Showing papers in "Laryngoscope in 2012"

Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins.

Abstract: Objectives/Hypothesis: Our objective was to determine the safety, feasibility, and the adequacy of surgical margins for transoral robotic surgery (TORS), by reviewing the early results from independent institutional review board-approved clinical trials in three separate institutions. Study Design: Pooled Data from Independent Prospective Clinical Trials. Methods: One hundred ninety-two patients were initially screened, but inadequate exposure did not permit TORS in 13 (6.7%). For two additional patients, TORS was begun but intraoperatively converted to an open procedure. Thus, the intent-to-treat population was 177 patients (average age, 59 years; 81% male), predominantly comprised of tumors arising in the oropharynx (139, 78%) and larynx (26, 15%). TORS was performed for 161 (91%) patients with malignant disease: 153 (95%) with squamous cell carcinoma (T1 [50, 32.7%], T2 [74, 48.4%], T3 [21, 13.7%], T4 [8, 5.2%]), six patients (3.72%) with salivary gland tumors, and two patients with carcinoma in situ. The average follow-up was 345 days. Results: There was no intraoperative mortality or death in the immediate postoperative period. Average estimated blood loss was 83 mL; no patient required transfusion. The rate of positive margins was 4.3%. Twenty-nine patients (16%) experienced 34 serious adverse events that required hospitalization or intervention (grade 3) or were considered life threatening (grade 4, 2.3%). Tracheostomy was performed in 12.4% of all patients (22/177), but only 2.3% had a tracheostomy at last follow-up. For all patients undergoing TORS without previous therapy, the percutaneous endoscopic gastrostomy dependency rate was 5.0%. The average hospital stay was 4.2 days. Conclusions: Based on this multicenter study, TORS appears to be safe, feasible, and as such play an important role in the multidisciplinary management of head and neck cancer.

Endoscopic skull base reconstruction of large dural defects: A Systematic Review of Published Evidence

Abstract: Objectives/Hypothesis: Systematically review the outcomes of endoscopic endonasal techniques to reconstruct large skull base defects (ESBR). Such surgical innovation is likely to be reported in case series, retrospective cohorts, or case-control studies rather than higher level evidence. Study Design: Systematic review and meta-analysis. Methods: Embase (1980–December 7, 2010) and MEDLINE (1950–November 14, 2010) were searched using a search strategy designed to include any publication on endoscopic endonasal reconstruction of the skull base. A title search selected those articles relevant to the clinical or basic science of an endoscopic approach. A subsequent abstract search selected articles of any defect other than simple cerebrospinal fluid (CSF) fistula, sella only, meningoceles, or simple case reports. The articles selected were subject to full-text review to extract data on perioperative outcomes for ESBR. Surgical technique was used for subgroup analysis. Results: There were 4,770 articles selected initially, and full-text analysis produced 38 studies with extractable data regarding ESBR. Of these articles, 12 described a vascularized reconstruction, 17 described free graft, and nine were mixed reconstructions. Three had mixed data in clearly defined patient groups that could be used for meta-analysis. The overall CSF leak rate was 11.5% (70/609). This was represented as a 15.6% leak rate (51/326) for free grafts and a 6.7% leak rate (19/283) for the vascularized reconstructions (χ2 = 11.88, P = .001). Conclusions: Current evidence suggests that ESBR with vascularized tissue is associated with a lower rate of CSF leaks compared to free tissue graft and is similar to reported closure rates in open surgical repair.

Prevalence and causes of dysphonia in a large treatment-seeking population.

Abstract: Objectives/Hypothesis: To determine the prevalence and common causes of dysphonia as diagnosed by primary care physicians (PCPs) and otolaryngologists and to evaluate differences in etiologies offered by these providers. Study Design: Retrospective analysis of data from a large, nationally representative administrative U.S. claims database. Methods: Patients were identified as dysphonic based on International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2004, to December 31, 2008. Data regarding age, sex, geographic location, and type of physician providing the dysphonia diagnosis were collected. Overall and age-related prevalence rates, as well as frequency of specific etiologies by provider type, were calculated. Results: Of the almost 55 million individuals in the database, 536,943 patients (ages 0 to >65 years) were given a dysphonia diagnosis (point prevalence rate of 0.98%). The prevalence rate was higher among females as compared to males (1.2% vs. 0.7%) and among those >70 years of age (2.5%). The most frequent diagnoses overall were acute laryngitis, nonspecific dysphonia, benign vocal fold lesions, and chronic laryngitis. PCPs more commonly diagnosed acute laryngitis, whereas otolaryngologists more commonly diagnosed nonspecific dysphonia and laryngeal pathology. Gastroesophageal reflux was more commonly diagnosed as a comorbid condition by otolaryngologists than by PCPs. Overall laryngeal cancer prevalence in this treatment-seeking population was 2.2% and was greatest among males >70 years of age. Conclusions: This analysis of insurance claims data from a nationally representative database represents the largest study of its kind. Important differences in dysphonia prevalence related to age, sex, diagnosis, and physician type were identified. Laryngoscope, 122:343–348, 2012

A multi-institutional analysis of tracheotomy complications.

