Showing papers in "Laryngoscope in 2011"

Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement.

Abstract: Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual nerve identification. Despite the increasing use of IONM, review of the literature and clinical experience confirms there is little uniformity in application of and results from nerve monitoring across different centers. We provide a review of the literature and cumulative experience of the multidisciplinary International Neural Monitoring Study Group with IONM spanning nearly 15 years. The study group focused its initial work on formulation of standards in IONM as it relates to important areas: 1) standards of equipment setup/endotracheal tube placement and 2) standards of loss of signal evaluation/intraoperative problem-solving algorithm. The use of standardized methods and reporting will provide greater uniformity in application of IONM. In addition, this report clarifies the limitations of IONM and helps identify areas where additional research is necessary. This guideline is, at its forefront, quality driven; it is intended to improve the quality of neural monitoring, to translate the best available evidence into clinical practice to promote best practices. We hope this work will minimize inappropriate variations in monitoring rather than to dictate practice options.

Efficacy of preoperative neck ultrasound in the detection of cervical lymph node metastasis from thyroid cancer.

Abstract: Objectives/Hypothesis: This study was performed to assess the diagnostic accuracy of surgeon-performed preoperative neck ultrasound (US) in the detection of both central and lateral cervical lymph node metastases from thyroid cancer. Study Design: Prospective cohort study. Methods: Data for all patients with thyroid cancers and follicular thyroid lesions who were evaluated by means of preoperative neck US were reviewed. The cervical lymph nodes were assessed for suspicion of metastasis based on US characteristics. The diagnostic accuracy of US was determined according to whether histologically confirmed cancer was present in surgical cervical lymph node specimens. Results: The sensitivity and specificity of US in predicting papillary thyroid carcinoma (PTC) metastasis in the central neck were 30.0% and 86.8%, respectively. The sensitivity and specificity of US in predicting metastasis in the lateral neck were 93.8% and 80.0%, respectively. A subset of patients underwent US followed by revision neck dissection for PTC, and the sensitivity and specificity of US in predicting metastasis in the lateral neck were 100% and 100%, respectively. Conclusions: Preoperative neck US is a valuable tool in assessing patients with thyroid cancers. The highly sensitive and specific nature of US in predicting cervical lymph node metastasis in the lateral neck, especially in the setting of recurrent disease, can provide reliable information to assist in surgical management. Although US for central compartment lymphadenopathy in the presence of the thyroid gland is less sensitive and specific than US for the lateral neck, it still provides useful information that can be obtained at the same time the primary thyroid pathology is assessed.

Systematic review and meta-analyses of randomized controlled trials examining tinnitus management.

Abstract: Objectives/Hypothesis: To evaluate the existing level of evidence for tinnitus management strategies identified in the UK Department of Health's Good Practice Guideline. Study Design: Systematic review of peer-reviewed literature and meta-analyses. Methods: Searches were conducted in PubMed, Cambridge Scientific Abstracts, Web of Science, and EMBASE (earliest to August 2010), supplemented by hand searches in October 2010. Only randomized controlled trials that used validated questionnaire measures of symptoms (i.e., measures of tinnitus distress, anxiety, depression) were included. Results: Twenty-eight randomized controlled trials met our inclusion criteria, most of which provide moderate levels of evidence for the effects they reported. Levels of evidence were generally limited by the lack of blinding, lack of power calculations, and incomplete data reporting in these studies. Only studies examining cognitive behavioral therapy were numerous and similar enough to perform meta-analysis, from which the efficacy of cognitive behavioral therapy (moderate effect size) appears to be reasonably established. Antidepressants were the only drug class to show any evidence of potential benefit. Conclusions: The efficacy of most interventions for tinnitus benefit remains to be demonstrated conclusively. In particular, high-level assessment of the benefit derived from those interventions most commonly used in practice, namely hearing aids, maskers, and tinnitus retraining therapy needs to be performed.

Recurrent laryngeal nerve monitoring versus identification alone on post-thyroidectomy true vocal fold palsy: A meta-analysis†

Abstract: Objectives/Hypothesis: To compare by meta-analysis the effect of recurrent laryngeal nerve (RLN) monitoring versus RLN identification alone on true vocal fold palsy rates after thyroidectomy. Study Design: Systematic review and meta-analysis. Methods: A search of MEDLINE (1966–July 2008), EMBASE (1980–July 2008), Cochrane Central Register of Clinical Trials (CENTRAL), Cochrane Database of Systematic Reviews, clinicaltrials.gov, and The National Guideline Clearinghouse databases was performed. References from retrieved articles, presentation data, and correspondence with experts was also included. All authors used a detailed list of inclusion/exclusion criteria to determine articles eligible for final inclusion. Two authors independently extracted data including study criteria, methods of vocal fold function assessment, laryngeal nerve monitor type, and surgical procedure. Odds ratios (OR) were pooled using a random-effects model. Associations with patient and operative characteristics were tested in subgroups. Results: One randomized clinical trial, seven comparative trials, and 34 case series evaluating 64,699 nerves-at-risk were included. The overall incidence of true vocal fold palsy (TVFP) was 3.52% for intraoperative nerve monitoring (IONM) versus 3.12% for nerve identification alone (ID) (OR 0.93; 95% confidence interval [CI], 0.76-1.12]. No statistically significant difference in transient TVFP (2.74% IONM vs. 2.49% ID [OR 1.07, 95% CI, 0.95-1.20]), persistent TVFP (0.75% IONM vs. 0.58% ID [OR 0.99, 95% CI, 0.79-1.23]), or unintentional RLN injury (0.12% IONM vs. 0.33% ID [OR 0.50, 95% CI, 0.15-1.75]) was found. Conclusions: This meta-analysis demonstrates no statistically significant difference in the rate of true vocal fold palsy after using intraoperative neuromonitoring versus recurrent laryngeal nerve identification alone during thyroidectomy.

