Showing papers in "Laryngoscope in 2009"

Effects of olfactory training in patients with olfactory loss

Abstract: Objectives: Olfactory function is known to be modulated by repeated exposure to odors. The aim of this investigation was whether patients with olfactory loss would benefit from “Training” with odors in terms of an improvement of their general olfactory function. It was hypothesized that olfactory Training should produce both an improved sensitivity towards the odors used in the Training process and an overall increase of olfactory function. Study Design: The prospective study was performed in patients with olfactory dysfunction. Methods: One group of patients performed the Training (n = 40), whereas another part did not (n = 16). Exclusion criteria for patients were sinunasal disease. Olfactory training was performed over a period of 12 weeks. Patients exposed themselves twice daily to four intense odors (phenyl ethyl alcohol: rose, eucalyptol: eucalyptus, citronellal: lemon, and eugenol: cloves). Olfactory testing was performed before and after training using the “Sniffin' Sticks” (thresholds for phenyl ethyl alcohol, tests for odor discrimination and odor identification) in addition to threshold tests for the odors used in the training process. Results: Compared to baseline, training patients experienced an increase in their olfactory function, which was observed for the Sniffin' Sticks test score and for thresholds for the odors used in the training process. In contrast, olfactory function was unchanged in patients who did not perform olfactory training. The present results indicate that the structured, short-term exposure to selected odors may increase olfactory sensitivity. Laryngoscope, 119:496–499, 2009

Fungal rhinosinusitis: A categorization and definitional schema addressing current controversies

Abstract: Background Fungal (rhino-) sinusitis encompasses a wide spectrum of immune and pathological responses, including invasive, chronic, granulomatous, and allergic disease. However, consensus on terminology, pathogenesis, and optimal management is lacking. The International Society for Human and Animal Mycology convened a working group to attempt consensus on terminology and disease classification.

Lemierre's syndrome: A systematic review.

Abstract: Objectives/Hypothesis: Lemierre's syndrome is characterized by a history of recent oropharyngeal infection, clinical or radiological evidence of internal jugular vein thrombosis, and isolation of anaerobic pathogens, mainly Fusobacterium necrophorum. It was once called the forgotten disease because of its rarity, but it may not be that uncommon after all. This review aims to provide physicians with an update on the etiology, management, and prognosis of Lemierre's syndrome. Methods: Systematic review using the terms: Lemierre's syndrome, postanginal septicemia, fusobacterium, internal jugular vein thrombosis. Inclusion criteria: English literature; reviews, case reports, and case series. Exclusion criteria: variants or atypical Lemierre's syndrome cases, negative fusobacteria cultures, and papers without radiological evidence of thrombophlebitis. Results: Eighty-four studies fulfilled our inclusion criteria. The male to female ratio was 1:1, 2, and the ages ranged from 2 months to 78 years (median, 22 years). Main sources of infection were tonsil, pharynx, and chest. Most common first clinical presentation was a sore throat, followed by a neck mass and neck pain. The most common offending micro-organism was F. necrophorum. Treatment modalities used were antimicrobial, anticoagulant, and surgical treatment. Morbidity was significant with prolonged hospitalization in the majority of patients. The overall mortality rate was 5%. Conclusions: Lemierre's syndrome may not be as rare as previously thought. This apparent increase in the incidence may be due to antibiotic resistance or changes in antibiotic prescription patterns. Successful management rests on the awareness of the condition, a high index of suspicion, and a multidisciplinary team approach. Laryngoscope, 2009

Transoral robotic surgery for oropharyngeal squamous cell carcinoma: A prospective study of feasibility and functional outcomes

Abstract: Objectives/Hypothesis: To investigate the feasibility of transoral robotic surgery as a method of surgical treatment of oropharyngeal squamous cell carcinoma. Study Design: Prospective case study. Methods: Forty-five patients with previously untreated oropharyngeal squamous cell carcinoma underwent transoral robotic surgical removal of the tumor with or without neck dissection and with or without adjuvant therapy. Patients were observed and data were recorded on surgical time, blood loss, surgical complications, tracheostomy tube course, enteral feeding, and resumption of oral diet, speech outcomes, swallowing outcomes, and tumor recurrence. Results: All 45 patients underwent complete transoral robotic surgical excision with simultaneous unilateral or bilateral neck dissection. Margins were negative for tumor. Mean operating time for tumor removal was 71.3 minutes for the last 35 cases. There were 15 stage T1 tumors, 18 T2 tumors, 3 T3 tumors, and 9 T4a tumors. Twenty-six patients had base of tongue primary tumors and 19 had tonsillar fossa tumors. Fourteen patients had a tracheostomy tube placed at surgery, and all patients had their tracheostomy tube removed (mean duration of use, 7.0 days). Twenty-two patients (48.9%) had a nasogastric feeding tube placed, and all patients had their feeding tube removed (mean duration of use, 12.5 days). Eight patients had percutaneous gastrostomy (PEG) tubes placed, and all eight eventually had their PEG tubes removed (mean duration of use, 140.3 days). Average hospital stay was 3.8 days. There were no major complications and no procedure was aborted because of an inability to remove the tumor. Conclusions: Transoral robotic surgery is a safe and efficacious method of surgical treatment of oropharyngeal neoplasms. Advantages of the technique include adequate ability to visualize and manipulate with two hands lesions in the base of tongue. Patients were able to retain or rapidly regain oropharyngeal function in the majority of cases. Laryngoscope, 2009

Long-term outcomes from the English national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis.