Abstract: Objectives/Hypothesis: To define the prevalence of tracheotomy tube complications and evaluate risk factors (RFs) associated with their occurrence. Study Design: Multi-institution historical cohort. Methods: Data regarding tracheotomy tube complications from consecutive surgeries performed across eight participating institutions between January 1, 2008 and December 31, 2009 were retrospectively collected. Patient demographics, comorbidities, physician specialty, and surgical technique were recorded and statistically analyzed to identify the incidence of surgical complications following tracheotomy and associated RFs. Results: The charts of 1,175 tracheotomy procedures were reviewed from eight academic institutions. Otolaryngologists performed 66.2% of the tracheotomies. Intraoperative, early ( 7.5) and obesity were associated with the development of airway stenosis (P < .05).Twenty-two percent of patients undergoing tracheotomy died during hospitalization. Conclusions: Perioperative tracheotomy complications are rare; however, the rate of death for all causes is high (22%) in this population. Obesity and the use of endotracheal tubes over 7.5 in size are major risk factors for the development of airway stenosis. Although percutaneous tracheotomy resulted in a significantly higher rate of postoperative bleeding (6.6%) than the open method (1.9%) (P < .05), the use of outer flange tracheostomy tube sutures may reduce this complication.Laryngoscope, 122:38–45, 2012

Validating the clinical assessment of eustachian tube dysfunction: The Eustachian Tube Dysfunction Questionnaire (ETDQ-7).

Abstract: Objectives/Hypothesis Eustachian tube dysfunction (ETD) is a common condition that is associated with otologic and rhinologic symptoms. The complete assessment of ETD is limited without a valid symptom score. We developed and conducted initial validation of the seven-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7), a disease-specific instrument to assess symptoms with respect to ETD.

Longitudinal study of children with unilateral hearing loss

Abstract: Objectives/Hypothesis: Children with unilateral hearing loss (UHL) have been found to have lower language scores,and increased rate of speech therapy, grade failures, or needing Individualized Education Plans (IEPs). The objective of thisstudy was to determine whether language skills and educational performance improved or worsened over time in a cohort ofchildren with UHL.Study Design: Prospective longitudinal cohort study.Methods: Forty-six children with permanent UHL, ages 6 to 12 years, were studied using standardized cognitive,achievement, and language testing at yearly intervals for 3 years. Using standardized test scores allowed implicit comparisonto norms established by national cross-sectional samples. Secondary outcomes included behavioral issues, IEPs, receipt ofspeech therapy, or teacher report of problems at school. Analysis utilized repeated measures analysis of variance and multile-vel random regression modeling.Results: Several cognitive and language mean standardized scores increased over time. Possible predictors of increasewith time included higher baseline cognitive levels and receipt of interventions through an IEP. However, standardizedachievement scores and indicators of school performance did not show concomitant improvements. Rates of IEPs remained>50% throughout, and rates of speech therapy were consistently about 20%.Conclusions: Children with UHL demonstrated improvement in oral language and verbal intelligence quota scores overtime, but not improvements in school performance. Parents and teachers reported persistent behavioral problems and aca-demic weaknesses or areas of concern in about 25%. The provision of IEPs for children with UHL, and acknowledging UHLas a hearing disability, may be an effective intervention to improve language skills over time.Key Words: Unilateral hearing loss, children, speech or language delay.Level of Evidence: 1b.Laryngoscope, 122:2088–2095, 2012

Microbiome complexity and Staphylococcus aureus in chronic rhinosinusitis

Abstract: Objectives/Hypothesis The aim of this study was to compare microbiological culture-based and culture-independent (16S rRNA gene sequencing) methodologies for pathogen identification in chronic rhinosinusitis (CRS) patients. We hypothesized that (a) bacterial culture and DNA sequencing would yield largely concurrent results, though sequencing would detect greater bacterial diversity, and (b) the sinonasal microbiomes of CRS patients would differ in composition and diversity compared with non-CRS controls.

Implanted upper airway stimulation device for obstructive sleep apnea

Abstract: Objectives/Hypothesis: Previous feasibility studies have shown that electrical stimulation of the hypoglossal nerve can improve obstructive sleep apnea (OSA). The current study examined the safety and preliminary effectiveness of a second generation device, the Upper Airway Stimulation (UAS) system, and identified baseline predictors for therapy success. Study Design: Two consecutive open prospective studies. Methods: UAS systems were implanted in patients with moderate to severe OSA who failed or were intolerant of continuous positive airway pressure (CPAP). The study was conducted in 2 parts. In part 1, patients were enrolled with broad selection criteria. Apnea hypopnea index (AHI) was collected using laboratory-based polysomnography at preimplant and postimplant visits. Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ) were also collected. In part 2, patients were enrolled using selection criteria derived from the experience in part 1. Results: In part 1, 20 of 22 enrolled patients (two exited the study) were examined for factors predictive of therapy response. Responders had both a body mass index � 32 and AHI � 50 (P < .05) and did not have complete concentric palatal collapse. Part 2 patients (n ¼ 8) were selected using responder criteria and showed an improvement on AHI from baseline, from 38.9 6 9.8 to 10.0 6 11.0 (P < .01) at 6 months postimplant. Both ESS and FOSQ improved significantly in part 1 and 2 subjects. Conclusions: The current study has demonstrated that therapy with upper airway stimulation is safe and efficacious in a select group of patients with moderate to severe OSA who cannot or will not use CPAP as primary treatment.

The interpretation of clinical tests of peripheral vestibular function.

Abstract: Recently, new clinical tests of canal and otolith function have been introduced. They rest on sound anatomical and physiological evidence; however, the interpretation of the results of these tests has only recently been clarified. This review summarizes the anatomical and physiological evidence underpinning the tests of both canal and otolith function to provide a full picture of the interpretation of the tests, which allow the clinician to assess the status of the peripheral vestibular function of a patient—all six canals and four otoliths. The present review does not document all the minute details associated with each test, but provides an overview of the interpretation of properly presented tests and shows typical response profiles of patients with various types of vestibular loss, based on published anatomical, physiological, and clinical evidence.

Surgery for obstructive sleep apnea: sleep endoscopy determinants of outcome.