One hundred consecutive patients undergoing drug‐induced sleep endoscopy: Results and evaluation

Abstract: Objectives/Hypothesis: Polysomnography (PSG) is mandatory in the diagnostic workup of obstructive sleep apnea (OSA); drug-induced sleep endoscopy (DISE) is a valid addition. DISE is a dynamic, safe, easy-to-perform technique that visualizes the anatomic sites of snoring or apneas and guides the making of a tailor-made treatment plan in individual cases. The aim of this prospective study was to document the results of 100 consecutive DISE procedures and investigate associations between PSG and DISE findings. Study Design: This prospective, single-center, observational study enrolled 100 consecutive patients between June and August 2010. Methods: All 100 patients eligible for sleep surgery or a mandibular repositioning appliance (MRA) underwent PSG and DISE (using midazolam or propofol). DISE findings were reported using the VOTE classification system; site, degree of airway narrowing, and configuration of obstruction were reported. Associations were analyzed between PSG results, patient characteristics, and DISE findings. Results: Our results suggest that a multilevel collapse, a complete collapse, and a tongue-base collapse are statistically significantly associated with higher apnea hypopnea index values. A tongue base collapse or epiglottal collapse is associated with positional OSA. Complete concentric collapse is statistically significantly associated with an increased body mass index. Conclusions: The results of this small-scale study help us understand the pathogenesis of OSA and the various associations between PSG outcomes and DISE results, as well as assisting the sleep surgeon in tailoring surgery for the patient. Laryngoscope, 121:2710–2716, 2011

Complications in endoscopic sinus surgery for chronic rhinosinusitis: a 25-year experience.

Abstract: Objectives/Hypothesis: The aim of this study was to review complications occurring as a result of endoscopic sinus surgery by one surgeon in an academic practice during a 25-year period. Study Design: Retrospective clinical study. Methods: A register of complications was tabulated during a period of 25 years for endoscopic sinus surgery performed for chronic rhinosinusitis in 3,402 patients (6,148 sides). All complications were reviewed as a whole and were not divided into major or minor categories. Results: A total of 105 patients were found to have complicated endoscopic sinus surgery, for an overall patient complication rate of 0.031, or 0.017 per operated side. The most common complications were hemorrhage (n = 41), orbital complications (n = 29), and CSF leak (n = 19). The following factors were noted to have increased risk for complications: age, revision surgery, nasal polyps, anatomic variation, extensive disease, overall health, medications, and underlying factors. Certain types of instrumentation such as powered instrumentation placed patients at greater risk. The use of image guidance or surgical experience did not eliminate complications from occurring. Conclusions: Complications of endoscopic sinus surgery still occur 25 years after the initial introduction of the surgery in 1985. Many complications can be managed without a bad outcome. The key to prevention is knowledge of anatomy, preparation, anticipation, and experience. Even then, complications can occur in the most experienced hands. Patients most at risk for complications include those with revision surgery, extensive disease, skull base anatomic or radiologic variations or dehiscences related to disease or previous surgery, and the use of powered instrumentation.

Robotic facelift thyroidectomy: II. Clinical feasibility and safety

Abstract: Objectives: A number of remote access thyroidectomy techniques have been described in the last several years. These approaches are technically challenging, can be performed on only a limited patient population, and have been associated with significant complications. We describe a novel robotic facelift approach for thyroidectomy and report our initial clinical experience. Design: Planned analysis of a prospectively maintained database with institutional review board approval. Methods: Robotic facelift thyroidectomy (RFT) was performed on all patients. Demographic and surgical data were obtained and analyzed. Data collected included patient age, gender, body mass index (BMI), pathology, complications, and duration of surgery. Results: A total of 18 RFT procedures were undertaken in 14 patients. There were 13 females and 1 male, with a mean age of 33.7 ± 18.1 years (range: 12–70). The mean BMI was 26.9 ± 4.5. The procedures included 13 lobectomies, one bilateral thyroidectomy, and 3 completion thyroidectomies. All but the first procedure was performed on an outpatient basis without use of a drain. There were no conversions to open surgery, no permanent nerve injuries, and no cases of hypoparathyroidism. Operative times ranged from 97 to 193 minutes. Conclusions: RFT is a feasible remote access thyroidectomy approach. It appears from our initial experience that it may be performed in a safe and reproducible manner without a drain and on an outpatient basis. Additional clinical experience is warranted to further validate this technique.

Health state utility values in patients undergoing endoscopic sinus surgery.