Abstract: Objectives/Hypothesis: We present a large, prospective cohort study following patients who underwent surgery for chronic rhinosinusitis (CRS), with or without nasal polyps, in hospitals in England and Wales. Five-year outcomes will be reported, and we will revisit a previous analysis of the effectiveness of extensive surgery in the treatment of nasal polyposis. Methods: Baseline clinical data was collected for 3,128 patients undergoing surgery for CRS (with or without nasal polyps). Outcomes are described in terms of the proportion of patients undergoing revision surgery and mean Sino-Nasal Outcome Test (SNOT-22) scores. Results: A total of 1,459 (52.2%) patients responded to 5-year follow-up. Revision surgery rates increased at each time point. Of the patients responding, 279 patients (19.1%) had undergone further surgery during the 5 years since their original operation. Of the patients with polyps, 20.6% had undergone revision compared to 15.5% of patients with CRS alone. The mean SNOT-22 score for all patients was 28.2 (standard deviation [SD] = 22.4) at 5 years after surgery. This is remarkably similar to the results observed at 3 months (25.5), 12 months (27.7), and 36 months (27.7), and represents a 14-point improvement over the baseline score. Polyp patients report better SNOT-22 scores at 5 years (mean = 26.2; SD = 21.6) than patients with CRS alone (mean = 33.3; SD = 23.7). Of the patients who had originally received simple polypectomy, 21.2% had undergone revision surgery compared to 20.0% of patients who had also received additional sinus surgery. The difference in unadjusted revision surgery rates is not statistically significant (χ2 = 0.22; P = .64). However, the difference becomes statistically significant when a multivariate logistic regression is used to adjust for baseline characteristics, with patients undergoing additional sinus surgery being less likely to undergo further surgery within the study period (adjusted odds ratio = 0.66; P = .04). Conclusions: We have shown sinonasal surgery to be safe and effective in reducing the symptoms associated with CRS over a 5-year period. The reduction in symptoms is large, with no significant decline in symptomatic improvement from 12 to 60 months postsurgery. However, revision surgery rates approach 20% over this time, and patients should be counseled accordingly prior to surgery. Laryngoscope, 2009

Diagnostic evaluation of squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site

Abstract: Background. The purpose of this study was to evaluate the efficacy of the modern diagnostic evaluation for squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. Methods. One hundred thirty patients were evaluated be- tween June 1983 and June 1997. All underwent head and neck examinations, head and neck computed tomography (CT), and/or magnetic resonance imaging (MRI) scans, panendoscopies, and biopsies of head and neck mucosal sites. Twenty-four patients underwent 2-(fluorine-18)-2-deoxy-D-glucose (FDG) single pho- ton emission computed tomography (SPECT); 34 patients under- went tonsillectomy. Results. The primary site was identified in 56 patients (43%); the likelihood was increased in patients with suggestive findings on physical examination and/or radiographic evaluation. Eighty- three percent of the lesions were located in the tonsillar fossa and base of tongue. Results of FDG-SPECT scans were positive in 20 patients (83%); the primary tumor was detected in 7 patients (35%). Twelve (35%) of 34 patients who underwent tonsillectomy had a primary tumor discovered in the tonsillar fossa. Multivariate analysis of successful primary site detection revealed that sug- gestive findings on physical examination (p = .0225) and sugges- tive findings on CT and/or MRI (p = .0013) were significantly related to this end point. Conclusion. The primary lesion will be detected in over 40% of patients with physical examination of the head and neck and CT and/or MRI followed by panendoscopy and biopsies. Limited data pertaining to FDG-SPECT suggest that this provides addi- tional useful information in a small subset of patients. Tonsillec- tomy is useful for those with suggestive findings on physical ex- amination and/or radiographic evaluation. © 1998 John Wiley & Sons, Inc. Head Neck 20: 739-744, 1998.

Minimally invasive endoscopic pericranial flap: A new method for endonasal skull base reconstruction

Abstract: Objectives: One of the major challenges of cranial base surgery is reconstruction of the dural defect. Following a craniofacial resection, the standard reconstructive technique is direct suture repair of the dural defect with a fascial graft and rotation of an anteriorly based pericranial scalp flap to cover the dura. The introduction of endoscopic techniques and an endonasal approach to the ventral skull base has created new challenges for reconstruction. The nasoseptal flap has become the workhorse for vascularized endoscopic skull base reconstruction; however at times, the septal mucosal flap may be unavailable for reconstruction. This can be due to prior surgical resection or involvement of the nasal septum by sinonasal cancer. We have developed a minimally invasive endoscopic pericranial flap for endoscopic skull base reconstruction. The use of a pericranial scalp flap for reconstruction during endonasal skull base surgery using minimally invasive techniques has not been previously reported. Methods: We performed cadaveric studies to illustrate feasibility of an endoscopic pericranial flap for endonasal skull base reconstruction, then applied this novel technique to an elderly patient after endonasal skull base and dural resection of an esthesioneuroblastoma. Results: The technical report of the minimally invasive pericranial flap is outlined and the advantages and limitations during endonasal skull base reconstruction are discussed. The patient had excellent healing of her skull base and had no evidence of any postoperative cerebrospinal fluid leak. Conclusions: The minimally invasive endoscopic pericranial flap provides another option for endonasal reconstruction of cranial base defects. There is minimal donor site morbidity, and it provides a large flap that can cover the entire ventral skull base. The issues of intranasal tissue tumor involvement and the need for radiotherapy make the endoscopic pericranial flap an ideal reconstruction for anterior cranial base defects resulting from endonasal sinonasal and skull base cancer resections. Laryngoscope, 119:13–18, 2009

Transoral laser microsurgery (TLM) +/- adjuvant therapy for advanced stage oropharyngeal cancer: outcomes and prognostic factors.