Abstract: Objectives/Hypothesis: Although drug-induced sleep endoscopy is often employed to determine the site of obstruction in patients with obstructive sleep apnea (OSA) who will undergo upper airway surgery, it remains unknown whether its findings are associated with surgical outcome. This study tested the hypothesis that drug-induced sleep endoscopy variables can predict the outcome of upper airway surgery in OSA patients. Study Design: Case series retrospective analysis. Methods: Forty-nine OSA patients (41 male; mean apnea-hypopnea index [AHI] 30.9 ± 18.5 events/hour) underwent propofol-induced sleep endoscopy followed by upper airway surgery (palatal surgery, and/or radiofrequency ablation of the tongue base, and/or hyoid suspension) and subsequently a follow-up polysomnography to assess surgical outcome. Results: Twenty-three patients (47%) were responders, and twenty-nine were nonresponders (53%). Nonresponders had a higher occurrence of complete or partial circumferential collapse at velum and complete antero-posterior collapse at tongue base or epiglottis in comparison with responders. Multivariate logistic regression analysis revealed that among baseline clinical and polysomnographic characteristics (e.g., AHI, body mass index) and sleep endoscopy findings, the presence of complete circumferential collapse at velum, and of complete antero-posterior collapse at tongue base were the only independent predictors of upper airway surgery failure. Conclusions: Drug-induced sleep endoscopy can be used to predict higher likelihood of response to upper airway surgery in OSA. Laryngoscope, 2012

Systematic review and meta-analysis of the risk factors for sudden sensorineural hearing loss in adults†‡§

Abstract: Objectives/Hypothesis: To review the medical literature evidence of potential risk factors for sudden sensorineural hearing loss (SSNHL) in the adult general population. Study Design: Systematic review of prospective and retrospective studies; meta-analysis of case-controlled studies. Methods: Three researchers independently reviewed MEDLINE (January 1, 1950–November 30, 2010), Embase (January 1, 1980–November 30, 2010), and Evidence-Based Medicine Reviews databases in addition to conducting a manual reference search. Randomized controlled trials, prospective cohort studies, consecutive/nonconsecutive case series, and retrospective reviews in which a clear definition of SSNHL was stated were included in the study. Researchers individually extracted data regarding patient information and the presumed risk factors. Discrepancies were resolved by mutual consensus. Results: Twenty-two articles met the inclusion criteria. Cardiovascular risk factors (smoking, increased alcohol consumption) appeared to be associated with a higher risk of developing SSNHL. A low level of serum folate may also be implicated as a risk factor. Factor V Leiden and MTHFR gene polymorphisms were found to occur more frequently in patients with SSNHL in several studies, suggesting these inherited prothrombophilic mutations could be independent risk factors of SSNHL. Conclusions: Acquired and inherited cardiovascular risk factors appeared to be associated with an increased risk of developing SSNHL.

Balance disorders in the elderly: Epidemiology and functional impact

Abstract: Objectives/Hypothesis: To quantify the prevalence and determine the impact of dizziness and balance disorders in the elderly. Study Design: Cross-sectional analysis of a national database. Methods: The balance problems survey module of the 2008 National Health Interview Survey was examined, and cases of reported dizziness or balance problems in persons ≥65 years old were identified. The prevalence of balance disorders and associated symptoms and their impacts on self-reported functional limitations were determined. The related impact on daily activities for elderly persons with balance problems was quantified. Sex-based differences in balance problems were determined. Results: Among 37.3 ± 0.9 million elderly persons (mean age, 74.4 ± 0.1 years; 56.9% ± 0.9% female), 7.0 ± 0.2 million persons (19.6% ± 0.7%) reported a problem with dizziness or balance in the preceding 12 months. Balance problems included difficulty with unsteadiness (68.0%), walking on uneven surfaces (54.8%), vertigo (30.1%), and faintness (29.6%). Prescription medication triggered the balance problem in 18.7%. Among the 50.0% of elderly persons with balance problems who sought care, 85.6%, 30.3%, 23.9%, and 16.8% saw a general practitioner, internist, neurologist, or otolaryngologist, respectively. Of this group, 27.4% reported that balance problems specifically prevented them from participating in activities including exercise (61.2%), social events (45.8%), and driving (47.1%). Females were more likely to experience balance problems than males (21.0% vs. 17.7%, P = .025). Conclusions: Approximately one in five elderly persons experiences annual problems with dizziness or balance. Given the significant prevalence and negative effect of balance problems on daily activities in the elderly, balance disorders merit special attention, particularly in the face of an aging population.

Prognostic factors and survival unique to surgically treated p16+ oropharyngeal cancer