Abstract: Objectives/Hypothesis: The primary study goal was to measure health state utility values in patients with chronic rhinosinusitis (CRS) before and after undergoing endoscopic sinus surgery (ESS). A secondary goal was to assess the meaning of these values by comparing them with other chronic disease processes and currently available medical or surgical treatments. Study Design: Prospective, observational cohort study. Methods: Adults with CRS were enrolled after electing ESS and were observed for a 5-year period. Baseline demographic and medical comorbidities were recorded for each patient, as well as findings from computed tomography (CT), endoscopy, olfaction, and disease-specific quality of life scores. Utility values were derived using the Short-Form 6D (SF-6D) at baseline and again after surgery. Results: The mean SF-6D utility value for the baseline health state of all patients with CRS (n = 232) was 0.65 (95% confidence interval [CI]: 0.63-0.66). Baseline utility values correlated with disease-specific quality of life as measured by the Rhinosinusitis Disability Index (r = −0.660; P < .001), but not baseline CT, endoscopy, or olfactory scores. Follow-up utility values (≥6 months) after ESS improved by 0.087 (95% CI: 0.06-0.12; P < .001) in patients with no history of sinus surgery and 0.062 (95% CI: 0.04-0.09; P < .001) in those undergoing a revision procedure. Conclusions: Patients with CRS who failed medical therapy and elected to undergo ESS reported health state utility values that were significantly lower than the US population norm. Utility values showed improvement after ESS, which was statistically and clinically significant. These results provide the initial data necessary for formal cost-effectiveness analyses incorporating ESS.

Robotic thyroid surgery: An initial experience with North American patients

Abstract: Objective: To review the initial experience of gasless transaxillary robot-assisted endoscopic thyroid surgery in a series of patients and describe modifications of the technique for the North American patients, selection criteria, and other issues related to this technology. Methods: Retrospective review of the first 31 consecutive cases at a single institution. Results: Thirty-one patients underwent robotic thyroid surgery. Twenty thyroid lobectomies and 11 total thyroidectomies were performed. Improvements in the length of time to perform components of the procedure were noted from the early group of cases to later group of cases. No major or permanent complications occurred. Conclusions: Robotic thyroid surgery is feasible in North American patients and can be safely performed. The procedure has potential complications and a definite learning curve exists for both surgeons and operating room staff. Training methods need to be validated to ensure safe adoption. More studies need to be performed to further evaluate the relative benefits of this technique. Laryngoscope, 2011

Hemorrhage following tonsil surgery: a multicenter prospective study.

Abstract: Objectives/Hypothesis: Postoperative hemorrhage as a serious complication after tonsillectomy (TE), tonsillotomy (TO), or adenoidectomy (AE) is covered in many studies, using rather inconsistent measurement methods. We introduce a new classification for the severity of postoperative hemorrhage and investigate risk factors for the frequency and severity of bleeding episodes. Study Design: Prospective, multicenter cohort study. Methods: Our study is based on a prospective census recording all TEs, TOs, and AEs from October 1, 2009, to June 30, 2010, in Austria. Information concerning surgery indication, grade of surgeon, operation technique, and postoperative hemorrhage, classified as any bleeding episode after extubation according to severity, were collected. Results: A total of 9,405 patients were included. Hemorrhage rate for TE ± AE was 15.0%, for TO ± AE was 2.3%, and for AE was 0.8%. Rate of return to the operating room for TE ± AE was 4.6%, for TO ± AE was 0.9%, and for AE was 0.3%. Minor bleeding episodes increased the risk of a subsequent severe bleeding episode (P < .001). Elevated hemorrhage rates were observed for adults (P < .001), TE ± AE (P < .001), and cold steel dissection combined with bipolar diathermy (P = .05). Multivariate logistic regression model for the frequency of post-TE hemorrhage showed significant odds ratios for males, children aged <6 years, children aged 6–15 years, abscess TE, and cold steel combined with bipolar diathermy. In addition, we found a significantly higher risk of severe bleeding episodes for children aged 6–15 years (P = .007), males (P = .02), and all bipolar operation techniques (P = .005). Conclusions: The occurrence of a postoperative minor bleeding episode increases the risk of a subsequent severe bleeding episode. Laryngoscope, 121:2553–2560, 2011

Staphylococcus aureus biofilms: Nemesis of endoscopic sinus surgery.

Abstract: Objectives/Hypothesis: Chronic rhinosinusitis (CRS) patients with biofilms have persistent postoperative symptoms, ongoing mucosal inflammation, and recurrent infections. Recent evidence suggests that biofilms of differing species confer varying disease profiles in CRS patients. We aimed to prospectively investigate the effects of Staphylococcus aureus, Pseudomonas aeruginosa, Haemophilus influenzae, and fungal biofilms on outcomes following endoscopic sinus surgery (ESS). Study Design: Prospective blinded study. Methods: In this prospective blinded study, 39 patients undergoing ESS for CRS assessed their symptoms preoperatively using internationally accepted standardized symptom scoring systems and quality-of-life measures (10-point visual analog scale, Sino-Nasal Outcome Test-20, global severity of CRS). Their sinonasal mucosa was graded (Lund–Kennedy scale) and extent of radiologic disease on computed tomography scans scored (Lund-McKay scale). Random sinonasal tissue samples were assessed for different bacterial species forming biofilms by using fluorescent in-situ hybridization and confocal laser microscopy. For 12 months after surgery, CRS symptoms, quality of life, and objective evidence of persisting disease were assessed by using the preoperative tools. Results: Different bacterial species combinations were found in 30 of 39 patients; 60% of these 30 biofilms were polymicrobial biofilms and 70% had S aureus biofilms. Preoperative nasendoscopy and radiologic disease severity were significantly worse in patients with multiple biofilms (P = .02 and P = .01, respectively), and they had worse postsurgery mucosal outcomes on endoscopy (P = .01) requiring significantly more postoperative visits (P = .04). Those with S aureus biofilms progressed poorly with their symptom scores and quality-of-life outcomes, with significant differences in nasendoscopy scores (P = .007). Conclusions: S. aureus biofilms play a dominant role in negatively affecting outcomes of ESS with persisting postoperative symptoms, ongoing mucosal inflammation, and infections.