Abstract: Objectives/Hypothesis: Document survival, prognostic variables, and functional outcomes of patients with AJCC stage III or IV oropharyngeal cancer, treated with transoral laser microsurgery (TLM) ± adjuvant therapy. Study Design: Analysis of prospectively assembled data pertaining to the above-described patient cohort. Methods: Patients treated with TLM for AJCC stage III or IV oropharyngeal cancer at Washington University School of Medicine from 1996 to 2006 were followed for a minimum of 2 years. Recurrence, survival, functional, and human papilloma virus data were analyzed. Results: Eighty-four patients met inclusion criteria. Mean follow-up was 52.6 months. Overall AJCC stages were: III 15% and IV 85%. T stages were T1-2, 74%; T3-4, 26%. Eighty-three patients underwent neck dissection, 50 received adjuvant radiotherapy, and 28 received adjuvant chemoradiotherapy. Overall survival at 2 and 5 years was 94% and 88%, respectively. Disease-specific survival at 2 and 5 years was 96% and 92%, respectively. Six patients recurred (7%): locally (one), regionally (four), and distant (five). T stage, positive margins, and p16 status significantly impacted survival. The addition of adjuvant chemotherapy in high-risk patients did not significantly impact survival. Five patients (6%) had major surgical complications, but without mortality. Eighty-one percent of patients had acceptable swallowing function at last follow-up. Immediately postoperatively, 17% required G-tubes, which dropped to 3.4% of living patients at 3 years. Conclusions: In this population, our findings validate TLM ± adjuvant therapy as a highly effective strategy for survival, locoregional control, and swallowing recovery in AJCC stage III and IV oropharyngeal cancer. Our finding also show that p16 positivity improves survival.

Endoscopic endonasal surgery for petrous apex lesions.

Abstract: Background: Endoscopic endonasal approaches to the ventral skull base are categorized based on their orientation in coronal and sagittal planes. For all of these approaches, the sphenoid sinus is the starting point, and provides orientation to important vascular and neural structures. Surgical approaches to the petrous apex include 1) a medial approach, 2) a medial approach with internal carotid artery (ICA) lateralization, and 3) a transpterygoid infrapetrous approach (inferior to the petrous internal carotid artery). The choice of a surgical approach depends on the relationship of the lesion to the internal carotid artery (medial or inferior), degree of medial expansion, and pathology. The purpose of this paper is to discuss the anatomic and technical features of endoscopic surgical approaches to the petrous apex, provide a new classification for approaches that focuses on the relationship of the lesion to the petrous internal carotid artery, and provide outcomes data on our first 20 endoscopic petrous apex approaches. Methods: A retrospective clinical outcome study of endoscopic petrous apex surgeries was performed at the University of Pittsburgh Medical Center. The medical records from patients with endoscopic endonasal approaches to isolated petrous apex lesions were reviewed for demographics, diagnoses, presentation, endoscopic approach, and clinical outcomes. Patients with lesions that extended into the petrous apex but were not isolated to the petrous apex were excluded (e.g., clival chordoma with extension into the petrous apex). Results: Twenty patients were included in the analysis: 13 inflammatory cystic lesions (9 cholesterol granulomas and four petrous apicitis) and 7 solid lesions. Chondrosarcoma was the most common solid petrous apex lesion in our series. Twelve of 13 cystic lesions were drained endoscopically (one surgery was aborted early in the series). All drained patients had resolution of presenting symptoms. One patient had closure of the outflow tract without return of symptoms and one patient had revision endoscopic drainage due to scarring and neo-osteogenesis and return of unilateral headache. No carotid injuries and no new cranial neuropathies occurred perioperatively. The advantages and limitations of the medial transsphenoidal approaches (with and without carotid mobilization) and the transpterygoid infrapetrous approach are discussed. Conclusions: The endoscopic endonasal approach to petrous apex lesions is safe and effective for appropriately selected patients in the hands of experienced endoscopic skull base surgeons. If offers advantages of removing the hearing and facial nerve risks from the transtemporal/transcranial approaches and allows for a larger and more natural drainage pathway into the sinuses. Laryngoscope, 119:19–25, 2009

Outcome of minimally invasive management of salivary calculi in 4,691 patients.

Abstract: Objective: To evaluate the application of minimally invasive techniques in the management of salivary stones. Background: The incidence of salivary calculi is 60 cases/million/year, with most stones situated in the mid or proximal duct. The current treatment of these stones is adenectomy. This paper reports the results of minimally invasive methods of stone removal that avoid gland excision. Methods: Observational study of 5,528 consecutive patients treated by lithotripsy, endoscopy, basket retrieval, and /or surgery in five centers from 1990 to 2004 inclusive. A total of 567cases were excluded, leaving 4,691 patients (parotid n = 1,165, submandibular n = 3,526) for analysis. Results: Salivary calculi were eliminated in 3,775/4,691 (80.5%) of cases and partly cleared in 782/4,691 (16.7%). Salivary glands were removed in 134/4,691 (2.9%) of patients with symptoms in whom treatment failed. Conclusions: Minimally invasive techniques move treatment of salivary calculi to an outpatient or a day case setting. They are reliable ways of both retrieving stones and eliminating symptoms, and mean that the gland rarely has to be removed. Laryngoscope, 2009

Endoscopic pedicled nasoseptal flap reconstruction for pediatric skull base defects

Abstract: Objectives/Hypothesis: A prospective study of endoscopic expanded endonasal approaches (EEA) with nasoseptal flap reconstructions revealed anecdotal evidence of less available relative septal length in pediatric patients. Our goal is to use radioanatomic analysis of computed tomography (CT) scans to determine limitations of the nasoseptal flap in pediatric skull base reconstruction and to describe clinical outcomes after using the nasoseptal flap in six pediatric patients. Study Design: Six pediatric patients who underwent EEA with nasoseptal flap reconstruction were prospectively analyzed for flap coverage and postoperative cerebrospinal fluid (CSF) leak. Fifty maxillofacial CTs of individuals <18 years of age and 10 adult images underwent radioanatomic analysis. Methods: Measurements included potential nasoseptal flap dimensions and dimensions required to reconstruct an anterior skull base defect, a trans-sellar defect, and a transclival defect. Measurements were compared to determine if flap size would be sufficient to cover independent EEA defects within different age groups. Results: Two out of three patients 14 years of age had adequate flap coverage. Average potential flap length is less than average anterior skull base length until age 9 years to 10 years, and less than average trans-sellar defect length until age 6 years to 7 years. Septal growth is most rapid between 10 years and 13 years. Conclusions: The pedicled nasoseptal flap may not be a viable option for EEA reconstruction in children 14 years of age, as their septums are comparable to adults. Patients 10 years to 13 years of age require careful consideration of facial analysis and preoperative radioanatomic evaluation on an individual basis. Laryngoscope, 2009

CD44 variant isoforms in head and neck squamous cell carcinoma progression.