Abstract: Objectives/Hypothesis: Current head and neck epidemiology demonstrates a steadily increasing incidence of p16+ human papillomavirus-related oropharynx squamous cell cancer (OPSCC). This distinct tumor subtype is associated with better survival outcomes. There is a growing recognition of the need to define management regimens that take into account the inherent patho-biological attributes of these cancers and provide optimum oncological control with minimum morbidity. This is facilitated by a clear understanding of the prognostic variables that predict disease outcome in patients with p16+ OPSCC. To provide prognostic estimates, pathological staging and histopathological parameters are usually superior to clinical staging. However, knowledge of pathological predictors is sparse, mainly because of commonly employed nonsurgical management policies utilizing chemoradiotherapy. Minimally invasive approaches to the oropharynx, particularly transoral laser microsurgery (TLM), are well-reported effective primary treatments for oropharynx cancers. From such series, it is feasible to conduct a detailed appraisal based on pathologic information from surgical specimens of both the primary and neck, to establish prognosticators unique to p16+ oropharynx cancer patients. Study Design: A prospectively assembled database of oropharynx cancer patients treated with primary TLM ± neck dissection ± adjuvant therapy from 1996 to 2010, analyzed retrospectively for survival and recurrence. Methods: The fundamental inclusion criteria were: 1) previously untreated biopsy-proven OPSCC treated with primary TLM ± neck dissection, 2) diffuse p16 positivity in the surgical specimen, 3) availability for adjuvant therapy, if indicated, and 4), minimum follow-up of 12 months or to death. Cox proportional hazard regression analyses were used to identify variables that were prognostic for disease-free survival (DFS), the primary end point of the study, as well as disease-specific survival (DSS) and overall survival. Kaplan-Meier survival estimates and patterns of disease recurrence were also assessed. We also explored concordance for T and N staging, when assessed by clinical (cT, cN) and pathological (cT, pT) measures. Results: Of 211 patients in the TLM database, 171 met all the eligibility criteria. The median follow-up was 47 months. The 3- and 5-year Kaplan-Meier estimates for DFS were 91% and 88%, respectively, whereas for DSS they were 95.5% and 94.4%, respectively. A total of 12 (7%) recurrences occurred: two local, four regional, and six distant. Of all T-stage categories, pT4 tumors were strongest predictors of poorer DFS. cT4 tonsil primaries, ever smoking status, three or more metastatic nodes, pN2b+ stage, and radiation-based adjuvant therapy were other prognosticators for DFS. Angioinvasion and T3-T4 tumors were prognostic for reduced DSS, although smoking parameters were not. Extracapsular spread, N stage, and margins were nonprognosticators. Recursive partitioning analysis defined high- and low-risk groupings of prognosticators. Downstaging of clinical T stage was observed for 31% of tumors on application of pathological classification. Conclusions: We document a well-delineated set of prognostic variables that specifically and accurately identify individuals at risk of reduced outcomes in an otherwise good prognosis p16+ OPSCC cohort. Based on these prognosticators, appropriate patient counseling, adjuvant treatment recommendations, and stratification for trials can more accurately be made. We also observed an additional edge conferred by TLM toward more accurate clinical as well as pathological T staging.

Direct health care costs of laryngeal diseases and disorders.

Abstract: Objectives/Hypothesis: To estimate the annual direct costs associated with the diagnosis and management of laryngeal disorders. Study Design: Retrospective analysis of data from a large, nationally representative, administrative US claims database. Methods: Patients with a laryngeal disorder based on International Classification of Diseases,Ninth Revision-Clinical Modification codes from January 1, 2004 to December 31, 2008 and who were continuously enrolled for 12 months were included. Data regarding age, gender, geographic location, and type of physician providing the diagnosis were collected. Medical encounter, medication, and procedure costs were determined. Total and mean costs per person for 12 months were determined. Results: Of almost 55 million individuals in the database, 309,300 patients with 12 months follow-up, mean age of 47.3 years (standard deviation: 21.3), and 63.5% female were identified. Acute and chronic laryngitis, nonspecific causes of dysphonia, and benign vocal fold lesions were the most common etiologies. The total annual direct costs ranged between $178,524,552 to $294,827,671, with mean costs per person between $577.18 and $953.21. Pharmacy claims accounted for 20.1% to 33.3%, procedure claims 50.4% to 69.9%, and medical encounter claims 16.3% to 8.6% of overall direct costs. Antireflux medication accounted for roughly 10% and antibiotics 6% of annual direct costs. Conclusions: This study establishes the economic impact of the assessment and management of patients with laryngeal disorders and permits cost comparisons with other diseases. Laryngoscope, 2012

Infiltrating lymphocytes and human papillomavirus-16--associated oropharyngeal cancer.

Abstract: Objectives/Hypothesis: Human papillomavirus-16 (HPV-16)–associated carcinoma of the oropharynx has a favorable prognosis. Such patients have elevated CD8+ T-lymphocyte levels that correlate with response to chemotherapy and survival. Tumor-infiltrating lymphocyte (TIL) subpopulations were assessed in pretreatment biopsies from a prospective patient cohort to determine if TIL subsets differed by HPV status, clinical factors, or patient outcome or correlated with peripheral blood T-cell levels. Study Design: Retrospective immunological correlative study of patients entered in a prospective Phase 2 clinical trial. Methods: Measured were CD8, CD4, CD68, and Treg (FoxP3) lymphocytes by immunohistochemistry in a tissue microarray created from patients (n = 46) with advanced oropharyngeal cancer. Correlations with peripheral blood levels, HPV status, expression of epidermal growth factor receptor (EGFR), clinical tumor, and patient characteristics and outcome were determined. Median follow-up was 6.6 years. Results: HPV-16–positive patients had improved survival (P = .016). Degree of T-cell infiltration did not differ by HPV status but was significantly related to disease-specific survival (DSS) and overall survival (OS). Even after adjusting for HPV status, we found that CD8, FoxP3, and total T cells were significantly associated with DSS (P = .0236, P = .0040, and P = .0197, respectively) and OS (P = .0137, P = .0158, and P = .0115, respectively). Less T-cell infiltration (P = .0130) and CD4 cells in particular (P = .0792) were associated with higher EGFR expression. Conclusions: Improved outcomes are associated with increased TILs independent of HPV status and suggest the local immune response may be more related to factors such as tumor size, EGFR expression, or performance status than HPV status. Further study of larger numbers of patients and infiltrates combined with functional analysis of individual subsets may be necessary to detect significant differences in local immunity in HPV-16–related cancers.Laryngoscope, 122:121–127, 2012

Diagnostic significance of blood eosinophil count in eosinophilic chronic rhinosinusitis with nasal polyps in Chinese adults.