Transoral robotic resection and reconstruction for head and neck cancer

Abstract: Objectives/Hypothesis: To evaluate the patterns of failure, survival, and functional outcomes for patients treated with transoral robotic surgery (TORS) and compare these results with those from a cohort of patients treated with concurrent chemoradiation (CRT). Study Design: Prospective non-randomized case control study. Methods: Between April 2007 and April 2009, 30 patients with head and neck squamous cell carcinoma were treated with primary TORS and adjuvant therapy as indicated on an institutional review board–approved protocol. Patients were evaluated before treatment, after treatment, and at subsequent 3-month intervals after completing treatment to determine their disease and head and neck–specific functional status using the Performance Status Scale for Head and Neck Cancer and the Functional Oral Intake Score (FOIS). Functional scores were compared to a matched group of head and neck patients treated with primary CRT. Results: The TORS patient population included 73% stage III-IV and 23% nonsmokers. The median follow-up was 20.4 months (range, 12.8–39.6 months). The 18-month locoregional control, distant control, disease-free survival, and overall survival were 91%, 93%, 78%, and 90%, respectively. Compared to the primary CRT group, TORS was associated with better short-term eating ability (72 vs. 43, P = .008), diet (43 vs. 25, P = .01), and FOIS (5.5 vs. 3.3, P < .001) at 2 weeks after completion of treatment. In contrast to TORS patients who returned to baseline, the CRT group continued to have decreased diet (P = .03) and FOIS (P = .02) at 12 months. Conclusions: Our early experience in treating selected head and neck cancers with TORS is associated with excellent oncologic and functional outcomes that compare favorably to primary CRT.

Facial determinants of female gender and feminizing forehead cranioplasty.

Abstract: Objective/Hypothesis: Information determined by viewing a face includes familiarity, emotion, attractiveness, and gender. However, the specific facial characteristics that enable one to identify gender are largely unknown. Research suggests that femininity is a critical component of beauty; however, the most important identifiers of a woman's face are unknown. The objectives of this article were: 1) determine the area of the face most significant in identifying female gender, 2) determine if individuals with gender-confirming surgery of the face are identified as male or female, 3) review the efficacy and safety of a series of feminizing forehead cranioplasties. Study Design: 1) Prospective evaluation of computer simulated changes and postoperative patient images, 2) retrospective review of medical records. Methods: 1) Photographs of men were digitally altered to adjust (a) the forehead (b) the nose/lip, (c) the jaw. Each change a, b, or c is done in isolation in both frontal and profile views. Subjects were shown the three profile and the three frontal photographs and asked to rate which of each set is the most feminine. 2) Photographs of male-to-female (MTF) transgender patients who may have had forehead, midface, or jaw surgery were shown to subjects. Subjects were asked the gender of the person in each picture. 3) Medical records and operative reports of 168 patients who underwent feminizing forehead cranioplasty were evaluated for surgical technique, and complications. Results: For Experiment 1, in frontal views of all subjects the forehead modification was selected as the most feminine, whereas in no cases was the forehead modification selected as least feminine by a majority of respondents. For the profile view, again the forehead modification was selected as most feminine by respondents for the majority of subjects, but surprisingly, the strength of the association between frontal modification and femininity, while strongly statistically significant, was more evident in the frontal view. For Experiment 2, among transgendered faces shown to viewers, 82% of postoperative forehead modifications were judged as women, 87% of postoperative midface modifications were judged as women, and 85% of postoperative lower faces were judged as women. For section 3, the review of safety and technique in 168 feminizing forehead cranioplasties, there were three basic surgical techniques utilized with only three complications for an overall complication rate of 1.8%. Conclusions: Feminization of the forehead through cranioplasty is safe and has a significant impact in determining the gender of the patient. The strong association between femininity and attractiveness can now be more specifically attributed to the upper third of the face and the interplay of the glabellar prominence of the forehead, along with the eyebrow shape and position, and hairline shape and position. These results have strong implications for a paradigm shift in the method of facial analysis used to select aesthetic procedures and illuminates the processes by which femininity and attractiveness are interpreted in faces. Laryngoscope, 2010

Immunohistochemical characterization of human olfactory tissue

Abstract: Objectives/Hypothesis: The pathophysiology underlying human olfactory disorders is poorly understood because biopsying the olfactory epithelium (OE) can be unrepresentative and extensive immunohistochemical analysis is lacking. Autopsy tissue enriches our grasp of normal and abnormal olfactory immunohistology and guides the sampling of the OE by biopsy. Furthermore, a comparison of the molecular phenotype of olfactory epithelial cells between rodents and humans will improve our ability to correlate human histopathology with olfactory dysfunction. Study Design: An immunohistochemical analysis of human olfactory tissue using a comprehensive battery of proven antibodies. Methods: Human olfactory mucosa obtained from 21 autopsy specimens was analyzed with immunohistochemistry. The position and extent of olfactory mucosa was assayed by staining whole mounts (WMs) with neuronal markers. Sections of the OE were analyzed with an extensive group of antibodies directed against cytoskeletal proteins and transcription factors, as were surgical specimens from an esthesioneuroblastoma. Results: Neuron-rich epithelium is always found inferior to the cribriform plate, even at advanced age, despite the interruptions in the neuroepithelial sheet caused by patchy respiratory metaplasia. The pattern of immunostaining with our antibody panel identifies two distinct types of basal cell progenitors in human OE similar to rodents. The panel also clarifies the complex composition of esthesioneuroblastoma. Conclusions: The extent of human olfactory mucosa at autopsy can easily be delineated as a function of age and neurologic disease. The similarities in human versus rodent OE will enable us to translate knowledge from experimental animals to humans and will extend our understanding of human olfactory pathophysiology.