Abstract: OBJECTIVES/HYPOTHESIS: The CD44 family of receptors includes multiple variant isoforms, several of which have been linked to malignant properties including migration, invasion, and metastasis. The objective of this study was to investigate the role of the CD44 v3, v6, and v10 variant isoforms in head and neck squamous cell carcinoma (HNSCC) tumor progression behaviors. STUDY DESIGN: Laboratory study involving cell cultures and clinical tissue specimens. METHODS: Analysis of the expression of standard CD44s and the CD44 variant isoforms v3, v6, and v10 was carried out in the HNSCC cell line, HSC-3. The role of CD44 isoforms in migration, proliferation, and cisplatin resistance was determined. Immunohistochemical analysis was performed on clinical tissue specimens obtained from a series of 82 HNSCC patients. The expression of standard CD44s and the CD44 v3, v6, and v10 variants in primary tumor specimens (n = 82) and metastatic cervical lymph nodes (n = 24) were analyzed with respect to various clinicopathologic variables. RESULTS: HSC-3 cells express at least four CD44 isoforms, and these CD44 isoforms mediate migration, proliferation, and cisplatin sensitivity. Compared with primary tumors, a greater proportion of metastatic lymph nodes demonstrated strong expression of CD44 v3 (lymph node 14/24 vs. primary tumor 38/82), CD44 v6 (lymph node 18/24 vs. primary tumor 26/82), and CD44 v10 (lymph node 14/24 vs. primary tumor 16/82), while expression of standard CD44 was not significantly different in metastatic lymph nodes and primary tumors (lymph node 10/24 vs. primary tumor 60/82). Expression of CD44 variant isoforms were associated with advanced T stage (v3 and v6), regional (v3) and distant (v10) metastasis, perineural invasion (v6), and radiation failure (v10). CD44 v6 and CD44 v10 were also significantly associated with shorter disease-free survival. CONCLUSIONS: CD44 isoforms mediate migration, proliferation, and cisplatin sensitivity in HNSCC. Furthermore, expression of certain CD44 variants may be important molecular markers for HNSCC progression and should be investigated as potential therapeutic targets for therapy.

Systematic review and meta-analysis of the adverse effects of thyroidectomy combined with central neck dissection as compared with thyroidectomy alone

Abstract: Objectives/Hypothesis: Meta-analysis to assess the increased morbidity of performing a central neck dissection with thyroidectomy to thyroidectomy alone. Study Design: Systematic review and meta-analysis. Methods: Published articles were searched for using PubMed. Suitability was assessed by using predefined inclusion/exclusion criteria. Meta-analysis on the data was performed using the Mantel-Haenszel method and a risk difference calculated. Results: Five studies with a total of 1,132 patients were included. For every 7.7 central neck dissections performed with thyroidectomy, there was one extra case of temporary hypocalcemia when compared to thyroidectomy alone. There was no significant increased risk of permanent hypocalcemia or temporary or permanent vocal cord palsy when a central neck dissection was performed in addition to a thyroidectomy. Conclusions: The benefits of prophylactic central neck dissection in differentiated thyroid carcinoma may be debated but there is no increased permanent morbidity by performing the procedure at the same time as thyroidectomy. Laryngoscope, 2009

Comparison of transnasal endoscopic and open craniofacial resection for malignant tumors of the anterior skull base.

Abstract: Objective/Hypothesis: Craniofacial resection (CFR) represents the traditional approach for resection of anterior skull base (ASB) malignancies. However, this past decade has witnessed the emergence of transnasal endoscopic ASB resection (TER) as a feasible alternative. The aim of this study was to compare TER and CFR for ASB malignancy resection. Methods: Retrospective analysis at a tertiary care medical center on 66 patients undergoing ASB malignant tumor resection between September 1997 and December 2006. Results: Eighteen patients were treated with TER, whereas 48 patients underwent CFR. The two groups showed no significant difference in complication rate (27.8% for TER and 25.0% for CFR, P > 0.05), survival (94.4% for TER and 83.3% for CFR, P > .05), and metastasis (11.1% for TER and 8.3% for CFR, P > .05). A significant difference was observed in hospital stay with an average of 3.8 days in the TER group compared to 8.1 days in the CFR group (P < .05). Local recurrence approximated significance (5.6% for TER and 29.2% for CFR, P = .051) Conclusions: TER of ASB malignancy is associated with a decreased hospital stay and faster recovery when compared to open CFR. Lower local recurrence rate in the TER group may reflect a discrepancy in histology and clinical stage. We found no significant differences in survival, metastatic, or complication rates in the two groups, whereas patients in the TER group had the added benefit of a desirable cosmetic outcome. Overall, TER seems to be an excellent alternative to CFR in properly selected cases. Laryngoscope, 2009

Defining the Nasopalatine Line: The Limit for Endonasal Surgery of the Spine

Abstract: Objectives The expanded endoscopic endonasal approach (EEA) to the odontoid process is performed for decompression of the brainstem and to access tumors at the foramen magnum. Caudal exposure is limited by the nasal bones anteriorly and the hard palate posteriorly. We define the line connecting these two points as the nasopalatine line (NPL) and the nasopalatine angle (NPA) as the angle between the nasopalatine line and the plane of the hard palate. Study design This study was a retrospective cohort study. Methods Pre and post-operative computed tomographic (CT) scans of 17 patients who underwent transodontoid EEA were reviewed. The position of the odontoid and the inferior extent of the tumor and surgical dissection were compared to the NPL. Factors affecting the posterior projection of the NPL, including basilar invagination and head position, were examined. Results The mean NPA was 27.1 degrees (range 21-31 degrees ). The NPL intersects the spinal column at 8.9 mm (range -9.0-8.7 mm) above the base of the C2 body. The base of the odontoid process and the inferior extent of surgical dissection were always above this line. Both basilar invagination and head position affect the relative position of the NPL. Patients with basilar invagination demonstrated a significantly lower posterior projection of the NPL than those without (P Conclusions The NPL accurately predicts the most inferior extent of surgical dissection. Further caudal dissection may require the use of angled instruments or a transoral approach.