Abstract: Objectives/Hypothesis: Over half of chronic rhinosinusitis with nasal polyps (CRSwNP) patients in China show noneosinophilic inflammation. The aim of this study was to compare the clinical characteristics of eosinophilic and noneosinophilic CRSwNP and to identify the predictors of eosinophilic CRSwNP. Study Design: A retrospective study. Methods: There were 155 CRSwNP patients enrolled in the Tongji cohort. Eosinophilic CRSwNP was diagnosed according to our previously published histologic criterion. The demographic and clinical features were compared between eosinophilic and noneosinophilic CRSwNP. Factors associated with eosinophilic CRSwNP were determined with regression analysis, and optimal cutoff points of the predictors were determined by a receiver operating characteristic curve. The optimal cutoff points of the predictors were validated in an independent group of 35 CRSwNP patients referred to as the Taizhou cohort. Results: A male preponderance, a higher prevalence of smoking and atopy, and higher peripheral blood eosinophil absolute count and percentage and blood IgE levels were found in eosinophilic CRSwNP compared with noneosinophilic CRSwNP. Peripheral eosinophil absolute count and percentage were independently and significantly associated with eosinophilic CRSwNP. An absolute blood eosinophil count ≥0.215 × 109/L yielded a sensitivity of 74.2% and a specificity of 86.5%, and a blood eosinophil percentage ≥3.05% yielded a sensitivity of 80.3% and a specificity of 75.3% for the diagnosis of eosinophilic CRSwNP in the Tongji cohort. The validation study in the Taizhou cohort revealed a lower sensitivity and specificity. Conclusions: Eosinophilic and noneosinophilic CRSwNP displayed significant differences in certain clinical features. Peripheral blood eosinophil count could distinguish eosinophilic and noneosinophilic CRSwNP in Chinese adults.

Routine central neck dissection in differentiated thyroid carcinoma: A systematic review and meta‐analysis

Abstract: Objective/Hypothesis: The role of central neck dissection (CND) remains controversial in differentiated thyroid cancer (DTC). Study Design: Systematic review and meta-analysis. Methods: A systematic review and meta-analysis focusing on surgical morbidities and locoregional recurrence after total thyroidectomy (TT) with CND versus TT alone was performed. Results: Sixteen trials were analyzed. There was no increased risk of recurrent laryngeal nerve (RLN) injury (temporary or permanent), permanent hypocalcemia, or locoregional recurrence when CND was performed in addition to TT. Postoperative temporary hypocalcemia was more common after TT with CND than after TT alone. Conclusions: TT alone results in less surgical morbidity in the immediate postoperative period and an identical locoregional recurrence rate compared with TT plus CND. Laryngoscope, 2012

Cochlear implant performance in geriatric patients

Abstract: Objectives/Hypothesis: To evaluate the hearing performance with cochlear implants (CIs) in patients who were 70 years or older at the time of implantation (geriatric patients) and compare it with the performance in younger adults. Study Design: Individual, retrospective, cohort study. Methods: A cohort of 1,005 postlingually deafened adults was selected for this study. According to their age at the time of cochlear implantation, patients were divided into four age groups: group 1, 18 to 39 years; group 2, 40 to 59 years; group 3, 60 to 69 years; and group 4, 70 years and older). The test battery was composed of four standard German speech tests: Freiburger Monosyllabic Test, Speech Tracking Test, and Hochmair-Schulz-Moser (HSM) Sentence Test in quiet and in 10 dB noise. Results: Geriatric patients showed a similar learning curve as the younger adults in the first 2 years after implantation. The direct comparison of speech perception in the Freiburger Monosyllabic Test, Speech Tracking Test, and HSM Test in quiet revealed no differences between the average performance of the geriatric patients and younger adults. However, in the HSM Test in noise, the performance of the geriatric group was significantly lower than the younger adults. Conclusions: Geriatric CI patients have a similar learning curve to younger adults, and in speech tests in quiet they show a comparable performance. However, their performance is significantly lower in noisy surroundings. This may be due to the central presbycusis in patients older than 70 years and should be taken into account in postoperative fitting of these patients. Further prospective studies are required to evaluate the role of special rehabilitation methods and cognitive training to improve the speech perception in noise in geriatric CI patients.

Rapid salivary pepsin test: blinded assessment of test performance in gastroesophageal reflux disease.

Abstract: Objective/Hypothesis: Pepsin lateral flow device (LFD) is a rapid noninvasive test to detect salivary pepsin as a surrogate marker for gastroesophageal reflux disease (GERD). We aimed to establish the test sensitivity, specificity, positive and negative predictive values (PPV, NPV) in patients with symptomatic and objective evidence of GERD compared to healthy controls. Study Design: Prospective, blinded, controlled cohort study. Methods: A total of 230 samples were analyzed. In vitro bench testing was conducted on 52 gastric juice and 54 sterile water samples to assess test sensitivity and specificity. Saliva was collected from 58 patients with GERD and 51 controls. All patients with GERD underwent esophagogastroduodenoscopy (EGD) and wireless 48-hour pH monitoring off acid suppressive therapy. PPV and NPV were calculated based on disease definition of esophagitis and/or abnormal pH monitoring. Results: Receiver operating characteristics analysis of in vitro samples found assay sensitivity and a specificity of 87%. There were 6/51 (12%) control subjects and 13/58 (22%) patients with GERD who tested positive for salivary pepsin (P = .25). There was a step-wise increase in the prevalence of positive salivary pepsin: esophagitis (55%), abnormal pH monitoring (43%), GERD symptoms only (24%) (P < .001). Salivary pepsin test showed a PPV of 81% and NPV of 78% for those with objective evidence of GERD (abnormal pH and/or esophagitis). Conclusions: Rapid LFD for salivary pepsin has acceptable test characteristics in patients with GERD. A positive salivary pepsin test in this group may obviate the need for more expensive diagnostic testing by EGD or pH monitoring.