Risk factors for postoperative hemorrhage following tonsillectomy.

Abstract: Objectives/Hypothesis: To identify the main risk factors associated with postoperative hemorrhage following tonsillectomy. Study Design: Prospective multicenter observational study. Methods: The Surgical Instrument Surveillance Programme (SISP) was established in 2003 to monitor tonsil and adenoid surgery and the associated complications in all hospitals in Wales. Data were examined between April 1, 2003, and June 30, 2008, by using binary logistic regression, for risk factors that may contribute to primary (R1) or secondary (R2) postoperative hemorrhage of a severity sufficient to require a return to the operating theater. Results: A total of 17,480 procedures were included. Patients aged ≥12 years were 1.5 (1.0–2.1; P < .05) and 3 times (2.2–4.9; P < .0001) more likely to experience R1 and R2 complications, respectively. There were 2.5 times as many females as males aged ≥12 years who underwent tonsillectomy, but males were almost twice as likely to experience R1 (1.4–2.8), P < .0001, or R2 (1.2–2.5), P < .001, postoperative hemorrhage. There was a 1.9-fold increased likelihood of R1 (1.1–3.3), P < .05, with the most junior surgeon, and no relationship with R2. All techniques that used heat had a significantly greater adjusted odds of R2 as compared with cold dissection, with odds ranging from 2.7 (1.5–4.7), P < .001, for dissection plus bipolar diathermy and ties, to 13.0 (5.8–29.1), P < .0001, with coblation when used with other techniques. No additional risk was associated with specified single-use instruments. Conclusions: Patient age and sex and operative technique were the most significant factors affecting the risk and timing of serious postoperative hemorrhage, with no additional risk associated with the use of specified single-use instruments. Laryngoscope, 2010

Cochlear implantation has a positive influence on quality of life, tinnitus, and psychological comorbidity.

Abstract: Objectives: To determine the effect of cochlear implantation (CI) on health-related quality of life (HRQoL), tinnitus, and psychological comorbidity in patients with severe to profound postlingual hearing loss and to analyze the relationship between these parameters. Study Design: Prospective study. Methods: Using six validated questionnaires, we evaluated the pre-CI and post-CI scores of HRQoL, tinnitus, perceived stress, symptoms of depression and anxiety, and coping strategies in 43 patients implanted unilaterally with a multichannel implant for at least 6 months. Results: In addition to improvements in hearing, speech understanding, and disease-specific HRQoL, psychological comorbidity was reduced and coping strategies were improved following CI. In the 39 tinnitus patients, their tinnitus was reduced. We found negative correlations between HRQoL and stress, depression, and anxiety. Pre-CI, tinnitus severity did not correlate with HRQoL and psychological comorbidity. However, patients with a high-level tinnitus had lower HRQoL as well as a higher level of perceived stress and anxiety symptoms than patients with a low-level tinnitus and no/incidental tinnitus before CI. Moreover, patients with severe hearing loss had a higher level of perceived symptoms of stress and depression than patients with profound hearing loss before CI. Conclusions: The present study provides evidence that tinnitus and psychological comorbidity may play an important role in the rehabilitation of CI patients, and that there is a correlation between HRQoL and these parameters. In addition to hearing tests, tinnitus, stress, and psychological comorbidity should be assessed using validated questionnaires before and after CI. This will help to improve the rehabilitation process.

Cochlear implantation in children with labyrinthine anomalies and cochlear nerve deficiency: implications for auditory brainstem implantation.

Abstract: Objectives/Hypothesis: Compare outcomes among children with inner ear malformations and/or cochlear nerve deficiency (CND) who have received a cochlear implant (CI). Study Design: Individual retrospective cohort study from 1993 to 2010. Methods: A select cohort of 76 children was identified. Imaging characteristics, operative findings, complications, mapping parameters, and performance were assessed. Comparisons among the different groups were undertaken. Results: Surgery was mostly uncomplicated. Nearly all children demonstrated behavioral responses to CI stimulation irrespective of inner ear morphology or the presence of CND. Children with CND had higher pure tone averages (PTAs) and required greater charge for stimulation than other malformation types. Open-set speech perception was achieved in 100% of children with incomplete partition-enlarged vestibular aqueduct (IP-EVA), 50% of those with hypoplastic malformations, and 19% of CND cases. Robust responses on eighth nerve compound action potential (ECAP) testing through the implant was associated with higher levels of speech perception. Manually supplemented communication strategies were more common among children with hypoplastic malformations (69%) and CND (95%) than those with IP-EVA (18%). Conclusions: Children with IP-EVA malformations have an excellent prognosis for developing open-set speech perception and using oral communication modes following CI. On the contrary, children with severe malformations or CND may have elevated charge requirements for attaining sound detection alone. These children's prognosis for obtaining open-set speech understanding, using exclusive oral communication, and participating in mainstream education is more limited. These findings have important implications for considering alternative forms of intervention such as auditory brainstem implantation and/or supplementation with visually based communication strategies.

