of 5 factors (eating, speech, appearance, pain or discomfort, and fatigue) in that decision. Main Outcome Measures The 5 factors were scored on a 5-point Likert scale (5 being most important) as to their importance in the decision to discontinue work. The relationships of patient, disease, and treatment variables to employment status were evaluated. Results Of the 666 patients, 239 were employed at the time of their diagnosis. After treatment, 91 (38.1%) of the 239 reported discontinuing work because of their cancer and treatment. Eighty-two (90.1%) of these 91 patients rated each of the 5 factors. Fatigue had the highest percentage (58.5%) of 4 or 5 ratings, followed by speech (51.2%), eating (45.1%), pain or discomfort (37.8%), and appearance (17.1%). Thirty-seven (40.7%) of the 91 patients who discontinued work returned to work within 1 year of treatment. Conclusion Identification of the factors associated with the decision to discontinue work is a first step in providing focused solutions to minimize disability.

Health insurance and stage at diagnosis of laryngeal cancer : Does insurance type predict stage at diagnosis?

Abstract: Objective To examine whether patients with no insurance or Medicaid are more likely to present with advanced-stage laryngeal cancer. Design Retrospective cohort study from the National Cancer Database, 1996-2003. Setting Hospital-based practice. Participants Patients with known insurance status diagnosed as having invasive laryngeal cancer at Commission on Cancer facilities (N = 61 131) were included. Adjusted and unadjusted logistic regression models analyzed the likelihood of presenting at a more advanced stage. Main Outcome Measures Overall stage of laryngeal cancer (early vs advanced) and tumor size (T stage) at diagnosis. Results Patients with advanced-stage laryngeal cancer at diagnosis were more likely to be uninsured (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.79-2.15) or covered by Medicaid (OR, 2.40; 95% CI, 2.21-2.61) compared with those with private insurance. Similarly, patients were most likely to present with the largest tumors (T4 disease) if they were uninsured (OR, 2.92; 95% CI, 2.60-3.28) or covered by Medicaid (OR, 3.97; 95% CI, 3.56-4.34). Patients who were black, between ages 18 and 56 years, and who resided in zip codes with low proportions of high school graduates or low median household incomes were also more likely to be diagnosed as having advanced disease and/or larger tumors. Conclusions Individuals lacking insurance or having Medicaid are at greatest risk for presenting with advanced laryngeal cancer. Results for the Medicaid group may be influenced by the postdiagnosis enrollment of uninsured patients. It is important to consider the impact of insurance coverage on stage at diagnosis and associated morbidity, mortality, quality of life, and costs.

Balloon laryngoplasty as a primary treatment for subglottic stenosis

Abstract: Objective To present our experience with balloon laryngoplasty (BL) as a means of establishing control of the compromised airway and as a definitive alternative to open surgery in infants with acquired subglottic stenosis (SGS). Design The medical charts of 10 consecutive infants diagnosed as having acquired SGS secondary to a history of intubation and treated initially with BL were reviewed. Setting Academic tertiary care children's hospital. Patients A total of 10 patients (3 girls and 7 boys), with a mean age of 4.8 months (range, 2-12 months), met the inclusion criteria for the study. Main Outcome Measures The medical charts were assessed for the patients’ demographics, clinical presentation, and outcomes, which were defined by postoperative symptomatology, endoscopic grading of residual SGS, complications, and the need for subsequent interventions to control SGS. Results All 10 patients presented with biphasic stridor, and 8 had significant retractions noted on examination. In all patients, control of the airway was established with BL followed by intubation. Four patients were completely asymptomatic after the initial BL. An additional 3 patients had recurrent stridor during the postoperative period and required a second BL before having complete, persistent resolution of symptoms. Balloon laryngoplasty failed in 3 patients, of whom 2 went on to undergo single-staged laryngotracheal reconstruction and 1 required a tracheotomy. Conclusions Balloon laryngoplasty is a safe means of establishing the airway in infants with obstruction secondary to acquired SGS. It was an effective, stand-alone procedure for the management of SGS in 7 of our 10 patients, obviating the need for tracheotomy or cricoid split.

Characteristics and prognosis of malignant external otitis with facial paralysis.

Abstract: Objective To compare the characteristics and prognosis of patients with malignant (necrotizing) external otitis (MEO) with and without facial nerve palsy in today's era of third-generation antibiotics. Design Comparative retrospective case series. Setting Department of Otolaryngology–Head and Neck Surgery, Rabin Medical Center, a tertiary care medical center. Patients Forty-eight patients with MEO diagnosed and treated from 1990 to 2004. Eight had facial paralysis and 40 had normal facial nerve function. Main Outcome Measures Clinical, laboratory, and imaging findings and survival. Results There was no statistically significant difference between patients with and without facial nerve involvement in terms of age, comorbidities, duration of complaints, physical findings, erythrocyte sedimentation rate, and bone scan findings. Computed tomography indicated a more progressive disease in patients with facial nerve involvement. However, no statistically significant between-group difference was found in overall survival. Conclusion Although facial nerve involvement is a sign of progression of MEO, it does not, by itself, worsen prognosis.