Mitomycin C and the endoscopic treatment of laryngotracheal stenosis: are two applications better than one?

Abstract: Objectives/Hypothesis: Endoscopic treatment of laryngotracheal stenosis by airway dilation, despite short-term improvement, is often associated with long-term relapse. Mitomycin-C (MMC) inhibits fibroblast proliferation and synthesis of extracellular matrix proteins, and thereby modulates wound healing and scarring. MMC application at the time of endoscopic dilation and laser surgery has been suggested to improve outcomes, but this has not been studied in a rigorous manner. This study examines the hypothesis that two topical applications of MMC given 3–6 weeks apart will result in decreased scarring/restenosis of the airway, when compared to a single topical application. Study Design: A randomized, prospective, double-blind, placebo-controlled clinical trial. Methods: Twenty-six patients with laryngotracheal stenosis due to idiopathic subglottic stenosis, postintubation stenosis, or Wegener's granulomatosis entered a protocol to receive three endoscopic CO2 laser and dilation procedures over a 3-month interval. At the first procedure, after radial CO2 laser incision and airway dilation, all patients received topical application of MMC (0.5 mg/mL) to the airway lesion. One month later, a second endoscopic incision and dilation was performed and the patients were randomized to either a second application of mitomycin-C or to application of saline placebo. A third dilation procedure was performed 2 months later, without MMC application. Patients were followed for up to 5 years for relapse of airway stenosis with clinical symptoms sufficient to require a subsequent procedure. Results: The relapse rates at 1, 3, and 5 years were 7%, 36%, and 69% for patients treated with two applications of MMC compared to 33%, 58%, and 70% for patients treated with one application of MMC. The median interval to relapse was 3.8 years in the two-application group, compared with 2.4 years in the one-application group. Conclusions: This prospective randomized double-blind placebo-controlled trial suggests that, in the endoscopic management of laryngotracheal stenosis, two applications of MMC given 3–4 weeks apart after airway radial incision and dilation reduces the restenosis rate for 2 to 3 years after treatment when compared to a single application. However, restenosis and delayed symptom recurrence continues so that at 5 years the relapse rates are the same. Thus, MMC may postpone, but does not prevent, the recurrence of symptomatic stenosis in the majority of patients. Laryngoscope, 2009

Treatment of esthesioneuroblastoma: a 16-year meta-analysis of 361 patients.

Abstract: Objectives/Hypothesis: This study reviews the published outcomes related to surgical (open, endoscopic, and endoscopic-assisted) and nonsurgical treatment for esthesioneuroblastoma. Study design: Literature meta-analysis. Methods: A meta-analysis of individual patient data for esthesioneuroblastoma publications between 1992 (the earliest identified description of endoscopic resection) and 2008 was conducted. A total of 49 journal articles, comprising 1,170 cases of esthesioneuroblastoma, were included in the study. Criteria for meta-analysis inclusion were five or more patients in a study with sufficient patient data resolution for analysis. Twenty-three studies comprising 361 patients met all inclusion criteria. The overall treatment and outcome at final follow-up of each patient was recorded. Patients were pooled according to treatment techniques and compared to one another using a Kaplan-Meier survival curve and the Mann-Whitney U test to examine differences in follow-up times and publication years. Results: Log-rank tests showed a greater published survival rate for endoscopic surgery compared to open surgery (P = .0019), even when stratifying for publication year (P = .0018). There was no significant difference in follow-up time. Review of Kadish tumor staging for each modality showed larger tumors were more often treated with an open approach, but open and endoscopic survival measures were comparable. Conclusions: These results suggest that endoscopic surgery is a valid treatment method with comparable survival to open surgery. Further prospective analysis will be beneficial.

Prognostic significance of human papillomavirus in oropharyngeal squamous cell carcinomas.

Abstract: Objectives/Hypothesis: The human papillomavirus (HPV) has been identified as a causative factor in 20% to 25% of all head and neck squamous cell carcinomas (HNSCC). Ongoing research suggests that the presence of HPV DNA in HNSCC predicts a positive prognosis with respect to disease-free and overall survival. However, most studies have been limited by the heterogeneity in treatment regimens and/or anatomic subsites of tumor origin. In this study, we correlate clinical outcomes with HPV status for patients with oropharyngeal carcinomas who were uniformly treated with a concurrent chemoradiation treatment protocol. Study Design: Retrospective study. Methods: Demographic and clinicopathologic parameters, including age at diagnosis, gender, race, smoking and alcohol history, tumor stage and grade, locoregional recurrence, metastatic spread, recurrence-free survival, overall survival and disease-specific death, were obtained from medical charts and established databases. These parameters were correlated with HPV status of the tumors established by in situ hybridization analysis. Results: HPV positivity correlated with improved clinical outcomes regarding locoregional control (P = .042), recurrence-free survival (P = .009), overall survival (P = .017), and disease-specific death (P = .09). Advanced T stage was a significant risk factor for recurrence and death independent of HPV status. Conclusions: In patients with oropharyngeal carcinoma uniformly treated with chemoradiation, the presence of HPV is a favorable prognostic indicator with respect to recurrence and overall survival. However, advanced T stage was an independent risk factor for recurrence and death that can to some degree offset this benefit.

Randomized, double blind, placebo controlled trial on the safety and efficacy of continuous intratympanic dexamethasone delivered via a round window catheter for severe to profound sudden idiopathic sensorineural hearing loss after failure of systemic therapy.