Effect of temporary vocal fold injection medialization on the rate of permanent medialization laryngoplasty in unilateral vocal fold paralysis patients

Abstract: Objectives/Hypothesis: To determine whether temporary vocal fold injection affects the need for permanent medialization laryngoplasty in patients with unilateral vocal fold paralysis (UVFP). Study Design: Retrospective chart review. Methods: A total of 175 patients with dysphonia resulting from UVFP were identified. Patients with documented recovery of vocal fold mobility, <9 months of follow-up after diagnosis of UVFP, previous treatment at other institutions, neoplastic disease involving the larynx, or history of radiation to the larynx were excluded. Fifty-four patients met all inclusion/exclusion criteria. Rates of permanent medialization laryngoplasty in patients undergoing vocal fold injection were compared with those of patients who chose observation or voice therapy. Results: A total of 35% of patients underwent temporary injection medialization, and the remaining 65% chose conservative management. Five of 19 of the temporary injection medialization patients subsequently underwent permanent intervention compared to 23 of 35 of the conservative management group (P = .0131). Conclusions: UVFP patients who underwent vocal fold injection with an agent intended to provide temporary medialization were statistically significantly less likely to undergo permanent medialization laryngoplasty compared to those patients who were treated with conservative management only.

Medialization versus reinnervation for unilateral vocal fold paralysis: a multicenter randomized clinical trial.

Abstract: Purpose Vocal fold medialization laryngoplasty (ML) and laryngeal reinnervation (LR) as treatments for unilateral vocal fold paralysis (UVFP) were compared in a multicenter, prospective, randomized clinical trial.

Health-related and specific olfaction-related quality of life in patients with chronic functional anosmia or severe hyposmia.

Abstract: Objectives/Hypothesis: To measure health-related and olfaction-related quality of life (QoL) in patients with permanent, severe hyposmia or functional anosmia. Study Design: A case study in a university ENT department of patients with severe olfactory dysfunction defined by Sniffin' Sticks olfactory test kit with a score for odor threshold, discrimination, and identification (TDI) < 20 and a dysfunction lasting longer than 6 months. Methods: Assessment of QoL by using the SF-36 Health Survey questionnaire and the Questionnaire for Olfactory Dysfunction (QOD). Results: A total of 958 patients were tested for smell disturbances from 1999 to 2009. Surveys were mailed to 527 patients who fulfilled the inclusion criteria; 280 (53%) returned completed surveys. All SF-36 domains in severely hyposmic and anosmic patients were lower than in the German normal population. Lower SF-36 QoL was found for some domains in female patients, older patients, and hyposmic patients (P < .05 for all groups). Based on the QOD, women showed more parosmia, and anosmic patients had more olfactory-related impairment (P < .05 for both); in general, higher olfactory impairment and higher parosmia score measured by QOD correlated with lower TDI values (all P < .05). Multivariate analysis revealed, for SF-36 domains, the following independent risk factors: female sex was a risk factor for bodily pain; higher age was a risk factor for physical functioning and role, bodily pain, and general health; hyposmia was a risk factor for bodily pain and mental health; QOD QoL was a risk factor for all SF-36 scales; and QOD parosmia was a risk factor for physical role (all P < .05). Conclusions: QoL is severely impaired in patients with chronic severe hyposmia or anosmia. The QOD allows a more olfaction-specific assessment of QoL than the SF-36 instrument. Laryngoscope, 2011

Evidence for distinct histologic profile of nasal polyps with and without eosinophilia.

Abstract: Objective/Hypothesis: To evaluate the histology, RNA, and protein signatures of nasal polyps (NPs) in order to demonstrate specific subtypes of disease and differentiate “idiopathic” NPs based on tissue eosinophilia. Study Design: Prospective laboratory-based study. Methods: NP tissue was obtained from patients referred to the University of Virginia Health System for sinus surgery. Histology analyses included hematoxylin-eosin, Gomori's trichrome, toluidine blue, and chloroacetate staining. RNA and protein were extracted from tissue and cytokine transcript or protein concentrations determined. Results: Idiopathic NPs can be divided into distinct subsets characterized by absence (NE) and presence (E) of prominent eosinophilia. The validity of this distinction is supported by the demonstration that NE polyps are further distinguished by glandular hypertrophy, dense collagen deposition, and mononuclear cellular infiltrate. In contrast, E-NP display edema, rare glandularity, and minimal collagen deposition except within the basement membrane. Total mast cell numbers were reduced in E-NP, whereas connective tissue mast cells were increased in NE-NP. Consistent with the distinctive pattern of increased fibrosis, NE-NP displayed increased transforming growth factor-β and vascular endothelial growth factor transcripts. Similarly, NE-NPs had higher concentrations of transforming growth factor-β, fibroblast growth factor-β, and platelet-derived growth factor protein. Conclusions: Idiopathic NPs can be distinguished by NE and E and are supported by the observations that these display distinct histologic, gene, and protein expression patterns. The findings suggest that as unique diseases, idiopathic NPs will require distinct therapeutic interventions.

Nonresponders to pharyngeal surgery for obstructive sleep apnea: insights from drug-induced sleep endoscopy

Abstract: Objectives/Hypothesis To examine DISE findings in nonresponders to previous pharyngeal OSA surgery

Systematic review of topical vasoconstrictors in endoscopic sinus surgery.

Abstract: Objective: The objective of this study is to systematically review the literature and examine the safety for the use of topical vasoconstrictors in endoscopic sinus surgery. Study Design: Systematic review clinical trials. Method: A systematic literature search was performed in MEDLINE, EMBASE, The Cochrane Library, and National Guideline Clearinghouse, and references in the selected articles. Results: The search criteria captured 42 manuscripts with relevant titles. A systematic review on the topical use of phenylephrine was found; however, no other systematic review, meta-analyses, or clinical guidelines were identified. Six randomized clinical trials or comparative studies, as well as multiple case reports and review articles were also identified. The literature supports the safety of oxymetazoline and epinephrine when used judiciously in carefully selected patients undergoing endoscopic sinonasal surgery; however, topical phenylephrine is not recommended because of its risk profile. Conclusion: In sinus or nasal surgery, topical vasoconstrictors should be used in a manner that minimizes the risk of cardiovascular morbidity.