Tracheotomy-related catastrophic events: results of a national survey.

Abstract: Objectives/Hypothesis: To gather qualitative and semiquantitative information about catastrophic complications during and following tracheotomy. Study Design: National survey distributed to American Academy of Otolaryngology–Head and Neck Surgery members via the Academy weekly email newsletter during April and May 2011. Methods: A total of 478 respondents provided estimates of the number of four specific tracheotomy-related complications (innominate artery fistula, esophageal fistula, acute tracheotomy occlusion, and obstructing granuloma), all catastrophic events, and events resulting in death or permanent disability encountered during their careers. There were 253 respondents who provided 405 free-text descriptions of specific events. Results: The respondents experienced approximately one catastrophic event every 10 years and one event resulting in death or permanent disability every 20 years. More than 90% occurred more than 1 week after surgery. Categories of physicians who experienced more events per year included academic physicians and laryngologists. Pediatric otolaryngologists had twice as many innominate artery fistulas per year of practice as others. Qualitative (free-text) descriptions of the most serious events demonstrated that more of these events involved loss of airway and volume bleeds, usually from innominate or carotid artery erosion. Many of the events due to airway loss involved potentially correctable deficits in family education, nursing care, home care, and other structural factors. Conclusions: Even when we allow for selection bias, these data suggest that a substantial number of tracheotomy complications leading to death or permanent disability occur at a national level. The vast majority of events occur more than 1 week after the procedure. Many of the described events were caused by factors that should be amenable to prospective system improvement strategies. Laryngoscope, 122:30–37, 2012

Paradoxical vocal cord motion: Classification and treatment

Abstract: Paradoxical vocal cord motion (PVCM), or vocal cord dysfunction, is a descriptive term for inappropriate adduction of the vocal folds during respiration. The laryngeal mistiming leads to breathing difficulty and is often misdiagnosed as refractory asthma. The etiology of PVCM has been unclear but has long been hypothesized to be psychological. The present thesis is a prospective study of 170 patients older than 18 years being evaluated for PVCM, with 117 of the 170 (68.8%) identified as having PVCM by video laryngoscopy. Laryngeal edema (P = .021) and reflux (P = .026) were increased in patients with PVCM. A flat inspiratory arm of the flow volume loop during spirometry testing was a predictor of PVCM (P = .034). A subgroup of 47 newly diagnosed patients with PVCM underwent psychological analysis. The psychological profiles were elucidated using the Minnesota Multiphasic Personality Inventory and the Life Experiences Survey to evaluate stress. Compared to established normative data, PVCM demonstrated a conversion disorder pattern (P < .01) but not an anxiety disorder or a correlation with stress. A subgroup, 11 of the 47 (23.4%), had normal psychological outcomes, and two of the 47 (4.3%) were identified as malingering. Previous studies have suggested that PVCM is strictly a psychological disorder. It is proposed that PVCM is a descriptive term that is multifactorial and the etiology should direct treatment. A classification scheme divides PVCM into primary, or psychological, and secondary. The secondary form consists of medical disorders divided into irritable larynx syndrome and neurologic disorders.

Lateral oropharyngeal wall and supraglottic airway collapse associated with failure in sleep apnea surgery.

Abstract: Objectives/Hypothesis: To identify patterns of airway collapse during preoperative drug-induced sleep endoscopy (DISE) as predictors of surgical failure following multilevel airway surgery for patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). Study Design: Retrospective clinical chart review. Methods: Medical records of patients who underwent site-specific surgical modification of the upper airway for treatment of OSHAS were reviewed. Patients were included in this study if they had a preoperative airway evaluation with DISE as well as preoperative and postoperative polysomnography. Airway obstruction on DISE was described according to airway level, severity, and axis of collapse. Severe airway obstruction was defined as >75% collapse on endoscopy. Surgical success was described as a postoperative apnea-hypopnea index (AHI) of 50% decrease in preoperative AHI. Results: A total of 34 patients were included in this study. The overall surgical success rate was 56%. Surgical success (n = 19) and surgical failure (n = 15) patients were similar with regard to age, gender, body mass index, preoperative AHI, Friedman stage, adenotonsillar grades, and surgical management. DISE findings in the surgical failure group demonstrated greater incidence of severe lateral oropharyngeal wall collapse (73.3% vs. 36.8%, P = .037) and severe supraglottic collapse (93.3% vs. 63.2%, P = .046) as compared to the surgical success group. Conclusions: The presence of severe lateral pharyngeal wall and/or supraglottic collapse on preoperative DISE is associated with OSAHS surgical failure. The identification of this failure-prone collapse pattern may be useful in preoperative patient counseling as well as in directing an individualized and customized approach to the treatment of OSHAS.