Abstract: Objectives: To study the safety and efficacy of continuous intratympanic dexamethasone-phosphate (Dex-P) for severe to profound sudden idiopathic sensorineural hearing (ISSHL) or sudden idiopathic anacusis after failure of systemic therapy. Study Design: Randomized, double-blind, placebo controlled multicenter trial. Methods: Patients with ISSHL and insufficient recovery (mean 4PTA = 97 dB HL) after systemic high dose glucocorticoid therapy received either Dex-P (4mg/ml) or placebo (NaCl 0.9%) continuously applied for 14 days into the round window niche via a temporarily implanted catheter. For ethical reasons, intratympanic treatment was continued with Dex-P in all patients for another 14 days after the placebo-controlled study period. According to a two-step adaptive study design an interim analysis was performed after inclusion of 23 patients. Results: Intention-to-treat analysis for the primary outcome criterion (4PTA: 0.5-3kHz) during the placebo controlled study period (14 days) showed an average hearing improvement in the treatment group of 13.9 dB (SD: 21.3) and in the placebo group of 5.4 dB (SD: 10.4). This difference in hearing improvement between the two groups (mean: 8.4 dB, SD: 17.0, 95% CI: −7.1–24.1) was statistically not significant (p = .26). Of the secondary outcome parameters, the largest benefit of local salvage therapy was found for maximum speech discrimination with an improvement of 24.4% (SD: 32.0) in the treatment and 4.5% (SD: 7.6) in the placebo group (p = 0.07). After a 3 month follow-up period (i.e. after all patients received intratympanic Dex-P) hearing improvement in the two groups was very similar. No serious adverse events were observed. Sample size calculation after the interim analysis resulted in stopping of the trial. Conclusions: The tendency toward better hearing improvement in the treatment group, the rather conservative inclusion criteria, the limited placebo-controlled observation period and the absence of serious adverse events supports further investigation local inner ear drug delivery as a first or second line treatment option for ISSHL. Laryngoscope, 119:359–369, 2009

Middle turbinate flap for skull base reconstruction: cadaveric feasibility study.

Abstract: Objectives/Hypothesis: Surgical resection of intradural pathology through an endonasal corridor creates defects that communicate the subarachnoid space with the sinonasal tract. Reconstruction of these defects with vascularized tissue is superior to any other method. The purpose of this study is to describe a novel vascularized pedicled flap from the middle turbinate (MT) mucosa and to assess its feasibility using a cadaveric model. Methods: Twelve middle turbinate flaps (MTFs) were raised in six fresh cadaveric heads previously injected with colored silicone. Arteries supplying the MT were identified as the turbinate mucoperiosteum was harvested from both its medial and lateral aspects. Length and surface area of the flaps, as well as their ability to cover dural defects of the sella, planum sphenoidale, and fovea ethmoidalis reach were noted. Results: All MTFs adequately covered defects of the planum and fovea ethmoidalis; however, two of the twelve MTFs were not suitable to cover a sellar defect. The mean surface area of the MTFs was 5.6 cm2. As an independent factor surface area did not correlate with the ability of the flap to cover the sellar defects. However, those flaps that were not suitable for sellar repair were less than 4.0 cm in length. Conclusions: Harvesting of a vascular pedicle flap from the MT is feasible, albeit technically demanding. It should be considered as an alternative for the reconstruction of small defects of the fovea ethmoidalis, planum, and sella, particularly for patients for whom a reconstruction with vascularized tissue is desirable but the nasoseptal flap is not available. Laryngoscope, 2009

Radiotherapy for cutaneous squamous and basal cell carcinomas of the head and neck.

Abstract: Objectives/Hypothesis: To discuss the role of radiotherapy (RT) in the treatment of cutaneous squamous and basal cell carcinomas of the head and neck. Methods: Review of the pertinent literature. Results: The likelihood of cure with a good cosmetic outcome is high for patients with early-stage cancers treated with definitive RT. The probability of local control is higher for previously untreated cancers and is inversely related to tumor size. The likelihood of cure for patients with perineural invasion (PNI) is related to the presence of symptoms and to the radiographic extent of disease. It decreases as the tumor extends centrally towards the central nervous system. Patients with incidental PNI have a local control rate of 80% to 90% compared with about 50% to 55% for those with clinical PNI. The optimal treatment for patients with clinically positive nodes is surgery and postoperative RT. The likelihood of cure for those with positive parotid nodes is approximately 70% to 80%. Conclusions: Definitive RT is useful for treating early-stage skin cancers where resection would result in a significant cosmetic and/or functional deficit. Postoperative RT is indicated in situations where the probability of residual disease after surgery is high and the chance of successful salvage is modest. Patients with parotid-area node metastases are optimally treated with surgery and postoperative RT. Laryngoscope, 2009

Efficacy and safety of OK-432 immunotherapy of lymphatic malformations†

Abstract: Objectives: To determine the efficacy and safety of the immunostimulant OK-432 (Picibanil) as a treatment option in the management of children with cervicofacial lymphatic malformations. Study Design: A prospective, randomized, multi-institutional phase II clinical trial at 27 U.S. academic medical centers. Methods: 182 patients with lymphatic malformations (LM) were enrolled between January 1998 and November 2004. Of the 151 patients with complete case report forms, 117 patients were randomized into immediate or delayed treatment groups; 34 patients were nonrandomized and assigned to the open-label group. Treatment consisted of a four-dose intralesional injection series of OK-432 at eight-week intervals. Patients randomized into the delayed treatment group served as observational controls for spontaneous regression. Response to therapy was measured radiographically by quantitating change in lesion size and graded as complete (90%–100%), substantial (60%–89%), intermediate (20%–59%), or none (<20%). Results: Of 117 patients randomized with intent-to-treat, 68% demonstrated a complete or substantial response to OK-432 immunotherapy. Response data for macrocystic LM were higher, with a complete or substantial response in 94% of patients; 63% of patients with mixed macrocystic-microcystic LM responded to treatment; no patients with microcystic LM responded to treatment. Spontaneous resolution occurred in less than 2% of patients. Median follow-up of 2.9 years demonstrated a 9% recurrence rate. Major adverse effects related to therapy occurred in 11 patients. As compared to historical surgical data on LM, OK-432 immunotherapy is more effective (P < .001) and has a lower morbidity (P < .001). Conclusions: OK-432 immunotherapy is an effective, safe, and simple treatment option for the management of macrocystic cervicofacial LM. Trial Registration: ClinicalTrials.gov Identifier: NCT00010452. Laryngoscope, 119:107–115, 2009

Cigarette smoke condensate inhibits transepithelial chloride transport and ciliary beat frequency.