Traditional reflux parameters and not impedance monitoring predict outcome after fundoplication in extraesophageal reflux

Abstract: Objectives/Hypothesis: Fundoplication is considered in patients with refractory extraesophageal reflux symptoms. However, postoperative symptom resolution is inconsistent. This analysis investigates which presenting symptoms and preoperative objective parameters predict postoperative symptom improvement. Study Design: Retrospective cohort study. Methods: A total of 237 patients referred for extraesophageal reflux symptoms refractory to medical therapy underwent esophageal function testing. Fundoplication was performed in 27 patients with objective evidence of gastroesophageal reflux disease. Symptomatic improvement was assessed at postoperative intervals. Logistic regression determined which symptoms and objective parameters predicted improvement of the presenting extraesophageal reflux symptom. Results: Overall, 59% of patients reported at least partial improvement of their presenting extraesophageal symptom after fundoplication. Predictors of symptomatic improvement were the presence of heartburn with or without regurgitation concomitant to their primary presenting symptom (odds ratio [OR], 6.6; 95% confidence interval [CI], 0.97-44.9; P = .05) and pH < 4 more than 12% of a 24-hour period (OR, 10.5; 95% CI, 1.36-81.1; P = .02). Probability of postoperative extraesophageal reflux symptom improvement was 90% if both conditions were present. Conclusions: Both heartburn with or without regurgitation and esophageal pH < 4 more than 12% of a 24-hour period predicted postfundoplication resolution of the presenting extraesophageal reflux symptom.

Invasive fungal rhinosinusitis: a 15-year experience with 29 patients.

Abstract: Objectives/Hypothesis Document a 15-year experience with 29 cases of acute invasive fungal rhinosinusitis (AIFR) and evaluate factors predictive of disease clearance and overall survival. Study Design Case series with chart review. Methods Patients were identified by review of department billing records between 1995 and 2010. Medical records were reviewed for patient demographics, disease characteristics, clinical course including surgical and medical therapy, treatment outcomes, and long-term survival. Results Twenty-nine patients with AIFR were identified. Causes of immunosuppression included hematologic malignancy (n=16), diabetes (n=12), medication (n=10), and acquired immunodeficiency syndrome (n=1), with 10 patients having multiple causes of immunosuppression. Facial pain, swelling and orbital symptoms were the most common presenting symptoms. Fungal organisms included Mucor (n=18) and Aspergillus (n=10) species, with one patient infected with both. Disease-specific survival (DSS) from AIFR was 57%. Intracranial (P=.01) and ethmoid sinus (P=.05) involvement were significantly linked with short-term disease-related mortality. Overall survival (OS) at 6 months was 18%. For OS, intracranial involvement (hazard ratio [HR], 4.47; 95% confidence interval [CI], 1.51–13.22) and cranial neuropathy at presentation (HR, 3.2; 95% CI, 1.3–8.2) were significantly associated with shortened survival. Of the five patients surviving >6 months, two developed long-term major sinonasal complications. Conclusions DSS and OS remain low for patients with AIFR. Extensive surgical resection in patients with these poor prognostic signs should be considered carefully in light of their poor survival. Long-term survivors are at significant risk of sinonasal complications and should be followed closely. Level of Evidence 4. Laryngoscope, 2012

Endoscopic endonasal dissection of the infratemporal fossa: Anatomic relationships and importance of eustachian tube in the endoscopic skull base surgery

Abstract: Objectives: Endoscopic endonasal approaches to the pterygopalatine and infratemporal fossae are technically challenging due to the complex anatomy of these areas. This project attempts to develop an anatomic and surgical model to enhance the understanding of these spaces from the endonasal endoscopic perspective. Methods: Eight pterygopalatine and infratemporal fossae were dissected in four adult human specimens in accordance with institutional protocols. All specimens were prepared with vascular injections using colored latex. Both the pterygopalatine and infratemporal fossae were accessed using a transpterygoid approach, which included a medial maxillectomy. Rod lens endoscopes (with 0°, 30°, and 45° lenses), surgical microscope, microsurgical and endoscopic instruments were used to complete the dissections. Results: Endoscopic endonasal approaches provided adequate access to the pterygopalatine and infratemporal fossae. Dissection of the internal maxillary artery and its terminal branches, and detachment of the medial and lateral pterygoid muscles were critical steps to access deeper structures of the infratemporal fossa. The lateral pterygoid plate was the most useful landmark to locate foramen ovale, and the mandibular branch of the trigeminal nerve. The Eustachian tube, medial pterygoid plate, and styloid process were the most useful landmarks to locate parapharyngeal poststyloid structures (parapharyngeal segment of the internal carotid artery, internal jugular vein, cranial nerves IX and X). Conclusions: A medial maxillectomy coupled with a transpterygoid endoscopic approach, provides adequate access to the pterygopalatine and infratemporal fossae. The complex anatomy of the infratemporal fossa requires precise identification of surgical landmarks to assure preservation of neurovascular structures. Laryngoscope, 2011

Demographics and treatment trends in sinonasal mucosal melanoma.