Extracapsular dissection for benign parotid tumors: A meta-analysis†

Abstract: Objectives/Hypothesis: Recent studies suggest that extracapsular dissection (ECD) is an option for the resection of certain benign parotid tumors. This study investigates complication rates and effectiveness of ECD versus superficial parotidectomy (SP) for the treatment of primary benign parotid neoplasms. Study Design: Systematic literature review with meta-analysis. Methods: Studies available for inclusion evaluated the complications and effectiveness of ECD and SP as surgical techniques for the treatment of solitary, benign parotid tumors. An Ovid/Medline search revealed nine articles that met inclusion criteria. A critical review and meta-analysis of these articles was performed. Results: The included studies evaluated a total of 1,882 patients. There was no observed difference in tumor recurrence between the ECD and SP groups (odds ratio [OR], 0.557; 95% confidence interval [CI], 0.271-1.147). There was a significantly lower rate of transient facial nerve paresis (OR, 0.256; 95% CI, 0.174-0.377) in the ECD group (59 of 741; 8.0%) compared to the SP group (81 of 397; 20.4%); however, there was no observed difference in permanent facial paralysis between the ECD and SP groups (OR, 0.878; 95% CI, 0.282-2.730). Frey's syndrome was less often observed (OR, 0.117; 95% CI, 0.071-0.191) after ECD (27 of 602; 4.5%) compared to SP (75 of 287; 26.1%). Conclusions: This systematic review with meta-analysis suggests that ECD has a similar recurrence rate as SP with fewer postoperative complications. ECD may be considered an alternative surgical modality for select benign parotid neoplasms.

Olfaction-associated quality of life in chronic rhinosinusitis: adaptation and validation of an olfaction-specific questionnaire.

Abstract: Objectives/Hypothesis: To detect validity and reliability of the Questionnaire of Olfactory Disorders (QOD) compared to other quality-of-life (QoL) questionnaires, to explore its ability to reflect olfaction-related QoL changes, and to investigate age- and gender-related effects of olfactory changes on QOD results. Study Design: Prospective clinical study. Methods: One hundred two patients (56 males, 46 females; mean age, 41.15 ± 16.31 years), suffering from chronic rhinosinusitis, whose olfactory function was measured using Sniffin' Sticks test were studied. All patients completed three validated general health-related QoL questionnaires (Short Form-36 Health Survey [SF-36], Beck Depression Inventory [BDI], and Zung anxiety scale), and the olfaction-related QOD. Results: Internal consistency and test-retest reliability for the QOD was high. Convergent validity assessment showed statistically significant negative correlations of the QOD and the QOD-negative statements (NS) with overall SF-36 score (P < .05 for all groups) and positive correlations of the same scores with BDI and Zung (P < .001). The QOD-positive statements (PS) was positively correlated to SF-36. Discriminative validity demonstrated statistically significant differences of the QOD and QOD-NS scores between all groups of patients (normosmics, hyposmics, anosmics; all pairwise comparisons, P < .001). The QOD-PS score was significantly higher in normosmics and hyposmics compared to anosmics. Patients' age was negatively correlated with the QOD-PS, whereas it was positively correlated with BDI (P < .001) and Zung (P = .007). Females presented significantly higher scores in the QOD, QOD-NS, BDI, and Zung (all P < .001) compared to males. Conclusions: The QOD proved to be a valid, reliable, and easy-to-use method of assessment of olfaction-related QoL with high specificity and sensitivity. Laryngoscope, 2012

A double-blind study on clonazepam in patients with burning mouth syndrome

Abstract: Objectives/Hypothesis: In the treatment of burning mouth syndrome (BMS), various approaches have been tried with equivocal results. The aim of the present randomized clinical trial was to determine the efficacy of clonazepam, a GABA agonist designed as an antiepileptic drug that exerts the typical effects of benzodiazepines. Study Design: Randomized clinical trial. Methods: Twenty patients with idiopathic BMS were carefully selected. Clonazepam (0.5 mg/day, n = 10) or placebo (lactose, n = 10) were randomly assigned to the patients. Results: Patients on clonazepam significantly improved in pain ratings (P < .001). These changes were less pronounced in the placebo group (P < .11). No significant changes were observed in a mood scale (P = .56) or for depression scores (P = .56). Taste test and salivary flow increased over sessions, but were not different between groups (P = .83 and P = .06, respectively). Conclusions: Clonazepam appears to have a positive effect on pain in BMS patients. Laryngoscope, 2012

A nomenclature paradigm for benign midmembranous vocal fold lesions

Abstract: Objectives/Hypothesis: There is a significant lack of uniform agreement regarding nomenclature for benign vocal fold lesions (BVFLs). This confusion results in difficulty for clinicians communicating with their patients and with each other. In addition, BVFL research and comparison of treatment methods are hampered by the lack of a detailed and uniform BVFL nomenclature. Study Design: Clinical consensus conferences were held to develop an initial BVFL nomenclature paradigm. Perceptual video analysis was performed to validate the stroboscopy component of the paradigm. Methods: The culmination of the consensus conferences and the video-perceptual analysis was used to evaluate the BVFL nomenclature paradigm using a retrospective review of patients with BVFL. Results: An initial BVFL nomenclature paradigm was proposed utilizing detailed definitions relating to vocal fold lesion morphology, stroboscopy, response to voice therapy and intraoperative findings. Video-perceptual analysis of stroboscopy demonstrated that the proposed binary stroboscopy system used in the BVFL nomenclature paradigm was valid and widely applicable. Retrospective review of 45 patients with BVFL followed to the conclusion of treatment demonstrated that slight modifications of the initial BVFL nomenclature paradigm were required. With the modified BVFL nomenclature paradigm, 96% of the patients fit into the predicted pattern and definitions of the BVFL nomenclature system. Conclusions: This study has validated a multidimensional BVFL nomenclature paradigm. This vocal fold nomenclature paradigm includes nine distinct vocal fold lesions: vocal fold nodules, vocal fold polyp, pseudocyst, vocal fold cyst (subepithelial or ligament), nonspecific vocal fold lesion, vocal fold fibrous mass (subepithelial or ligament), and reactive lesion.