Abstract: Objectives/Hypothesis: Although the pathophysiology leading to rhinosinusitis is complex, evidence indicates that decreased mucociliary clearance (MCC) is a major contributing feature. Normal respiratory epithelial MCC is an important host defense mechanism that is dependent on proper ciliary beating and the biological properties of the airway surface liquid (ASL). The role that tobacco smoke exposure plays as an inhibitor of MCC has yet to be elucidated. The present study investigates the consequences of cigarette smoke exposure on ciliary function and transepithelial chloride (Cl - ) secretion, a major determinant of ASL. Study Design: In vitro investigation. Methods: Well-characterized primary murine nasal septal epithelial (MNSE) and human sinonasal epithelial (HSNE) cultures were exposed to cigarette smoke condensate (CSC) and compared to control cultures. Effects on ciliary beat frequency (CBF) and Cl - secretion were investigated using pharmacologic manipulation. Results: Change in forskolin-stimulated current (ΔI SC ), representing transepithelial Cl - secretion, was significantly decreased in CSC exposed MNSE (14.97 ± 1.2 μA/cm 2 vs. control, 19.1 ± 1.56 μA/cm 2 [P = .04]) and HSNE (2.68 ± 0.79 μA/cm 2 vs. control, 10.8 ± 1.73 μA/cm 2 ) cultures (P = .001). Forskolin-stimulated CBF was also significantly reduced when acutely exposed to CSC (5.64 ± 0.06 Hz vs. control 7.15 ± 0.18 Hz). Conclusions: The present study provides direct evidence that tobacco smoke diminishes two major components of MCC. This links tobacco smoke as a potential contributing and/or exacerbating factor in exposed individuals with chronic rhinosinusitis.

Incidence and indications for revision cochlear implant surgery in adults and children.

Abstract: Objectives/Hypothesis: To identify the incidence of and common causes for cochlear implant revision. Study Design: Retrospective case series. Methods: Operative records were reviewed for all cases of revision cochlear implantation from 1992 to 2006. The causes for reimplantation were classified as hard device failure, soft device failure, exposure/infection, receiver/stimulator migration, and electrode migration. Manufacturers' failure analysis of explanted devices was likewise determined. Results: Eight hundred and six cochlear implants were performed during the study period including 44 (5.5%) revision procedures. The revision rate was 7.3% for children and 3.8% for adults and reached statistical significant difference. The most common reasons for revision were device failure (78%; 55% hard failure, 23% soft failure) followed by electrode migration (9%) and receiver/stimulator migration (7%). Manufacturers' analysis of failed devices revealed loss of hermetic seal and cracked cases to be the most common causes of failure. Bench analysis of 5/10 explanted devices that were soft failures demonstrated identifiable device defects. Conclusions: Revision cochlear implant surgery is an infrequent occurrence. Its incidence appears to be higher in children than in adults, although in this series does not appear to be due to increased wound complications, infections, or trauma. Explanted implants that have soft failure as the etiology may have demonstrable defects on bench testing. Laryngoscope, 119:152–157, 2009

Rhinovirus enhances various bacterial adhesions to nasal epithelial cells simultaneously

Abstract: Objectives/Hypothesis: Viral upper respiratory tract infections are often followed by secondary bacterial infections in the form of acute rhinosinusitis. We investigate the effect of rhinovirus infection on the expression of cell adhesion molecules and bacterial adherence to primary human nasal epithelial cells. Methods: Cells were infected with rhinovirus serotype 16 (RV-16), and then Staphylococcus aureus, Streptococcus pneumoniae, or Hemophilus influenzae were added to the culture. Rhinovirus-induced expression of fibronectin, platelet-activating factor receptor, and carcinoembryonic antigen-related cell adhesion molecule, was assayed by confocal microscopy, real-time polymerase chain reaction, and Western blot analysis. Bacterial adhesion to cells was assessed by confocal microscopy and the fluorescence intensity of adherent bacteria was analyzed using Image-Pro Plus 5.1 (Media Cybernetics, Inc., Bethesda, MD). Results: RV-16 infection significantly increased the gene and protein expression of fibronectin, platelet-activating factor receptor, and carcinoembryonic antigen-related cell adhesion molecule in nasal epithelial cells. Compared with rhinovirus-uninfected control cells, the adhesion of S. aureus, S. pneumoniae, and H. influenzae increased significantly to 2.53-fold, 1.51-fold, and 2.74-fold of control levels, respectively, in rhinovirus-infected nasal epithelial cells. Conclusions: These findings suggest that increased expression of host cell adhesion molecules may be the mechanism accounting for the increase in susceptibility to bacterial rhinosinusitis associated with rhinovirus-induced upper respiratory infections. Laryngoscope, 2009

The Effect of treatment on survival in patients with advanced laryngeal carcinoma