Abstract: Objectives/Hypothesis: To evaluate the population characteristics of mucosal melanoma of the nasal cavity and paranasal sinuses and determine the impact of the new staging classification. Study Design: Analysis of a national database. Methods: Patients were identified from the Surveillance, Epidemiology, and End Results tumor registry data with mucosal melanoma of the nasal cavity and paranasal sinuses between 2000 and 2007. Tumors were classified using the American Joint Committee on Cancer (AJCC) 6th edition site-specific staging as well as 7th edition staging for head and neck mucosal melanoma (HNMM). Incidence rates and descriptive statistics were calculated, and multivariate analysis was performed to examine the impact of demographic factors and staging on survival. Results: A total of 304 patients were identified. The incidence rate was 0.05 per 100,000. Fifty-six percent were female, 92% were >50 years old, and more than 90% were Caucasian; 81.6% of patients were treated with surgery, and 38.5% of patients received postoperative radiation. Overall, the 5-year survival rate was 24.2%. Significant differences in survival were observed for surgery with radiation (P = .005) and surgery alone (P = .04) compared with radiation alone. TNM staging using the AJCC 6th and 7th edition classification schemes yielded similar survival curves. However, the new classification for HNMM allows for better delineation of stage IV disease, revealing slightly improved survival for stage IVA disease. Conclusions: HNMM is a rare disease with a poor prognosis. Surgery remains the treatment of choice, with some role for adjuvant therapy. The new staging classification for HNMM appears to more efficiently stage this disease. Demographics and therapeutic findings are discussed.

Long-Term Results of Calcium Hydroxylapatite for Vocal Fold Augmentation

Abstract: Objectives/Hypothesis: Studies have shown excellent results for 12-month post–injection augmentation data for calcium hydroxylapatite (CaHA) for glottal incompetence; however, the longevity of the material past one year was unknown. Our objective was to report the long-term effectiveness of CaHA as a vocal fold injectable by assessing data from a cohort of patients who underwent injection for glottal insufficiency. Study Design: Retrospective chart review. Methods: Patients who underwent CaHA injection for glottal insufficiency of any etiology were considered for inclusion in the study. The change in Voice Handicap Index (VHI)-10 scores between preinjection scores and best postinjection scores as well as between the preinjection and the most recent VHI-10 scores were used as primary outcome measures to determine the persistence of benefit or the time to loss of benefit. Complications among the cohort were identified. Results: Ninety patients who underwent 108 vocal fold injections with CaHA were evaluated for inclusion. Twenty patients with 22 injections met the criteria for inclusion. Fourteen of 22 (64%) subjects showed loss of benefit of the CaHA material. The average length of benefit was 18.6 months, with a range of 8 to 36 months. Three complications were identified among the original cohort of 108 injections. Conclusions: CaHA remains a safe and effective long-term vocal fold injectable with an average length of benefit of 18.6 months. Three complications were seen among 108 CaHA injections. CaHA is a long-term injectable with an excellent track record that does not appear to warrant concern for permanent or late complications.

Anterior pedicle lateral nasal wall flap: a novel technique for the reconstruction of anterior skull base defects.

Abstract: Objectives: Expansion of the clinical indications for ablative endoscopic endonasal approaches has behooved us to search for new reconstruction alternatives. We present the anatomic foundations of a novel anterior pedicled lateral wall flap (Hadad-Bassagaisteguy 2 or HB2 flap) for the vascularized reconstruction of anterior skull base defects. Study Design: Anatomic description. Feasibility study. Technical report Methods: Using a cadaveric model, we investigated the feasibility of harvesting an anteriorly based mucoperiosteal flap from the lateral nasal wall. We then applied the techniques developed in the anatomical laboratory to reconstruct two patients with defects resulting from the endoscopic endonasal resection of esthesioneuroblastomas and one patient with an extensive meningoencephalocoele of the anterior cranial fossa. Results: HB2 flaps were harvested and transposed to reconstruct anterior skull base defects in cadaveric specimens, and subsequently, in three patients. The HB2 flap provided adequate coverage in the cadaveric model, as well as clinically in our three patients. Their postoperative healing was uneventful. Conclusions: The HB2 flap is a feasible alternative for the reconstruction of anterior skull base defects in select

Do biofilms contribute to the initiation and recalcitrance of chronic rhinosinusitis

Abstract: Chronic rhinosinusitis is a common disease whose underlying aetiopathogenesis has not been completely understood. Amongst a range of other potential environmental triggers in this disease, a role has recently been proposed for bacterial biofilms. Adopting the biofilm paradigm to explain the initiation and maintenance of this disease may help to clarify previous inconsistencies in this disease that have resulted in the role of bacteria being questioned. Of particular interest is the association of bacterial biofilms with recalcitrant disease states. Over the last five years, research has progressed rapidly since biofilms were first identified on the surface of diseased sinonasal mucosa. Their presence there has now been associated with more severe disease that is often recalcitrant to current management paradigms. Technological advances are allowing accurate characterization of the bacterial and fungal species within these biofilms, which would appear to be an important step in improving our understanding of how these bacterial communities might interact with the host to cause disease. This is an unanswered, yet highly important, question in this field of research that will undoubtedly be an area of investigation in the near future. As the body of evidence suggesting biofilms may be involved in this disease grows, research interest has switched to the development of antibiofilm therapies. Given the unique properties of bacteria existing in this form, biofilm eradication strategies will need to incorporate novel medical therapies into established surgical practices as we attempt to improve the outcomes of our most difficult patients.