Meta‐analysis of endoscopic versus sublabial pituitary surgery

Abstract: Objectives/Hypothesis: To determine whether the endoscopic or sublabial transseptal transsphenoidal approach for pituitary surgery has superior outcomes or decreased complication rates. Study Design: Retrospective meta-analysis of literature. Methods: A MEDLINE search was conducted identifying all relevant literature in the English language from 1998 through 2010. Studies explicitly identifying pure sublabial or completely endoscopic approaches were included. Meta-analysis comparing the two techniques was performed for multiple outcome measures utilizing a random effects approach. Results: A total of 21 endoscopic studies (n = 2,335) and 17 sublabial studies (n = 2,565) met inclusion criteria. Analysis revealed significantly superior rates of gross tumor resection (79% vs. 65%, P < .0001), as well as lower rates of cerebral spinal fluid leak (5% vs. 7%, P < .01), septal perforation (0% vs. 5%), and postoperative epistaxis (1% vs. 4%, P < .0001) for the endoscopic approach compared to the sublabial approach. There was no difference between the two techniques in the incidence of meningitis, diabetes insipidus, or resolution of hormonal abnormality. Hospital stay (P = .01) was shorter for endoscopic surgery compared to sublabial surgery, and there was no significant difference in terms of length of operation. Conclusions: The sublabial transsphenoidal approach has been the gold standard for pituitary surgery for many years. However, meta-analysis of the recent literature demonstrates superior outcomes and decreased postoperative complications with the endoscopic approach, potentially justifying a shift toward endoscopic pituitary surgery.

Elderly patients benefit from cochlear implantation regarding auditory rehabilitation, quality of life, tinnitus, and stress.

Abstract: Objectives/Hypothesis: To determine the effect of cochlear implantation on quality of life, speech performance, tinnitus, perceived stress, and coping strategy in patients aged ≥70 years in comparison with younger patients Study Design: Retrospective study Methods: A total of 55 postlingually deafened adults who were unilaterally implanted with a multichannel cochlear implant for at least 6 months were included in the study Twenty patients were aged ≥70 years (70–84 years), and 35 patients were <70 years (19–67 years) Speech perception was measured using the Freiburg monosyllable test in quiet and the Hochmair-Schulz-Moser sentence test In addition, the patients filled in six validated questionnaires Results: Speech perception and subjectively assessed auditory ability were similar in the two age groups after implantation Disease-specific quality of life was improved in patients aged ≥70 years and even to a higher extent as compared to younger patients Tinnitus annoyance and perceived stress were reduced in elderly patients to the same extent as in younger patients in the case of high initial severity level The scores for the coping subdomain “seeking support” were reduced in elderly patients Conclusions: The present study provides evidence that cochlear implantation constitutes a very successful procedure of auditory rehabilitation, even for patients aged ≥70 years In addition, elderly patients benefit from implantation, with increased quality of life and reduced tinnitus and stress

Tracheotomy Outcomes and Complications: A National Perspective

Abstract: Objectives/Hypothesis: To provide national level data on frequency of tracheotomy and complication rate and in-hospital mortality following tracheotomy. Study Design: Retrospective cohort study. Methods: Retrospective cohort study using a public national database, the Nationwide Inpatient Sample, 2006. Results: There were 113,653 tracheotomies performed in patients 18 years or older in 2006. The overall complication rate was 3.2%, and the in-hospital mortality rate was 19.2%. The data suggest that in-hospital mortality is usually due to the underlying illness rather than the tracheotomy. Mortality was higher in patients older than 50 years, those with cardiac conditions, particularly congestive heart failure, those with public insurance, and patients in Northeast hospitals. Patients with neurologic conditions, trauma, and upper airway infection are more likely to survive to discharge. In-hospital mortality is slightly higher in nonteaching hospitals. Conclusions: This database study determined baseline data for the rate of complications (3.2%) for patients undergoing tracheotomy; it showed that only 80% of adult patients who underwent tracheotomy in the United States survived to discharge. Patients located in the Northeast, patients more than 50 years old, and patients with cardiac conditions were at particularly high risk for mortality. This study provides normative data for these outcomes for patient counseling and planning future quality improvement initiatives in this patient population.Laryngoscope, 122:25–29, 2012

Human papillomavirus DNA strongly correlates with a poorer prognosis in oral cavity carcinoma

Abstract: Objectives/Hypothesis: The prevalence of human papillomavirus (HPV) in a clinical series of 162 patients with oral squamous cell carcinoma (OSCC) was studied. Furthermore, we analyzed the correlation between the immunohistochemical expression of p16, p53, epidermal growth factor receptor (EGFR), and HPV status to predict survival in OSCC patients. Study Design: Retrospective study. Methods: Paraffin-embedded samples from OSCC patients (n = 162) were evaluated for the presence of HPV DNA using both GP5+/GP6+ consensus polymerase chain reaction (PCR) and type-specific E6/E7 PCR to detect HPV types 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 67, and 68. Immunohistochemical staining for p16, p53, and EGFR was also performed. Results: The type-specific E6/E7 PCR demonstrated that 65 of the 147 OSCC patients (44%) presented with high-risk (hr) HPV types and that 38 of the 147 OSCC patients (26%) presented with low-risk (lr) HPV types. Comparable p53 and EGFR expression levels were observed in the hr HPV+ group (41.5% p53+, 92% EGFR+) and the lr HPV+ group (57% p53+, 92% EGFR+). Conversely, a slight increase in the proportion of p16+ tumors was observed in the hr HPV+ group (65%) compared with the lr HPV+ group (44%). In regard to patient outcome, the presence of HPV was correlated with a worse prognosis (P = .007). Conclusions: A high prevalence of hr and lr HPV infections was detected in the OSCC patients included in the study. Moreover, hr HPV positivity was correlated with a decreased 5-year disease-free survival rate compared with HPV− and lr HPV+.