Abstract: Objectives/Hypothesis: Over the last 2 decades, survival from laryngeal cancer has decreased. We sought to identify factors associated with decreased survival in laryngeal cancer. Methods: Patients diagnosed with laryngeal squamous cell carcinoma from 1985 to 2002 were retrospectively reviewed. Results: A total of 451 patients met study criteria. Five-year survival rates were 85% for stage I, 77% for stage II, 51% for stage III, and 35% for stage IV disease. Survival for patients with stage I-III disease was similar for patients treated operatively or noperatively (P = .4). However, patients with stage III disease treated nonoperatively had worse survival with radiation alone (XRT) compared to chemoradiation (CR) (P = .006). Patients with stage IV disease had significantly better survival with surgery (49%) than CR (21%) or XRT alone (14%) (P < .0001). Analysis by primary tumor stage demonstrated that survival for T1―T3 disease was independent of treatment modality (P = .2); however, for T4 patients, operative treatment was associated with significantly better survival (55%) than CR (25%) or XRT (0%) (P < .0001). Proportional hazards models confirmed significantly worse survival for stage IV, T4, N2 or N3 disease, and nonoperative treatment. For T4 disease, after controlling for nodal status, nonoperative treatment was the only significant predictor of worse survival. Conclusions: Primary surgical treatment is associated with improved survival for patients with stage IV disease and specifically T4 primary tumors. These data suggest that the observed national decrease in survival from laryngeal cancer may be due to a shift toward nonoperative treatment in that subset of patients with advanced primary disease.

Fungus ball of the paranasal sinuses: experience in 160 patients treated with endoscopic surgery.

Abstract: Objectives/Hypothesis: Herein we present our experience in the management of fungus ball (FB) of the paranasal sinuses. Preoperative imaging strategy and findings, surgical technique, and pathologic and microbiologic results are discussed. Study Design: Retrospective chart review of patients with FB of the paranasal sinuses who underwent endoscopic surgery at the Department of Otorhinolaryngology of the University of Brescia, Italy. Methods: From January 1990 to December 2006, 160 patients with sinonasal fungus ball were treated with a purely endoscopic approach. All patients underwent preoperative computed tomography (CT) and/or magnetic resonance (MR) imaging; an endo-oral dental x-ray or orthopantomography and odontological evaluation were also performed in patients with maxillary sinus localization. All removed material was sent for pathologic and microbiologic evaluation. All patients were prospectively followed with endoscopic control every 2 months during the first postoperative year and subsequently every 6 months. Results: The patient cohort included 118 females and 42 males, with an age from 19 to 85 years (mean, 52.7 years). FB was located in the maxillary sinus in 135 (84.4%) patients; in two cases both sinuses were affected. Sphenoid and ethmoid involvement was observed in 23 (14.4%) and 1 (0.6%) patients, respectively. Simultaneous ethmoid and sphenoid involvement was found in one (0.6%) case. In all patients complete removal of fungal debris was obtained through wide sinusotomy. No recurrence was observed. Conclusions: Endoscopic surgery is a safe and effective treatment for paranasal sinuses FB. A proper imaging study by MR and/or CT can address diagnosis, which is based upon detection of fungal hyphae at histology. Laryngoscope, 2009

Advances in office-based diagnosis and treatment in laryngology.

Abstract: No abtracts.

Management of meningoencephalic herniation of the temporal bone: Personal experience and literature review.

Abstract: Objectives/Hypothesis: Temporal bone meningoencephalic herniation is a rare condition with potentially dangerous complications. The aim of this study is to analyze the pathogenesis, clinical presentation, surgical treatment, and postoperative outcome of 133 cases of surgically confirmed temporal bone meningoencephalic herniations. A review of the literature is also presented. Study Design: Retrospective case series (quaternary referral otology and skull base center). Methods: This study is based on the analysis of the collected data of 133 cases of temporal bone meningoencephalic herniations surgically treated from 1984 to 2006. The follow-up ranged from 12 to 204 months with a mean of 38.4 months. Results: Meningoencephalic herniations were divided into four etiologic groups: spontaneous (24.8%), secondary to chronic otitis media (21.8%), iatrogenic (45.9%), and posttraumatic (7.5%). Different surgical techniques were used for treatment: transmastoid approach (27.8%), middle cranial fossa approach (27.8%), combined technique (transmastoid plus minicraniotomy, 3%), and middle ear obliteration with blind sac closure of the external auditory canal (41.4%). Conclusions: Temporal bone meningoencephalic herniations are potentially life threatening, and surgery must take place expeditiously. The choice of the most appropriate surgical approach must be based on the localization and size of the herniated tissue, preoperative auditory function, the presence of active infection, intraoperative cerebrospinal fluid leak, and concomitant pathology. Laryngoscope, 2009

Assessment of septal deviation effects on nasal air flow: a computational fluid dynamics model.

Abstract: Objectives/Hypothesis: The purpose of this article is to analyze the effects of septal deviation on the aerodynamic air flow pattern compared with that of a normal nose by computational fluid dynamics (CFD) tools. Methods: Two 3-dimensional (3-D) models of nasal cavities were constructed from the magnetic resonance imaging and computed tomography scans of a healthy human nose and a nose with septal deviation, with the use of the software MIMICS 12.1 (The Materialise Group, Leuven, Belgium). Thereafter high-resolution 3-D volume meshes comprising boundary layer effect and computational domain exterior to the nose were constructed. Numerical simulations were carried out using FLUENT (ANSYS, Canonsburg, PA) for CFD simulations. The Reynolds-averaged Navier-Stokes equations were solved for the turbulence flow with the shear stress transport k − ω model. Results: In the nose model with septal deviation, major changes in the pattern of inspiratory airflow (e.g., flow partitioning and nasal resistance, velocity and pressure distributions, intensity and location of turbulence), wall shear stress, and increasing of total negative pressure through the nasal cavity were demonstrated qualitatively and quantitatively. In the healthy nose, the area with the highest intensity of turbulent flow was found in the functional nasal valve region, but it became less apparent or even disappeared in the septal deviation one. Conclusions: This CFD study provides detailed information of the aerodynamic effects of nasal septal deviation on nasal airflow patterns and their associated physiological functions. Laryngoscope, 2009